The migration of UK trained GPs to Australia: Does risk attitude matter?

Highlights

• Risk attitude plays a role in migration as these are risky decisions.

• UK-qualified GPs who migrated to Australia were compared to GPs in Scotland.

• They have a similar risk attitude towards financial risk.

• They were more risk averse with regards to career and clinical risk.

• Migration may be associated with lower career and clinical uncertainty in Australia.

Abstract

Background

Little is known about the drivers of migration of GPs. Risk attitude may play an important role as migration is fundamentally a risky decision that balances the risks of staying with the risks associated with leaving. This paper examines the association between risk attitudes and the migration of UK GPs to Australia.

Methods

GPs who qualified in the UK but work in Australia and who responded to the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal survey of doctors, were compared with GPs based in Scotland who responded to a survey. Risk attitudes were elicited for financial risks, career and professional risks and clinical risks on a scale from 1 to 5.

Results

GPs in Scotland and UK trained GPs in Australia have similar risk attitudes for financial risk. However, UK trained GPs in Australia are less willing to take clinical and career risks.

Conclusion

GPs who migrated to Australia after qualifying in the UK were more risk averse about their career and clinical risks. This may suggest that more risk averse GPs migrate to Australia due to pull factors such as less uncertainty around career and clinical outcomes in Australia. The uncertain NHS climate may push more risk averse doctors away from the UK.

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.