Improving the recruitment and retention of doctorsBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7149.2 (Published 28 June 1998) Cite this as: BMJ 1998;316:S2-7149
- Jane Harvey, medical officer,
- Helen Davison, medical officer,
- Hilary Bichovsky, research assistant
Poor working conditions in the NHS are the main cause of “wastage” of doctors. Jane Harvey, Helen Davison, and Hilary Bichovsky report from the Don't Waste Doctors project.
Don't Waste Doctors is an innovative, Manchester based project set up to respond to the North West region's crisis in the recruitment and retention of doctors: in October 1995, 32% of senior house officer posts in the North West Region remained unfilled after interview. Since it started in 1995, Don't Waste Doctors has had a double remit: to conduct research and to act practically.
Don't Waste Doctors's practical work has centred on establishing new, less than full time (LTFT) posts in the North West region. With money from the task force to meet the requirements of the new deal, Don't Waste Doctors worked in conjunction with Manchester and Merseyside postgraduate departments and local NHS trusts to create nine new pilot LTFT training posts. These differ from traditional flexible training posts in that they are substantive not supernumerary. This means that funding and educational approval are attached to the post rather than the trainee and that they are available through open competition at trust level. There were bids from 15 NHS trusts for 24 posts, and funding was allocated to the nine posts that combined the greatest new deal needs with a good training environment. It is hoped that these posts will act as an example for other NHS trusts looking at developing more family friendly and flexible working patterns. Some trusts have taken up this idea even without extra funding.
Don't Waste Doctors has also identified a need for retraining posts, particularly for doctors who have not worked for several years. Two retraining posts for junior doctors were set up that provided initial intensive consultant supervision until the doctor had gained sufficient confidence and skills to work in a routine post.
We maintain a database of doctors interested in LTFT posts in the North West region. It currently holds details of 167 doctors (151 women and 16 men) from all specialties and grades. Most are still in training or general practitioners, but 20% are unemployed or working outside medicine. The doctors on the database receive a newsletter and bulletins detailing local LTFT jobs that have been notified to the project.
It was quickly realised that doctors often did not know where to go when looking for career guidance or advice regarding options for working less than full time. Don't Waste Doctors has collected this information and, in conjunction with the local postgraduate departments, directs doctors to appropriate sources of career advice or support. To share the relevant information more widely a newsletter was launched, for which the mailing list was over 300 in May 1998.
It seems that at times of career crisis doctors particularly value access to support from peers. Don't Waste Doctors has provided advice, support, and information to such doctors, and a local general practitioner has provided additional careers guidance. As a result of contact with the project, several doctors who had completely left the NHS have returned either to clinical posts or medically related jobs.
Alongside its practical work, Don't Waste Doctors has been conducting research into a 10 year cohort of medical graduates from the North West region to ascertain wastage rates.
We used the Department of Health's 1994 census to identify doctors in the cohort not in substantive contract with the NHS, which included doctors on the retainer scheme and locums. We sent a questionnaire to the doctors identified by the census as not working for the NHS to obtain answers to the following questions: How many of the doctors were not working for the NHS on 30 September 1994? What were these doctors' occupations? Why did they leave the NHS? What would have stopped them leaving or brought them back to the NHS? Would a greater availability of LTFT posts have reduced their time out of the NHS? When possible, open ended questions that required free text answers were used to allow the doctors to express themselves freely, rather than predetermining their answers.
Of the 10 year cohort of 3,805 graduates, 924 (24%) were identified by the census as not working for the NHS and were sent a questionnaire. Of the 497 respondents (54% response rate) to the questionnaire, 357 (72%) confirmed that they were not working for the NHS. We used the method of the Medical Career Research Group and further information from the 1994 Medical Directory((1)) to find out about non-respondents. We estimate that 18% of the total cohort were not working for the NHS in September 1994.
By September 1996, 99 doctors had returned to the NHS. Of the 258 who were still not working for the NHS, 88 intended to return (more than two thirds of whom were women) and 144 did not intend to return. Just over half the doctors either had returned to the NHS at some point during the study period (1994-6) or intended to return. The doctors who were least likely to intend to return were those who were working in private medicine, in medically related work, in non-medical work, and abroad as doctors. These categories were mainly men. How- ever, 52 of the doctors who had no intention of returning expressed the possibility of changing this decision if conditions were different.
Reasons for leaving
The doctors' reasons for leaving the NHS fell into three broad categories. The commonest was poor working conditions: in particular, long hours and their effects (including exhaustion and needing a break) and disillusionment with the NHS. The second most commonly mentioned category was career and training related issues: doctors said they were looking for new opportunities elsewhere, that there was a lack of adequate career opportunities within the NHS, or that their career goal was outside NHS medicine. The third category was personal reasons, including travel, working abroad permanently, and pregnancy or child care.
Reasons for leaving the NHS
“Long hours, poor representation, unfair responsibilities, little supervision or encouragement that was constructive”
“I felt there was a lack of adequate supervision for junior doctors. I find the Ñsee one, do one, teach one' mentality horrifying”
“Appalling physical environment, poor morale amongst staff”
“The possibility of my wife and I living in different cities to pursue our medical careers”
“To achieve a lifestyle/work life more suitable for raising a family“
What would bring them back?
“Paid retraining programme which would need to include additional training rather than stepping straight into part-time clinical post”
“More interesting part-time work with professional recognition”
“To be able to do recognized retraining on a very part-time basis”
“Tax-relief on child care”
“Recognition of skills and experience obtained outside medicine and open policy/attitudes towards those spending time out”
Effects of long hours
Long hours affected the ability of many doctors to work full time. More than half of the women with children were unable to work full time in medicine, but most of these were able to work part time. Long hours of work also affected the ability to study for exams, with half of the doctors (equal proportions of men and women) admitting to difficulties in studying for postgraduate exams, most for this reason. Despite this, more than half of this group had gained their college membership exams, refuting the idea that this group of doctors are low achievers.
We found no evidence to support the view that women are a more uncertain investment of resources than men. By 1996, 51 (27%) women and 48 (29%) men had returned to the NHS. Of those doctors who were still not working in the NHS in 1996, the women were twice as likely as men to intend to return to the NHS, with half of those who answered saying that they intended to return compared with only 23% of the men.
In general, the men who were not working in the NHS had established alternative careers for themselves. Many of the women, however, were working as general practitioner locums, on the retainer scheme, or not working, and were more likely to retain an interest in substantive NHS posts.
Family friendly working
Part time work in the NHS often involves similar hours to full time work elsewhere, but it is still the best current way to pursue a “family friendly” NHS career. “Part time work suited to family life” and “better hours” were both mentioned as factors that would change a doctor's decision not to work for the NHS. Fifty two of the doctors said that LTFT posts would have prevented them from leaving NHS employment, and 48% of the sample (142 women and 30 men) were interested in a LTFT post, most of them being interested in job sharing. This was despite the fact that knowledge of the availability of flexible training was poor and experience was very limited.
The women were considerably more interested in LTFT posts than men (despite many men mentioning long hours as a reason for leaving the NHS). Men expressed more concern about pay than women and it may be that this made such work unattractive to them. Of the doctors who wanted to work part time, 81 wanted a refresher course before taking up an NHS post.
Of the doctors who were not working in the NHS, 54% were fully trained general practitioners (120 women and 72 men). General practitioners commonly left the NHS because they were unable to find the right general practice partnership or they were reluctant to enter general practice at a young age. It seemed that, overall, general practitioners had a greater commitment to the NHS than other groups of doctors and were more likely to return (59% compared with 44%).
Our research showed high but potentially remediable wastage rates. Reducing working hours and providing more part time or flexible working opportunities would help some doctors to return to the NHS sooner and tempt some to return who would otherwise not do so. NHS trusts could increase their pool of doctors by having more family friendly posts with flexible working patterns to help retain and re-recruit female doctors. There is a need to support doctors throughout their careers, particularly at the recognised vulnerable attrition point - that is, five to seven years after graduation.
There will always be some loss from the NHS to other organisations and related careers. Improving working conditions in the NHS is the best way to minimise this loss.
Key research findings
18% of doctors were not working for the NHS on one date
40% of respondents did not intend to return to the NHS but 15% said they could be tempted back if conditions were different
The most commonly given reason for leaving the NHS was working conditions, especially the hours of work
Better job opportunities, more flexible work and better childcare facilities would speed up doctors' return to the NHS
48% of respondents were interested in less than full time work and 91% of those would consider job-sharing