Doctors leaving New Zealand:

Report Doctors leaving New Zealand: analysis of online survey results Medical Council of New Zealand Protecting the public, promoting good medical practice Te tiaki i te iwi whānui me te whakatairanga pai i te mahi e pā ana ki te taha rongoā Laura Lumley December 2011 1

Executive summary The Medical Council of New Zealand (Council) undertook this survey to determine why doctors chose to leave New Zealand and what might encourage them to return. A survey was carried out of 182 doctors who were leaving New Zealand, over a 15 month period and the findings are summarised in this report. The highest proportion of doctors responding to the survey was those registered in a general scope of practice who had worked in New Zealand for longer than 3 years. The majority of these doctors worked in general practice, general medical and surgical runs (house officers and senior house officers) or internal medicine. The main reasons identified as factors for leaving New Zealand related to the desire for training opportunities and work experience in overseas settings. The intention to earn a higher income than what was available in New Zealand was the next largest indicator for leaving. The findings indicated that the majority of doctors leaving New Zealand intend to return. Their planned length of time overseas was for less than 3 years, although a significant portion did not know how long they would be away for. Some doctors are leaving for reasons which would be expected of doctors with primary medical qualifications (PMQ) gained overseas, such as visa restrictions and desire to be closer to family. Doctors with a PMQ gained in New Zealand were the most likely to return. The findings identified three main profiles that represent the types of doctors leaving New Zealand. These were: the New Zealand graduate, the doctor with a PMQ gained overseas, and the doctor seeking overseas locum work. Each group has their particular reasons for leaving New Zealand and these differ between the profiles. 2

Introduction The Council has four strategic directions. One of the strategic directions is Medical Workforce, and it focuses on assisting all doctors, including international medical graduates (IMGs) 1 to integrate safely and successfully into the New Zealand medical workforce. 1. 2009 / 10 survey of IMGs requesting a Certificate of Good Standing (CGS) As part of this programme of work, in October 2009 the Council developed and implemented an online survey and invited all IMGs who had applied for a CGS to complete it. The purpose of the survey was to determine the reasons IMGs come to New Zealand to work and the reasons they leave. The survey was conducted in two stages with a total of 51 surveys completed by IMGs leaving New Zealand by mid March 2010. Results from the survey indicated: 4 of the respondents had been practising in the United Kingdom, and 20% in the United States of America immediately prior to coming to New Zealand 75% had been working in a hospital environment while in New Zealand 52% had been working in the city, 32% in provincial towns, 8% in rural areas, and 8% had worked in a variety of settings in New Zealand 4 had only intended to stay in New Zealand for a short period of time at the time of arrival 24% left New Zealand for family reasons, 22% left to take up other professional opportunities or higher training, and 16% left for higher remuneration. In terms of responses to the question of what would make the doctors remain in New Zealand, factors included: ease for family to come to New Zealand, with nine respondents (18%) indicating that partners were unable to get visas or jobs ability to receive a higher income level, with eight (16%) specifically mentioning low pay as a reason to leave Council acknowledgement of previous qualifications and experience. 2. 2010 / 11 survey of all doctors requesting a CGS In April 2010, after reviewing the report from the 2009/10 survey of IMGs, the Council decided to extend the online survey to invite all doctors requesting a CGS to participate, rather than only IMGs. The purpose of extending the survey was to capture more extensive information across a larger number of doctors. In particular, the Council was interested to collect information about: The scope of practice the doctor had been registered in. Why doctors were leaving New Zealand. What may encourage doctors to return to New Zealand. 1 IMGs are defined as doctors new to New Zealand who are registered in a provisional general or provisional vocational scope of practice working under supervision and have not got permanent registration in New Zealand. 3

Methodology From 1 April 2010 to 30 June 2011 all doctors requesting a CGS, who had indicated that they were leaving New Zealand, were sent an email containing an electronic link to an online survey, inviting them to participate in the survey. Personal confidentiality was assured with the collation of results unable to be attributed to any particular respondent. The online survey tool used was drafted by Council staff and approved for use by the Council. The online survey was hosted by an online survey site Zoomerang.com. Email invitations with survey links were sent to 330 doctors, with those who wished to participate clicking on the electronic link and were taken to a login portal at the Zoomerang website. Once logged in, doctors were asked to complete the following 10 questions. 1. In what country did you obtain your primary medical qualification? 2. What scope of practice are you registered within in New Zealand? 3. How long have you been practising medicine in New Zealand? 4. What specialty do you practise in? 5. Why are you leaving New Zealand? 6. How long are you intending to be away from New Zealand? 7. What country will you be practising medicine in? 8. Do you have a job to go to? 9. What would encourage you to stay/return to practise in New Zealand? 10 Is there anything else you would like Council to know? (eg, general comments, ideas for improvements etc) 4

Limitations During the analysis of the survey findings, a number of limitations to the data were identified. There was a small sample size for some groups of respondents, in particular those registered in provisional general, provisional vocational, and special purpose scopes of practice. This limits the value of findings for these groups in some areas. When indicating the country in which they intended to practise medicine, three respondents stated Ireland. Without seeking further information it is difficult to identify if this meant the Republic of Ireland (Europe) or Northern Ireland (United Kingdom). For the purposes of this report we have assumed that the Republic of Ireland was the intended destination. Some quantitative questions were answered in unexpected ways, which meant that data could not easily be derived in a statistical format. Question four (What specialty do you practise in?) in particular showed varied ways of answering and every effort has been made to group the areas of medicine listed in the responses under the umbrella vocational scope. Many of the respondents were working in many areas of medicine, undertaking general medical and general surgical runs (house officers and senior house officers) and these have also been grouped together under this heading. Where possible, the responses to the more quantitative questions have been represented statistically and graphically. Other data has been interpreted using qualitative methods and have been reflected using diagrams and quotations. 5

Findings Overview Approximately 55 percent of doctors who were invited to participate in the survey completed it, with a total of 182 surveys completed. The numbers of doctors registered in special purpose, provisional general and provisional vocational scopes of practice in this survey are very small and caution is necessary before drawing conclusions from these groups. Therefore, some of the analysis excludes these groups. Unless otherwise stated, findings are derived from the total of all responses received from the 182 respondents and represents doctors who are registered across all of the different scopes of practice. At various points during the findings and discussion, reference is made to specific findings within the different scopes of practice. 6

Question one: In what country did you obtain your primary medical qualification? Proportion of respondents by country of primary medical qualification New Zealand United Kingdom Australia South Africa United States India Canada Ireland Netherlands Nigeria Zimbabwe Belgium Bolivia Bulgaria Germany Ghana Hong Kong Iraq Pakistan Philippines Romania Sri Lanka Sweden Unknown 5% 5% 3% 2% 25% 48% 0% 10% 20% 30% 40% 50% 60% Figure 1 The largest group of respondents gained their primary medical qualification (PMQ) in New Zealand (87 doctors or 48%) The second largest group were doctors who qualified in the United Kingdom (42 doctors or 25%) followed by; Australian trained doctors (9 doctors or 5%) and South African trained doctors (9 doctors or 5%). Doctors who had gained their PMQ from a total of 24 countries were represented in this result. 7

Question two: What scope of practice are you registered within in New Zealand? Scope of practice Number % Figure 2 % of medical register 2 General 88 48 35.7 Vocational 65 36 54.1 Provisional general 19 10 8.6 Provisional vocational 5 3 0.9 Special purpose - 3 2 0.3 postgraduate training Special purpose - locum tenens 2 1 0.4 Totals 182 100 100 What scope of practice are you registered within in New Zealand? 3% 2% General 10% 36% 48% Vocational Provisional general Provisional vocational Special purpose- postgraduate training Special purpose- locum tenens Figure 3 48% of respondents were registered in a general scope of practice 36% were vocationally registered 10% held a provisional general registration the remaining 6% of doctors were registered in either a provisional vocational scope of practice, or registered in a special purpose scope. The special purpose scopes respondents were on a time limited registration whilst completing postgraduate training or working in locum tenens positions. 2 Based on the number of doctors on the New Zealand Medical Register holding a current practising certificate as at 20 September 2011. 8

Type of registration by country of primary medical qualification* New Zealand 52 27 4 4 (87) Type of registration held in New Zealand United Kingdom 24 11 11 (46) General Australia 6 3 (9) Vocational South Africa 9 (9) Provisional General Provisional Vocational 0 20 40 60 80 100 Number of respondents Figure 4 * Only countries represented by at least 9 doctors have been included. When broken down by scope of practice, over half of the respondents were registered in a general scope of practice for each of the following countries: o New Zealand (52 out of 87) o United Kingdom (24 out of 46) o Australia (six out of nine). The largest group of respondents with a vocational scope of practice gained their PMQ in New Zealand 3. All respondents who gained their PMQ in South Africa were registered in a vocational scope of practice in New Zealand. 3 May also be referred to in this report as New Zealand graduates. 9

Question three: How long have you been practising medicine in New Zealand? 70% 60% 50% 40% 30% 20% 10% 0% Proportion of respondents by length of time spent practising medicine in New Zealand Less than 1 year Between 1 and 3 years More than 3 years Figure 5 The results indicate that: 6 of respondents had been practising medicine in New Zealand for more than 3 years. 26% had been practising for between 1 and 3 years. 13% for less than 1 year. 10

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Length of time spent practising medicine in New Zealand by scope of practice 8% 48% 44% 2% 94% 68% 5% 5% 26% General Vocational Provisional General 0% 40% 60% Provisional Vocational Less than 1 year Between 1 and 3 years More than 3 years Figure 6 When the results are broken down by scope of practice they show that: 94 % of vocational scope and 60 % of provisional vocational scope doctors stayed in New Zealand for more than 3 years, compared with 48% of general and 26 % of provisional general scopes. 68 % of provisional general scope doctors stayed in New Zealand for less than 1 year. 11

Question four: What specialty do you practise in? Proportion of respondents by area of medicine practised General practice General medical and surgical runs Internal medicine Anaesthesia Psychiatry Emergency medicine Orthopaedic surgery Unknown Paediatric surgery Obstetrics & gynaecology Urology Pathology Diagnostic and interventional radiology Radiation oncology Occupational medicine Neurosurgery Intensive care medicine Sports medicine Rural hospital medicine Otolaryngology Cardiothoracic surgery 2% 2% 2% 2% 5% 5% 4% 8% 7% 7% 13% 15% 23% 0% 5% 10% 15% 20% 25% Figure 7 The responses to this question show that: 23% advised they were working in general practice 15% worked in general medical and surgical runs 13% in internal medicine 8% of doctors are working in anaesthesia 7% are working in either psychiatry or emergency medicine. 12

Proportion of respondents by area of medicine practised -registered in a vocational scope of practice General Practice Internal medicine Psychiatry Anaesthesia Orthopaedic surgery Emergency medicine Diagnostic and interventional radiology General surgery Occupational medicine Sports medicine Rural hospital medicine Radiation oncology Pathology Otolaryngology Unknown 3% 2% 2% 2% 2% 2% 2% 2% 2% 1 9% 8% 8% 6% 43% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Figure 8 When looking only at those respondents registered in a vocational scope of practice: 43% held a vocational scope of general practice 1 in internal medicine 9% psychiatry 8% in both anaesthesia and orthopaedic surgery. 13

Proportion of respondents by area of medicine practised -registered in a general scope of practice General medical & surgical runs Internal medicine General practice Anaesthesia Emergency medicine Unknown Paediatrics Orthopaedic surgery Obstetrics & gynaecology Intensive care medicine Psychiatry Urology Paediatric surgery Cardiothoracic surgery Occupational medicine Pathology Radiation oncology Diagnostic & interventional radiology 3% 2% 2% 2% 2% 9% 8% 8% 8% 7% 18% 23% 0% 5% 10% 15% 20% 25% Figure 9 Of those respondents registered in a general scope of practice: 23% worked in general medical and surgical runs 18% in internal medicine 9% in general practice 8% in each of anaesthesia, emergency medicine and unknown or unlisted specialties. 14

Question five: Why are you leaving New Zealand? 180 of the 182 respondents provided a reason for leaving New Zealand. Most respondents identified multiple reasons. The most common reasons identified were: undertaking further training increased remuneration family reasons improved working conditions locum opportunities. When broken down by scope of practice, the data reflects that doctors registered in different scopes of practice leave for different reasons. Doctors on general scope were more likely to identify further training as a reason for leaving New Zealand compared to doctors on a vocational scope (approximately 40% of doctors on a general scope compared to 26% of doctors on a vocational scope). Doctors on a vocational scope tended to respond to the question citing increased remuneration and further training as their reasons for leaving New Zealand whereas for doctors on a general scope, the most common reason mentioned was clearly further training. 15

Question six: How long are you intending to be away from New Zealand? Proportion of respondents by length of time they intend to be away from New Zealand 35% 30% 27% 29% 27% 25% 20% 15% 10% 9% 9% 5% 0% Figure 10 Less than 1 year Between 1 and 3 years Longer than 3 years Permanently Don't know 29% of respondents indicated that they intend to be away from New Zealand from between 1 and 3 years. 27% intend to be away from New Zealand for less than 1 year; and 27% don t know how long it will be before they return. Almost 1 in 10 doctors intend to leave New Zealand permanently (9%) with the same proportion (9%) advising they intend to stay away for longer than 3 years. 16

40% 35% 30% 25% 20% 15% 10% 5% 0% Length of time respondent intends to be away from New Zealand by scope of practice 20% 32% 27% 34% 27% 10% 10% 9% 5% 25% 32% 16% 0% 2 General Vocational Provisional general 32% Less than 1 year Between 1 and 3 years Longer than 3 years Permanently Don't know Figure 11 When broken down by scope of practice, the data indicated that: Doctors on a provisional general scope either intend to be away from New Zealand for less than a year or have no intention to return. Doctors on a vocational scope were more likely to intend to return to New Zealand within a year than those doctors on a general scope (34 percent for vocational compared with 20 percent for general). Even when the Less than 1 year and Between 1 and 3 years categories are combined, doctors on a vocational scope are most likely to intend to return to New Zealand within 3 years (61 percent for vocational scope compared to 52 percent for general scope). 17

Question seven: What country will you be practising medicine in? What country will you be practising medicine in? Australia United Kingdom Canada United States of America Ireland Papua New Guinea PNG Zambia Unknown Singapore Sri Lanka South Africa Qatar Netherlands Malawi Malasyia Hong Kong Germany France 5% 3% 2% 2% 19% 6 0% 10% 20% 30% 40% 50% 60% 70% Figure 12 The survey identified that most doctors leaving New Zealand were intending to practice in Australia, with the United Kingdom as the second most popular destination. 18

Destination country by scope of practice 80% 75% 70% 60% 63% 50% 40% 30% 20% 10% 0% 42% 32% 22% 16% 13% 9% 1 6% 3% 5% 5% 0% 0% General Vocational Provisional General Australia United Kingdom Canada Other United States of America Figure 13 When destination country is broken down by scope of practice, the data indicates that: 75% of doctors on a vocational scope are going to Australia compared with 63% of doctors on a general scope and just 32% of doctors on a provisional general scope. The largest group of doctors on a provisional general scope were going to the United Kingdom (42%) compared with 22% of doctors on a general scope and only 6% of doctors on a vocational scope. 19

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% Destination country by country of primary medical qualification 89% 70% 50% 38% 20% 9% 1 13% 0% 0% 0% 0% 0% 0% Australia New Zealand South Africa United Kingdom Country of primary medical qualification Australia South Africa United Kingdom Other Figure 14 When destination country is analysed by country of primary medical qualification, the data shows that: All Australian graduates are returning to Australia and are joined by almost 90% of South African graduates and 70% of New Zealand graduates. By comparison, only 38% of United Kingdom graduates are going to Australia with the largest group of United Kingdom graduates (50%) returning to the United Kingdom. No South African graduates were returning to South Africa. 20

Question eight: Do you have a job to go to? 90% 80% 70% Proportion of respondents with arranged employment by scope of practice 78% 73% 78% 60% 50% 40% 30% 20% 22% 27% 22% 10% 0% General Vocational Provisional general Employment No employment Figure 15 78% of respondents reported that they have employment to go to when leaving New Zealand. This trend is unchanged when the data is analysed by scope of practice. 21

Question nine: What would encourage you to stay/return to practise in New Zealand? For the large majority of respondents who had gained their PMQ in New Zealand, the offer of a higher salary in the New Zealand job market was provided as a reason that would encourage them to return home. A further common recurring theme provided by the respondents was the desire for student loan write off or repayment assistance, indicating that some doctors are driven to seek overseas work to help repay their debts gained by studying. The desire for better working conditions came up frequently in the responses of New Zealand and Australian medical graduates. A number commented on the amount of time spent dealing with paperwork outweighed the perceived balance with clinical time. There was also a clear disenchantment with the DHB management and primary healthcare system by some of these doctors however exact details of their issues were not shared. In comparison, doctors who gained primary medical qualifications overseas indicated that if they were to return to New Zealand it would be for the opportunity of a job offer. Many noted that they enjoyed their time in New Zealand and expressed the desire to return in the future, however for many, the issue of their families being located so far away was the driver for their departure. 22

Question ten: Is there anything else you would like Council to know? (e.g. general comments, ideas for improvements etc) Doctors with a primary medical qualification gained overseas generally commented positively on their time in New Zealand, with some expressing their desire to return. Some made note of the positive dealings that they have had with Council, expressing their appreciation of a helpful organisation with simple processes. In comparison, New Zealand graduated doctors tended to use this question as a forum for commenting on issues they had which were outside of the Council s control. Of note, this was particularly focused around the issue of low salary rates or working conditions in DHBs. In terms of issues that doctors highlighted which were in Council s jurisdiction, these tended to be based on their own particular experiences of dealings with Council (in relation to restrictions on obtaining particular registration), others indicated their frustrations of not getting the types of registration they wanted for reasons based on their country of qualification. It is worth noting that of the 182 respondents, only 88 doctors chose to make comments in this section of the survey and of this group, 19 responses were to answer no or don t know to the question. 23

Discussion Introducing the sample population According to the results of Council s 2010 New Zealand workforce survey, 58.9 percent of doctors in the New Zealand medical workforce of 2010 4 gained their PMQ in New Zealand. In contrast only 48 percent of the sample population of this survey was attributed to this same group. Proportionally, there are fewer doctors who gained their PMQ in New Zealand leaving compared to those who gained their PMQ overseas. Almost two thirds (61 percent) of the doctors who had been practicing in New Zealand had been doing so for over 3 years. Based on comments made in response to the qualitative questions, a number of these doctors had been practicing for over 20 years. Comments indicated that these were not just New Zealand graduates. Doctor A (PMQ gained in the Netherlands): I have worked all my life as a doctor in New Zealand (since 1975) and am most likely to return here Of the respondents, 94 percent of doctors in a vocational scope of practice had been practicing in New Zealand for over 3 years. In contrast, more general scope doctors left New Zealand earlier, with 44 percent leaving after 1-3 years. Provisional general scope doctors tended to leave New Zealand within a year of arriving, however 60 percent of provisional vocational scope doctors left after 3 or more years. None left within a year of arriving. Doctors on a provisional general scope either intend to spend time away from New Zealand for less than a year or have no intention to return. This reflects that provisional general registration is used for two very different purposes: firstly by doctors who come to New Zealand to work for a short period of time and secondly; as a pathway to full registration. The largest group of doctors on a provisional general scope were going to the United Kingdom (42 percent) compared with 22 percent of doctors on a general scope and only six percent of doctors on a vocational scope. This will in part be because a large number of doctors come to New Zealand from the United Kingdom as it is both a competent authority and a comparable health system under Council policy allowing for a fast registration process. Doctors working in general practice featured as the largest group in terms of specialties leaving New Zealand to work overseas, followed closely by doctors in general medical and surgical runs or internal medicine. This also correlates to the findings of the 2010 New Zealand workforce survey 5 in terms of doctors in each specialty within New Zealand. Of the doctors who had gained their PMQ in a country other than New Zealand (95 in total), 54 percent had been practising in New Zealand for over 3 years. 21 and 25 percent had practised for less than a 4 Medical Council of New Zealand. The New Zealand Medical Workforce in 2010. P1 5 Medical Council of New Zealand. The New Zealand Medical Workforce in 2010. P7 24

year and between 1 and 3 years respectively. Many of those leaving were due to family reasons, the wish to further their training or simply expressed a desire to return home. Doctor s reasons for leaving New Zealand The survey indicated numerous factors for leaving, with a large number of the respondents giving mention of more than one reason for their decision to leave New Zealand. Given the qualitative nature of the question, it was difficult to gain statistical data, however the general themes of the responses and their weighting in terms of times mentioned can be represented in figure 16 below. Training and work experience Higher income Family reasons Better work conditions Intend to do locum roles Figure 16. Main drivers for leaving Training and work experience opportunities The most common reason for doctors leaving New Zealand is to seek further training opportunities, especially with regard to gaining fellowship or further experience: Doctor B: To obtain overseas working experience. Doctor C: to have more overseas experience and exposure temporarily. The data showed a trend of doctors with overseas PMQs returning to the country where they gained their qualification to undertake further training. This was, as indicated by some, because it would be too expensive to complete in New Zealand due to their status as an international student for Universities and training providers. Others weree leaving as their time in New Zealand for Fellowship training had come to an end. Doctor D: I returned to England to do an MSc in Sports and Exercise Medicine as this would be too expensive for me to do in NZ. Also, I was not able to [apply] for GP training as I was not a NZ resident and thus further prompted a return to England where it will be easier for me to achieve a place on a GP training scheme.. An overwhelming number of New Zealand medical graduates leaving for overseas indicated that they wished to go in order to seek further training, in particular for Fellowship training. Further investigation may be warranted to compare the numbers of doctors going overseas for Fellowship training to those coming to New Zealand for their Fellowship training. It was also noted by some respondents that some 25

vocational training programmes in New Zealand have highly competitive entry criteria and causing them at times to seek overseas training opportunities. Doctor E: To go on fellowship training in Canada Many mentioned the desire to gain overseas experience coupled with the opportunity to travel. Two thirds responded that they intended to be away from New Zealand for up to 3 years. 70 percent of New Zealand graduates leaving had been practising in New Zealand for over 3 years. It needs to be considered that an overseas experience is a tradition for young New Zealanders, generally after university graduation, and therefore an undetermined proportion of respondents could be classed in this category with every intention of returning and cited no particular issues with the New Zealand healthcare system as drivers to them leaving. Seeking higher incomes In terms of remuneration, many doctors felt that they could earn more in overseas countries, with Australia being the most commonly mentioned. Anecdotally, one doctor noted: Money is the reason, I can earn up to three times my salary here if I work as a cardiologist. Many responses coupled a better lifestyle with better money, indicating that in addition to seeking better financial reward, they sought a better overall lifestyle for themselves and for their family. Other New Zealand graduates indicated that better financial reward overseas offered the opportunity for student loans to be paid off. This is an issue for the Government to address, but it is noted that this issue may be shared by other New Zealand university graduates; although costs of medical education tend to be greater therefore student loans are higher. The issue of seeking a higher income was common amongst respondents; however this is an issue which is unlikely to be addressed in the current New Zealand healthcare system with a pressure on resourcing. Focus instead should be around identifying what factors encourage doctors to stay in New Zealand for reasons other than income and work to ensure that these outweigh the financial incentive to go elsewhere. Family reasons As would be expected, the consequence of working in New Zealand for many doctors with a PMQ gained overseas was that many had family living a significant distance from them. For some, the option of moving family with them is possible, but for many their family remains overseas and there may be a need to return for various reasons (such as caring for an elderly parent). A number of New Zealand medical gradates indicated the reason for the move was due to their partners/spouses gaining work overseas (predominantly Australia). 26

Better working conditions Mention was made particularly by New Zealand graduates that they were leaving due to discontent with working conditions. In particular, factors such as lack of appreciation, bureaucracy and concern around the introduction of the Multi Employer Collective Agreement. An issue commented on in other forums 6 came up in some of the responses, which was that highly sought after emergency medicine runs are hard to come by. This appears to be due to emergency medicine runs being offered by DHBs to UK doctors as an incentive to come and work in New Zealand. Doctor F: to complete ED training in retrieval job and 3 months as ED consultant in Australia to increase experience. Doctor G: To get contiguous runs in ED (not able to get in Auckland) Get the rotations I am after (e.g. ED, ICU). Locum tenen positions A large number of doctors responding to the survey were in fact applying for a CGS so that they could go to Australia to complete locum work (in the short-term) which was considered more lucrative, and all members of this group of respondents intended to return to New Zealand. Intention to return Whilst further investigation would be required to compare with actual figures on doctors coming in to New Zealand to work, it is worth noting that 5 in 10 general scope doctors intended to return within 3 years, with a further 3 in 10 indicating don t know. In contrast 6 in 10 vocationally registered doctors planned to return within 3 years and 2.5 in 10 saying don t know. Doctors with a vocational scope of practice tended to indicate that they would be overseas for up to 3 years, with few opting for longer or permanent absence from the New Zealand health system. When matched to the responses in question five, this could indicate that they choose to go overseas for training or short term financial reward, with the intention of returning to New Zealand. Those in provisional general scope of practice tended to either be doctors who had gained their PMQ in New Zealand and were going overseas for training or remuneration purposes, intending to return within 3 years. Others were IMGs returning home (predominantly to the United Kingdom) either permanent or they were unsure as to whether they would return. 6 Consultation for the review of prevocational training for doctors in New Zealand. 27

Profile of the departing doctor From the data collected, it is clear that there are three main groups represented in this survey. These are profiled below. The New Zealand Graduate The New Zealand graduate gained their PMQ in New Zealand. They generally intend to return to New Zealand within 3 years. Their reasons for leaving are primarily to gain further training, earn higher salaries and to get overseas experience. Some have partners who have found work overseas and see this as an opportunity for their own careers. Some have found issue with health system management and look to find better working conditions overseas. Following my partner, as his job contract puts him in Australia for at least the next 2 years. It will also work out well for gaining some experience that I couldn t get in New Zealand. We are planning on coming back after 2-3 years. Better pay rates so I can pay off my student loan quicker. Gain experience of a different medical system. Better training, research and career opportunities. [I would come back if] conditions of employment improves dramatically and the level of appreciation. The doctor with a PMQ gained overseas The doctor who gained their PMQ is by and large sad to leave New Zealand as they had a good experience. However, they generally feel that they would like to receive further training overseas or return to be closer to their families. They would like to return to live and work in New Zealand should their circumstances allow although some frustrations with the registration system occur. Missing family and friends. Fiancé unable to find employment in New Zealand. Because my fiancé and family are back home in England. I would stay if the UK recognised the FRACP. I would return sooner if NZ recognised the MRCP. Getting married in the UK and offered a training programme for GP there. [I m going] to complete my specialist training in psychiatry at home in the UK. I love New Zealand but, being British, it s a long way from my family and I miss the easy accessibility of living in Europe. 28

The doctor seeking overseas locum work These doctors wish to remain in New Zealand but feel that they can gain better remuneration or experience by locuming in Australia. This may be only a very short term excursion or a more frequent commute. Family overseas can quite often be a factor in the choice to spend time in Australia. Locum overseas Returning to do locums periodically in New Zealand. Planning to have short locums in Australia; 3 to 4 weeks at a time. 1. For a change/new experience. 2. Earn more money. 3. To enable me to pursue interests outside medicine (paragliding). Intend to complete training in NZ. Australia has better locum rates and more opportunities. I am not leaving New Zealand, I will be living in New Zealand, but thinking of doing locum work in Australia to earn money and get to spend some time with my son who lives in Australia. Figure 17 29

Conclusions and recommendations This report finds that there is no single factor or particular issue that causes concern in relation to the movements of doctors from New Zealand overseas. There are some issues highlighted that could be addressed by the Council, HWNZ and employers (suggestions are identified below). However, there are a number of factors for doctors leaving which are beyond the control of these organisations and are to be expected to arise when a doctor is working in a country from which they do not originate. These factors revolve around family and a desire or need to be nearer to them. Most New Zealand qualified doctors indicated that they intended to return following overseas training experience, quite often this was for Fellowship training. Without further investigation it is hard to determine whether this is reflected in actual migration statistics, but it is positive in that they do not leave New Zealand with no plans to return. The results from the survey demonstrate potential benefits from doctors spending time overseas. For example, working in a setting with a higher population, budget and technological advances will expose a doctor to new skills and knowledge that could be brought back and potentially improve the New Zealand healthcare system in the future. Many doctors who had obtained their PMQ overseas noted that they had to return to their country of PMQ in order to receive training in their specialist field. This saw a number of doctors leaving not through want, but through necessity as recognition of prior learning did not occur in New Zealand. Mention of a desire for a higher income appeared frequently in responses. This factor, whilst frequently mentioned, does not have any real solutions. Therefore focus must be given toward ensuring other factors outweigh this and encourage retention in New Zealand. For some doctors who had gained their PMQ overseas, a key reason for returning was to be closer to their family, another factor that is somewhat beyond the control of MCNZ or other organisations. Family reasons were also cited by some doctors who were leaving the country because their spouse had gained employment overseas. Better work conditions were mentioned by some doctors as a reason for leaving New Zealand. They expressed dissatisfaction with the current system and this was impinging on the way they carried out their job. A proportion of doctors indicated that they did not intend to leave New Zealand at all and had applied for a CGS so that they could carry out short term locum roles in Australia either for extra money or for opportunities to experience other healthcare systems. This does not pose any immediate problems, and further research may indicate that doctors from Australia are taking locum positions in New Zealand. 30

How can the New Zealand healthcare system retain doctors? Offering comparable salaries to those available in Australia and other countries is not an option that is available, this therefore requires creative solutions to identify what other factors would encourage doctors to want to live and work in New Zealand that would outweigh the income level in other countries. Whilst for some doctors, the ability to migrate their families to New Zealand is not always an option, moves to ensure that those who can are provided with all the support required to ensure a successful transition into New Zealand for the families as well as the doctors. Issues of unfavourable working conditions need to be addressed by employers and DHBs and reviewed if necessary to address issues such as those mentioned in doctor s responses. The findings of this report alone should not dictate the future direction of workplace conditions. 31

Acknowledgements The Medical Council of New Zealand would like to thank the doctors who completed the online survey. This report was prepared by Laura Lumley with assistance from Andrew Cullen and Joan Crawford who helped check the data and peer review the report. 32

Responses to open questions Question 5: Why are you leaving New Zealand? 1 To support my wife and gain overseas experience. 2 Intend further post graduate study. Need change in career direction. 3 Better pay in Australia. 4 Earthquakes. 5 End of Fellowship 6 Family and relationship reasons. 7 Short term locum work. 8 Husband's job and greater availability of part time positions in Australia. 9 Am tired of rural practice and the on call and looking for a different challenge. 10 To complete my specialist training in psychiatry at home in the UK. I love New Zealand but, being British, it s a long way from my family and I miss the easy accessibility of living in Europe. 11 DHB attitudes, pay, and conditions. 12 To pursue further training abroad. 13 Sabbatical. 14 After 24 years-have had an offer to teach for 1 year in WA - time for a change in life. 15 5 year contract, overseas experience, substantial income improvement, access to improve my skills in skin cancer medicine. 16 I returned to England to do an MSc in Sports and Exercise Medicine as this would be too expensive for me to do in NZ. Also, I was not able to for GP training as I was not a NZ resident and thus further prompted a return to England where it will be easier for me to achieve a place on a GP training scheme. NZ is a wonderful place to work and has a fantastic healthcare system, if there was more flexibility with GP applications I would have likely stayed. 17 Not leaving as yet. Just renewing my practising rights in Australia so that I can return home to do a sabbatical. 18 My wife wants to be in warmer weather, too cold in Porirua. She doesn't like the mould on our clothes and walls and the windy Wellington weather. It is not the money that is sending us to Oz. 19 Back home to Australia + pay discrepancy + employment opportunities + weather is better. 20 Training. 21 Travel, OE. Before returning for specialist training. Not sure for how long but certainly less than three years, maybe only 9 months. 33

22 Family reasons. 23 Money and lifestyle. 24 Training opportunities. 25 Opportunity for new adventure and to make money. 26 Travel. Visit family. 27 It s not home for me. 28 Relationship. Further post-graduate study. 29 More money in Australia. 30 Job ended and visa expired. 31 Was only locuming there short-term. 32 End fellowship. 33 Temporary locum work. 34 Leaving NZ to do voluntary work in Zambia (under supervision of other doctors) for 11 weeks. 35 Short working holiday. 36 Two reasons: my partner has a work opportunity overseas. I saw this as a good opportunity to have work experience overseas. 37 Fellowship. 38 Did not get general registration. 39 Because I am not allowed to work here more than 2 years. 40 Following my partner, as his job contract puts him in Australia for at least the next 2 years. It will also work out well for gaining some experience that I wouldn't get in NZ. We are planning on coming back after 2-3 years. 41 Advanced training Fellowship position in Melbourne. 42 Fellowship. 43 Poor management and clinical leadership in my dept over many years. Burnout. 44 For better training in Australia. 45 Better pay for Jobs in Australia, as well as current uncertainties with MECA likely to cause upheaval. 46 To complete registrar training in UK and gain consultant status. 47 Fellowship. 48 To have more overseas experience and exposure temporarily. 49 Fellowship training and lack of consultant positions available in public. 50 Fellowship. 51 I am returning to the US due to better opportunities and conditions to practice my specialty. 52 Simply to do a sabbatical in Australia. 34

53 1. Partner s job 2. better pay 3. more input in how clinical service is delivered in the new position with less interference from management 4. more potential to be creative in how I work. 54 Family in UK. 55 To difficult and restrictive medical registration situation in New Zealand. This makes it very difficult for me to function here (at a reasonable level compared to my experience) and almost impossible to have any real advancement in skill/training. 56 I am not leaving New Zealand. I just want to get a reciprocal Fellowship in Australia as per our RNZCGP agreement with RACGP. 57 Training opportunities. 58 Fellowship training. 59 Returning to live in the UK. 60 Poor pay & don't feel valued by DHB. 61 I'm not. 62 Better work and lifestyle opportunities. 63 Consultant job in UK. 64 Earn more money. 65 Going to Australia for 3 weeks break to work in Aboriginal health. Just taking a break from my practice for a few weeks. 66 I work as a locum. 67 Personal reasons - partner s job. 68 Going to do fellowship training post. 69 I'm not leaving NZ yet, just going over to Australia for some locum work. Experience and better pay. We are planning to return to Sweden in about 1.5 years for family reasons. 70 Family, challenge, opportunity, remuneration. 71 I am not leaving, only doing 2 week locum in Australia. 72 To complete ED training in retrieval job and 3 months as ED consultant in Australia to increase experience. 73 To do training and working prospects in a clinic. 74 For a change and for husband's interests. 75 Better money. 76 Part leave to locum prior to returning. 77 Higher academic education. 78 Escape work place bullying. 79 Different experience. 80 Returning to work in US. 81 Family circumstances. 82 SET training scheme sending me to Australia. 83 Travel opportunities, earning capacity overseas, improved work conditions overseas. 35

84 Financial benefits. 85 To go home. 86 Multiple factors: biggest is the lack of sense of being appreciated as a health professional workforce. In both individual level and collective national level. 87 Have been offered good opportunity in Western Australia where I have previously lived and practiced. 88 Fellowship. 89 Further subspecialty Fellowship training. 90 To experience a different lifestyle and for different work experience. 91 Training in Australia. 92 Wife is from Oz, better remuneration & climate. 93 Better pay rates so I can pay off my student loan quicker. Gain experience of a different medical system. 94 Resigned from DHB frustrated with poor management. Now looking for locum work in Australia which pays better than locus work here. 95 Completion of Fellowship. 96 Because my fiancé and my family are back home in England. 97 To join my partner who is based overseas. 98 To get experience of tropical medicine. 99 Husband's work. 100 Fellowship. 101 Better training, research and career opportunities. 102 Not leaving, just going to be doing loca. Money is the reason, I can earn up to three times my salary here if I work in Australia as a cardiologist. I love my job, the people - everything. I lost everything when I left (Zimbabwe) 10 years ago, and although I appreciate I am paid a good wage by local standards, the salaries offered over there are a lot more especially in my specialty. 103 Financially bonded to Fiji govt. 104 To get contiguous runs in ED (not able to get in Auckland). Higher remuneration. 105 Husband has a job overseas. 106 Partner is doing research in Melbourne for a year. 107 Requirement of vocational training with RACP. 108 To continue training. 109 Unable to get into the training program. 110 I am not. 111 Cannot obtain a consultant position. 112 For locum work. 113 Short term employment Australia. 114 To return to training in UK. 115 Pay discrepancy. 116 To broaden the experience in my field, adventure and earn more money to pay of my bond. 36

117 Health. 118 Going to go to Canada, Vancouver to be with family - working for a year. 119 Planning to have short locums in Australia; 3 to 4 weeks at a time. 1. for a change/new experience 2. earn more money (this not the primary reason) 3. to enable me to pursue interests outside medicine (paragliding). 120 To do my 3rd year advance training in gastroenterology. Unable to get 3rd year position in Auckland in the beginning of the training year. Offered a post in Australia despite late application. Hoping to finish training and get back to NZ. 121 To earn some decent money as a locum so that I can buy my first house. 122 Now 61yrs and family presently in Australia. 123 Have left my practice and away as a stopgap. 124 Sabbatical. 125 To work in Australia. 126 To obtain overseas working experience. 127 Family. 128 Need a break. Sick off endless bureaucracy which seems to have no point but to satisfy auditors which change every time a rest home, practice is audited. 129 Overseas experience. 130 Family and money. 131 Because the district health board is totally bereft of direction, the Ministry is run by a cult of the individual and no amount of money is going to fix the mess. 132 To go on fellowship training in Canada. 133 Volunteer service abroad. 134 For a short-term assignment with VSA. 135 Locum work for more money. 136 Lifestyle and money. 137 For further training in cardiology as part of my Fellowship. 138 To gain further experience before returning to the UK. 139 Residence is in Canada. 140 Going to complete training in UK. 141 More money. 142 Personal reasons. 143 For fellowship. 144 Only to train for one year which is part of the Royal Australasian College of Surgeons training programme. 145 Work in Canada. 146 Returning home from year out. 147 For overseas training, in larger emergency departments. For travel and pleasure reasons. 148 Going back home. 37

149 Time to move home. 150 Getting married in the UK and offered a training programme for GP there. 151 Returning home to Canada. I was only working in NZ for 6 months as a working holiday. We may come back in the future to do the same thing. 152 I am not leaving New Zealand. 153 Money and experience. 154 To locum overseas. 155 Overseas experience pre vocational training in NZ. 156 Post-graduate fellowship training in orthopaedic oncology. 157 Missing family and friends. Fiancé unable to find employment in New Zealand. 158 To go home. 159 Planned half year was up, planning on returning. 160 To finish my sub-specialty training. 161 Better working conditions and higher salary. Overseas experience. 162 Locum overseas. 163 Training. 164 To pursue specialist training in the UK and to return closer to family. 165 To be closer with family. 166 To gain research experience in a laboratory in the UK. 167 To do brief locums in the US. This is not a permanent move. 168 Holiday and work. 169 Partner from overseas / new experience. 170 To work as a missionary in West Africa. 171 I'm not leaving, but will be working in Australia as well as in New Zealand. 172 Pursue research opportunities overseas. 173 Unable to make any financial progress in NZ - moved to Australia for better remuneration and conditions. 174 Medical aid work. 175 I am not leaving New Zealand, I will be living in New Zealand, but thinking of doing locum work in Australia to earn money and get to spend some time with my son who lives in Australia. 176 Returning to the UK to undertake core medical training. 177 Better financially. 178 My husband has been relocated to Australia for work. 38