OPINION: Many countries are short of healthcare workers, thousands of whom have left healthcare since the COVID-19 pandemic.
The migration of doctors is a particular challenge to Aotearoa New Zealand. Although the New Zealand health system is regarded highly among its international counterparts, there is a shortage of doctors and other health workers.
In a report last year by Te Whatu Ora – Health New Zealand, New Zealanders learnt, for the first time, the extent of these staffing issues. The estimated shortfall was 1,700 doctors, a gap that is projected to increase to 3,400 by 2032.
Many New Zealand doctors are choosing to move overseas to practice. The latest medical workforce data reports that the number of New Zealand-trained doctors practicing in Australia alone is 187.
This article outlines and discusses the reasons which may influence New Zealand-trained doctors to move overseas. An overview of strategies for doctor retention is provided, demonstrating the potential next steps to addressing the issue of migration.
The workforce
Historically, government funding of medical school places in New Zealand has been inconsistent. Prior to this year, the last major increase in student numbers took place after the 2008 election when National promised an additional 200 places across the two medical schools. The intended increase was in anticipation of the growing population demand for health services over the coming decades. Once elected, however, National's plan to boost the medical school intake was reduced, eventually funding 175 places by the end of 2015.
Subsequent appeals for an increase were declined until 2023, when the Labour government approved funding for 50 additional places, increasing the total to 589. Poor planning for the future medical workforce has resulted in low medical graduation rates.
This shortage is especially visible in rural areas of New Zealand and in specialties such as general practice. In addition, the workforce is aging, with many doctors in their mid- to late-career considering opportunities for career breaks and retirement.
Overall, there is no longer an adequate number of doctors to care for and meet the increasingly complex medical and socio-cultural demands in New Zealand.
The COVID-19 pandemic highlighted this mismatch.
Loss of the workforce
While many young doctors have traditionally left the country to gain overseas experience, increasing numbers of younger and older doctors are leaving because the current working conditions created by these shortages are not sustainable. Excessive workloads, significant on-call duties, long hours and unpaid administrative tasks are some reasons which contribute to burnout.
Other factors include feeling undervalued and frustrated with a controlling management culture.
High rates of burnout are associated with an intention to leave the workforce.
A study conducted by the Association of Salaried Medical Specialists (ASMS) in 2016 reported that half of the senior doctors and dentists who responded reported symptoms of burnout.
Unsurprisingly, burnout is more common in areas of the workforce that face severe shortages. The recent GP workforce survey report found that nearly 80% of GP respondents had experienced some burnout, with high levels being reported by 48%.
Issues linked with mental health and wellbeing among medical students have also been documented. Among medical students studying at the University of Otago, Christchurch Campus last year (2023), "severe" to "extremely severe" levels of stress were reported by 19% of participants.
Similar levels of depression and anxiety were reported by 20% and 30% of students, respectively--a concerning finding for individuals at the start of their medical career.
Alongside difficulties with working conditions is the issue of remuneration. In New Zealand and internationally, literature highlights low wages as a driver for doctors leaving the country in which they trained.
This has been the primary motivation behind strike action across the country, with doctors expressing frustration with Te Whatu Ora - Health New Zealand for their refusal to provide a salary that aligns with inflation.
General practitioners are becoming increasingly disheartened by the lack of pay parity with doctors practicing in hospital-based disciplines. The result is that doctors feel under-valued.
This, along with higher salaries in Australia and other countries, has encouraged doctors to leave.
Most locally trained doctors who are practicing overseas do so in Australia. The Australian health system is appealing for a number of reasons: it recognises New Zealand qualifications, it provides doctors the opportunity to work in well-resourced hospitals and there is greater earning potential. The average salary for New Zealand doctors is less than 60% of the Australian average.
What is the fundamental importance of New Zealand trained doctors?
The importance of locally trained doctors cannot be overstated. Ideally, the New Zealand medical workforce should reflect the sociocultural demographics of New Zealand society. For decades, however, the New Zealand health system has been dependent on overseas-trained doctors to compensate for the gaps in our workforce.
International medical graduates (IMGs) offer a short-term solution for the staffing shortages across the country. Out of OECD countries, New Zealand has the second highest dependency on overseas-trained doctors (second only to Israel), with IMGs making up 42% of the workforce.
Overseas-trained doctors are less likely to remain in the country compared with New Zealand doctors. Currently, around 60% of IMGs leave within 2 years of registration, with significant costs to the New Zealand health system.
New Zealand-trained doctors stay longer, suggesting that a locally trained workforce is more sustainable. Other issues with the IMG workforce include a lack of familiarity with the New Zealand healthcare system, potential language barriers, the moral question of employing doctors from developing countries who need them and uncertainty around the provision of culturally appropriate care for Māori.
The latter is particularly important. Medical education in New Zealand places significant
emphasis on cultural training for students. Māori experience poorer health outcomes and shorter life expectancies compared with most other population groups in New Zealand.
In response to these inequities, both medical schools (Otago, Auckland) now have a core curriculum domain of Hauora Māori, with a focus on community based teaching and cultural immersion.
For example, at Otago, second year medical students experience a week-long Hauora Māori immersion programme, which includes marae-based learning about Māori health models and the Hui process to help guide culturally safe interactions with future patients. Te reo Māori and concepts of tikanga are incorporated into courses.
Students at both medical schools also receive teaching in Pacific health. This involves in-context learning directly from Pacific communities about their worldview and health models. Such teaching is vital to ensure that students are equipped with the specific knowledge and skills to improve Indigenous health and reduce inequalities. IMGs are unlikely to have received this culturally relevant training.
There is also an ongoing issue with representation in the workforce. Both medical schools in New Zealand are committed to training more Māori and Pacific doctors through dedicated entry pathways and ongoing support for these students.
A similar entry scheme is in place for students from rural backgrounds. The goal is a representative workforce, one that shares cultural values and beliefs with that of the diverse communities of New Zealand and strengthens the belief that the healthcare services are serving them. This is harder to achieve with a heavy reliance on IMGs.
While there are benefits from the skills and experience of an imported workforce, there are also practical and socio-cultural advantages to training New Zealanders and retaining them.
Strategies for retention - what works?
Research into retention has been relatively limited, with most research focussing on reasons for leaving, rather than how to improve retention.
Studies that explicitly examine retention strategies for doctors tend to be predominantly concerned with GP or rural workforces. However, the principles behind this research can still be applied.
Better pay: Evidence suggests that pay is linked to retention, with higher income correlating with an intention to stay among medical practitioners.
Ideally, doctors should be paid in a way which reflects the ongoing challenges and pressures associated with working in healthcare, such as high workload, frequent on-call duties and long hours.
Fair pay, which takes into account these factors, is a key determinant of retention. Remuneration is cited as one of the most important factors that would influence a doctor's decision to continue working in the public health sector.
It is important to note, however, the relationship between pay and retention is complex.
Financial compensation, alone, may not provide adequate incentive to stay if poor working conditions persist.
Other financial incentives, such as loan repayments, bonding for work in hard-to-staff areas and lump sum payments, appear to be less effective, and more closely associated with recruitment rather than long-term retention.
This is shown by the limited success of New Zealand's Voluntary Bonding Scheme, which since 2009 offered a restricted number of payments to doctors in exchange for service in hard-to-staff areas. The only review of the scheme, in 2012, reported that more than half of graduates had opted out after just 3 years.
Overseas recruitment: In the short-term, there will be continued reliance on IMGs to supplement our workforce, especially for GPs and rural areas. Maintaining adequate and stable staffing might reduce the current issues associated with burnout, hours worked, on-call commitments and workload.
With better working conditions, we could see improved retention across the country. Given the length of medical training in New Zealand, the short-term goal must be recruiting more doctors from overseas.
In 2023, 942 IMGs registered to practice in New Zealand, which is insufficient. Amidst a global shortage of healthcare workers, development of strategies to increase recruitment of IMGs include removal of unnecessary barriers to visas and registration, incentives to attract IMGs to hard-to-staff areas and ensuring appropriate pay.
Alongside this, we need to invest in ongoing education to ensure overseas doctors are fit to practice within the cultural context of New Zealand.
Local training: In the long-term, increased capacity to train New Zealand doctors is required. There is no shortage of young New Zealanders wanting to train as medical doctors, as evidenced by the highly competitive entry pathways into Auckland and Otago medical schools.
What limits the number of graduates we currently produce is the number of places available for these students.
Investment in training more doctors by increasing the number of medical school places for New Zealand citizens and residents seems obvious. But simply increasing the number of students overall will not solve the demographic and geographic imbalances in our workforce.
Further investment in increasing Māori and Pacific medical workforces should be a priority, as part of our obligation to Te Tiriti and to help ensure culturally safe working conditions. Training students from rural backgrounds is also important, as research has shown that doctors of rural origin are more likely to stay and work in rural areas long-term.
Any increase in the number of medical school places would need to be mirrored by a corresponding increase in the number of postgraduate clinical placements and vocational training posts.
Conclusion
In summary, the doctor shortage in New Zealand needs urgent attention. We need to train more, retain more and recruit more to work our way out of this problem.
We need to train more doctors, as well as attract doctors from overseas amidst a global medical worker shortage. Existing evidence suggests that issues around retention are a systemic problem with no simple solution.
In addition, we need to try and ensure these doctors are appropriately supported and remunerated and have a working environment that is safe and sustainable. It is impossible to achieve this without significant investment into the future of our medical workforce.
This article is republished from the New Zealand Medical Journal with permission.
