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Geographic distribution of primary care physicians in Japan and Britain
ARTICLE IN PRESS Health & Place 16 (2010) 164–166
Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
Short Report
Geographic distribution of primary care physicians in Japan and Britain Masatoshi Matsumoto a,, Kazuo Inoue b, Jane Farmer c, Haruhiko Inada d, Eiji Kajii e a
Division of Community and Family Medicine, Centre for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan Department of Community Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi, Tokyo 173-8605, Japan Centre for Rural Health, UHI Millennium Institute, Centre for Health Science, Old Perth Road, Inverness IV2 3JH, Scotland, UK d Department of Public Health, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-0033, Japan e Division of Community and Family Medicine, Centre for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan b c
a r t i c l e in f o
a b s t r a c t
Article history: Received 23 May 2009 Received in revised form 21 July 2009 Accepted 27 July 2009
Geographic distributions of primary care physicians in Japan and Britain were compared with each other. Regional variation in the number of primary care physicians per unit population was larger in Japan than in Britain. The Gini coefficient of primary care physicians against population in Japan (0.1755) was more than twice that observed for Britain (0.0837), indicating a substantially less equal distribution in Japan. The results can probably be explained by differences in the primary care systems of the two countries. & 2009 Elsevier Ltd. All rights reserved.
Keywords: Physicians Primary health care Japan Great Britain
1. Introduction Over-concentration of physicians in urban areas and subsequent shortages in rural areas have been observed, causing political concern in many countries (Australian Medical Workforce Advisory Committee, 2000; Gravelle and Sutton, 2001; Kobayashi and Takaki, 1992; Bureau of Health Professions, 1992). Primary care physicians (PCPs) and generalists distribute more equally than specialists do (Newhouse, 1990). However, maldistribution of PCPs does exist (Australian Medical Workforce Advisory Committee, 2000; Gravelle and Sutton, 2001; Hann and Gravelle, 2004), and its impact on accessibility of healthcare for the general population is considerable. The distribution of PCPs can be influenced by the medical system of a country. Particularly, the function and structure of primary care can impact the distribution. This can only be evaluated by international comparative studies, preferably of countries with markedly different primary care systems. The British medical system has a clear division between primary care (PC) and non-PC, in terms of both academic discipline and healthcare domain. The production and distribution of PCPs (general practitioners—GPs) are regulated by the
Corresponding author. Tel.: +81 285587394; fax: +81 285440628.
E-mail addresses: [email protected] (M. Matsumoto), [email protected] (K. Inoue), [email protected] (J. Farmer), [email protected] (H. Inada), [email protected] (E. Kajii). 1353-8292/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2009.07.005
publicly funded healthcare organisation (National Health Services—NHS). In contrast, the Japanese medical system does not have a formally certified PC discipline (Ishibashi, 1987). More than 95% of physicians in Japan are classified as organor disease-based specialists (Ministry of Health, Labour and Welfare, 2005). They are trained and work as specialists at hospitals early in their careers. In the middle or late career, some physicians open their own private clinics, become PCPs, and provide PC largely within their specialties. Moreover, physicians in Japan can choose their own practice locations without governmental regulation. Japanese medical facilities are classified into primary (clinics), secondary (community hospitals) and tertiary care facilities (specialised hospitals). Patients are expected (but not obliged) to visit primary care facilities, and if needed, are referred to secondary or tertiary facilities. The whole population in Japan is covered by the uniform fee-for-service national health insurance, and the medical service fee is strictly regulated by the government (Ikegami and Campbell, 1996). Primary care in Japan and Britain is thus similar in that patients can obtain access without a substantial financial burden and PCPs are expected to play a role as gatekeeper. Clinical capability and freedom of practice choice of PCPs, however, differ between the two countries. This international comparative study highlights how equitably PCPs are distributed within the two different medical systems, and argues that the differences of both primary care systems can affect the difference in distribution.
ARTICLE IN PRESS M. Matsumoto et al. / Health & Place 16 (2010) 164–166
165
2. Methods
3. Results
The geographical unit of analysis in Japan is designated as the secondary healthcare area (SHA). SHA is defined by national law as a region within which most of the healthcare services are provided and managed. Each SHA consists of several municipalities (cities, towns, villages), and there were 368 SHAs as of December 2004, covering all of Japan. The population data source was the National Basic Resident Register, where data were gathered in March 2004 by the Ministry of Internal Affairs and Communications. Physician data were collected by the National Physician Census gathered in December 2004 by the Ministry of Health, Labour and Welfare (Ministry of Internal Affairs and Communications, 2004; Ministry of Health, Labour and Welfare, 2005). In this study, active medical doctors working for clinics (medical institutions with less than 20 inpatient beds) were recognised as ‘PCPs’. Because we deleted data of SHAs, which underwent complicated re-demarcation between the two census periods, the final resultant number of SHAs analysed was 359. In this study, all active GPs were recognised as ‘PCPs’ in Britain. English and Welsh data were extracted from the online database of the GP workforce at the National Health System (NHS) Information Centre (NHS Information Centre, 2009). Scottish data were obtained from the GP workforce database at the Information Services Division (ISD), Scotland (ISD Scotland, 2009). Data for Northern Ireland were unavailable. The geographic units of Britain used were the Primary Care Trust (PCT) for England, Local Health Board (LHB) for Wales, and Community Health Partnership (CHP) for Scotland. Numbers of residents and all of the active GPs in each of the 365 PCTs/LHBs/CHPs in September 2005 were used for analysis. For evaluating the equity of PCP distribution, the Gini coefficient was calculated for each country. The Gini coefficient has widely been used for the analysis of physician distribution (Brown, 1994; Gravelle and Sutton, 2001; Hann and Gravelle, 2004; Kobayashi and Takaki, 1992). All of the regions were ranked by physician-to-population ratio, and the cumulative proportion of physicians and that of the population of each region was plotted in the plane of coordinates. The plotted line is the Lorenz curve, and the Gini coefficient is the area between the Lorenz curve and the 451 line, divided by the triangle under the 451 line. Gini coefficient varies between 0 (complete equity) and 1 (complete inequity) according to the degree of variation in physician-topopulation ratios.
Analysed populations were 125.2 million in Japan and 61.3 million in Britain. The numbers of PCPs were 91,987 (73.4 per 100,000 residents) in Japan and 39,188 (63.9) in Britain. The proportion of PCPs among all medical doctors in Japan was 34.4% and that in Britain was 27.1%. Of the PCPs in Japan, 41.8% specialised in internal medicine, 8.0% in ophthalmology, 7.2% in orthopaedics, 6.8% in paediatrics, 5.6% in otolaryngology, 5.5% in surgery, 4.7% in obstetrics/ gynaecology, 4.7% in dermatology, and 15.6% in others. Distributions of PCPs per 100,000 residents among the regions of Japan (Fig. 1A) and Britain (1B) are shown. The average population in a region was 348.9 thousand in Japan and 167.9 thousand in Britain. The average number of PCPs per 100,000 residents in a region was 66.1 (standard deviation 23.2; range 18.6–287.4) in Japan and 65.5 (14.6; 47.9–208.4) in Britain. The proportion of the number of regions whose PCPs-to-population ratios less than 50 per 100,000 residents was 22.6% (81/359) and the proportion of their population was 14.5% (18.1/125.2 million) in Japan, while the proportions were 2.7% (10/365) and 2.8% (1.7/ 61.3 million) in Britain, respectively. Equity of PCP distribution against regional populations is shown in Fig. 2. The Gini coefficient of the Japanese PCPs (0.1755) was more than twice as large as that for the British PCPs (0.0837), indicating a substantially lower equity of PCP distribution against population in Japan.
4. Discussion Although an inequitable distribution of GPs in Britain has been noted and this continuing trend over 30 years has been reported (Gravelle and Sutton, 2001; Hann and Gravelle, 2004), the distribution of British PCPs was found to be substantially more equitable when compared with the distribution of community populations than the distribution of Japanese PCPs. The first reason proposed for the more equitable distribution of PCPs in Britain is that PC in Britain is provided as an integrated form, while in Japan it is provided as fragmented pieces. Each Japanese PCP has his/her own specialty and cares for patients with diseases within the parameters of the specialty. Compared with a British GP, who can deal with all PC-level health problems, a ‘‘specialoid’’ PCP in Japan needs a larger population for attracting
300 Physicians per 100,000 population
Physicians per 100,000 population
300 250 200 150 100 50 0
Regions
250 200 150 100 50 0
Regions
Fig. 1. Distribution of primary care physician-to-population ratios among all geographic regions in Japan (1A) and Britain (1B). Primary care physicians are clinic physicians in Japan and general practitioners (GPs) in Britain. Regions are secondary healthcare areas in Japan and PCTs/LHBs/CHPs in Britain.
ARTICLE IN PRESS 166
M. Matsumoto et al. / Health & Place 16 (2010) 164–166
Cumulative proportion of physicians
1.0
be further improved since the new GP contract that raised salaries and ended out-of-hours working requirements. Studies exploring the impact of the new British GP contract are lacking, although anecdotally it is reported to have positively affected numbers applying for rural GP positions. These changes may have widened the gap of the PCP distributions of both countries seen in this study. Maldistribution of physicians has been one of the most serious political concerns in modern Japan. Production of PC generalists and regulation of practice location of physicians would be beneficial for a more equitable distribution of PCPs in Japan.
.8
.6
Britain (Gini coefficient 0.0837)
.4 Japan (0.1755)
Funding
.2
0.0 0.0
.2
.4 .6 Cumulative proportion of population
.8
1.0
Fig. 2. Lorenz curve and Gini coefficient of primary care physicians against population in Japan and Britain. Gini coefficient ranges between 0 (complete equity) and 1 (complete inequity) according to variation in the physician-to-population ratios among communities.
Pfizer Health Research Foundation (Tokyo), The Health Care Science Institute (Tokyo), and Ministry of Education, Culture, Sports, Science and Technology (Tokyo) sponsored this research without any involvement in study design, collection, analysis and interpretation, writing of the report, and decision to submit the paper for publication.
Competing interests patients to sufficiently maintain his/her income. This can lead to the concentration of PCPs in urban areas resulting in a shortage in rural areas. Another reason is that the practice location of physicians in Britain is better regulated. In Japan there is no quota of physicians in each area, and no financial incentive for rural practice exists. Hence, maldistribution of PCPs in Japan is more difficult to redress than that in Britain, where entry of GPs to over-supplied areas is controlled, and area-related incentives such as deprivationweighted capitation payments are implemented. A limitation of this study is the difference in definition of PCPs between the two countries. Some of the Japanese clinic physicians may provide highly specialised care; for example, some physicians in Japan conduct radiation therapy at clinics. Having ‘superspecialists’ at clinics may have exacerbated the appearance of maldistribution of the Japanese PCPs in this study since such specialists usually practice in very urban areas. Conversely, a considerable number of hospital physicians in Japan work as PCPs rather than specialists. The distribution of hospitals is biased more toward urban areas than that of clinics. This study thus may have underestimated the maldistribution of Japanese PCPs by excluding the ‘hospital PCPs’. There are much more ‘hospital PCPs’ than ‘clinic super-specialists’ in Japan (Ministry of Health, Labour and Welfare, 2005). So the overall bias created by these two types of physicians in Japan is probabaly underestimation rather than overestimation of the real maldistribution, which does not weaken our conclusion. Another limitation is that this study did not evaluate a most recent change of PCP distribution. Maldistribution of physicians in Japan was reported to have worsened since 2004 (Toyabe, 2009), while distribution of British GPs may
None. References Australian Medical Workforce Advisory Committee, 2000. The General Practice Workforce in Australia. AMWAC, Sydney. Brown, M.C., 1994. Using Gini-style indices to evaluate the spatial patterns of health practitioners: theoretical considerations and an application based on Alberta data. Social Science and Medicine 38, 1243–1256. Bureau of Health Professions, 1992. Rural Health Professions Facts: Supply and Distribution of Health Professions in Rural America. Health Resources and Services Administration, Rockville. Gravelle, H., Sutton, M., 2001. Inequality in the geographical distribution of general practitioners in England and Wales 1974–1995. Journal of Health Services Research and Policy 6, 6–13. Hann, M., Gravelle, H., 2004. The maldistribution of general practitioners in England and Wales: 1974–2003. British Journal of General Practice 54, 894– 898. Ikegami, N., Campbell, J.C., 1996. The Art of Balance in Health Policy: Maintaining Japan’s Low-Cost, Egalitarian System. Chuko-shinsyo, Tokyo. Information Services Division, Scotland, 2009. General practice workforce. /http:// www.isdscotland.org/isd/3793.htmlS (last accessed 1.5.09). Ishibashi, Y., 1987. Why is family medicine needed in Japan?. Journal of Family Practice 25, 83–86. Kobayashi, Y., Takaki, H., 1992. Geographic distribution of physicians in Japan. Lancet 340, 1391–1393. Ministry of Health, Labour and Welfare, 2005. The National Physician Census 2004. MHLW, Tokyo. Ministry of Internal Affairs and Communications, 2004. Population and Population Dynamics Based on the National Basic Resident Register. MIAC, Tokyo. National Health System Information Centre, 2009. NHS staff numbers. /http:// www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbersS (last accessed 1.5.09). Newhouse, J.P., 1990. Geographic access to physician services. Annual Review of Public Health 11, 207–230. Toyabe, S., 2009. Trend in geographic distribution of physicians in Japan. International Journal for Equity in Health 8, 5.
Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
Short Report
Geographic distribution of primary care physicians in Japan and Britain Masatoshi Matsumoto a,, Kazuo Inoue b, Jane Farmer c, Haruhiko Inada d, Eiji Kajii e a
Division of Community and Family Medicine, Centre for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan Department of Community Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi, Tokyo 173-8605, Japan Centre for Rural Health, UHI Millennium Institute, Centre for Health Science, Old Perth Road, Inverness IV2 3JH, Scotland, UK d Department of Public Health, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-0033, Japan e Division of Community and Family Medicine, Centre for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan b c
a r t i c l e in f o
a b s t r a c t
Article history: Received 23 May 2009 Received in revised form 21 July 2009 Accepted 27 July 2009
Geographic distributions of primary care physicians in Japan and Britain were compared with each other. Regional variation in the number of primary care physicians per unit population was larger in Japan than in Britain. The Gini coefficient of primary care physicians against population in Japan (0.1755) was more than twice that observed for Britain (0.0837), indicating a substantially less equal distribution in Japan. The results can probably be explained by differences in the primary care systems of the two countries. & 2009 Elsevier Ltd. All rights reserved.
Keywords: Physicians Primary health care Japan Great Britain
1. Introduction Over-concentration of physicians in urban areas and subsequent shortages in rural areas have been observed, causing political concern in many countries (Australian Medical Workforce Advisory Committee, 2000; Gravelle and Sutton, 2001; Kobayashi and Takaki, 1992; Bureau of Health Professions, 1992). Primary care physicians (PCPs) and generalists distribute more equally than specialists do (Newhouse, 1990). However, maldistribution of PCPs does exist (Australian Medical Workforce Advisory Committee, 2000; Gravelle and Sutton, 2001; Hann and Gravelle, 2004), and its impact on accessibility of healthcare for the general population is considerable. The distribution of PCPs can be influenced by the medical system of a country. Particularly, the function and structure of primary care can impact the distribution. This can only be evaluated by international comparative studies, preferably of countries with markedly different primary care systems. The British medical system has a clear division between primary care (PC) and non-PC, in terms of both academic discipline and healthcare domain. The production and distribution of PCPs (general practitioners—GPs) are regulated by the
Corresponding author. Tel.: +81 285587394; fax: +81 285440628.
E-mail addresses: [email protected] (M. Matsumoto), [email protected] (K. Inoue), [email protected] (J. Farmer), [email protected] (H. Inada), [email protected] (E. Kajii). 1353-8292/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2009.07.005
publicly funded healthcare organisation (National Health Services—NHS). In contrast, the Japanese medical system does not have a formally certified PC discipline (Ishibashi, 1987). More than 95% of physicians in Japan are classified as organor disease-based specialists (Ministry of Health, Labour and Welfare, 2005). They are trained and work as specialists at hospitals early in their careers. In the middle or late career, some physicians open their own private clinics, become PCPs, and provide PC largely within their specialties. Moreover, physicians in Japan can choose their own practice locations without governmental regulation. Japanese medical facilities are classified into primary (clinics), secondary (community hospitals) and tertiary care facilities (specialised hospitals). Patients are expected (but not obliged) to visit primary care facilities, and if needed, are referred to secondary or tertiary facilities. The whole population in Japan is covered by the uniform fee-for-service national health insurance, and the medical service fee is strictly regulated by the government (Ikegami and Campbell, 1996). Primary care in Japan and Britain is thus similar in that patients can obtain access without a substantial financial burden and PCPs are expected to play a role as gatekeeper. Clinical capability and freedom of practice choice of PCPs, however, differ between the two countries. This international comparative study highlights how equitably PCPs are distributed within the two different medical systems, and argues that the differences of both primary care systems can affect the difference in distribution.
ARTICLE IN PRESS M. Matsumoto et al. / Health & Place 16 (2010) 164–166
165
2. Methods
3. Results
The geographical unit of analysis in Japan is designated as the secondary healthcare area (SHA). SHA is defined by national law as a region within which most of the healthcare services are provided and managed. Each SHA consists of several municipalities (cities, towns, villages), and there were 368 SHAs as of December 2004, covering all of Japan. The population data source was the National Basic Resident Register, where data were gathered in March 2004 by the Ministry of Internal Affairs and Communications. Physician data were collected by the National Physician Census gathered in December 2004 by the Ministry of Health, Labour and Welfare (Ministry of Internal Affairs and Communications, 2004; Ministry of Health, Labour and Welfare, 2005). In this study, active medical doctors working for clinics (medical institutions with less than 20 inpatient beds) were recognised as ‘PCPs’. Because we deleted data of SHAs, which underwent complicated re-demarcation between the two census periods, the final resultant number of SHAs analysed was 359. In this study, all active GPs were recognised as ‘PCPs’ in Britain. English and Welsh data were extracted from the online database of the GP workforce at the National Health System (NHS) Information Centre (NHS Information Centre, 2009). Scottish data were obtained from the GP workforce database at the Information Services Division (ISD), Scotland (ISD Scotland, 2009). Data for Northern Ireland were unavailable. The geographic units of Britain used were the Primary Care Trust (PCT) for England, Local Health Board (LHB) for Wales, and Community Health Partnership (CHP) for Scotland. Numbers of residents and all of the active GPs in each of the 365 PCTs/LHBs/CHPs in September 2005 were used for analysis. For evaluating the equity of PCP distribution, the Gini coefficient was calculated for each country. The Gini coefficient has widely been used for the analysis of physician distribution (Brown, 1994; Gravelle and Sutton, 2001; Hann and Gravelle, 2004; Kobayashi and Takaki, 1992). All of the regions were ranked by physician-to-population ratio, and the cumulative proportion of physicians and that of the population of each region was plotted in the plane of coordinates. The plotted line is the Lorenz curve, and the Gini coefficient is the area between the Lorenz curve and the 451 line, divided by the triangle under the 451 line. Gini coefficient varies between 0 (complete equity) and 1 (complete inequity) according to the degree of variation in physician-topopulation ratios.
Analysed populations were 125.2 million in Japan and 61.3 million in Britain. The numbers of PCPs were 91,987 (73.4 per 100,000 residents) in Japan and 39,188 (63.9) in Britain. The proportion of PCPs among all medical doctors in Japan was 34.4% and that in Britain was 27.1%. Of the PCPs in Japan, 41.8% specialised in internal medicine, 8.0% in ophthalmology, 7.2% in orthopaedics, 6.8% in paediatrics, 5.6% in otolaryngology, 5.5% in surgery, 4.7% in obstetrics/ gynaecology, 4.7% in dermatology, and 15.6% in others. Distributions of PCPs per 100,000 residents among the regions of Japan (Fig. 1A) and Britain (1B) are shown. The average population in a region was 348.9 thousand in Japan and 167.9 thousand in Britain. The average number of PCPs per 100,000 residents in a region was 66.1 (standard deviation 23.2; range 18.6–287.4) in Japan and 65.5 (14.6; 47.9–208.4) in Britain. The proportion of the number of regions whose PCPs-to-population ratios less than 50 per 100,000 residents was 22.6% (81/359) and the proportion of their population was 14.5% (18.1/125.2 million) in Japan, while the proportions were 2.7% (10/365) and 2.8% (1.7/ 61.3 million) in Britain, respectively. Equity of PCP distribution against regional populations is shown in Fig. 2. The Gini coefficient of the Japanese PCPs (0.1755) was more than twice as large as that for the British PCPs (0.0837), indicating a substantially lower equity of PCP distribution against population in Japan.
4. Discussion Although an inequitable distribution of GPs in Britain has been noted and this continuing trend over 30 years has been reported (Gravelle and Sutton, 2001; Hann and Gravelle, 2004), the distribution of British PCPs was found to be substantially more equitable when compared with the distribution of community populations than the distribution of Japanese PCPs. The first reason proposed for the more equitable distribution of PCPs in Britain is that PC in Britain is provided as an integrated form, while in Japan it is provided as fragmented pieces. Each Japanese PCP has his/her own specialty and cares for patients with diseases within the parameters of the specialty. Compared with a British GP, who can deal with all PC-level health problems, a ‘‘specialoid’’ PCP in Japan needs a larger population for attracting
300 Physicians per 100,000 population
Physicians per 100,000 population
300 250 200 150 100 50 0
Regions
250 200 150 100 50 0
Regions
Fig. 1. Distribution of primary care physician-to-population ratios among all geographic regions in Japan (1A) and Britain (1B). Primary care physicians are clinic physicians in Japan and general practitioners (GPs) in Britain. Regions are secondary healthcare areas in Japan and PCTs/LHBs/CHPs in Britain.
ARTICLE IN PRESS 166
M. Matsumoto et al. / Health & Place 16 (2010) 164–166
Cumulative proportion of physicians
1.0
be further improved since the new GP contract that raised salaries and ended out-of-hours working requirements. Studies exploring the impact of the new British GP contract are lacking, although anecdotally it is reported to have positively affected numbers applying for rural GP positions. These changes may have widened the gap of the PCP distributions of both countries seen in this study. Maldistribution of physicians has been one of the most serious political concerns in modern Japan. Production of PC generalists and regulation of practice location of physicians would be beneficial for a more equitable distribution of PCPs in Japan.
.8
.6
Britain (Gini coefficient 0.0837)
.4 Japan (0.1755)
Funding
.2
0.0 0.0
.2
.4 .6 Cumulative proportion of population
.8
1.0
Fig. 2. Lorenz curve and Gini coefficient of primary care physicians against population in Japan and Britain. Gini coefficient ranges between 0 (complete equity) and 1 (complete inequity) according to variation in the physician-to-population ratios among communities.
Pfizer Health Research Foundation (Tokyo), The Health Care Science Institute (Tokyo), and Ministry of Education, Culture, Sports, Science and Technology (Tokyo) sponsored this research without any involvement in study design, collection, analysis and interpretation, writing of the report, and decision to submit the paper for publication.
Competing interests patients to sufficiently maintain his/her income. This can lead to the concentration of PCPs in urban areas resulting in a shortage in rural areas. Another reason is that the practice location of physicians in Britain is better regulated. In Japan there is no quota of physicians in each area, and no financial incentive for rural practice exists. Hence, maldistribution of PCPs in Japan is more difficult to redress than that in Britain, where entry of GPs to over-supplied areas is controlled, and area-related incentives such as deprivationweighted capitation payments are implemented. A limitation of this study is the difference in definition of PCPs between the two countries. Some of the Japanese clinic physicians may provide highly specialised care; for example, some physicians in Japan conduct radiation therapy at clinics. Having ‘superspecialists’ at clinics may have exacerbated the appearance of maldistribution of the Japanese PCPs in this study since such specialists usually practice in very urban areas. Conversely, a considerable number of hospital physicians in Japan work as PCPs rather than specialists. The distribution of hospitals is biased more toward urban areas than that of clinics. This study thus may have underestimated the maldistribution of Japanese PCPs by excluding the ‘hospital PCPs’. There are much more ‘hospital PCPs’ than ‘clinic super-specialists’ in Japan (Ministry of Health, Labour and Welfare, 2005). So the overall bias created by these two types of physicians in Japan is probabaly underestimation rather than overestimation of the real maldistribution, which does not weaken our conclusion. Another limitation is that this study did not evaluate a most recent change of PCP distribution. Maldistribution of physicians in Japan was reported to have worsened since 2004 (Toyabe, 2009), while distribution of British GPs may
None. References Australian Medical Workforce Advisory Committee, 2000. The General Practice Workforce in Australia. AMWAC, Sydney. Brown, M.C., 1994. Using Gini-style indices to evaluate the spatial patterns of health practitioners: theoretical considerations and an application based on Alberta data. Social Science and Medicine 38, 1243–1256. Bureau of Health Professions, 1992. Rural Health Professions Facts: Supply and Distribution of Health Professions in Rural America. Health Resources and Services Administration, Rockville. Gravelle, H., Sutton, M., 2001. Inequality in the geographical distribution of general practitioners in England and Wales 1974–1995. Journal of Health Services Research and Policy 6, 6–13. Hann, M., Gravelle, H., 2004. The maldistribution of general practitioners in England and Wales: 1974–2003. British Journal of General Practice 54, 894– 898. Ikegami, N., Campbell, J.C., 1996. The Art of Balance in Health Policy: Maintaining Japan’s Low-Cost, Egalitarian System. Chuko-shinsyo, Tokyo. Information Services Division, Scotland, 2009. General practice workforce. /http:// www.isdscotland.org/isd/3793.htmlS (last accessed 1.5.09). Ishibashi, Y., 1987. Why is family medicine needed in Japan?. Journal of Family Practice 25, 83–86. Kobayashi, Y., Takaki, H., 1992. Geographic distribution of physicians in Japan. Lancet 340, 1391–1393. Ministry of Health, Labour and Welfare, 2005. The National Physician Census 2004. MHLW, Tokyo. Ministry of Internal Affairs and Communications, 2004. Population and Population Dynamics Based on the National Basic Resident Register. MIAC, Tokyo. National Health System Information Centre, 2009. NHS staff numbers. /http:// www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbersS (last accessed 1.5.09). Newhouse, J.P., 1990. Geographic access to physician services. Annual Review of Public Health 11, 207–230. Toyabe, S., 2009. Trend in geographic distribution of physicians in Japan. International Journal for Equity in Health 8, 5.