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WHY DO THEY EMIGRATE?
1210
Special
Articles
392 British born and trained doctors left Britain and did not return ".11 This figure includes emigration to all countries. WHY DID THEY
WHY DO THEY EMIGRATE? STEVEN JONAS M.D. New York
THE controversy over emigration of doctors from Great Britain has been going on for some time, but until about a year ago, the dispute was mainly concerned with the number of doctors who were leaving each year. Several authorities thought the number was quite large, while others thought it insignificant. In July, 1964, Abel-Smith and Galespublished a definitive study which settled the question of the annual emigration-rate for doctors, apparently to everyone’s satisfaction. Since then the controversy
primarily concerned with why British doctors emigrate. I would like to try to answer that question, but first I shall briefly review the history of the estimates of the numbers of doctors emigrating. has been
NUMBERS EMIGRATING
That emigration of doctors might be a serious problem for the Health Service was first considered, in passing, by Lafitte and Squire in their critique of the Willink Report.22 Davison presented the first firm estimate of emigration, in 1961. Using statistics of the Canadian Department of Citizenship and Immigration, he estimated that, in 1955-59, 1104 British doctors had emigrated to Canada. In 1962 Seale published a fairly detailed study of emigration to some " highincome " countries: United States, Canada, Australia, New Zealand, South Africa, and North and South Rhodesia. Using figures obtained from local licensing and immigration authorities, he estimated that the emigration-rate to these countries for 1956-60 was 600 per annum.4 Davison, again using figures from immigration authorities, estimated that the emigrationrate to the United States and Canada alone for the period 1953-60 was 311 per annum.-I At this point the Minister of Health at that time, Mr. Enoch Powell, came to the defence of the Health Service, and treated the statistics of Seale and Davison with derision.Platt,’ The Lancet,8 and Titmuss9 also felt that these estimates were far too
high.
In 1964 Seale published revised estimates of the emigrationrate, stating that he had found sources of error in his original and now considered the rate to be 480 per annum to study " " high-income countries alone.10 In July, the Abel-Smith and Gales study was published.
After
a
careful discussion of
sources
of
error
in earlier
studies, Abel-Smith and Gales presented their detailed findings. They drew a 5 % sample of all doctors listed on the British Medical Register for the period 1925-59. This amounted to 3590 men and women. Since the major problem under consideration was the extent of emigration and its consequences for Great Britain, Abel-Smith and Gales decided to concentrate their efforts on the 2332 doctors in their sample who were both born and trained in Great Britain, since doctors from other countries who left Great Britain could not rightly be termed subsequently " emigrants ". Of this group, 275 were resident outside Great Britain in July, 1962. From this sample, AbelSmith and Gales were able to estimate " that for each year of the period January 1955 to July 1962 an average of 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Abel-Smith, B., Gales, K. British Doctors London, 1964. Lafitte, F., Squire, J. Lancet, 1960, ii, 538. Davison, R. H. ibid. 1961, i, 1107. Seale, J. R. Br. med. J. 1962, i, 782. Davison, R. H. ibid. p. 786. Powell, E. ibid. suppl. p. 268. Platt, R. Times, April 14, 1962. Lancet, 1963, ii, 871. Titmuss, R. Med. Care, 1963, 1, 21. Seale, J. R. Br. med. J. 1964, i, 1173.
EMIGRATE ?
emigrating because they object strongly to " socialised medicine ", whatever that ill-defined term may mean? Do they object to the principle of financing medical care from general taxation, or to giving people free care at the time of treatment ? Or are they more troubled by problems related to the general structure of British medical practice ? Seale’s answer to the " why " question was couched in somewhat vague terms: Are doctors
at
Home and Abroad.
"
A possible explanation [of the high rate of emigration] is that practice in the National Health Service is relatively unattractive to young doctors economically, professionally, and
idealistically. 114 Davison
was
quite a bit more forthright:
"
The cause is not difficult to find. Not only has the N.H.S. provided outrageous terms and conditions of service, it has completely failed to inspire respect among the younger members of the profession, who see through its Fabian humbug."5 Even the Medical Practitioners Union, known to be a friend of the N.H.S., has attacked it bitterly, in broad, general terms. The General Secretary of the M.P.U. said recently: " Established practitioners have uprooted themselves and their families and begun afresh overseas to escape the frustrations and limitations of the service."12 (My italics.) Further, the M.P.U. have said, Each year for many "
years 400 doctors have
emigrated rather
than submit any longer to conditions in the N.H.S. in Britain." 12 (My italics.) But is it the N.H.S. which is to blame, or is it rather certain features of medical practice in Britain which existed before the Health Service was established that should be held to account ? None of those who blame the N.H.S. for the emigration of doctors actually asked the doctors why they left. They just guessed at the reasons. As part of their study, however, Abel-Smith and Gales sent a questionary to all the doctors in their sample who were resident overseas. Of those who were born and trained in Britain, 189 were resident in a " high-income " country in July, 1962. There was no specific question on reasons for emigrating, but 123 of the group used a space marked " comment " to discuss the matter. Only 9% gave " socialised medicine " as their reason for going abroad. The balance referred to conditions of practice, both in and out of hospital. To quote Abel-Smith and Gales: many doctors working abroad stressed the wider field of work which they could undertake in general practice and criticised the limited role of the general practitioner in Britain," and, " the most frequent complaint which doctors made about the British hospital service was that they failed to obtain a post of desired seniority in the specialty of their choice."’ These are the two major criticisms of British medical "
practice which Abel-Smith and emigre doctors. They both refer
Gales found among conditions of practice which existed well before 1948. The N.H.S. can only be accused of not solving these problems, not of causing them. The current problems of general practice in Great Britain are well known. But the situation before the 1939-45 war was very similar. This is demonstrated by a report on British Health Services in 1937.13 The report to
11. ibid. 1964, ii, 1. 12. Medical Practitioners Union. Med. Wld Newsl. Jan. 16, 1965. 13. Report Political and Economic Planning: Report on British Health Services. London, 1937.
1211 discussed overwork, low pay, the lack of
guaranteed offduty nights, free weekends, sick-leave, or vacations, the scarcity of ancillary help, the difficulty of keeping up with
the medical advances because of lack of time, the poor surgeries, the isolation of practitioners from their colleagues, and the second-class status accorded to general practitioners. One can read just this sort of summary in both the leaders and the correspondence columns of British medical journals today. In the correspondence these problems are sometimes blamed on the " evils " of socialised medicine ". Since these evils existed before the Health Service, this position is not easily defended. Difficulty in obtaining consultant appointments also predated the Health Service. In the voluntary-hospital system, the existing consultants were very influential both "
in selecting men to fill posts which had become vacant and in creating new posts. Without a voluntary-hospital appointment a specialist had little hope of developing private practice. Although a variety of measures have been taken to eliminate the personal factors which operated before 1948, there is still no guarantee that a specialistin-training will gain a consultant post at the end of his senior registrarship. There have been simply not enough vacancies to go round. Through their positions on the various advisory committees both at hospital-managementcommittee and regional-hospital-board level, consultants still influence both appointments to posts which fall vacant and the creation of new posts. Indeed, new posts are normally created only when the consultant in the particular department requests that this be done. In addition, creation of new posts can be inhibited by a variety of administrative barriers, and, more importantly, by lack of funds. It is clear that the cause of the major complaint by emigre doctors about the hospital service has to do, not with " socialised medicine ", but with a problem which existed long before 1948. WHY IS EMIGRATION A NEW
FEATURE ??
serious problem before the Emigration 1939-45 war. Abel-Smith and Gales found that, of the 275 British born and trained doctors in their sample who were resident abroad in 1962, only 30 had left before 1949. If conditions were so bad before the N.H.S. was formed, why did not more doctors emigrate ? There are no definitive answers to this question, but several can be postulated. Firstly, the world-wide economic depression which existed from 1929 until the outbreak of the 1939-45 war and the economic slump in Great Britain which had been almost continuous since 1919 must have inhibited was
not
a
emigration. Doctors, unlike labourers, cannot emigrate a penniless condition, and it is difficult to accumulate extra cash during a depression. The increasingly unsettled political conditions in the years just before the war would probably have been a further hindering influence: most people like to be home " if a war seems to be coming on. in
"
Moreover, the
overseas demand for doctors was not as great as it is now. For example, in the United States from 1932 onwards the American Medical Association applied an active policy of limitation.14 In any case, it was not so simple, physically, to emigrate. One could not fly out to look over a prospective place of residence on holiday. A final decision would have to be made without seeing one’s new country and place of work beforehand. Finally, the insularity of Britons before the war is well known. Emigration as a possible solution to their problems probably just did not occur to very many doctors. 14.
Rayack, E.
Med.
Care, 1964, 2,
244.
CONCLUSION
The basic changes introduced into the organisation of British medical care by the National Health Service Act were concerned mainly with patterns of financing. Apart from the nationalisation of the hospitals and the partial rationalisation of the local-authority health services, both of which were warmly welcomed by the medical profession, little was done to change the patterns of medical practice. Indeed the leading position of the most powerful group in the profession-the consultants-was confirmed and strengthened. The only provision which could have radically changed patterns of practice-the health-centre system-was never implemented. On the existing evidence it is precisely the conditions of practice, and not the socialist principles of financing, which are causing doctors to
emigrate.
It is likely, therefore, that emigration would not be reduced by either scrapping the Health Service or increasing private practice. Conditions of service must be changed, new premises built, more ancillary help provided. Increasing private practice would do none of these
things. General practice must instead be made professionally rewarding, and the second-class status which has been attached to it by the consultant branch amended. This would involve allowing general practitioners who wished to do so to take care of their own patients in hospital. There would also need to be a basic change in medical education, so that students would be taught the value and true place of general practitioners in the Health Service. It would also be necessary to meet many of the general practitioners’ demands on conditions of service. For this to be accomplished efficiently and at a reasonable cost the general practitioners themselves would probably have to consent to being organised in some form of group practice. It appears that the problem of retaining the specialists could be solved only by changing the career structure of the N.H.S. so that many more senior positions with full responsibility were created. It is not easy to say just who or what causes the congestion in career development in the N.H.S. The consultants certainly exert influence in the matter of creating new positions. There are certainly administrative and financial difficulties to cope with as well. But hitherto there have been simply not enough consultant posts to go round. On the basis of reasons for leaving given by emigres, it does not seem that implementing the recommendations of the Platt Committee 15 will help. In order to meet hospital staffmg problems and to give jobs to registrars who " don’t make it ", the committee proposed the creation of a new post-a permanent, middle-grade, glorified house-officer, to be called a " medical assistant". How many men who have spent seven years or more in hospital training could be expected to accept permanent second-class status, when the alternative is to emigrate ? The only answer is to create more consultant posts at home. There is certainly no surfeit of specialists, with only 8000 for a population of over 50 million. The changes necessary to decrease emigration are the same ones which are needed to revitalise the Health Service as a whole. In 1948 the financing of medical care in Great Britain was revolutionised, and the result has been a boon to the British people. The time has now come to change the organisation of care, and with it the structure of medical practice. 15. Medical Staffing Structure in the Office, 1961.
Hospital Service. H.M. Stationery
Special
Articles
392 British born and trained doctors left Britain and did not return ".11 This figure includes emigration to all countries. WHY DID THEY
WHY DO THEY EMIGRATE? STEVEN JONAS M.D. New York
THE controversy over emigration of doctors from Great Britain has been going on for some time, but until about a year ago, the dispute was mainly concerned with the number of doctors who were leaving each year. Several authorities thought the number was quite large, while others thought it insignificant. In July, 1964, Abel-Smith and Galespublished a definitive study which settled the question of the annual emigration-rate for doctors, apparently to everyone’s satisfaction. Since then the controversy
primarily concerned with why British doctors emigrate. I would like to try to answer that question, but first I shall briefly review the history of the estimates of the numbers of doctors emigrating. has been
NUMBERS EMIGRATING
That emigration of doctors might be a serious problem for the Health Service was first considered, in passing, by Lafitte and Squire in their critique of the Willink Report.22 Davison presented the first firm estimate of emigration, in 1961. Using statistics of the Canadian Department of Citizenship and Immigration, he estimated that, in 1955-59, 1104 British doctors had emigrated to Canada. In 1962 Seale published a fairly detailed study of emigration to some " highincome " countries: United States, Canada, Australia, New Zealand, South Africa, and North and South Rhodesia. Using figures obtained from local licensing and immigration authorities, he estimated that the emigration-rate to these countries for 1956-60 was 600 per annum.4 Davison, again using figures from immigration authorities, estimated that the emigrationrate to the United States and Canada alone for the period 1953-60 was 311 per annum.-I At this point the Minister of Health at that time, Mr. Enoch Powell, came to the defence of the Health Service, and treated the statistics of Seale and Davison with derision.Platt,’ The Lancet,8 and Titmuss9 also felt that these estimates were far too
high.
In 1964 Seale published revised estimates of the emigrationrate, stating that he had found sources of error in his original and now considered the rate to be 480 per annum to study " " high-income countries alone.10 In July, the Abel-Smith and Gales study was published.
After
a
careful discussion of
sources
of
error
in earlier
studies, Abel-Smith and Gales presented their detailed findings. They drew a 5 % sample of all doctors listed on the British Medical Register for the period 1925-59. This amounted to 3590 men and women. Since the major problem under consideration was the extent of emigration and its consequences for Great Britain, Abel-Smith and Gales decided to concentrate their efforts on the 2332 doctors in their sample who were both born and trained in Great Britain, since doctors from other countries who left Great Britain could not rightly be termed subsequently " emigrants ". Of this group, 275 were resident outside Great Britain in July, 1962. From this sample, AbelSmith and Gales were able to estimate " that for each year of the period January 1955 to July 1962 an average of 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Abel-Smith, B., Gales, K. British Doctors London, 1964. Lafitte, F., Squire, J. Lancet, 1960, ii, 538. Davison, R. H. ibid. 1961, i, 1107. Seale, J. R. Br. med. J. 1962, i, 782. Davison, R. H. ibid. p. 786. Powell, E. ibid. suppl. p. 268. Platt, R. Times, April 14, 1962. Lancet, 1963, ii, 871. Titmuss, R. Med. Care, 1963, 1, 21. Seale, J. R. Br. med. J. 1964, i, 1173.
EMIGRATE ?
emigrating because they object strongly to " socialised medicine ", whatever that ill-defined term may mean? Do they object to the principle of financing medical care from general taxation, or to giving people free care at the time of treatment ? Or are they more troubled by problems related to the general structure of British medical practice ? Seale’s answer to the " why " question was couched in somewhat vague terms: Are doctors
at
Home and Abroad.
"
A possible explanation [of the high rate of emigration] is that practice in the National Health Service is relatively unattractive to young doctors economically, professionally, and
idealistically. 114 Davison
was
quite a bit more forthright:
"
The cause is not difficult to find. Not only has the N.H.S. provided outrageous terms and conditions of service, it has completely failed to inspire respect among the younger members of the profession, who see through its Fabian humbug."5 Even the Medical Practitioners Union, known to be a friend of the N.H.S., has attacked it bitterly, in broad, general terms. The General Secretary of the M.P.U. said recently: " Established practitioners have uprooted themselves and their families and begun afresh overseas to escape the frustrations and limitations of the service."12 (My italics.) Further, the M.P.U. have said, Each year for many "
years 400 doctors have
emigrated rather
than submit any longer to conditions in the N.H.S. in Britain." 12 (My italics.) But is it the N.H.S. which is to blame, or is it rather certain features of medical practice in Britain which existed before the Health Service was established that should be held to account ? None of those who blame the N.H.S. for the emigration of doctors actually asked the doctors why they left. They just guessed at the reasons. As part of their study, however, Abel-Smith and Gales sent a questionary to all the doctors in their sample who were resident overseas. Of those who were born and trained in Britain, 189 were resident in a " high-income " country in July, 1962. There was no specific question on reasons for emigrating, but 123 of the group used a space marked " comment " to discuss the matter. Only 9% gave " socialised medicine " as their reason for going abroad. The balance referred to conditions of practice, both in and out of hospital. To quote Abel-Smith and Gales: many doctors working abroad stressed the wider field of work which they could undertake in general practice and criticised the limited role of the general practitioner in Britain," and, " the most frequent complaint which doctors made about the British hospital service was that they failed to obtain a post of desired seniority in the specialty of their choice."’ These are the two major criticisms of British medical "
practice which Abel-Smith and emigre doctors. They both refer
Gales found among conditions of practice which existed well before 1948. The N.H.S. can only be accused of not solving these problems, not of causing them. The current problems of general practice in Great Britain are well known. But the situation before the 1939-45 war was very similar. This is demonstrated by a report on British Health Services in 1937.13 The report to
11. ibid. 1964, ii, 1. 12. Medical Practitioners Union. Med. Wld Newsl. Jan. 16, 1965. 13. Report Political and Economic Planning: Report on British Health Services. London, 1937.
1211 discussed overwork, low pay, the lack of
guaranteed offduty nights, free weekends, sick-leave, or vacations, the scarcity of ancillary help, the difficulty of keeping up with
the medical advances because of lack of time, the poor surgeries, the isolation of practitioners from their colleagues, and the second-class status accorded to general practitioners. One can read just this sort of summary in both the leaders and the correspondence columns of British medical journals today. In the correspondence these problems are sometimes blamed on the " evils " of socialised medicine ". Since these evils existed before the Health Service, this position is not easily defended. Difficulty in obtaining consultant appointments also predated the Health Service. In the voluntary-hospital system, the existing consultants were very influential both "
in selecting men to fill posts which had become vacant and in creating new posts. Without a voluntary-hospital appointment a specialist had little hope of developing private practice. Although a variety of measures have been taken to eliminate the personal factors which operated before 1948, there is still no guarantee that a specialistin-training will gain a consultant post at the end of his senior registrarship. There have been simply not enough vacancies to go round. Through their positions on the various advisory committees both at hospital-managementcommittee and regional-hospital-board level, consultants still influence both appointments to posts which fall vacant and the creation of new posts. Indeed, new posts are normally created only when the consultant in the particular department requests that this be done. In addition, creation of new posts can be inhibited by a variety of administrative barriers, and, more importantly, by lack of funds. It is clear that the cause of the major complaint by emigre doctors about the hospital service has to do, not with " socialised medicine ", but with a problem which existed long before 1948. WHY IS EMIGRATION A NEW
FEATURE ??
serious problem before the Emigration 1939-45 war. Abel-Smith and Gales found that, of the 275 British born and trained doctors in their sample who were resident abroad in 1962, only 30 had left before 1949. If conditions were so bad before the N.H.S. was formed, why did not more doctors emigrate ? There are no definitive answers to this question, but several can be postulated. Firstly, the world-wide economic depression which existed from 1929 until the outbreak of the 1939-45 war and the economic slump in Great Britain which had been almost continuous since 1919 must have inhibited was
not
a
emigration. Doctors, unlike labourers, cannot emigrate a penniless condition, and it is difficult to accumulate extra cash during a depression. The increasingly unsettled political conditions in the years just before the war would probably have been a further hindering influence: most people like to be home " if a war seems to be coming on. in
"
Moreover, the
overseas demand for doctors was not as great as it is now. For example, in the United States from 1932 onwards the American Medical Association applied an active policy of limitation.14 In any case, it was not so simple, physically, to emigrate. One could not fly out to look over a prospective place of residence on holiday. A final decision would have to be made without seeing one’s new country and place of work beforehand. Finally, the insularity of Britons before the war is well known. Emigration as a possible solution to their problems probably just did not occur to very many doctors. 14.
Rayack, E.
Med.
Care, 1964, 2,
244.
CONCLUSION
The basic changes introduced into the organisation of British medical care by the National Health Service Act were concerned mainly with patterns of financing. Apart from the nationalisation of the hospitals and the partial rationalisation of the local-authority health services, both of which were warmly welcomed by the medical profession, little was done to change the patterns of medical practice. Indeed the leading position of the most powerful group in the profession-the consultants-was confirmed and strengthened. The only provision which could have radically changed patterns of practice-the health-centre system-was never implemented. On the existing evidence it is precisely the conditions of practice, and not the socialist principles of financing, which are causing doctors to
emigrate.
It is likely, therefore, that emigration would not be reduced by either scrapping the Health Service or increasing private practice. Conditions of service must be changed, new premises built, more ancillary help provided. Increasing private practice would do none of these
things. General practice must instead be made professionally rewarding, and the second-class status which has been attached to it by the consultant branch amended. This would involve allowing general practitioners who wished to do so to take care of their own patients in hospital. There would also need to be a basic change in medical education, so that students would be taught the value and true place of general practitioners in the Health Service. It would also be necessary to meet many of the general practitioners’ demands on conditions of service. For this to be accomplished efficiently and at a reasonable cost the general practitioners themselves would probably have to consent to being organised in some form of group practice. It appears that the problem of retaining the specialists could be solved only by changing the career structure of the N.H.S. so that many more senior positions with full responsibility were created. It is not easy to say just who or what causes the congestion in career development in the N.H.S. The consultants certainly exert influence in the matter of creating new positions. There are certainly administrative and financial difficulties to cope with as well. But hitherto there have been simply not enough consultant posts to go round. On the basis of reasons for leaving given by emigres, it does not seem that implementing the recommendations of the Platt Committee 15 will help. In order to meet hospital staffmg problems and to give jobs to registrars who " don’t make it ", the committee proposed the creation of a new post-a permanent, middle-grade, glorified house-officer, to be called a " medical assistant". How many men who have spent seven years or more in hospital training could be expected to accept permanent second-class status, when the alternative is to emigrate ? The only answer is to create more consultant posts at home. There is certainly no surfeit of specialists, with only 8000 for a population of over 50 million. The changes necessary to decrease emigration are the same ones which are needed to revitalise the Health Service as a whole. In 1948 the financing of medical care in Great Britain was revolutionised, and the result has been a boon to the British people. The time has now come to change the organisation of care, and with it the structure of medical practice. 15. Medical Staffing Structure in the Office, 1961.
Hospital Service. H.M. Stationery