The migration of UK trained GPs to Australia: Does risk attitude matter?
Introduction
Labour and skill shortages in the health sector is a policy concern in many OECD countries [1]. One issue is outward migration by doctors, whose training is often in part subsidised by the state. In the UK, the focus of this paper, one in ten General Practitioners (GPs) have indicated that they plan to leave the UK to work overseas [2] and the number of UK doctors working in Australia and New Zealand has seen a recent increase, growing by 17% between 2014 and 2016 to 5378 [3]. NHS England has just announced a new policy to encourage GPs who left the UK for Australia to return to the NHS. Increasing our understanding of migration decisions is crucial to develop interventions and policies aimed at encouraging doctors to stay in the UK.
The traditional economic approach assumes that individuals weigh up the uncertain changes in the costs and benefits of migration. Evidence suggests that internal migration is determined by a wide range of economic and non-economic push and pull factors [4]. Push factors are generally present in donor countries, and pull factors relate to receiving countries. Economic push factors include low wages, high taxes, high unemployment and overpopulation. Non-economic push factors include discrimination, poor health care, corruption, crime, compulsory military service, natural disaster and famine. Economic pull factors include demand for labour, high wages, generous welfare benefits, good healthcare and education systems, strong economic growth, technology and low cost of living. Non-economic pull factors include family and friends/networks, rights and freedoms, property rights, law and order and amenities [4].
There is relatively limited research on the drivers of physician immigration between developed countries (there is a larger literature on (the ethical issue) of) rich countries attracting health workers form poor countries). There is some evidence that the presence of larger migrant networks and the Gross Domestic Product of the origin country influences the decision to immigrate to the United States [5], as does a short-term shortage of doctors in the ‘receiving’ country [6]. Age was also a significant factor for migration between Canadian provinces for physicians [7]. Alongside these broader factors, there can be more personal or cultural reasons to emigrate. For Lithuanian doctors, a lower rating for teamwork culture was associated with a higher desire to emigrate [8]. The important interaction between the culture and institutions of a system [9] suggest that there is the possibility to self-select a system that more closely matches one’s preferences.
In this paper we focus on the role of a doctor’s attitude towards risk in migration. Uncertainty exists across all of the factors driving migrations discussed above, with respect to whether the destination country will lead to net increase in welfare. Migration is fundamentally a risky decision as individuals have more information about income, work environment, leisure opportunities and other important factors in their home country compared to other countries. Individuals vary widely in their attitude towards risk, and risk attitude correlates with a range of behaviours including clinical decision-making, such as triage decisions for emergency patients [10]. In the economics literature it has been recognised that risk attitude plays a role in migration decisions: several empirical studies have confirmed that risk seeking individuals are more likely to migrate [[11], [12], [13], [14], [15], [16], [17], [18], [19]]. However, none of the previous studies have focused on health professionals. There is some evidence that health professionals may have different risk attitudes [20] and this may affect the relationship between risk attitude and migration.
The aim of this paper is to compare risk attitudes of General Practitioners (GPs) who qualified in the UK and migrated to Australia with those who are currently practising in Scotland. Surveys increasingly include questions to measure risk attitude but different questions often limits comparability between groups. This paper exploits a unique opportunity to compare a longitudinal survey of doctors in Australia with a survey conducted in Scotland which included an identical risk attitude measure. It is the first study to examine the role of risk attitudes in migration of doctors.
Migration is influenced by both “push” and “pull” factors: push factors are generally present in donor countries, and pull factors relate to receiving countries [21]. This is important to recognise as push and pull factors may represent different levels of uncertainty and this influences the relationship between risk attitude and migration. For example, funding cuts in the NHS, revalidation, and other moves to improve productivity (e.g. seven day working) without increasing earnings may increase uncertainty about working in the UK NHS. This may increase the strength of push factors. Risk averse doctors may, therefore, be more likely to migrate if future conditions in their home country are more uncertain than their destination country. Health systems are organised and financed in different ways which is likely to be associated with different levels of uncertainty across different domains such as financial, career and clinical domains. The relationship between risk attitudes and migration depends on the relative levels of uncertainty in each country.
The way the health system is organised and financed differs markedly between the UK and Australia and different push and pull factors are therefore likely to be at play. The NHS is mainly financed through general taxation and is based on the principle of being free at the point of use. Australia has a national tax-financed universal health insurance scheme (Medicare). Diagnostic tests such as ultrasounds and MRIs are readily available in Australia, as private facilities outside of public hospitals offer these tests which are subsidised by Medicare (and mainly bulk-billed so there is no out of pocket cost). Many GP practices have rooms within their practices that are rented out to pathology companies where blood tests can be taken. This could reduce clinical uncertainty through avoiding long waiting times for diagnostics tests and reducing the risk of misdiagnosis. In the UK, GPs have a fixed patient list and they are required to provide necessary care for all patients on their list. The workload has been increasing and this can lead to higher levels of uncertainty around clinical care if for example the workload results in the provision of lower quality of care. In Australia GPs are paid by uncapped fee-for-service and they can more easily control their workload. Given the different push and pull factors, our hypotheses as to how domain-specific risk attitudes (e.g, across financial risks, clinical risks and career risks) may influence GP migration are ambiguous.
Section snippets
Data sources and study sample
Data from two sources are used: survey of GPs in Scotland and the Medicine in Australia: Balancing Employment and Life (MABEL) survey. The cross-sectional survey in Scotland was conducted in 2015 to examine the relative value GPs place on health benefits at different points in time [22]. The survey included the time preference questions, the risk questions used in this study, and demographic and practice characteristics. The survey was sent to a random sample of 2001 General Practitioners in
Sample and GP characteristics
In Scotland, 322/2001 questionnaires were returned (16%). The response rate is in line with other studies [30] including Riise et al. [31] who conducted a cross country comparison of GPs’ stated prescription behaviour. After excluding GPs with incomplete data, we had a study sample of 295 GPs in Scotland. Our estimation sample averages are 59% female (population 56%), list size 7844 (population 5800) and average number of GPs per practice six (population five). The larger list size and average
Discussion
This paper compared the risk attitudes of UK qualified GPs who have migrated to Australia with those who are currently practising in Scotland. Risk attitude was measured across three domains: financial risks, career/professional risks and clinical risks. The results showed that GPs who migrated to Australia after qualifying in the UK were similar in their risk attitude toward financial risk but more risk averse with regards to career and clinical risk compared to GPs in Scotland. The difference
Conclusion
This study showed that GPs who migrated to Australia after qualifying in the UK were similar in their risk attitude toward financial risk but more risk averse with regards to career and clinical risk compared to GPs in Scotland. These findings suggest that GP migration to Australia may be associated with lower levels of uncertainty in the career and clinical domains in Australia, relative to Scotland. Both push and pull factors may be the reasons for this association, including the NHS climate
Funding
No specific funding was received for this work. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates funds HERU. Alastair Irvine’s PhD studentship was funded by the Institute of Applied Health Sciences, University of Aberdeen. This research used data from the MABEL longitudinal survey of doctors conducted by the University of Melbourne and Monash University (the MABEL research team). Funding for MABEL comes from the National Health and Medical Research
Ethical approval
The MABEL study was approved by the University of Melbourne Faculty of Economics and Commerce Human Ethics Advisory Group and the Monash University Standing Committee on Ethics in Research Involving Humans. The Scottish study was approved by Life Sciences and Medicine Ethics Review Board (CERB) at the University of Aberdeen. No additional ethical approval was necessary for this secondary data analysis.
Declaration of Competing Interest
The authors have declared no competing interests.
Acknowledgement
We would like to thank Ophelie Bezannier for research assistance.
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