'Should I stay or should I go now?': A qualitative study of why UK doctors retire.

OBJECTIVES: Health care delivery and education face critical potential shortages in the foreseeable future in terms of retaining doctors nearing the time of retirement - doctors who have experience-based knowledge to pass onto the next generation. Retirement decisions are driven by a combination of macro-related, job and individual factors. This is a constantly shifting space; findings from earlier studies do not always help us understand the retirement decisions of contemporary cohorts of doctors. To address these issues, and identify new knowledge to inform approaches to retaining expertise, we aimed to identify and explore what may keep an older doctor in the workforce ('stay') factors and ('go') factors that might prompt retirement. METHODS: We invited doctors aged 50 years or over from diverse areas of Scotland to participate in qualitative, semi-structured interviews. Initial analysis of interview transcripts was inductive. The embeddedness theory of Mitchell et al encompassing the dimensions of 'link,' 'fit' and 'sacrifice,' was used for subsequent theory-driven analysis. RESULTS: A total of 40 respondents participated. In terms of 'link,' retiring could feel like a loss when work links were positive, whereas the opposite was true when relationships were poor, or peers were retiring. Considering 'fit,' intrinsic job satisfaction was high but respondents had less confidence in their own abilities as they grew older. However, the data foregrounded the inverse of the notion of Mitchell et al's 'sacrifice'; for UK doctors, staying in work can involve sacrifice because of tax penalties, work intensity and arduous demands. CONCLUSIONS: Retirement stay and go factors seem enmeshed in the cultural, social and economic structures of health care organisations and countries. Systems-level interventions that address ultimate causes, such as sufficient staffing, supportive systems, non-punitive taxation regimes and good working conditions are likely to be most effective in encouraging doctors to continue to contribute their knowledge and skills to the benefit of patients and learners.

Today's doctors: What do men and women value in a training post?

OBJECTIVES: Recent studies suggest that traditional male-female differences may be changing in terms of what is valued in a medical career but there have been no studies directly quantifying the relationship between gender and stated career-related preferences. To address this gap, we examined the differences between male and female doctors in terms of the strength of their work-related preferences at the point of eligibility to enter residency or specialty training in the UK. METHODS: This was a quantitative study using a survey incorporating a discrete choice experiment (DCE). Respondents were asked a series of questions in which they had to choose between two or more scenarios, differing in terms of attributes. The attributes were: location; familiarity with specialty; culture of the working and learning environment; earnings; working conditions, and opportunities for professional development. The main outcome measure was willingness to accept compensation to forgo a desirable attribute within a training position. Conditional logistic regression models were run separately for males and females. RESULTS: A total of 5005 out of 6890 (73%) Foundation Year 2 doctors completed the DCE. The relative value of each attribute was similar for males and females, with location most valued and familiarity with the specialty least valued. There was a pattern of female respondents valuing the move between the best and worst levels of each training attribute more than men, and significantly more than men in respect of the importance of working culture. CONCLUSIONS: This study adds to existing knowledge in terms of quantifying gendered values in respect of training or residency preferences. That men value a supportive working culture significantly less than women is well established. However, our findings that location, working conditions and working culture are increasingly important to both men and women, suggests that traditional gender norms may be changing. This intelligence can inform gender-responsive workforce planning and innovation, and future research.

What can discrete choice experiments do for you?

CONTEXT: In everyday life, the choices we make are influenced by our preferences for the alternatives available to us. The same is true when choosing medical education, training and jobs. More often than not, those alternatives comprise multiple attributes and our ultimate choice will be guided by the value we place on each attribute relative to the others. In education, for example, choice of university is likely to be influenced by preferences for institutional reputation, location, cost and course content; but which of these attributes is the most influential? An understanding of what is valued by applicants, students, trainees and colleagues is of increasing importance in the higher education and medical job marketplaces because it will help us to develop options that meet their needs and preferences. METHODS: In this article, we describe the discrete choice experiment (DCE), a survey method borrowed from economics that allows us to quantify the values respondents place on the attributes of goods and services, and to explore whether and to what extent they are willing to trade less of one attribute for more of another. CONCLUSIONS: To date, DCEs have been used to look at medical workforce issues but relatively little in the field of medical education. However, many outstanding questions within medical education could be usefully addressed using DCEs. A better understanding of which attributes have most influence on, for example, staff or student satisfaction, choice of university and choice of career, and the extent to which stakeholders are prepared to trade one attribute against another is required. Such knowledge will allow us to tailor the way medical education is provided to better meet the needs of key stakeholders within the available resources.

What do UK medical students value most in their careers? A discrete choice experiment.

CONTEXT: Many individual- and job-related factors are known to influence medical careers decision making. Previous research has extensively studied medical trainees' (residents') and students' views of the factors that are important. However, how trainees and students trade off these factors at times of important careers-related decision making is under-researched. Information about trade-offs is crucial to the development of effective policies to enhance the recruitment and retention of junior doctors. OBJECTIVES: Our aim was to investigate the strength of UK medical students' preferences for the characteristics of training posts in terms of monetary value. METHODS: We distributed a paper questionnaire that included a discrete choice experiment (DCE) to final-year medical students in six diverse medical schools across the UK. The main outcome measure was the monetary value of training post characteristics, based on willingness to forgo and willingness to accept extra income for a change in each job characteristic calculated from regression coefficients. RESULTS: A total of 810 medical students answered the questionnaire. The presence of good working conditions was by far the most influential characteristic of a training position. Medical students consider that, as newly graduated doctors, they will require compensation of an additional 43.68% above average earnings to move from a post with excellent working conditions to one with poor working conditions. Female students value excellent working conditions more highly than male students, whereas older medical students value them less highly than younger students. CONCLUSIONS: Students on the point of completing medical school and starting postgraduate training value good working conditions significantly more than they value desirable geographical location, unit reputation, familiarity with the unit or opportunities for partners or spouses. This intelligence can be used to address the crisis in workforce staffing that has developed in the UK and opens up fruitful areas for future research across contexts and in terms of examining stated preferences versus actual career-related behaviour.

What do UK doctors in training value in a post? A discrete choice experiment.

CONTEXT: Many individual and job-related factors are known to influence medical careers decision making. Medical trainees' (residents) views of which characteristics of a training post are important to them have been extensively studied but how they trade-off these characteristics is under-researched. Such information is crucial for the development of effective policies to enhance recruitment and retention. Our aim was to investigate the strength of UK foundation doctors' and trainees' preferences for training post characteristics in terms of monetary value. METHODS: We used an online questionnaire study incorporating a discrete choice experiment (DCE), distributed to foundation programme doctors and doctors in training across all specialty groups within three UK regions, in August-October 2013. The main outcome measures were monetary values for training-post characteristics, based on willingness to forgo and willingness to accept extra income for a change in each job characteristic, calculated from regression coefficients. RESULTS: The questionnaire was answered by 1323 trainees. Good working conditions were the most influential characteristics of a training position. Trainee doctors would need to be compensated by an additional 49.8% above the average earnings within their specialty to move from a post with good working conditions to one with poor working conditions. A training post with limited rather than good opportunities for one's spouse or partner would require compensation of 38.4% above the average earnings within their specialty. Trainees would require compensation of 30.8% above the average earnings within their specialty to move from a desirable to a less desirable locality. These preferences varied only to a limited extent according to individual characteristics. DISCUSSION: Trainees place most value on good working conditions, good opportunities for their partners and desirable geographical location when making career-related decisions. This intelligence can be used to develop alternative models of workforce planning or to develop information about job opportunities that address trainees' values.

Rurality, healthcare and crises: Investigating experiences, differences, and changes to medical care for people living in rural areas.

Healthcare provision in rural areas is a global challenge, characterised by a dispersed patient population, difficulties in the recruitment and retention of healthcare professionals and a physical distance from hospital care. This research brings together both public and doctor perspectives to explore the experience of healthcare across rural Scotland, against the backdrop of contemporary crises, including a global pandemic and extreme weather events. We draw on two studies on rural healthcare provision to understand how healthcare services have been experienced, changed and might move on after periods of short- and longer-term change caused by such crises. We highlight the importance of communicating service changes to aid in setting healthcare expectations and advocate a mixed approach to the introduction of digital solutions to best balance access to services in rural areas with the challenges of digital connectivity and literacy.

Won't you stay just a little bit longer? A discrete choice experiment of UK doctors' preferences for delaying retirement.

INTRODUCTION AND AIMS: Health systems around the world face difficulties retaining their workforce, which is exacerbated by the early retirement of experienced clinicians. This study aims to determine how to incentivise doctors to delay their retirement. METHODS: We used a discrete choice experiment to estimate the relative importance of job characteristics in doctors' willingness to delay retirement, and the number of extra years they were willing to delay retirement when job characteristics improved. 2885 British Medical Association members aged between 50 and 70 years, registered with the General Medical Council, practising in Scotland (in December 2019), and who had not started to draw a pension were invited. We compared the preferences of hospital doctors (HDs) and general practitioners (GPs). RESULTS: The response rate was 27.4% (n = 788). The number of extra years expected to work was the most important job characteristic for both respondents, followed by work intensity for GPs, whereas working hours and on-call were more important for HDs. Personalised working conditions and pension taxation were the least important characteristics for both groups. Setting all characteristics to their BEST levels, GPs would be willing to delay retirement by 4 years and HDs by 7 years. CONCLUSIONS: Characteristics related to the job rather than pension could have the greatest impact on delaying retirement among clinicians.

Determinants of general practitioners' wages in England.

We analyse the determinants of annual net income and wages (net income/hours) of general practitioners (GPs) using data for 2271 GPs in England recorded during Autumn 2008. The average GP had an annual net income of £97,500 and worked 43 h per week. The mean wage was £51 per h. Net income and wages depended on gender, experience, list size, partnership size, whether or not the GP worked in a dispensing practice, whether they were salaried of self-employed, whether they worked in a practice with a nationally or locally negotiated contract, and the characteristics of the local population (proportion from ethnic minorities, rurality, and income deprivation). The findings have implications for pay discrimination by GP gender and ethnicity, GP preferences for partnership size, incentives for competition for patients, and compensating differentials for local population characteristics. They also shed light on the attractiveness to GPs in England of locally negotiated (personal medical services) versus nationally negotiated (general medical services) contracts.

The role of the staff MFF in distributing NHS funding: taking account of differences in local labour market conditions.

The National Health Service (NHS) in England distributes substantial funds to health-care providers in different geographical areas to pay for the health care required by the populations they serve. The formulae that determine this distribution reflect populations' health needs and local differences in the prices of inputs. Labour is the most important input and area differences in the price of labour are measured by the Staff Market Forces Factor (MFF). This Staff MFF has been the subject of much debate. Though the Staff MFF has operated for almost 30 years this is the first academic paper to evaluate and test the theory and method that underpin the MFF. The theory underpinning the Staff MFF is the General Labour Market method. The analysis reported here reveals empirical support for this theory in the case of nursing staff employed by NHS hospitals, but fails to identify similar support for its application to medical staff. The paper demonstrates the extent of spatial variation in private sector and NHS wages, considers the choice of comparators and spatial geography, incorporates vacancy modelling and illustrates the effect of spatial smoothing.

Analysis of consultants' NHS and private incomes in England in 2003/4.

OBJECTIVE: Consultants employed by the NHS in England are allowed to undertake private practice to supplement their NHS income. Until the introduction of a new contract from October 2003, those employed on full-time contracts were allowed to earn private incomes no greater than 10% of their NHS income. In this paper we investigate the magnitude and determinants of consultants' NHS and private incomes. DESIGN: Quantitative analysis of financial data. SETTING: A unique, anonymized, non-disclosive dataset derived from tax returns for a sample of 24,407 consultants (92.3% of the total) in England for the financial year 2003/4. MAIN OUTCOME METHODS: The conditional mean total, NHS and private incomes earned by age group, type of contract, specialty and region of place of work. RESULTS: The mean annual total, NHS and private incomes across all consultants in 2003/4 were pound 110,773, pound 76,628 and pound 34,144, respectively. Incomes varied by age, type of contract, specialty and region of place of work. The ratio of mean private to NHS income for consultants employed on a full-time contract was 0.26. The mean private income across specialties ranged from pound 5,144 (for paediatric neurology) to pound 142,723 (plastic surgery). There was a positive association between mean private income and NHS waiting lists across specialties. CONCLUSIONS: Consultants employed on full-time contracts on average exceeded the limits on private income stipulated by the 10% rule. Specialty is a more important determinant of income than the region in which the consultant works. Further work is required to explore the association between mean private income and waiting lists.

Vocation, Mental Illness, and the Absenteeism Decision.

OBJECTIVES: We explore sickness absenteeism variations within the public sector and in particular the role of mental illness. Distinctively, the public sector is segmented into vocational and nonvocational sector, assuming that vocation leads to a different degree of job attachment and alter sickness leave decision. METHODS: Using British Household Panel Survey, random-effects logit models are applied to estimate the odds ratio of sickness absence with alternative measures of vocational employment. The association between mental illness and sickness absence is also explored. RESULTS: Absenteeism and the effect of mental illness on absenteeism rates vary within the public sector after controlling for socioeconomic factors. The public vocational sector had the largest sickness absence odds ratios. CONCLUSION: Differences between absenteeism rates across sectors may be more about the nature of the job and less about the nature of the sector.

What factors are critical to attracting NHS foundation doctors into specialty or core training? A discrete choice experiment.

OBJECTIVES: Multiple personal and work-related factors influence medical trainees' career decision-making. The relative value of these diverse factors is under-researched, yet this intelligence is crucially important for informing medical workforce planning and retention and recruitment policies. Our aim was to investigate the relative value of UK doctors' preferences for different training post characteristics during the time period when they either apply for specialty or core training or take time out. METHODS: We developed a discrete choice experiment (DCE) specifically for this population. The DCE was distributed to all Foundation Programme Year 2 (F2) doctors across Scotland as part of the National Career Destination Survey in June 2016. The main outcome measure was the monetary value of training post characteristics, based on willingness to forgo additional potential income and willingness to accept extra income for a change in each job characteristic calculated from regression coefficients. RESULTS: 677/798 F2 doctors provided usable DCE responses. Location was the most influential characteristic of a training position, followed closely by supportive culture and then working conditions. F2 doctors would need to be compensated by an additional 45.75% above potential earnings to move from a post in a desirable location to one in an undesirable location. Doctors who applied for a training post placed less value on supportive culture and excellent working conditions than those who did not apply. Male F2s valued location and a supportive culture less than female F2s. CONCLUSION: This is the first study focusing on the career decision-making of UK doctors at a critical careers decision-making point. Both location and specific job-related attributes are highly valued by F2 doctors when deciding their future. This intelligence can inform workforce policy to focus their efforts in terms of making training posts attractive to this group of doctors to enhance recruitment and retention.

Using discrete choice experiments to estimate a preference-based measure of outcome--an application to social care for older people.

This paper reports the results of a study that used discrete choice experiment (DCE) methodology to estimate quality weights for a of social care outcome measure. To reflect different states of need, a five-dimensional profile measure was developed. Experimental design techniques were used to derive a sample of states for which preferences were elicited. The DCE approach was employed to elicit values and regression techniques used to estimate a model that could predict index scores for all 243 possible outcomes. The utility model, estimated on the basis of 297 responses, had good test-retest reliability and converged with preferences elicited from a rating exercise.

Pay or conditions? The role of workplace characteristics in nurses' labor supply.

Empirically rigorous studies of nursing labor supply have to date relied on extant secondary data and focused almost exclusively on the role of pay. Yet the conditions under which nurses work and the timing and convenience of the hours they work are also important determinants of labor supply. Where there are national pay structures and pay structures are relatively inflexible, as in nursing in European countries, these factors become more important. One of the principal ways in which employers can improve the relative attractiveness of nursing jobs is by changing these other conditions of employment. This study uses new primary data to estimate an extended model of nursing labor supply. It is the first to explore whether and how measures of non-pecuniary workplace characteristics and observed individual (worker) heterogeneity over non-pecuniary job aspects impact estimates of the elasticity of hours with respect to wages. Our results have implications for the future sustainability of an adequately sized nurse workforce and patient care especially at a time when European healthcare systems are confronted with severe financial pressures that have resulted in squeezes in levels of healthcare funding.

GPs' implicit prioritization through clinical choices - evidence from three national health services.

We present results from an extensive discrete choice experiment, which was conducted in three countries (Norway, Scotland, and England) with the aim of disclosing stated prescription behaviour in different decision making contexts and across different cost containment cultures. We show that GPs in all countries respond to information about societal costs, benefits and effectiveness, and that they make trade-offs between them. The UK GPs have higher willingness to accept costs when they can prescribe medicines that are cheaper or more preferred by the patient, while Norwegian GPs tend to have higher willingness to accept costs for attributes regarding effectiveness or the doctors' experience. In general, there is a substantial amount of heterogeneity also within each country. We discuss the results from the DCE in the light of the GPs' two conflicting agency roles and what we know about the incentive structures and cultures in the different countries.

Using discrete choice experiments to go beyond clinical outcomes when evaluating clinical practice.

BACKGROUND: This study builds on the results of a randomized controlled trial concerned with examining the effect of reducing waiting times on the health status of patients referred for non-urgent rheumatology opinion. No difference in clinical outcomes was found between a 'fast-track' and 'ordinary' appointment system. This suggests that rationing by waiting times is not detrimental to health. However, such an approach ignores the value patients attach to reducing waiting time. OBJECTIVES: To estimate the monetary value of reducing waiting time, as well as changes in duration of appointment and the introduction of a pain management service, in the provision of rheumatology services. METHODS: Discrete choice experiment (DCE). SETTING: The main outpatient clinic of the rheumatology service for the Lothian and Borders region. SUBJECTS: 262 patients who had received a specialist rheumatology opinion--73 had received fast-track treatment, 65 standard care and 124 were non-trial patients. RESULTS: A response rate of 71% was achieved. Patients valued a 9-week reduction in waiting time at 131 pounds sterling. However, the introduction of a pain management service was valued at 209 pounds sterling. Thus, the latter is of more value to respondents. Evidence was also found of the internal consistency and theoretical validity of the DCE approach. CONCLUSIONS: The reduction of waiting times is a central plank of NHS policy. Whilst a reduction in waiting time is of value, a pain management service is of more benefit than a 9-week reduction in waiting time. DCE were shown to be a potentially useful technique for valuing different aspects of health care interventions.

Hospital staffing and local pay: an investigation into the impact of local variations in the competitiveness of nurses' pay on the staffing of hospitals in France.

Spatial wage theory suggests that employers in different regions may offer different pay rates to reflect local amenities and cost of living. Higher wages may be required to compensate for a less pleasant environment or a higher cost of living. If wages in a competing sector within an area are less flexible and therefore less competitive this may lead to an inability to employ staff. This paper considers the market for nursing staff in France where there is general regulation of wages and public hospitals compete for staff with the private hospital and non-hospital sectors. We consider two types of nursing staff, registered and assistant nurses and first establish the degree of spatial variation in the competitiveness of pay of nurses in public hospitals. We then consider whether these spatial variations are associated with variation in the employment of nursing staff. We find that despite regulation of pay in the public and private sector, there are substantial local variations in the competitiveness of nurses' pay. We find evidence that the spatial variations in the competitiveness of pay are associated with relative numbers of assistant nurses but not registered nurses. While we find the influence of the competitiveness of pay is small, it suggests that nonpay conditions may be an important factor in adjusting the labour market as might be expected in such a regulated market.

Preferences for general practice jobs: a survey of principals and sessional GPs.

BACKGROUND: Many countries are experiencing recruitment and retention problems in general practice, particularly in rural areas. In the United Kingdom (UK), recent contractual changes aim to address general practitioner (GP) recruitment and retention difficulties. However, the evidence base for their impact is limited, and preference differences between principals and sessional GPs (previously called non-principals) are insufficiently explored. AIM: To elicit GP principals' and sessional GPs' preferences for alternative jobs in general practice, and to identify the most important work attributes. DESIGN OF STUDY: A discrete choice experiment. SETTING: National Health Service (NHS) general practices throughout Scotland. METHOD: A postal questionnaire was sent to 1862 principals and 712 sessional GPs. The questionnaire contained a discrete choice experiment to quantify GPs' preferences for different job attributes. RESULTS: A response rate of 49% (904/1862) was achieved for principals and 54% (388/712) for sessional GPs. Of responders, most principals were male (60%), and sessional GPs female (75%), with the average age being 42 years. All GPs preferred a job with longer consultations, no increase in working hours, but an increase in earnings. A job with outside commitments (for example, a health board or hospital) was preferable; one with additional out-of-hours work was less preferable. Sessional GPs placed a lower value on consultation length, were less worried about hours of work, and a job offering sufficient continuing professional development was less important. CONCLUSION: The differences in preferences between principals and sessional GPs, and also between different personal characteristics, suggests that a general contract could fail to cater for all GPs. Recruitment and retention of GPs may improve if the least preferred aspects of their jobs are changed. However, the long-term success of contractual reform will require enhancement of the positive aspects of working, such as patient contact.

Perceived need and barriers to continuing professional development among doctors.

There is growing need for continuing professional development (CPD) among doctors, especially following the recent introduction of compulsory revalidation for all doctors in the United Kingdom (UK). We use unique datasets from two national surveys of non-training grade doctors working in the National Health Service in Scotland to evaluate doctors' perceptions of need and barriers to CPD. We test for differences over time and also examine differences between doctor grades and for other characteristics such as gender, age, contract type and specialty. Doctors expressed the greatest need for CPD in clinical training, management, and information technology. In terms of perceived barriers to CPD, lack of time was expressed as a barrier by the largest proportion of doctors, as was insufficient clinical cover, lack of funding, and remoteness from main education centres. The strength of perceived need for particular CPD activities and the perceived barriers to CPD varied significantly by doctors' job and personal characteristics. An understanding of the perceived needs and barriers to CPD among doctors is an important precursor to developing effective educational and training programmes that cover their professional practice and also in supporting doctors towards successful revalidation.

Economic influences on GPs' decisions to provide out-of-hours care.

BACKGROUND: Introduction of the new general medical services contract offered UK general practices the option to discontinue providing out-of-hours (OOH) care. This aimed to improve GP recruitment and retention by offering a better work-life balance, but put primary care organisations under pressure to ensure sustainable delivery of these services. Many organisations arranged this by re-purchasing provision from individual GPs. AIM: To analyse which factors influence an individual GP's decision to re-provide OOH care when their practice has opted out. DESIGN OF STUDY: Cross-sectional questionnaire survey. SETTING: Rural and urban general practices in Scotland, UK. METHOD: A postal survey was sent to all GPs working in Scotland in 2006, with analyses weighted for differential response rates. Analysis included logistic regression of individuals' decisions to re-provide OOH care based on personal characteristics, work and non-work time commitments, income from other sources, and contracting primary care organisation. RESULTS: Of the 1707 GPs in Scotland whose practice had opted out, 40.6% participated in OOH provision. Participation rates of GPs within primary care organisations varied from 16.7% to 74.7%. Males with young children were substantially more likely to participate than males without children (odds ratio [OR] 2.44, 95% confidence interval [CI] = 1.36 to 4.40). GPs with higher-earning spouses were less likely to participate. This effect was reinforced if GPs had spouses who were also GPs (OR 0.52, 95% CI = 0.37 to 0.74). GPs with training responsibilities (OR 1.36, 95% CI = 1.09 to 1.71) and other medical posts (OR 1.38, 95% CI = 1.09 to 1.75) were more likely to re-provide OOH services. CONCLUSION: The opportunity to opt out of OOH care has provided flexibility for GPs to raise additional income, although primary care organisations vary in the extent to which they offer these opportunities. Examining intrinsic motivation is an area for future study.