Abstract
Summary
Objective
To report on the future career plans of senior doctors working in the NHS.
Design
Postal questionnaires.
Setting
All doctors who qualified in 1977 from all UK medical schools.
Main outcome measures
Future plans and whether participants had any unmet needs for advice on how to put their future plans into effect.
Results
25% definitely intended to continue with their current employment on the same basis until they retired; 75% hoped for change. A reduction in working hours was the most commonly desired change; but a substantial percentage also wanted changes in job content. 50% of respondents intended definitely (17%) or probably (33%) to work in the NHS to their normal retirement age; and 37% definitely (20%) or probably (17%) intended to retire early. 48% had made plans, in addition to the standard pension, to facilitate early retirement. The main factors given for considering early retirement were family reasons and wanting more time for leisure, a desire to maintain good health, excessive pressure of work, and disillusionment with NHS changes. A reduction in workload would be the greatest inducement to stay. 31% of respondents reported that they had unmet needs for advice about their future plans. Of these, about half were needs for advice about planning for retirement.
Conclusions
Many senior NHS doctors would like to reduce their working hours. Less than a quarter definitely intend to work in the NHS to normal retirement age. Even for senior doctors, advice on career development is needed.
Introduction
A skilled workforce is the most important single resource in the provision of health services. Adequate numbers of experienced doctors are essential to provide high standards of patient care and a suitable learning environment for doctors in training. For workforce planners concerned with retention of senior doctors, insights into doctors' views about their current job and their future plans are particularly important. 1 In the UK, knowledge about the future career plans of senior National Health Service (NHS) doctors is very limited. We report on the plans of the doctors who qualified from UK medical schools in 1977 – as an example of medical qualifiers from the 1970s – who were working in the NHS in 2004.
Methods
Procedure and population
Our basic methods have been outlined in the accompanying paper. 2 In 2004, we sent postal questionnaires to all doctors who had qualified from all UK medical schools in 1977. In this paper, we report on respondents who were working as NHS doctors. We include both those working on substantive NHS contracts and those in academic posts with honorary NHS contracts. We also compare the retirement intentions of the 1977 qualifiers in 2004 with those of the 1974 qualifiers when surveyed in 1998 using the same methods and similar questions. 3 , 4
The survey instruments
The questionnaires comprised structured, ‘closed’ questions, a few ‘open’ questions and a request for ‘free text’ comments on any aspect of the respondents' career or work. Question topics included career progression, current employment, future career plans, retirement intentions, and unmet needs for advice about future career plans and retirement.
Respondents were asked: ‘Do you expect to continue with your current employment on the same basis until you retire?’ Those who stated that they were not definite about continuing with the same pattern of work were then asked: (a) how they planned to change their employment; (b) what were the factors motivating their planned changes; and (c) whether they intended to spend ‘More time’, ‘Less time’ or ‘About the same’ on different specified aspects of their jobs.
We enquired about the normal retirement age for each respondent's post. We then asked: ‘Do you intend to practise in the NHS until the normal retirement age for your post?’ Those not replying ‘Yes – definitely’ were asked why they were considering early retirement, about any definite plans to facilitate early retirement, and what might encourage them to stay. In our earlier survey of the qualifiers of 1974 in 1998, responses to these latter questions were collected in free text format. The text provided by the respondents in 1998 was then analyzed, using qualitative methods, to report on the content of the replies. 4 For the 2004 survey, we used the profile of replies from the 1998 survey to define a structured list of possible replies which we put to the doctors, with space for additional free text if the respondents wished.
Respondents were asked: ‘Do you have any unmet needs, yourself, for advice on future career management/career change/retirement?’ The question was followed by ‘If yes, please give brief details’, with a space provided for a free text reply.
Data analysis
The replies were analyzed using descriptive statistics, χ2 tests, binary logistic regression and textual analysis. The χ2 tests and binary logistic regressions were carried out to identify possible associations between retirement intentions and a number of factors, namely sex, working in general practice/hospital practice, full-time/part-time working, the respondents' levels of satisfaction with their job and with the time their job left for leisure, and whether or not they reported unmet needs for advice on career changes.
In making multiple similar comparisons, we regarded the attainment of a significance threshold of p≤0.01 as evidence of significant difference.
Results
Response rates
Of 3135 doctors who qualified in 1977, 54 had died, 36 declined to participate in the survey and 2180 responded, giving an effective response rate of 71.6% (2180/3045). Of these respondents, 1888 (86.6%) worked in the NHS. For the 1974 qualifiers, the effective response rate was 77.4% (1717/2217); and 1460 (85.0%) worked as NHS doctors when surveyed in 1998. The mean and median ages at the times of the surveys for the 1977 qualifiers were both 51 years, and both were 48 years for the 1974 qualifiers.
Answers to the question ‘Do you expect to continue with your current employment on the same basis until you retire?’
Of the qualifiers of 1977 who worked as NHS doctors, 25% of respondents indicated that they would definitely continue with their current employment on the same basis until retirement and a further 47% stated that that they would probably continue (Table 1). Similar percentages of men and women indicated that they would definitely or probably continue (men 73.4%, women 70.9%, χ2 1=1.1, p=0.29).
Respondents' plans to change their work commitments
Percentages (and numbers) of NHS doctors who gave each answer to the question: ‘Do you expect to continue with your current employment on the same basis until you retire?’
1882/1888 (99.7%) gave valid replies
Percentages of NHS doctors not definitely planning to continue with their current employment on the same basis until retirement who cited each planned change and motivation for change
1246/1410 (88.4%) gave valid replies about planned changes and 1292/1410 (91.6%) gave valid replies about motivators.
The phrases in the table are those used in the questionnaire except for the last row referring to free text.
Planned changes to time commitments for NHS doctors hoping to work more, less or about the same in each area of work
Male-female comparisons: medical education/teaching (χ2 2=5.2, p=0.07); academic/research work (χ2 2=11.5, p=0.003); management/health policy work/administration (χ2 2=5.5, p=0.06); service work/treating patients (χ2 2=47.1, p<0.001).
See footnote, Table 2
Three factors were reported as influential in the desire to change the respondents' current employment (Table 2). These were family and/or lifestyle reasons (cited by 57% who wanted change), further development of professional aims and career progression (52%), and the desire for change itself and for new challenges (39%). The only significant difference between men and women was in the response about career progression: it was a motivating factor for a significantly higher percentage of men (27%) than women (20%).
We asked specific, structured questions about plans to change time commitments in four broad areas of work – teaching, research, management, and direct patient care (Table 3). Desire for change was common, although the desired direction of change varied between doctors. Men and women differed significantly in the categories of involvement in patient care (55% of men and 39% of women wanted to devote less time to direct patient care; p<0.001), and academic and research work (21% of men and 14% of women wanted to devote more time, p=0.008).
Answers to the question ‘Do you intend to practise in the NHS until the normal retirement age for your post?’
Percentages (and numbers) of NHS doctors who gave each answer to the question: ‘Do you intend to practise in the NHS until normal retirement age from your post?’; and potential mean years lost per doctor because of early retirement
1799/1888 (95.3%) gave valid replies to the first question. Of those not stating a definite intention to continue to normal retirement age, 1348/1494 (90.2%) stated both the retirement age for their post and the age they might leave the NHS. The number of years lost was calculated as the difference between these two variables.
We compared the results of the 2004 survey of the qualifiers of 1977 with those from the 1998 survey of the qualifiers of 1974. NHS doctors in the 2004 survey were significantly more likely than those in the 1998 survey to specify that they would definitely or probably remain in the NHS (49.5% vs 34.9%, χ2 1=67.8, p<0.001). The respondents in 2004 were also slightly more likely than those in 1998 to state that they would definitely work to normal retirement age (17.0% vs 14.8%, χ2 1=2.6, p=0.11).
In both surveys, men were more likely than women to express a definite intention to retire before normal retirement age (2004 survey: men 19.6%, women 12.5%, χ2 1=13.8, p<0.001; 1998 survey: men 28.3%, women 17.5%, χ2 1=17.6, p<0.001). In both surveys, a slightly higher percentage of GPs than hospital doctors definitely intended to continue working to normal retirement age (2004 survey: GPs 18.9%, hospital doctors 15.1%, χ2 1=4.2, p=0.04; 1998 survey: GPs 15.6%, hospital doctors 13.9%, χ2 1=0.7, p=0.4).
Doctors who intended to stay until normal retirement age
118 of the 305 doctors who signified that they intended to stay until normal retirement age provided ‘free text’ comments. Many expressed great satisfaction with their jobs. Others commented that changes in the content of their work had further invigorated their enthusiasm for work. Some wishing to work to normal retirement age said that that their income from working was a necessity. We provide examples of comments that illustrate these themes in ‘I love my job and I love patient care.’ ‘I have enjoyed my clinical work and my contact with patients and other medical professionals.’ ‘I love my job. I hate bad days but they are few and far between. I see and hear people in a multitude of jobs and careers, few of them seem as satisfied as I am.’ ‘I would happily tell any [medical] student that they were joining a fantastic profession despite all the negative press and reports of poor morale.’ ‘General practice has given me a wealth of opportunities and experience. Working in a well-run practice with excellent partners and staff is a great privilege. I have been able to be a Medical Director, lead a PCG, chair an LMC, teach undergraduate students, be a GP trainer … no other job could have given me so many opportunities.’ ‘Persuaded by a colleague to change consultant posts – with very specific sub-specialization within my specialty. Have also developed new interests in medical education and management becoming a Clinical Tutor and subsequently Clinical Director. Have regained my enthusiasm … happily continue to work.’ ‘From being an inner city GP [description of responsibilities]
*
… I am now a full-time rural GP working in a group practice in a stunningly beautiful, purpose built building with [description of facilities available]*. While I found the changes very challenging it has been extremely invigorating and I am enjoying my job far more than I have done in a long time.’ ‘A lot of the time I feel that I am doing my job just to pay the bills and support 3 children.’
*We have removed these details to ensure that the identity of the respondent cannot be deduced. Percentages of NHS doctors not definitely planning to practise until the normal retirement age who gave each reason for considering early retirement and potential inducements to stay When a respondent indicated more than one reason or inducement, each has been counted. 1390/1494 (93.0%) of respondents cited reasons. 1395/1494 (93.4%) of respondents stated inducements. See footnote, Table 2
Concern about work-related ill health featured strongly, with 70% citing maintaining good health and 6% citing ill health as a reason for considering early retirement. Significantly more men than women cited maintaining their good health as an important factor (p<0.001). GPs and hospital doctors did not differ much in their main reasons for considering early retirement except that, in citing reasons, a higher percentage of GPs than hospital doctors reported that pressure of work (χ2
1=7.1, p=0.007) and reduced job satisfaction in working with patients (χ2
1=20.7, p<0.001) were factors that influenced their intention to retire early. In each survey almost half of respondents had made plans to facilitate early retirement (2004 survey: 48.2% (720/1494), 1998 survey: 45.1% (548/1216), χ2
1= 2.5, p=0.11) (Table 6). The doctors in the 2004 survey had adopted a greater variety of plans than those in the 1998 survey. 59.9% of the respondents in 2004 had organized several plans compared with only 25.1% of the respondents in 1998 (χ2
1= 145.4, p<0.001). In all, 65.4% of the 2004 respondents (vs 42.2% of the 1998 respondents, χ2
1= 64.2, p<0.001) had pension supplements, alone or combined with other plans, to supplement their NHS occupational pension; 51.9% had financial investments (vs 16.1% in 1998, χ2
1= 162.7, p<0.001); 50.8% had private pensions, (vs 52.5% in 1998, χ2
1= 0.3, p=0.58) and 10.8% had planned other ways of increasing retirement income (vs 16.9% in 1998, χ2
1= 9.0, p=0.003). 138 (19.2%) of the doctors in the 2004 survey had arranged a combination of pension supplements, private pension and financial investments, compared with only 7 (1.4%) of those in the 1998 survey (χ2
1= 90.1, p<0.001). Plans made by NHS doctors to facilitate early retirement; comparison between the 1977 qualifers and the 1974 qualifers Of those who had made retirement plans, 719 (99.9%) of the 1977 qualifiers and 514 (93.8%) of the 1974 qualifiers stated what they were. Further comments about inducements to stay were provided by 16.1% (225/1395) of 1977 qualifiers. Of these, 60 replied that nothing wouldpersuade them to stay to normal retirement age. Some wished to pursue other interests or indicated that they had overriding family commitments. Others explained that they were irreversibly disillusioned with working in the NHS ( ‘I have a keen interest in promoting health in central Africa.’ ‘I consider the possibility of working in Australia, New Zealand in the final years of my career for interest.’ ‘I want to pursue artistic activity.’ ‘Husband may decide to move or retire early.’ ‘My main reason for retirement is related to my husband not myself.’ ‘Exhaustion, burnout. No perceived opportunity for improvement.’ ‘Absolutely nothing will make me change my mind.’ ‘Nothing – too many changes occurring – too much bureaucracy/government interference/non-clinical matters to deal with on a daily basis.’ Hospital doctors were more likely than GPs to be encouraged to stay by improvements in working conditions (χ2
1=10.9, p=0.001) and a reduction of on-call commitments (χ2
1=41.1, p<0.001). GPs were also more likely than hospital doctors to be persuaded to stay if there were fewer changes imposed on their work in the NHS (χ2
1=10.1, p=0.001). The respondents in 2004 rated their job satisfaction reasonably highly (median score 19.5, on a scale from 5 [low satisfaction] to 25 [high satisfaction]); but satisfaction with time available for leisure was low (median score 4.6, on a scale from 1 [low satisfaction] to 10 [high satisfaction]). NHS doctors with high levels of job satisfaction (those in the highest quartile, with scores between 22 and 25) were more likely than those with medium levels (18 to 21, central two quartiles) or low levels (5 to 17, lowest quartile) to state a probable or definite intention to continue to work in the NHS to normal retirement age (63.2% vs 51.0% vs 34.7% respectively, χ2
2= 75.5, p<0.001). NHS doctors with above-average levels of satisfaction with leisure time (scores over 5) were more likely than those scoring 5 or below to state a probable or definite intention to continue to work in the NHS to normal retirement age (53.2% vs 46.7%, χ2
1= 7.2, p=0.007). 31.5% (563/1785) of NHS doctors reported having unmet needs for advice about planning their future. Low job satisfaction and low levels of satisfaction with leisure time were associated with unmet needs for career advice (p<0.001 in each case). Unmet needs for advice were reported by a higher percentage of women than men (38.0% vs 28.3%, p<0.001), and by a higher percentage of hospital doctors than GPs (33.6% vs 27.9%, p=0.01). Both factors were statistically significant, independently of one another, as shown by a binary logistic regression. The same percentage of doctors who worked full-time and of those who worked part-time expressed unmet needs for advice about their future plans (p=0.1). ‘IT training. Formal management training.’ ‘Further development within my subspecialty of [named subspecialty]*.’ ‘Help to take sabbatical through the NHS would be useful.’ ‘Update my skills and knowledge as a GP.’ ‘I would value an opportunity to meet with a peer group of my own age and stage, especially other clinical directors in [named specialty]*.’ ‘Need a mentor on a regular basis.’ ‘Some sort of continuing informal mentoring.’ ‘Opportunity to work part time/flexible hours prior to complete retirement.’ ‘Need to investigate flexible working.’ ‘Advice on continuing medical work beyond retirement.’ ‘Would be interested in something akin to the ‘Lady doctor retainer scheme’ so that I could work part-time after 60 … ‘Relicensing is a deterrent to going into part-time retirement.’ ‘No knowledge of different types of retirement.’ ‘Unsure what flexible retirement means.’ ‘[I] do not fully understand NHS pension scheme.’ ‘I have very little understanding of pensions, retirement etc.’ ‘Pension advice/planning/arrangements/predictions.’ ‘Need impartial, authoritative advice on how practice profits should be divided relative to workload undertaken by partners.’ ‘Technicalities of disposing of practice premises unknown.’ ‘I would like to provide locum cover … advice on whom to approach would be useful.’ ‘I'd like specific guidance on life with [named illness]* and my prospects for the future.’ ‘[Description of time off work for ill health]* … considered early retirement on grounds of health. May be able to negotiate contract with which I can cope.’ ‘Medically retired from GP due to [named illness]* … I would love to be able to return to treating patients so am currently applying to return on the flexible GP scheme.’ ‘[Named illness]* and family commitments mean I need to maximize income as I can while protecting health and somehow making adequate provision for pension … Want to work but feel limited by my circumstances.’
*See footnote, Box 1. About a third of the respondents who specified needs for advice wished to develop or change their career within medical practice (Box 3). Some respondents wished to enhance their existing skills, or gain new skills in areas like management or information technology. Nearly half (44.9%) of those who expressed needs for advice specified retirement issues (pensions, flexible working, flexible retirement or general retirement). Nearly a third specifically said that they needed more information about their pension. Other respondents commented on needs for advice about business issues (notably in general practice), and some commented on their need for help in working with, or following, ill health (Box 3). The respondents identified a number of barriers to seeking and receiving career advice. Some reported that there were few avenues for seeking advice. Some stated that they would benefit from advice on career development but that they had insufficient time to seek it. Others commented that their working environment would be unsupportive if they sought advice. Some expressed doubts about whether confidentiality would be respected if they sought advice from colleagues or management. Others questioned the impartiality of advice that would be given. Some respondents believed that their personal circumstances were so complicated that they felt that career advisors would be unable to address their particular needs. Some who had taken on substantial management responsibilities, such as a role as a medical director of a Trust, expressed concern that they might find themselves in a ‘cul-de-sac’ and have difficulty in returning to full time clinical practice. We found that many senior NHS doctors would like to reduce their working hours, less than a quarter definitely intend to work in the NHS to normal retirement age, and almost a third would have liked advice on planning for the future. Other research suggests that whilst intentions to retire may not necessarily translate into action,
5
,
6
there is a correlation between behavioural intentions and employee turnover.
7
A strength of our study was that we actually asked our respondents who were considering early retirement whether they had made definite plans to facilitate this. Many had implemented such plans. A further strength of our study is consistency with findings of related research. The mainreasons cited for considering early retirement included pressure of work and reduced job satisfaction as a result of management changes in the NHS. These findings confirm those of other studies.
5
,
6
,
8
The desire for a reduction in workload was consistent with our respondents‘ dissatisfaction with the time their job left for leisure activities. Previous research has suggested that high workload may be a key source of dissatisfaction among doctors in Britain.
6
A limitation of our study was that, although our response rates were high, we cannot discount the possibility of responder bias: it is possible that those who are less satisfied with their jobs than others, or more satisfied, were the more likely to respond. In England the Department of Health has recently introduced policies to promote more flexible working arrangements, and financial incentives, to defer retirement.
1
,
5
,
9
,
10
These changes
11
,
12
follow the recommended model of employees ‘downshifting’ later in their working lives and thus avoiding the problems of facing the ‘cliff-face’ of switching directly from full-time work to no work.
13
The new policies aimed at retention of senior doctors post-date our 1998 survey and their announcement pre-dates the 2004 survey. The increase in those intending to remain in the NHS until normal retirement age indicate that these policies may be having some effect in encouraging more senior doctors to work to or beyond normal retirement age. However, if senior doctors' stated intentions to reduce hours or retire early are realized, there are implications for workforce planning. Many doctors, even those starting to consider retirement, seem unsure about their pension entitlements. We were surprised by the number of respondents who spontaneously raised this with us. Given the sums that NHS staff pay into NHS pension funds, the NHS Pension Scheme should do more to inform doctors regularly about what their contributions have purchased. Policy on the provision of career advice fordoctors has been dominated by the needs of doctors-in-training. However, our survey shows that the need for advice about career development is career-long:
14
about 30% of respondents signified that they had unmet needs for advice. The areas of advice required include how to develop their careers as experienced and senior doctors; for some, how to change work commitments in ways that are consistent with family commitments or age-related disabilities; and on to how to prepare for retirement. The patterns of response about wanting to change job content, reduce hours, and seek early retirement may not be specific to the medical profession. A possible area for future research is comparative studies of different professions' attitudes to changes in working patterns and early retirement.
The authors are very grateful to each doctor who participated. We thank Janet Justice and Alison Stockfordfor their careful dataentry, and Emma Ayres for survey administrationSelected comments from NHS doctors who intend to work until normal retirement age
Great job satisfaction:
Change invigorating enthusiasm:
Work as a necessity:
Reasons for considering early retirement
Early retirement plans
Inducements to stay to normal retirement age
Examples of free text replies by NHS doctors to the question: ‘What might encourage you to stay until normal retirement age?’ when the respondents indicated that they would not be persuaded to stay.
Desire to pursue other interests:
Family reasons:
Suggesting irreversible disillusionment with working in the NHS:
Potential influence of job satisfaction on retirement intentions
Needs for advice about future career plans
Comments by NHS doctors about unmet needs for advice
Career development (similar comments from 168 doctors)
Counselling and mentoring (similar comments from 50 doctors)
Flexible working/flexible retirement/general retirement (similar comments from 159 doctors)
Pensions (similar comments from 72 doctors)
Business advice/financial issues unrelated to retirement (similar comments from 15 doctors)
Other including ill health (comments from 78 doctors)
Discussion
Principal findings
Strengths and weaknesses of study
Implications: doctors' future intentions
Implications: doctors' needs for advice on planning their future
Future research
Footnotes
DECLARATIONS
Footnotes
Acknowledgements
References