Completing the Picture Survey

Views of doctors who have stopped practising in the UK, why they left and what might encourage them to return

A collaboration between the General Medical Council (GMC), Health Education

England (HEE), Department of Health (Northern I reland), NHS Education for Scotland

(NES) and Health Education and Improvement Wales (HEIW)

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Contents Executive Summary............................................................................................................... 3

Background.......................................................................................................................... 5

Objectives............................................................................................................................ 5

Method ............................................................................................................................... 6

Findings............................................................................................................................... 7

Section 1 − What are the key demographic characteristics of doctors who have left UK practice? . 7

Section 2 − What are the key motivators and issues causing doctors to leave UK practice? .......... 9

Section 3 − Of those doctors who have left UK practice who/how many are likely to return? ......13

Section 4 − What are the barriers and enablers to return to UK practice? .................................18

Section 5 − Would a formalised return programme encourage their return? .............................22

Section 6 − Doctors migration ............................................................................................24

Section 7 - Equality, diversity and inclusion ..........................................................................28

Discussion...........................................................................................................................30

Conclusions.........................................................................................................................31

Acknowledgements..............................................................................................................33

Appendix ............................................................................................................................34

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Executive Summary Background

This report was developed in partnership between the General Medical Council (GMC), Health

Education England (HEE), The Department of Health (Northern Ireland), NHS Education for Scotland

(NES) and Health Education and Improvement Wales (HEIW).

We refer to the research as ‘Completing the Picture’ because it added the views of those doctors

who have stopped practising in the UK, to those views we already collect from doctors who are still

practising.

Objectives

The overall aim of the research was: To gain insight into doctors who were previously practising in

the UK but who are not currently doing so– in terms of their characteristics/motivations and their

likelihood to return to clinical practice in the UK.

Method

13,158 doctors completed the online survey from an identified population of 91,313. Those

responses were then weighted to best represent the whole population (in some cases we show the

weighted percentages and elsewhere where relevant we show the absolute numbers). Excluding

those who we couldn’t contact/we didn’t have a working email for we achieved a completion rate of

20.3%. All respondents had previously practised in the UK more than three months but less than 15

years ago at the point of completing the survey. They could still have been practising abroad, but

they had to have stopped practising in the UK.

Findings

There is a wealth of possible analysis within the data from such a large survey, but in this report, we

focus on the following findings.

• Over half of doctors who have left (55%) are still working clinically abroad, while 30% are

retired (of whom the vast majority are in the UK).

• Around a quarter of doctors are likely to return (24%), however, for the majority (59%) we

can be confident they will not return, as they said they are both unlikely and unwilling to

return.

• Of those who are likely to return, just 10% are currently in the UK, while the remaining 90%

are currently abroad, the vast majority of whom are currently working clinically (93%).

• By comparison, retired doctors in the UK overwhelmingly do not want to return (94%), with

only 1.3% showing some likelihood to return.

• The reasons for leaving are very varied with a mix of more ‘neutral’ reasons, such as

returning to their country of previous residence (32%) and retiring (26.8%), and more

negative reasons, such as burnout (27.2%) and dissatisfaction (35.7%). Other less common

reasons are also noteworthy, including bullying (5.5%) and harassment (3.1%).

• The barriers to return are quite similar to the reasons for leaving, but also include some

specific barriers where action might be taken to reduce them, such as lack of induction

(8.1%) or being unsure where to find information (5.2%).

• The research suggests there is some enthusiasm for some form of induction/return

programme. Such programmes could look to tap into some of the more practical barriers to

returning that the research has identified.

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• The region or country where doctors worked in the past had no appreciable impact on their

reasons for leaving/ barriers to return.

• GPs seemed to be slightly different to other roles and showed particularly high levels of

burnout. They are also less likely to return than other doctors (with only 9% of GPs likely to

return compared with 25% of specialists, 32% of trainees and 35% of ‘other’). This is likely

related to the fact that a greater proportion of GPs left due to retirement than other roles .

• We also saw a lot of differences by ED&I characteristics, for example, disabled doctors more

often reported bullying as a factor in why they left, some religious groups reported higher

levels of bullying/harassment, LGBTQ+ doctors more commonly reported mental health

issues, while males tended to report greater dissatisfaction and females greater burnout. In

fact, there were noteworthy differences across almost every characterist ic we looked at

• It is also noteworthy that a relatively small pool of countries account for a very large

proportion of doctors moving abroad − one out of six going to Australia and one out of

fifteen going to New Zealand − despite a very small proportion of doctors having originally

come from those countries.

Conclusion

This survey shows there are large numbers of working age doctors making the decision to stop

practising in this country, many of whom are working clinically abroad instead. And while it is

certainly true that a large number of these doctors are returning to a country they have previously

lived in, or simply taking a year out and intend to return, many others are moving to a new country.

For those who have retired, rather than just moved abroad, leaving the profession feels permanent

and very few having made this decision demonstrate a wish or likelihood of returning.

The results help us to understand some of the factors that may be playing a part in this. It is based

not on a set of reasons people might give for a possible intention to leave the UK or retire in the

future; it is based on the reasons given by people who have ‘voted with their feet’ and already left.

It’s beyond the scope of this report to assess which factors identified are the most amenable to

change, in terms of stopping doctors leaving UK practice or facilitating their return; or

recommending priorities or precisely which groups of doctors might best be targeted. But we hope

that it will prove to be a valuable source of information in deciding how to direct efforts to improve

the retention of doctors yet to leave and the return of doctors who have.

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Background The GMC was initially approached by Health Education England (HEE) to conduct a survey to better

understand doctors who were no longer practising in the UK. Aside from inputting into policy

decisions regarding workforce, it was hoped that the survey might also inform more immediate

decisions around the formalised return programmes/activities HEE offers to doctors.

The GMC was conscious that aside from helping HEE address the specific questions around doctors’

return, the research also offered the potential for much wider benefits, in terms of informing

workforce planning for example. Clearly, these benefits would not have been unique to England, so

the GMC felt it was important to make this a truly four country project and for that reason the GMC

approached stakeholders from Northern Ireland, Scotland and Wales to ask them to partner on this

research. This meant that the project included representation from the GMC, HEE, Health Education

and Improvement Wales (HEIW), NHS Education for Scotland (NES) and the Department of Health

(Northern Ireland).

From an initial scan of the existing literature, it became apparent that a survey of this type, and

certainly of this scale, was at the very least uncommon - perhaps unique, with only one similar

survey being found in the USA. We felt this made it all the more important to consider the wider

implications and uses of the research, given that we would effectively be producing a unique

resource.

We were also conscious that we needed to be realistic about our ambitions. While it was deemed an

extremely worthwhile project, the GMC plans its research annually and this project fell outside of

that window, which necessitated a proportionate approach. This meant that tough decisions had to

be made. For example, we decided that we wouldn’t have the resources to include free text

responses in the survey, as coding those to a sufficiently high standard, especially for the size of the

survey, would require significant resources that were not available to us. HEE had already done quite

significant amounts of qualitative work in this area, so with their input we were confident of being

able to design a closed questionnaire that would give respondents sufficient scope to express

themselves.

This was an exploratory study and therefore we were certainly under no illusions that we would be

able to provide complete and conclusive answers to the questions we were studying. But we felt

that we would be able to move the conversations forwards substantially.

In selecting which analyses from the extensive data set to focus on, this report benefits from

extensive sharing of findings prior to publication. This collaboration with stakeholders considering

issues around retention and encouraging doctors to return to the profession has been our priority

since the survey was completed. This report is therefore a record of key information that has been

found useful to these discussions.

Objectives The overall aim of the research was:

To gain insight into doctors who were previously practising in the UK but who are not

currently doing so– in terms of their characteristics/motivations and their likelihood to

return to clinical practice in the UK

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This overall aim was further expanded into 5 specific research questions, which the survey sought to

address:

1) What are the key demographic characteristics of doctors who have left UK practice?

2) What are the key motivators and issues causing doctors to leave UK practice?

3) Of those doctors who have left UK practice who/how many are likely to return?

4) What are the barriers and enablers to return to UK practice?

5) Would a formalised return programme encourage their return?

Method It was agreed that an online survey would be the most appropriate and proportionate approach. The

survey questions were hosted using SmartSurvey software. Respondents were selected to take part

based on data held on the GMC’s database and invited to take part via email. Each respondent was

sent an initial invite, and then up to two reminders based on whether they had already completed or

contacted us to opt-out.

The survey took approximately 15 minutes to complete (see Annex 4 for a copy of the full survey). It

consisted of purely closed questions, which covered the key research aims alongside demographic

information.

A total population of 91,313 doctors were identified on the GMC’s systems, of whom 13,158 met our

criteria and completed the survey. All respondents completed the survey between the 21 January

2020 and 10 March 2020, of which 87% had completed by the 3 March.

The primary criteria for inclusion were that doctors had to have previously practised in the UK

(minimum three months not practising, maximum of 15 years). They could however still be

practising abroad. For full inclusion criteria see Annex 1.

All results in this report come from weighting the 13,158 responses to best represent the whole

population of 91,313 doctors identified that have left UK practice. For our full approach to data

cleaning and analysis, please see Annex 1.

Please note: While all fieldwork was completed before the first national lockdown in March 2020,

given the timings of this research it is possible that the coronavirus (COVID-19) pandemic might have

affected doctors’ responses or their subsequent behaviour. E.g. doctors who said in the survey that

they wouldn’t return might have done, or vice versa. This must be considered when interpreting any

results.

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Findings We achieved a very large number of responses (13,158 doctors). In this report, we draw out findings

that we think will be of greatest general utility, but we have also included a substantial data annex,

which includes additional tables and data, alongside other forms of analysis we conducted which we

haven’t included in the main report (see Annexes 1 & 3). We’re happy to consider requests for

access to the data for further research.

Section 1 − What are the key demographic characteristics of doctors who have left UK

practice? The first question we wanted to understand was ‘who’ has decided to leave medicine in the UK –

and by that we mean “what are the characteristics of those doctors who have left?”, in terms of

their gender, role, etc.

While on the face of it this data appears relatively simple, i.e. the proportion of specific groups of

doctors who have left, it is slightly more complex. We surveyed doctors that have left over the past

15 years, so the patterns we see in the data don’t necessarily relate to the current makeup of the

workforce. Similarly, the data may represent demographic patterns of leavers that have shifted over

time. As a practical example we know that the register used to comprise a higher proportion of

males and a lower proportion of international medical graduates (IMGs) than it does now. These

differences are important especially when thinking about future desire to return, because, as we

shall see, factors such as whether someone is or isn’t an IMG do seem to have an impact on their

desire to return.

To make sense of the data, we have split it to show the proportions of doctors who left in the past

three years (at the point of completing the survey) and those who left before then. We have then

included an additional column with data pulled from the register to show the makeup of the

register. This enables a comparison with the doctors who have left over the last three years to show

if there are any noteworthy differences.

All respondents were also asked about their role and grade – it’s important to consider that this was

the doctor’s role and grade when they last worked clinically in the UK. Given that the respondents

may have left UK practice up to 15 years ago, many will now be working in a different role or at a

different grade. All the data is summarised in Table 12 in the appendix. Below we have pulled out

some key highlights.

Doctors have left at different stages of their careers: 32% of those who have left were specialists

and 25% were GPs. Alongside this, a fifth (21%) were trainees of whom the majority were in

specialty training (45%), followed by Foundation Year 2 (28%). A further 22% described their role as

‘other’.

More males have left, most likely reflecting changing demographics of the profession: A greater

proportion of males have left UK practice in the past 15 years than females (57.7% vs 42.3%). The

proportion of males who have left in the past three years is higher than you might expect from their

relative size as a group on the register (57.2% vs 52.1%). However, this is likely as a result of the

changing demographics of the profession (ie historically there were more males on the register). The

changing demographics of the register is also a likely explanation as to why a greater proportion of

white, Christian, and ‘No Religion’ doctors have left in the past three years, compared with their

relative size on the register.

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Disabled doctors’ experiences are noteworthy: A greater proportion of disabled doctors left UK

practice than their relative size on the register (10.1% vs. 5.9%). It’s possible that some of these

doctors developed a disability after they finished practising given the number of years that have

elapsed. However, this doesn’t seem to be the case. Of the doctors who left in the past three years,

disabled doctors make up a higher proportion than their relative size on the register (10.6% vs.

5.9%). It must be noted, however, that doctors on the register are less likely to disclose their

disability status1.

A high proportion of EEA PMQ doctors have left: A high proportion of European Economic Area

(EEA) primary medical qualification (PMQ) doctors chose to leave UK practice, compared with the

proportion on the register (23.9% vs 8.7%). An obvious conclusion to jump to here would be that

Brexit may have had an impact. However, when we look at the proportion of EEA PMQ doctors who

have left in the past three years, we see that it’s actually much lower than it had been previously

(18.8% vs. 25.9%). However, that’s not to say that with the potential impact of Brexit, this will not

change.

1 See Disability in the medical profession (bma.org.uk) for more details

Summary

Some groups of doctors have been more likely to leave in the past three years than their size in

the doctor population would suggest. Notably, these include disabled doctors, EEA PMQ doctors

and male doctors. It doesn’t necessarily mean that those factors determined their decision to

leave (it could be due to other related factors), however, the numbers are noteworthy.

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Section 2 − What are the key motivators and issues causing doctors to leave UK

practice? All respondents were asked why they decided to stop/take a break from practising medicine in the

UK. They were presented with a list of options, from which they could select up to five reasons. It

was the respondents’ choice whether they selected a single answer, or multiple, and the order in

which they selected them. The question was asked in a descending order, so that the first reason

was deemed the primary reason, with the second option being a secondary reason, etc. Figure 1

below shows the total percentages across all doctors selecting each in any order.

The list of reasons for leaving contains some which are fairly neutral and some which reflect a

positive life choice, such as maternity/paternity leave. But there are also extremely negative

reasons, such as bullying. So, while it is important to consider the most common reasons, some of

the less commonly mentioned reasons are arguably more significant and may well merit action to

reduce their prevalence.

Figure 1 – Reasons for leaving as an overall percentage (generalisable to the population of 91,313)

0.12

1.49

1.65

2.35

2.41

2.55

3.08

3.9

4.66

5.27

5.47

5.54

6.15

6.45

6.61

7.83

9.29

9.61

11.51

12.47

16.21

19.22

19.73

21.91

26.75

27.22

32.04

35.72

0 5 10 15 20 25 30 35 40

Sexual harassment

As a result of fitness to practise proceedings ( local or national)

Worry about being perceived as too old

Decided medicine is not the right career

Maternity/paternity leave

Mental health issues (other than burnout/stress)

Harassment (other than sexual harassment)

Out of Programme Activities/fixed term role

Visa issues

Non-clinical job opportunity (inc. charity/research)

Bullying

Disability, il lness, physical health

Childcare

Lack of less than full time/ flexible work arrangements

Pension concerns

Other caring responsibility

Needed time to contemplate future career path

Unhappy with work location/lack of choice about location

Regulation

Worry about errors/medico-legal risks

Financial reasons (e.g. don’t need to work, moved to better …

Other

Desire to move abroad

Family reasons (other than caring, e.g. partner has a new job)

Retirement

Burnout/work related stress

Returned to country of previous residence

Dissatisfaction with role/ place of work/ NHS culture

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When we look at the findings at this overall level several things stand out.

• The most common reasons are a combination of more negative reasons about working

environments (dissatisfaction 35.7% and burnout 27.2%) and more neutral reasons

(returned to a country of previous residence 32%, retirement 26.8% and family reasons

21.9%).

• However, many of the less commonly mentioned reasons are still extremely important and

still affect very large numbers of doctors (bullying 5.5% and harassment 3.1%).

• There are also some commonly mentioned reasons which, in theory, might be more easily

actionable or amiable to change, either within or outside of healthcare, such as pension

concerns (6.6%), worry about medico-legal risks (12.5%) and visa issues (4.7%)

Another approach we took to analysing the data is shown in Table 1 below. This splits the top 3

reasons for leaving each person gave into two groups (as opposed to looking at all 5 reasons they

could have given).

1. NHS factors: bullying; sexual harassment; harassment (other than sexual harassment);

burnout/work related stress; lack of less than full time/flexible work arrangements;

unhappy with work location/lack of choice about location; and dissatisfaction with

role/place of work/NHS culture.

2. Lifestyle factors: retirement; maternity/paternity leave; childcare; other caring

responsibility; family reasons (other than caring, e.g partner has a new job); returned to

country of previous residence; and desire to move abroad.

This helps us to understand the extent to which the decision to leave was driven by factors

associated with working in medicine in the UK vs. more personal lifestyle factors which are perhaps

harder to influence. The table further splits these groups into whether these doctors are now living

in the UK or abroad, and how likely or willing they are to return to practising in the UK. We explore

this further in Section 3.

Lifestyle and NHS factors 22% (20,273) Lifestyle factors 56% (51,409)

Likely Don’t know

Wants to but unlikely

Doesn’t want to and unlikely

Likely Don’t know

Wants to but unlikely

Doesn’t want to and unlikely

Abroad 17.5% 7.6% 3.3% 23.6% 25.9% 9.4% 5.1% 27.3% UK 2.7% 1.8% 2.8% 40.7% 1.8% 1.3% 1.3% 27.9%

Total 20.2% 9.4% 6.1% 64.3% 27.7% 10.6% 6.4% 55.3% NHS factors 12% (11,399) Neither 9% (8231)

Likely Don’t know

Wants to but unlikely

Doesn’t want to and unlikely

Likely Don’t know

Wants to but unlikely

Doesn’t want to and unlikely

Abroad 10.5% 7.1% 4.0% 24.6% 15.5% 6.6% 4.5% 21.9% UK 3.1% 3.7% 6.1% 41.0% 3.9% 3.7% 6.1% 37.8%

Total 13.5% 10.8% 10.1% 65.6% 19.4% 10.3% 10.6% 59.7%

Table 1: Reasons for leaving grouped into categories, showing likelihood/desire of return by country

currently living in2

2 The column headings are Q15 and Q16 merged, where ‘likely’ includes all those who responded ‘likely’, ‘very likely’ and ‘definitely will’ at Q16, and ‘unlikely’ includes those who responded ‘unlikely’, ‘very unlikely’ and ‘definitely won’t’.

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The data demonstrates that the majority of doctors leave for lifestyle reasons (56%), rather than

NHS factors (12%), with the former more likely to want to return to UK practice (27.7%) compared

with the latter (13.5%).

Another important point is that doctors who have left and now live abroad are overwhelmingly more

likely to return across all four groups than those who have left practice and remained in the UK. We

explore this further later.

As well as grouping the reasons for leaving, we also cut the data in different ways to see if different

types of doctors reported leaving for different reasons.

Substantial differences by role: There were some differences that you would expect, eg trainees

were much less likely to have left due to retirement. However, in other cases the differences were

more interesting.

• GPs were almost twice as likely to report burnout as a reason for leaving (42.8%) compared

with specialists (22.2%). However, their levels of dissatisfaction were similar (37.3% vs 36%).

• GPs were much more likely to experience worry about errors/medico-legal risks (24.3%)

compared with specialists (9.6%)

• Specialists also seem to be experiencing particular challenges, as they were much more likely

to report bullying as an issue (7.2%) than GPs (2.7%). See Figure 1 in Annex 3 for full data.

Differences by specialty are complex: It is much harder to unpick the differences in reasons for

leaving by specialty, as there appears to be a greater conflation of the demographic characteristics

of those groups. This is important because the data suggests that IMG doctors, EEA PMQ doctors

and BME doctors tend to report lower levels of burnout, for example. So it’s hard to unpick if it is the

demographic composition of the specialty, or the specialty itself, that is driving some of the

differences. Putting that caveat to one side though, there are some noteworthy differences.

• Public health shows relatively low levels of burnout (19.5%), which contrasts with the very

high levels of dissatisfaction (45.3%).

• Obstetrics and gynaecology shows particularly high levels of bullying (8.9%), while surgery

shows relatively high levels of harassment (5.6%).

• Radiology is a frequent outlier, with the highest reported level of worry about pensions

(12.8%), the highest proportion of mentions of financial reasons for leaving (26.2%) and the

highest level of worry about errors/medico-legal risks (14.3%). Although, it’s still lower than

for GPs. See Figure 2 in Annex 3 for full data.

Doctors with past fitness to practise issues showed some unique characteristics: They were

significantly more likely to report mental health issues compared with doctors who hadn’t had

previous fitness to practise issues (19.7% vs. 2.3%). They were also more likely to report burnout

(38.1% vs. 27.1%). And they were more likely to report bullying (23.6% vs. 5.2%) and harassment

(16.7% vs. 2.9%). See Figure 3 in Annex 3 for full data.

Differences by UK country last worked in were relatively small: Given the four-country focus of this

report, we also explored the differences based on the UK country where doctors last worked.

Broadly speaking, this showed that there were no appreciable differences between the four

countries. While there were some differences in the percentage responses for certain factors, these

differences were much smaller than we have seen when we split the data in other ways. See Figure 4

in Annex 3 for full data.

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We have further information on differences by different characteristics in the Equality diversity and

inclusion section.

Summary

• Doctors’ reasons for leaving UK practice are varied and complex, often with no

single reason fully capturing why.

• While many doctors leave UK practice for neutral, or even positive reasons, a lot of

doctors also leave for negative reasons (eg dissatisfaction, burnout and bullying).

• What we can also see is that these reasons are not evenly spread, with certain

groups of doctors being disproportionately affected.

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Section 3 − Of those doctors who have left UK practice who/how many are likely to

return? We explored this research question in several ways. Firstly, doctors were asked if they wanted to

return to UK practice, and secondly, they were asked how likely they thought they would be to

return.

After weighting the data to the total population of 91,313 doctors, around a third (35.2%, 32,142)

wanted to return. However, only around a quarter thought that it was likely they would (23.5%,

21,459). In this section, we will try to unpick these numbers.

We also built statistical models to help disentangle the factors that were most related to wanting to

return or not, and to the likelihood of returning.

The factors most strongly related to being likely to return to medical practice in the UK were that

doctors still held a license or remained registered with the GMC. Also, controlling for confounds,

being an IMG or EEA PMQ doctor was related to being more likely to return, compared with UK PMQ

doctors. Being retired, working in a non-clinical job, or working clinically abroad, were all strongly

related to being unlikely to return − it’s important to stress here that the important factor was that

they were practising abroad, not simply living abroad.

One factor that didn’t seem to have an impact was the UK country where doctors last practised, with

our model suggesting that the likelihood of return was no different across countries.

We also clustered doctors by the main variables highlighted by our modelling, plus willingness and

likelihood to return (see Annex 1 for details). Clustering indicated that in terms of wanting to return

and the likelihood to do so, doctors grouped most strongly around age groups, living in the UK or

abroad, and current work situation (retired, working clinically abroad or working non-clinically, etc.).

These findings helped us to focus our further analysis.

Relationship between desire to return and likelihood of return

Table 2 below shows the relationship between willingness to and likelihood of return. It highlights

that there’s a large concentration of doctors who don’t want to return and are unlikely to do so,

alongside a smaller, but still significant group who want to and are likely. But there are also doctors

whose position seems a bit more ambiguous, eg those who want to return but who are unsure and

even some who don’t want to return but are likely to do so.

Table 2: Relationship between desire and likelihood of return

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Likelihood and country of return

To further unpick the above data, Table 3 below combines likelihood and desire of return so that we

can see how the questions relate. This shows that for 59% of doctors, we can be confident they will

not return (given they don’t want to and they think they’re unlikely to do so). This means that there

is still a sizable proportion (around 40%) who might return, albeit only 24% are likely to do so.

What the table also shows is where in the UK those doctors would be likely to return to practice.

What is quite interesting is that there is a large number (4,804) who are likely to return, but who are

not sure where in the UK they would return to.

Likely Don't know Wants to but

unlikely Doesn’t want to

and unlikely

Don't know 4,804 2,993 1,195 6,009 England 13,935 5,405 4,368 15,977

Northern Ireland/ Other

310 70 83 366

Scotland 1,677 818 602 2,850 Unknown 100 21 129 27,893

Wales 643 152 169 744 Total 21,469 (24%) 9,459 (10%) 6,546 (7%) 53,839 (59%)

Table 3: Relationship between likelihood/desire to return and country doctors would return to

In the previous section, we highlighted that the majority of doctors who are likely to return are

currently living abroad. For this reason, we chose to break out the data based on where the doctors

are currently living – albeit the stronger association is whether they are practising clinically abroad,

but we felt this was a more useful split.

We were also interested in how long it had been since they last practised in the UK. It’s worth noting

that our modelling indicated that practising longer ago was only very weakly related to the doctor

being less likely to return. However, we felt it was important to include given the large number of

doctors who have been out of practice for a long time and who want to return. It also helps to give a

sense of possible induction needs. Tables 4 and 5 below split out these two factors.

Living abroad Living in the UK

Likely Don't know

Wants to but

unlikely

Doesn’t want to

and unlikely

Likely Don't know

Wants to but

unlikely

Doesn’t want to

and unlikely

Don't know 4,667 2,775 1,013 5,070 137 217 182 939 England 12,288 4,152 2,609 10,286 1,647 1,253 1,759 5,691 NI/ Other 268 50 34 222 42 20 49 144

Scotland 1,463 620 392 1,828 214 199 210 1,021 Unknown 91 21 35 5,657 9 *3 94 22,236

Wales 542 96 53 376 100 56 116 368 Total 19,319 7,714 4,136 23,439 2,149 1,745 2,410 30,399

Table 4: Relationship between likelihood/desire to return and country the doctors would return to,

split by where they are currently living

3 See Annex 1, page 6 for an explanation of blank spaces.

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Left three years ago or less (at the point

of completing the survey) Left over three years ago (at the point of

completing the survey)

Likely Don't know

Wants to but

unlikely

Doesn’t want to

and unlikely

Likely Don't know

Wants to but

unlikely

Doesn’t want to

and unlikely

Don't know 1,127 692 235 1,353 3,676 2,301 960 4,656

England 3,936 1,331 989 4,503 9,999 4,074 3,378 11,474 NI / Other 79 9 23 85 231 60 60 282

Scotland 555 202 131 848 1,122 616 471 2,002 Unknown 37 11 26 8,189 63 11 103 19,704 Wales 226 48 61 228 417 104 108 516

Total 5,960 2,293 1,465 15,206 15,508 7,166 5,080 38,634 Table 5: Relationship between likelihood/desire to return and country the doctors would return to,

split by how long since they last practised in the UK

The data in Table 4 reinforces the point made earlier, that the overwhelming majority of doctors

who are likely to return are currently living abroad. In fact, it’s almost ten times as many doctors.

Interestingly, the table also shows that there is a higher proportion of doctors living in the UK saying

that they don’t know if they will return, or saying they want to, but are unlikely. In fact, the latter

figure is actually higher than the number saying that they are likely to return.

Table 5 shows us that, of those doctors likely to return, just over a quarter left in the past three

years, compared with almost three quarters who left more than three years ago. This is an important

point, as while many of these doctors will have been practising abroad still, they may require

different induction needs than those who have been away from UK practice for less time.

Likelihood and role

Table 6 below shows doctors’ likelihood of returning split by the type of roles they would return to.

What is perhaps of note is the relatively small proportion (less than 10%) of doctors who said they

would be likely to return as GPs. Our modelling also suggests that having last been in a GP role was

weakly related to being unlikely to return. Four country splits of the data are available in Annex 3,

Tables 1−4.

Likely Don't know Wants to

but unlikely

Doesn’t want to and

unlikely

Doctor in training (including FY1/FY2) 3,476 1,354 1,094 4,902 GP (on the GP register) 2,076 1,535 1,286 18,975

Other 5,782 2,239 1,177 7,299 Specialist (on the specialist register) 10,135 4,332 2,989 22,664

Total 21,469 9,460 6,545 53,839 Table 6: Relationship between likelihood/desire to return and the role the doctors would perform

Separately, we asked doctors if they were to return, would they return to the same role/grade:

52.5% would, 29.5% wouldn’t and 18.1% were unsure. Around half of the trainees would return as a

different specialty (46.4%) and of those doctors, the vast majority (82.9%) would return as a

specialist. This is interesting because it suggests that a large number may have completed training

overseas.

16

Likelihood and specialty

Table 7 below shows which specialty doctors say they would practise if they came back to the UK4.

This table contrasts strongly with the data we saw split by role. By and large, when you compare the

relative size of the groups who left the register, they are very similar to the groups that report they

are likely to return. Four country splits of this data are available in Annex 3, Tables 5−8.

Likely Don't know Wants to

but unlikely

Doesn’t want to and

unlikely

Anaesthetics and intensive care medicine 2,261 894 644 4511 Emergency medicine 845 313 250 1,802

General practice 2,518 1,748 1,403 19,554 Medicine 2,623 812 457 4,065 Obstetrics and gynaecology 1,149 301 175 1,428

Occupational medicine 46 73 65 538 Ophthalmology 594 199 190 1,075

Other or multiple specialty groups 3,009 1,509 883 5,228 Paediatrics 1,503 595 316 2,420 Pathology 380 139 84 985

Psychiatry 1,155 575 423 3,396 Public health 126 144 69 675

Radiology 658 338 157 1,324 Surgery 3,131 1,336 899 4,452 Total 19,999 8,976 6,015 51,453

Table 7: Relationship between likelihood/desire to return and the specialty the doctors would return

as

Retired doctors are very unlikely to return

Earlier, we highlighted that only a minority of doctors are likely to return (24%) and that the majority

of those are currently living abroad. In the exploratory data, we see that many of the doctors living

in the UK are retired, and overwhelmingly those doctors are not likely to return. In fact, our

modelling shows that being retired was by far the factor most strongly related to being unlikely to

return, with only 6% of retired doctors saying they wanted to return and only 1.3% saying they were

likely to do so.

In theory, this could be related to age as much as to retirement status. But the modelling we

conducted on the data (see Annex 1) suggests that older age was only weakly related to being

unlikely to return, whereas being retired was the crucial factor. We believe this is important for

policy-makers, as retired doctors are sometimes characterised as ‘low hanging fruit’ in terms of

being potential candidates for return to practice. Whereas, this research supports a different

narrative; that many doctors who have retired have crossed a threshold and are very unlikely to

return to practice.

4 NB this table includes doctors where they had a given specialty, including doctors in training and doctors who stated ‘other’. It should be thought of as a best estimate of how many doctors would return to each given specialty.

17

What hours are they likely to work?

We saw in Section 1 that 61% of doctors worked full time, 24% worked less than full time and 15%

were locums. We asked the doctors if they were to return, on what basis would they do so. Doctors

who said they would definitely not return were not asked this question, so the results are

generalisable to a population of 63,280. This time only 47% said full time, 35% said less than full time

and 18% said locum. However, if we look only at those doctors who said they are likely to return

(21,469), then 58% said full time, 22% less than full time and 20% locum.

Our modelling indicates there is no difference in the likelihood of return between doctors who were

previously practising in a full time role compared with a part-time role. However, those who had last

practised as a locum were more likely to return.

Summary

• While around a quarter of doctors reported they are likely to return, there are

crucial differences between doctors with certain characteristics .

• Doctors wanting to return are over ten times more likely to be living abroad, as

opposed to in the UK. However, our modelling shows this is not because they are

abroad per se, but rather the driver is that they are practising abroad.

• By comparison, retired doctors are extremely unlikely to want to return to practice.

• 25% of the population who left were GPs. However, less than 10% of those who

said they were likely to return said they would work as a GP.

• There are limited differences in terms of the specialties doctors are likely to return

to, compared with the size of the groups who left. That said, around half of doctors

who left as trainees said they would return as specialists.

18

Section 4 − What are the barriers and enablers to return to UK practice? Firstly, we asked respondents what they were currently doing instead of practising in the UK. The

majority (56.1%) were practising clinically abroad; 29.6% were retired; 5.3% were working non-

clinically in a job requiring a medical degree; 5.2% were not working; and 4.8% were working non-

clinically in a job not requiring a medical degree.

This shows that despite stopping practising in the UK, the majority of doctors are now practising

abroad. This potentially provides evidence for the idea that some doctors have moved abroad due to

better working conditions. However, we know from elsewhere that, while that may be the case for

some doctors, a large proportion have also returned to a country of previous origin, or have moved

to a new country for other reasons (eg their partner’s job). So, we do need to be careful with our

interpretation (see more on this in the migration section).

As with the question on leaving UK practice, respondents were asked to select up to five reasons

why they might not return to practising medicine in the UK (see Figure 2 below). They could select as

many or as few reasons as they wanted, they just had to order their reasons giving the most

important first. The list of reasons was very similar to those asking why they left, but with several

additional options.

Figure 2 – Reasons for not returning as an overall percentage (generalisable to the population of

91,313)

0.09

1.31

1.5

1.79

2.04

2.58

4.48

5.15

5.23

5.35

5.57

5.69

5.82

6.29

6.31

7.07

7.72

8.13

8.17

8.4

9.26

11.25

11.36

14.4

19.48

19.69

20.8

21.19

24.89

25.86

35.47

0 5 10 15 20 25 30 35 40

Past experiences of sexual harassment

Out of Programme Activities/fixed term role

Mental health issues (other than burnout/stress)

Past experiences of fitness to practise proceedings (local or…

Decided medicine is not the right career

Past experiences of harassment (other than sexual harassment)

Disability, illness, physical health

Past experiences of bullying

Unsure where to find information

Non-clinical job opportunity (inc. charity/research)

Unhappy with previous work location/ lack of choice about location

Worry about being perceived as too old

Other caring responsibility

Nervousness about returning to practice

Pension concerns

No reasons for not returning

Lack of less than full time/ flexible work arrangements

Lack of available formal induction/ retraining programmes

Childcare

Unsure of future career path

Visa issues

Worry about errors/medico-legal risks

Worry about potential skill fade

Other

Financial reasons (e.g. don’t need to work, moved to better paid …

Regulation

Family reasons (other than caring, e.g. partners job)

Past experiences of burnout/ work related stress

Retired

Dissatisfaction with previous role/ place of work/ NHS culture

Happy in current country of residence (if outside the UK)

19

The pattern of reasons given for doctors not returning are very similar to those for leaving, with the

top five reasons being the same (albeit in a slightly different order). Being happy in current country

of residence now becomes the main factor, which is not surprising as it’s the combination of two

factors from the reasons for leaving (desire to move abroad and returned to country of previous

residence). We also see that the total percentage of doctors selecting those top five reasons is lower

than was the case for the reasons for leaving. The data seems to show that the reasons for not

returning are more ‘spread out’, with the less commonly selected reasons being selected more.

Other key highlights from this data

• A large proportion of the reasons for not returning relate to induction, worry and

nervousness: 11.4% worry about skill fade, 11.3% worry about medico-legal risks, 8.1% cite

lack of induction/retraining, 6.3% cite nervousness, 5.7% worry about being perceived as too

old, and 5.3% are unsure where to find information. In fact, 28% of doctors selected at least

one of these as a barrier to returning. This suggests that there could be benefits to focusing

on some of these factors, many of which could be picked up by related interventions or

initiatives.

• Many of the factors remain fairly stable in terms of their relative importance, however, two

do jump out when we compare reasons for leaving against reasons for not returning. These

are visa issues (4.7% vs 9.3%) and regulation (11.5% vs 19.7%). Given that these are quite

broad categories, it’s hard to pin down exactly what is meant for each and more work here

may be beneficial. See the migration section for more information on visa issues. In terms of

regulation, we know that some of this is likely related to the revalidation process, but it ’s

also likely to encompass things like inspections and broader concerns about ‘paperwork and

bureaucracy’ or The Annual Review of Competency Progression.

• Some factors are less commonly selected as reasons for not returning as opposed to a

reason for leaving, for example, both burnout and dissatisfaction reduce by about a fifth

each. It’s possible that as time has passed the impact of these factors has faded to some

extent, or their relative importance has reduced. However, that isn’t the case for all the

negative experiences reported, for example, bullying remains a strong barrier to return with

little reduction (5.5% vs 5.2%).

The relationship between why doctors left and how that compares with why they won’t return is an

important one. For further information on this, see Annex 1, where we have mapped the primary

reasons for leaving against the primary reasons for not returning in a Sankey diagram.

As with the reasons for leaving, we also grouped the top 3 reasons each respondent gave for not

returning to give us a better sense of how the different reasons relate and how commonly they are

picked together5. In Table 8 below we compare how the groups of reasons for leaving compare with

the reasons for not returning. Interestingly, we see a large drop in the proportion of people stating

lifestyle factors and an increase in the proportion of NHS related factors, alongside an increase in the

number saying neither.

5 NHS factors: past experiences of bullying, past experiences of sexual harassment, past experiences of harassment (other than sexual harassment), past experiences of burnout/ work related stress, dissatisfaction with previous role/ place of work/ NHS culture, lack of less than full time/ flexible work arrangements, unhappy with previous work location/ lack of choice about location, lack of available formal induction/ retraining programmes Lifestyle factors: retired, childcare, other caring responsibility, family reasons (other than caring, eg partners job), happy in current country of residence (if outside the UK)

20

Reasons for leaving Reasons for not returning

Lifestyle and NHS factors 22% (20,273) 18.1% (16,436)

Lifestyle factors 56% (51,409) 28.6% (26,109)

NHS factors 12% (11,399) 22.6% (20,656)

Neither 9% (8,231) 30.8% (28,085)

Table 8: Reasons for leaving and reasons for not returning grouped into categories, showing the

relationship between the two

In Table 9 below we have further broken down the reasons for not returning by current country of

residence and probability of return. We see that doctors living abroad are the most likely to return.

This is particularly the case for those who reported only lifestyle factors as a barrier. This contrasts

with those who reported only NHS factors as a barrier, who were the least likely to return.

Lifestyle and NHS factors 18.1% (16,436) Lifestyle factors 28.6% (26,109)

Likely Don’t know

Wants to but

unlikely

Doesn’t want to

and unlikely

Likely Don’t know

Wants to but

unlikely

Doesn’t want to

and unlikely

Abroad 23.6% 10.1% 5.2% 49.1% 30.0% 13.1% 7.8% 37.9%

UK 2.6% 1.3% 1.1% 7.1% 1.6% 1.0% 0.5% 8.0%

Total 26.2% 11.4% 6.3% 56.1% 31.7% 14.2% 8.3% 45.9% NHS factors 22.6% (20,656) Neither 30.8% (28,085)

Likely Don’t know

Wants to but

unlikely

Doesn’t want to

and unlikely

Likely Don’t know

Wants to but

unlikely

Doesn’t want to

and unlikely

Abroad 10.9% 5.7% 2.7% 14.6% 19.0% 5.1% 2.5% 8.8% UK 2.0% 2.8% 4.8% 56.4% 3.1% 2.4% 3.9% 55.2%

Total 13.0% 8.5% 7.5% 71.0% 22.1% 7.6% 6.4% 63.9%

Table 9: Reasons for not returning grouped into categories, showing likelihood/desire of return by

country currently living in

As with the reasons for leaving, we also split the reasons for not returning by various factors and

characteristics.

Substantial difference by role: Some of the barriers were very similar to the reasons for leaving, eg

GPs’ past experiences of burnout are a major factor, as are their worries about medico-legal issues.

But, there are also other noteworthy differences that help to give insights into why doctors are not

returning. Trainees experience particular challenges, for example, they were the most unsure where

to find information (8%), most likely to be dissatisfied with NHS culture (29.7%), most affected by

lack of flexible working arrangements (11.6%) and most affected by lack of choice about location

(10.6%). Trainees were also most likely to report being happy in their current country of residence

(55.8%). See Figure 12 in Annex 3 for full data.

21

Some specialties stand out:

• Emergency medicine doctors mention past experiences of burnout (20.5%), dissatisfaction

(23.1%) and bullying (5.9%) the most. They were also most likely to report a lack of flexible

working (11.3%) and a lack of choice about location (5.9%) as barriers to returning.

• Radiologists were most likely to mention visa issues (16.2%).

• Public health also stood out, although that is likely to be due to differences in the

demographics within the specialty, as they were much more likely to be retired than the

other groups. See Figure 13 in Annex 3 for full data.

As with the reasons for leaving, the differences between countries were insubstantial: There is

variation in some of the factors, however, these differences are relatively minor when compared to

the other ways we have split the data. See Figure 14 in Annex 3 for full data.

For further information on the data split by ED&I characteristics see Section 7.

Summary

• Aside from just thinking about the reasons for not returning, it’s also important to

consider that over half of the doctors are now working clinically abroad, and almost

a third are retired.

• Many of the same reasons are given for leaving as not returning and while some of the negative reasons do fade slightly in terms of how many doctors report them,

some hardly change at all, for example, bullying.

• Some groups stand out as having different experiences and challenges, eg GPs, trainees and emergency medicine doctors.

• There are also several reasons mentioned that might potentially be more amenable to intervention, including induction, addressing nervousness and the provision of

information.

22

Section 5 − Would a formalised return programme encourage their return? A key focus of this research was to assess the impact a potential formalised return programme might

have and to try and understand what doctors returning to practise in the UK might want from such a

programme.

For the following section, doctors who stated that they definitely wouldn’t return to UK practice

were not asked these questions, so the results are generalisable to a population of 63,280 as

opposed to the whole population of 91,313.

Initially, the doctors were asked if they were planning to return to practising medicine in the UK and

if a formalised return programme was made available, which was individualised to their needs, how

likely would they be to use it? Perhaps unsurprisingly, expected uptake was very high with 83.5%

saying they would be either likely (36.1%) or very likely (45.4%) to use it, which equates to 52,839

doctors. Only 11.9% said they would be unlikely to use and only 4.6% said very unlikely.

What was perhaps more interesting was the response when the doctors were asked to what extent

they agreed with the following statement: ’If I had the option to take part in a formalised return

programme, which was individualised to my needs, it would make me more likely to return to

practising medicine in the UK.’ 68.8% either agreed (40.8%) or agreed strongly (28%) with that

statement, while only 14.5% disagreed, 7.5% strongly disagreed and 9.1% didn’t know. This suggests

that around 43,537 doctors might be encouraged to return to UK practice if there was a return

programme suited to their needs.

It must be remembered though that the real-world impact on some doctors might be small, for

example where other factors preclude them from returning (such as family commitments). That said,

a lack of formal induction was identified as a barrier for 8.1% (of the whole population) and a

specific reason given why they couldn’t return. For some groups it was higher, for example, for those

doctors who said they wanted to return but were unlikely to do so (6,545 doctors), it was as high as

18.9%. So, while we must be cautious about the real-world impact at the overall level, it does seem

some groups might benefit from an induction programme.

Figure 3: Relative importance given to different elements of a potential return programme

23

Doctors were also asked what they would want from a return programme. The results are shown in

Figure 3 on the previous page. The headline findings concur with research the GMC published in

2020, which showed that too much focus was placed on the corporate elements of induction and

not enough was placed on local/departmental induction. There was also a sense that the quality of

IT/resources inductions should be improved to make them more relevant to how doctors actually

have to work.

When reviewing the above, it’s important to remember that the data is ordered based on the

proportion of doctors who said that each factor was ‘extremely important’. This is notable because

some of the factors, particularly the two on ‘formal teaching sessions’ , split opinion slightly more

and the results are more broadly spread. Also, taking together aspects that were extremely and very

important, buddying and networking with peers would rank higher.

Summary

• Perhaps unsurprisingly, the uptake of a potential induction programme for

returners to UK practice would be high.

• Significantly, a large number of doctors said it would potentially make them more

likely to return to UK practice – although some caution must be taken here in terms

of assessing the real-world impact.

24

Section 6 − Doctors migration Doctors were asked several questions relating to their past and present locations. These included:

where they were living at the point of applying for their PMQ, where they received their PMQ, and

where they were living at the point of completing the survey. Using the data, it was possible to map

their location changes using Sankey diagrams, which effectively show the flow of doctors across time

(see Figures 4 and 5 on pages 26 and 27). It must be remembered that, in between doctors gaining

their PMQ and answering the survey, all of them had worked in the UK clinically at some point. The

diagrams show a tremendous number of insights, the next few paragraphs try to highlight the most

noteworthy findings.

A small number of countries are attracting many doctors: Perhaps the most obvious and striking

finding is that roughly one out of three doctors who move abroad did so to one of four anglophone

countries. Of doctors moving abroad, about one out of six moved to Australia, one out of fifteen to

New Zealand, one out of twenty-one to the USA, and one out of twenty-two to Canada. This is even

more striking considering that only a relatively small percentage of doctors moving to these

countries originally gained their PMQ there (Australia 20%, New Zealand 15%, Canada 10%, and USA

9%). This implies that doctors moving abroad haven’t simply moved back to a country of previous

residence, but rather they have made a conscious choice to move to a new country.

UK-trained doctors are leaving: Both diagrams show that the number of doctors leaving the UK is

much larger than the number arriving. One out of three doctors who graduated in the UK (33%)

moved abroad. Of those, 85% were living in the UK at the time of applying for medical school, 8%

were living abroad and returned to that same country and 7% were living abroad and went to a

different country.

The majority of doctors moving abroad are working clinically: The vast majority of doctors who

have moved abroad are currently working clinically (91%). This shows that relatively few of these

doctors are ‘retiring to the sun’ for example, but rather they are continuing their medical careers

when they move.

Other findings: Figure 4 shows that some countries (eg India and Pakistan) have fewer doctors at the

point of being surveyed, than were trained there, which suggests that not all doctors return there

after working in the UK. While other countries, especially many of the European countries (eg

Germany, Spain, etc) seem to have a fairly consistent proportion of doctors returning after working

in the UK, although the Republic of Ireland is an exception. There are also some countries,

particularly the Gulf States (eg UAE, Saudi Arabia, Qatar), which show some smaller, but noteworthy

increases in the number of doctors.

Figure 5 shows that there seems to be a large outflow of doctors from London after qualification,

which is perhaps not surprising because it encompasses the largest PMQ bodies, but a smaller

proportion of post-PMQ jobs. Figure 5 also shows that doctors moving to another country come

from all UK regions in similar proportions. And lastly, that the number of doctors moving from

Northern Ireland to the Republic of Ireland after gaining their PMQ is quite small relatively. It is,

however, roughly the same as that of doctors moving in the opposite direction.

Visa issues: As shown in Section 4, we also collected data on the barriers to return to UK practice

and one of the main ones was visa issues, which was selected by 9.3% of doctors. Below we have

further broken down the data, by likelihood of return and where the doctor received their PMQ (in

Tables 10 & 11).

25

Overall Abroad UK

Three years ago or less

Over three years ago

PMQ → Non-UK

UK Non-UK

UK Non-UK

UK Non-UK

UK Non-UK

UK

Likely 3.9% 0.2% 3.9% 0.2% 0.0% *6 0.9% 0.0% 3.0% 0.2%

Don't know 1.5% 0.2% 1.5% 0.2% 0.0% * 0.4% 0.0% 1.1% 0.2%

Wants to but unlikely

0.8% 0.1% 0.8% 0.1% * * 0.2% 0.0% 0.6% 0.1%

Doesn’t want to and unlikely

2.2% 0.3% 2.2% 0.3% * 0.0% 0.4% 0.1% 1.8% 0.2%

Total 8.4% 0.8% 8.4% 0.8% 0.1% 0.0% 1.9% 0.1% 6.5% 0.7%

Table 10: Those doctors who stated that visa issues were a barrier to return, showing the

relationship between likelihood/desire to return against whether they had a UK vs Non-UK PMQ,

split by whether they are living abroad or in the UK, and length of time since leaving UK practice

(showing percentages)

Overall Abroad UK

Three years ago or less

Over three years ago

PMQ → Non-UK

UK Non-UK

UK Non-UK

UK Non-UK

UK Non-UK

UK

Likely 3557 224 3521 224 36 * 834 28 2722 196 Don't know 1362 178 1344 178 18 * 360 38 1002 140

Wants to but unlikely

751 107 751 107 * 158 19 593 88

Doesn’t want to and unlikely

2023 253 2023 244 * 9 384 51 1639 202

Total 7693 762 7639 753 54 9 1736 136 5956 626 Table 11: Those doctors who stated that visa issues were a barrier to return, showing the

relationship between likelihood/desire to return against whether they had a UK vs Non-UK PMQ,

split by whether they are living abroad or in the UK, and length of time since leaving UK practice

(showing absolute numbers)

Perhaps unsurprisingly, the data demonstrates that the vast majority of doctors who thought visa

issues were a barrier had a non-UK PMQ and are currently abroad. What is also interesting is that a

large proportion of this group is likely to return. In fact, only around a quarter said they didn’t want

to and were unlikely. This links to our findings from our modelling indicating that a non-UK PMQ

importantly relates to being more likely to return, as opposed to holding a UK PMQ.

6 See Annex 1, page 6 for an explanation of blank spaces.

Summary

• A small number of countries are attracting a disproportionately large number of

doctors.

• A substantial proportion of doctors that left had a UK PMQ.

• The vast majority of doctors moving abroad are working clinically.

• Visa issues are a barrier for a significant number of doctors currently abroad, many of whom want to return to UK practice.

26

Figure 4: Sankey diagram showing the migration routes of doctors

Practised

in the UK

Country where

applied for PMQ

from

Country where

gained PMQ

Country where

now living

27

Figure 5: Sankey diagram showing the migration routes of doctors split by UK region

Practised

in the UK

Country where

applied for PMQ

from

Country where

gained PMQ Country where

now living

28

Section 7 - Equality, diversity and inclusion We were very conscious throughout this project that there are many different ways of exploring and

cutting the data. Clearly, we need to know about differences in terms of location of last practice and

the role doctors were carrying out. But we must also consider the doctors themselves and whether

certain groups have had different and, perhaps, less favourable experiences.

Comparing directly the reasons for leaving or not returning of different groups shows some very

interesting patterns. There is evidence to suggest that differences do exist and, in some cases,

certain groups seem to have had worse experiences.

Given the huge amount of data we have collected, we couldn’t hope to capture all of it here. So

instead, we have highlighted some of the main differences by group, while the data annex has the

full data (see Annex 3). It must be remembered when reviewing the data that other confounding

factors have not been controlled for, so for example, differences relating to gender might be linked

to other factors, eg differences in specialty choices.

Gender

• Male doctors tended to be more motivated to leave by financial reasons (20.5% vs 10.3%)

and pension concerns (9.1% vs 3.2%). While for female doctors, childcare (9.9% vs 3.4%) and

maternity/paternity were more much common (5% vs 0.5%). Female doctors also tended to

be more burnt out (30.5% vs 24.8%). While male doctors tended to be more dissatisfied

(38.9% vs 31.4%).

• Barriers to return showed similar patterns. However, female doctors tended to report being

more nervous about returning (9% vs 4.3%).

Disability

• Concerningly, disabled doctors more commonly cited bullying (9.1% vs 4.9%) and burnout

(38.8% vs 25.7%) as a reason for leaving, compared with those without a disability. Mental

illness was also a much more prominent factor in disabled doctors leaving (13.7% vs 1.2%).

• Nervousness is more likely to be a barrier to returning for disabled doctors (9.8% vs 5.8%), as

is worry about skill fade (18.2% vs 10.6%).

Ethnicity

• BME doctors were more likely to state a desire to move abroad (26.3% vs 17.2%) and return

to a country of previous residence (44.4% vs 28.1%) as a factor in why they left, alongside

visa issues (14.2% vs 1.4%), compared with white doctors. Family reasons (other than caring)

was also a more significant factor for BME doctors (32.4% vs 18.3%).

• Particularly worryingly, harassment (5.4% vs 2.1%) and bullying (6.9% vs 4.9%) were also more commonly stated as a reason for leaving by BME doctors.

• Being unsure where to find information was frequently mentioned as a barrier to return by BME doctors (8.5% vs 4.1%).

PMQ

• Perhaps unsurprisingly, EEA PMQ and IMG doctors were more likely to report returning to a country of previous residence than UK PMQ doctors (54.8% IMG, 69.4% EEA & 4.8% UK),

with IMGs being more likely to report issues with visas (16.2% IMG, 1% EEA, 1.1% UK).

29

• Interestingly, both IMG and EEA PMQ doctors were less likely to report issues with burnout

(19.6% IMG, 13.1% EEA & 37.1% UK) and dissatisfaction (31.2% IMG, 28% EEA & 41.3% UK)

than UK doctors.

• However, IMGs were more likely to report both bullying (6.5% IMG, 5% EEA & 5.3% UK) and

harassment (5.4% IMG, 2.4% EEA & 2.3% UK) as a factor in why they left, compared with

both UK and EEA PMQ doctors.

• Reasons for not returning reflected similar patterns. However, worry about skill fade was

much more common for UK doctors, which possibly reflects differences in life stage and that

they were less likely to be currently practising (6.1% IMG, 4.8% EEA & 16.8% UK).

Religion

• Two key themes emerged where some religious minorities reported greater levels of

bullying (eg Sikhs 8.6% vs no religion 4.9%) and harassment (eg Sikhs 13% vs no religion

2.1%) as reasons for leaving.

• Most of the religious minorities are less likely to report burnout (eg 32.5% no religion vs

20.5% Buddhist) and dissatisfaction (eg 41.5% no religion vs 26.5% Buddhist); with Buddhists

and Muslims being two key examples. Interestingly, modelling of the groups who most

wanted to return suggested that being Muslim or Buddhist was strongly associated (see

Annex 1), albeit the modelling only controlled for PMQ region, rather than country of origin,

so there may be a higher degree of granularity to be found.

Sexual orientation

• LGBTQ+ doctors were more than twice as likely to report mental health issues as a factor in

why they left (6.2% vs 2.4%). They also more commonly experience burnout (33.3% vs

26.9%) and dissatisfaction (45.5% vs 34.8%).

• Their barriers to returning were broadly similar to their reasons for leaving.

The doctors who have left practice in the UK are a diverse group, and we provide strong evidence

here that some groups of doctors’ experiences have been different, often in a negative way. Any

strategy aimed at supporting doctors to continue practising, or to help facilitate their return must

recognise that diversity and address those different experiences.

Summary

• The medical profession is extremely diverse, however, there is strong evidence to

suggest that the experiences of certain groups of doctors differ. Some groups

clearly have more negative experiences, especially around issues like bullying and

harassment.

30

Discussion The data presented here provide some insights that may be useful to those considering priorities for

encouraging workforce retention or increasing the return of doctors who have already left.

Going beyond those saying ‘likely’ to return

While it’s perhaps simplest to focus on those doctors who say they are likely to return, it’s also

important to consider the analysis of those doctors who reported that they were unsure about

whether they are going to return (10.4%), or perhaps more interestingly, those who said that they

want to return but are unlikely to do so (7.2%). Figures 5 & 15 show these breakouts in Annex 3.

When we look at those who want to return, but who are unlikely to do so, we see that there are

several barriers that they are much more likely to state e.g. Regulation 30.1%, lack of

induction/retraining 18.9%, worry about skill fade 16.9%, lack of flexible work arrangements 13.1%,

nervousness 12.3%, unsure where to find information 11.5% and worry about being perceived as too

old 11.1%. This is interesting because, in theory, some of these barriers might be more amenable to

change than others.

GPs stand out as being slightly different

The results show that GPs are different from other roles or specialties. They report much higher

levels of burnout compared with other roles and, proportionately they are also less likely to return.

Our modelling indicated that being a GP had a minor, but separate contribution to being less likely to

return once other factors like demographics are controlled for. These findings should be factored

into any decision making when working out who or how to address some of these issues.

Retired doctors do not want to return, but some doctors working clinically abroad do

A large proportion of the population are now retired and those doctors are incredibly unlikely to

return. People sometimes suggest that retired doctors represent ‘low hanging fruit’ in terms of

returning to practise. This idea possibly stems from the notion that because they have not left for

negative reasons, there is nothing stopping them from returning. However, our results suggest that

this is overwhelmingly not the case.

Our modelling demonstrates that, when you control for other factors including age, being retired is

the strongest factor related to being unlikely to return and not wanting to return. This finding

supports a different narrative, namely that retiring from the profession represents a major

emotional and psychological threshold for doctors, and that once the decision has been made to

retire, it is not an easy thing to come back. This may help to explain why such a high proportion of

those who want to return – and say they are likely to return – are currently working clinically abroad,

rather than retired in the UK.

Going beyond the headline reasons

Some of the most mentioned reasons for doctors leaving are retiring and moving back to a country

they have previously lived in. But, there’s also a cluster of negative reasons relating to the workplace

or job itself. Some are felt by large numbers, such as general dissatisfaction and burnout; and other

less often mentioned but also very serious reasons such as bullying and harassment. Furthermore,

many of the less commonly mentioned reasons for not returning may be some of the more easily

actionable ones such as a lack of induction or being unsure where to find information. If all of these

smaller issues were tackled, the difference in retention and encouraging return could be significant.

31

Equality, diversity and inclusion is an important consideration

Any efforts put in place to address some of these issues must also consider ED&I. This is not only a

legal and moral imperative, but also a practical one. The results demonstrate that certain groups of

people seem to be disproportionately experiencing some of these factors, for example:

• disabled doctors reported bullying as a bigger factor in why they left

• some religious groups reported higher levels of bullying/harassment

• LGBTQ+ doctors more commonly reported mental health issues,

• males tended to report greater dissatisfaction and females reported greater burnout.

In fact, there were noteworthy differences across almost every characteristic we looked at.

There is enthusiasm for induction/return programmes

As we have seen, there is enthusiasm for effective induction programmes, both in terms of likely

uptake, but also because it might make some doctors more likely to return to practise in the UK. We

do have to be careful with this finding, as the question doctors were asked didn’t quantify how much

more likely it would make them return. However, given that a number of doctors (7,424) flagged lack

of induction as a barrier to return, it is likely that such programmes would have some effect. This

could particularly be the case if they helped to address some of the barriers identified in this

research, for example, around some of the more psychological barriers preventing a return. This

concurs with research the GMC published last year on induction.

A small number of countries attract a large number of doctors

The migration data show that a great number of doctors return to a country where they have

previously lived, when they leave the UK. However, we also see that a small handful of advanced

economies (primarily New Zealand, Australia, Canada and the USA) have attracted a huge number of

doctors, vastly larger than the number of doctors who originally came from those countries.

While we can’t tell from this research what made those countries so attractive, the GMC has

conducted other research that gives some clues. It will be published later this year. Given the global

shortage of doctors, it’s important to consider what makes different countries more or less

appealing to practise in.

Conclusions This survey shows there are large numbers of working age doctors making the decision to stop

practising in the UK, the majority of whom are working abroad instead. And while it is certainly true

that many of these doctors are returning to a country they have previously lived in, or simply taking

a year out and intend to return, many others are moving to a new country. In fact, a very small pool

of developed countries accounts for a large proportion of the doctors working abroad. The research

also shows that for many, the decision to retire feels permanent, and very few having made this

decision demonstrate a wish or likelihood of returning.

The data helps us to understand some of the factors that may be playing a part in this. The research

is not based on a set of reasons people might give for a possible intention to leave the UK or retire in

the future; it is based on the reasons given by people who have ‘voted with their feet’ and have

already left.

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It’s beyond the scope of this report to assess which factors are the most amenable to change, in

terms of stopping doctors leaving UK practice or facilitating their return; or recommending priorities

or precisely which groups of doctors might best be targeted.

But what we can see is that there is enthusiasm for induction programmes and that there are many

reasons why doctors leave or don’t want to return – some of which are potentially more actionable

than others. Ultimately, we hope that it will prove a valuable source of information in deciding how

to direct efforts to improve the retention of doctors yet to leave and the return of doctors who

already have.

33

Acknowledgements The GMC would like to thank all those who contributed to the development of this research project

and the creation of this final report:

• Angie Oliver

• David Darton

• Dean Riddell

• Divya Mishra

• Javier Caballero

• Kerrin Clapton

• Madhu Kannan

• Peter Barbour

• Rachel Rummery

• Sheona MacLeod

• Steve Loasby

• Stewart Irvine.

The GMC would also like to thank the following partner organisations:

• Health Education England (HEE)

• The Department of Health (Northern Ireland)

• NHS Education for Scotland (NES)

• Health Education and Improvement Wales (HEIW).

The GMC would also like to give special thanks to Rachel Rummery, whose past research and

expertise in this area made an invaluable contribution to this project.

34

Appendix Table 12: Characteristics of those doctors who have left the UK practice

Characteristics of doctors

who have stopped practising in the UK

From survey (weighted data) From GMC database

Total

Practised more than three

years ago (at point

of completing survey)

Practised less than three years

ago (at point of

completing survey)

Registered with Licence as of 23 Jan

2020

Gender

Male 57.7% 57.9% 57.2% 52.1%

Female 42.3% 42.1% 42.8% 47.9%

Disability

Disability? Yes 10.1% 10.0% 10.6% 5.9%

Disability? No 87.9% 88.1% 87.5% 90.2%

Disability? Prefer not to say

2.0% 1.9% 2.0% 4.7%

LGBTQ+

LGBTQ+? Yes 3.8% 3.6% 4.4% 3.0%

LGBTQ+? No 89.0% 89.1% 88.6% 86.9%

LGBTQ+? Unknown/ Prefer not to say

7.2% 7.3% 7.0% 11.0%

Ethnicity

White 72.3% 71.7% 73.9% 57.8%

BME 25.2% 25.8% 23.6% 42.2%

PMQ region

UK 52.4% 49.4% 60.5% 64.9%

EEA 23.9% 25.9% 18.8% 8.7%

IMG 23.6% 24.7% 20.7% 26.5%

Religion

Christian 41.7% 42.3% 40.2% 33.4%

No religion 35.6% 34.7% 38.2% 27.1%

Muslim 7.0% 7.1% 6.8% 15.9%

Hindu 6.5% 6.8% 5.6% 9.5%

Prefer not to say 4.3% 4.2% 4.3% 9.3%

Buddhist 2.6% 2.6% 2.7% 2.0%

Jewish 1.0% 0.9% 1.2% 0.8%

Other 0.9% 1.0% 0.8% 1.1%

Sikh 0.4% 0.4% 0.3% 1.0%

35

Figure 1 (cont.) – Characteristics of those doctors who have left

Age

<35 26% 27% 22% 32.3%

35 − <45 26% 29% 19% 29.3%

45 − <55 15% 16% 13% 22.0%

55 − <65 31% 28% 41% 12.9%

65+ 2% 0% 5% 3.5%

Role

Specialist 32% 32% 34% 30%*

GP 25% 24% 26% 24%*

Trainee 21% 22% 18% 23%*

Other 22% 22% 22% 23%*

Training grade (only asked of those who stated they were a trainee – 21% of the population)

Specialty training 44% 47% 36% 43.8%**

Foundation Year 2 28% 26% 36% 11.5%**

Core training 13% 12% 17% 12.9%**

Foundation Year 1 11% 12% 9% 11.8%**

GP training 3% 3% 2% 20%**

Specialty (% based on those who stated they were a specialist or were licensed as one)

Other/multiple 17% 17% 16% 0.1%* Surgery 17% 17% 16% 17.6%* Anaesthetics + intensive care

13% 13% 13% 13.1%*

Medicine 13% 13% 13% 26.9%*

Psychiatry 9% 9% 9% 10.2%* Paediatrics 8% 8% 10% 7.6%* Obstetrics + gynaecology 5% 5% 5% 5.1%* Emergency medicine 5% 5% 4% 3.1%*

Radiology 4% 4% 4% 7.6%* Ophthalmology 3% 3% 3% 2.9%* Pathology 2% 2% 3% 3.7%* Public health 1% 1% 2% 1.3%*

Occupational medicine 1% 1% 2% 0.7%*

Working pattern

Full time 61% 63% 55% N/A

Less than full time 24% 22% 30% N/A

Locums 15% 15% 15% N/A

* Some doctors hold more than one of these statuses. For instance, a doctor may be simultaneously

registered and licensed as a GP, a surgeon, and be training for another specialty. Therefore, these

percentages sum to a value larger than 100%.

** Due to the refresh date of the data, these numbers are as of 24th Mar 2020