High Risk Warning: New Zealand losing its future specialist workforce
Ian Powell - June 2010
For good reason New Zealand prides itself in training a high quality specialist workforce. This is a tribute to both those who train and those who are trained. What we train has been and needs to continue to be the basis of our future specialist workforce in district health boards. Of equal importance to the ability to train well is the ability to retain what we train. But now New Zealand finds itself in high risk territory as increasingly we are training for an international market, particularly neighbouring Australia since the pattern of large collective agreement settlements commenced in 2006, especially in branches of medicine where fiscally attractive private practice options don’t act as a buffer to uncompetitive remuneration.
There are no official statistics kept on the number of specialists emigrating each year. However, an OECD paper conservatively estimates 29% of New Zealand doctors are working overseas, giving New Zealand the second-highest expatriation rate in OECD countries (behind the mighty Luxemburg). A survey by the ASMS found that in the 18 months to July 2007 New Zealand lost at least 80 specialists to Australia alone – the equivalent of a senior medical specialist workforce at a regional hospital.
Push, Push and Pull, and plain straight Pull
There is a range of “push” and “pull” factors that motivates specialists to leave. Key factors identified by delegates at the ASMS Annual Conference 2008 included: “onerous” on-call hours; shortages of resident doctors as well as senior staff (resulting in more work for senior doctors); lack of administrative support; lack of real non-clinical time; adversarial attitudes from management; unstable staffing with high dependence on locums; time for mentoring young doctors; and increasing numbers of staff working part-time putting more pressure on full-timers; as well as remuneration.
“Push” factors have been critical in this westwards trans-Tasman medical migration. But there is also mounting evidence that “pull” factors are also becoming increasingly important in their own right even where “push” factors are non-existent or minimal. One simple salary fact sums it up. It is possible to develop a notional average Australian staff specialist salary scale based on averaging the state scales. The top specialist step (15) in New Zealand is somewhere between Steps 1 and 2 of the notional Australian national scale. This is before considering other benefits such as higher superannuation, salary sacrifice and greater senior registrar support.
In fact the major constraint keeping salaried doctors from migrating to the ‘lucky country’ seems to be family commitments. But while this has been significant for the specialists of today, it is much less relevant for the specialists of tomorrow.
Kiwi registrars morphing into wallaby specialists
An ASMS national survey and telephone interviews with 112 training directors across five major specialties (psychiatry, anaesthesia, surgery, general medicine and intensive care), undertaken at the end of 2009, found that half of New Zealand’s registrars in their final year leave to take up their first specialist positions with overseas employers. The most common reason for leaving, according to the training directors, was for better salaries and conditions.
Better salaries and conditions were cited by respondents twice as many times as “training and experience” as reasons why registrars leave for Australia. Lack of available positions in New Zealand once registrars complete their training was also identified as a major reason for heading across the Tasman.
Similar results were found in an unpublished survey carried out in 2009, following up a 2002 survey of trainees’ career intentions in anaesthesia. The 2009 survey showed that while 80% of the 2002 cohort had intended to eventually work as a specialist in New Zealand, only 64.5% were working in New Zealand seven years later. In 2002, 13% stated Australia as their preferred destination while twice that amount (26%) were working there in 2009.
Significantly, this 2009 survey found that 75% of respondents currently working overseas agreed or strongly agreed that salary was an important influence on choosing their country of residence, whereas respondents working in New Zealand indicated lifestyle and family ties as the main reasons for staying.
The international literature also often points to personal and family factors, as well as the importance of pay and conditions, as common reasons for migration or staying put. Generally, the more independent and career-minded the person, the more open they are to moving. But, as one Canadian study found:
Despite expressions of discontent with involuntary long hours of work, or inadequate social infrastructure, research capacity or social amenities, discussion invariably settles on relative incomes as the chief determinant of migration…
Government and DHBs must face up to the risk
The unprecedented national stopwork meetings and support for industrial action by ASMS members during the last MECA negotiations, which came to a head in 2007, indicates pay and conditions in New Zealand are also key factors in many specialists’ career decisions. Feedback from ASMS members suggests the issue of remuneration is not merely a matter of how much they are paid but also how it impacts on other factors that determine the ability of their DHB to recruit and retain staff, which in turn impacts on the conditions in which they work.
The pay gap has significantly widened since a series of large collective agreement settlements in Australia, beginning with a landmark settlement in Queensland in 2006. These settlements are now being renegotiated in a further round. Already a pattern of salary increases of around 4% per annum is emerging as the recently re-negotiated settlement in Queensland suggests. This further widens the specialist pay gap and further incentivises our registrars to shift to greener pastures increasing the barrenness of our domestic soil.
The question is raised therefore that if the government and DHBs do not face up to this risk of the increasing loss of registrars to specialist positions overseas, an economic analysis might challenge why New Zealand continues to train young doctors. If we can’t retain the future specialists we train there is no return on the considerable investment the country commits to this costly training. It is completely bizarre but such a cost-benefit analysis might logically conclude that we would be better closing down a medical school and instead investing that money in recruiting from overseas. Absurd but logical if the risk continues.
Ian Powell
EXECUTIVE DIRECTOR
