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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 22-October-2004, Vol 117 No 1204

Physician job satisfaction in New Zealand versus the United Kingdom
Paul Grant
Abstract
Aims To compare and contrast levels of job satisfaction and job-related stress between doctors in New Zealand (NZ) and the United Kingdom (UK).
Methods Self-administered questionnaire to 593 NZ doctors and 795 UK doctors. Job satisfaction was scored using the Warr, Cook, and Wall scale. Job stress responses were correlated to satisfaction scores.
Results Overall, job satisfaction levels were high; however, UK hospital physicians were found to be significantly less satisfied with their work than both NZ physicians and surgeons. Satisfaction with work was found to vary with working hours, amounts of paperwork, level of governmental interference, and time spent in public or private practice.
Conclusion Doctors in the UK face greater difficulty in gaining satisfaction from their work, as exemplified by the subgroup of UK physicians. This is due to a complex array of factors including conditions of the working environment and sociopolitical factors that are absent or minimal in New Zealand.

There is an ongoing debate regarding whether doctors still retain their dominance in the healthcare world, and whether they still have their autonomy to set work conditions and make clinical decisions. The growing international literature signifies great variation in the impact of stress, job satisfaction, psychological symptoms, and morale on health professionals around the world.
New Zealand (NZ) and the United Kingdom (UK) have similar health services. Indeed, for many reasons (economic, experiential, working conditions, relationships), many NZ doctors transfer to the UK and visa versa. However, while both countries have faced the changes and challenges associated with significant health reforms, little published information remains the relative occupational satisfaction between NZ and UK physicians.
In 2001, a study by Dowell1 explored satisfaction and psychological stressors among NZ health professionals and found that doctors were generally satisfied with their jobs, although there were ever-present levels of psychological morbidity. In contrast, work by Davidson2 and Ramirez3 shows a downward trend of job satisfaction and increasing stress in UK doctors.
Dissatisfaction is a big concern among physicians, even if medical work pays well and medical schools still have an abundance of medical students—important factors in maintaining a high quality of care.
Current dissatisfaction may forecast future declines in numbers of practitioners within a speciality. Also, if prolonged, it may lead to health problems for the physicians themselves.4 Finally, dissatisfied doctors may be more inclined to ‘unionise’ and strike, which occurred in the town of Timaru (in South Canterbury, NZ) in 2003.5
Because of the ongoing transfer of UK and NZ doctors, we felt it was important to analyse directly levels of occupational satisfaction among physicians from both countries, using the same tools and discover whether any lessons can be learnt. There are implications for physician training, retention, working conditions, and (ultimately) patient care.6

Methods

Contact details for all doctors surveyed were obtained from the human resources departments of each Hospital Trust. In total, 757 physicians and 631 surgeons responded (92% of the total).
In the UK, the East Sussex and East Kent Hospitals Trusts were surveyed—a total of 795 doctors (57% of the total study population). In New Zealand, doctors from the Canterbury Health district and South Canterbury district were surveyed—a total of 593 doctors (43% of the total study population). See Table 1 for a full list of hospitals from which doctors were sampled.

Table 1. Hospitals surveyed

United Kingdom Hospitals
East Sussex Hospitals Trust—Conquest Hospital, Hastings; Eastbourne Hospital, Eastbourne.
East Kent Hospitals Trust—William Harvey Hospital, Ashford; Kent & Canterbury Hospital, Canterbury; Buckland Hospital, Dover.
New Zealand Hospitals
Canterbury District Health Board—Christchurch Hospital, Christchurch; Christchurch Women’s Hospital, Christchurch.
South Canterbury District Health Board—Timaru Hospital, Timaru.

Questionnaires were sent to doctors between January 2003 and April 2004. Questionnaires were numbered to allow the tracking of returns, but were completed anonymously to allow full disclosure. The questionnaire had been validated in several previous studies of physician job satisfaction,1,7,8 and it contained three distinct sections; demographic information, job satisfaction questions, and questions regarding sources of stress.
Job satisfaction was measured on the Warr, Cook, and Wall scale9 and questions scored on a seven-point Likert scale. Stress was similarly scored with questions exploring emotional stressors for physicians and their frequency. Responses ranged from ‘never’, to ‘sometimes’ to ‘everyday’.
To compare and contrast the perceived level of governmental interference in doctors’ practice, doctors were also asked to indicate whether they felt (in the past year) government funding had affected the level of patient care they were able to provide.
The data were analysed using Microsoft Access and SPSS (Statistical Package for the Social Sciences) software. Association between the variables were analysed with Spearman rank correlation coefficients. Group medians were used to enable comparison between groups. P values were all two-sided and calculated using the non-parametric Kruskal-Wallis tests. Statistical significance was set at the 0.05 level.

Results

Response rate—The final sample sizes were 795 for UK doctors and 593 for NZ doctors, with a response rate for completed questionnaires of 94% and 90%, respectively.
Demographics—Information on the demographic characteristics of both groups of doctors is shown in Table 2. Age and sex profiles were comparable between the two groups.
Job satisfaction (Table 3)—Overall, UK doctors (median score total=79) were less satisfied with their jobs than NZ doctors. There was a significant difference between the job satisfaction of UK physicians (median score=33) and NZ physicians (median score=51), (χ2=90, p<0.001). There was no significant difference between the satisfaction of UK surgeons (median score=46) and NZ surgeons (median score = 50).
Impacts of job stress (Table 4)—Compared with NZ doctors, UK doctors are significantly more likely to have contemplated giving up their job due to work stresses. UK physicians, in particular, were found to be less interested in their work secondary to job stress, and felt less able to stay in control at work than UK surgeons and NZ physicians and surgeons. For UK surgeons and NZ physicians/surgeons, median seven-point Likert scales scores (where ‘1’ is highly stressful) were 3 (2–5) and 4 (3–5), respectively.

Table 2. Demographic details of doctors

Variable
NZ Physicians
n=342
NZ Surgeons
n=251
UK Physicians
n=415
UK Surgeons
n=380
Male
256 (74%)
237 (94%)
336 (81%)
349 (91%)
Mean age
42.4 (9.5)
48.8 (10.1)
47.2 (8.3)
49.0 (9.9)
Mean years in occupation
18.0 (7.0)
24.5 (9.6)
22.7 (10.1)
23.9 (8.9)
Mean on-call days per month
6.5 (4.2)
7.1 (6.3)
6.9 (3.9)
7.5 (6.1)
Mean total hours worked per week
56.0 (22.4)
63.6 (17.0)
65.0 (12.9)
69.0 (18.8)
Mean time spent in public work (%)
80.3%
58.2%
84.0%
55.3%
NZ=New Zealand; UK=United Kingdom.

All UK doctors reported problems—specifically they reported higher levels (compared to NZ doctors) of paperwork and bureaucracy (median Likert score of UK doctors was 3 [2–5] vs NZ doctors’ median score of 4 [3–6]), and busy outpatient clinics
Both UK and NZ physicians reported more financial concerns than surgeons, and (on average) they spent more time in the public sector than the private sector.
When asked whether work interfered with family time and social life, all NZ and UK groups scored highly, although there was no significant difference between them.
There was a significant correlation between measures of job satisfaction and responses to the job stress questions for both UK and NZ doctors. Low job satisfaction correlated well with feeling unable to remain competent at work (r=−0.34; −0.32 respectively), frustration with bureaucratic interference (r=−0.40; −0.35 respectively), and disinterest in work due to job stresses (r=−0.26; −0.22 respectively).

Table 3. Median job satisfaction scores (WCS scale)1,2,3

Variable
NZ Physicians
n=342
NZ Surgeons
n=251
UK Physicians
n=415
UK Surgeons
n=380
Amount of variety in work
5 (4–6)
5 (4–6)
4 (3–5)
6 (4–7)
Physical work environment
6 (5–7)
6 (4–7)
4 (3–5)
5 (4–6)
Amount of responsibility given
6 (5–7)
5 (4–7)
3 (2–5)
5 (4–6)
Opportunity to use abilities
6 (5–7)
6 (4–7)
3 (2–5)
5 (4–7)
Colleagues and fellow workers
6 (5–6)
6 (5–7)
3 (2–5)
5 (4–6)
Freedom to choose own method of working
6
6
4
6
Recognition you get from your good work
6
6
3
5
Amount you earn
4
6
3
6
Hours of work
5
5
3
3
Total score
50
51
33
46
NZ=New Zealand; UK=United Kingdom, WCS scale=Warr, Cook, and Wall scale; Each question scores from 1-7, high score equals more satisfaction.

Table 4. Job stress. Comparisons between responses to descriptive statements.

Variable
NZ Physicians
%
NZ Surgeons
%
UK Physicians
%
UK Surgeons
%
Contemplated giving up work because of job stress
2 (1–4)
15%
2 (1–4)
18 %
3 (1–4)
22%
3 (1–4)
20%
Disinterested in work due to job stress
2 (1–4)
16%
3 (2–4)
20%
4 (3–5)
35%
3 (2–4)
22%
Felt unable to remain competent at work
2 (1–4)
11%
2 (1–3)
10%
4 (3–5)
30%
2 (1–4)
13%
Felt overwhelmed by paperwork
3 (2–6)
35%
4 (2–5)
33%
6 (5–7)
79%
5 (4–6)
60%
Felt stressed by financial concerns
3 (2–4)
24%
2 (1–4)
12%
4 (3–6)
38%
3 (2–4)
21%
Felt frustrated by bureaucratic interference
4 (3–6)
54%
5 (4–6)
58%
6 (4–7)
76%
6 (5–7)
79%
Has work interfered significantly with family / social life
5 (4–6)
54%
5 (4–6)
60%
5 (4–6)
58%
5 (4–6)
66%
Do you set aside time for stress relief
3 (2–4)
20%
3 (2–5)
24%
3 (3–4)
28%
3 (2–5)
30%
Likelihood of not repeating career choice again
3 (2–4)
18%
2 (1–4)
13%
4 (2–5)
31%
3 (2–5)
28%
Effect of government funding on patient care
4 (3–5)
32%
4 (4–6)
46%
5 (4–7)
60%
5 (4–6)
47%
Percentage of respondents who felt that work had affected their health
30.8%
32.5%
47.1%
39.9%
NZ=New Zealand; UK=United Kingdom. Median and (quartile range) % = percentage scoring greater than the midpoint on the Likert scale; First eight questions scored 1–7 on a Likert scale, 1=never 7=everyday; Second-to-last question, scored 1–7 on a Likert scale, 1=definitely 7=definitely not.

In terms of the likelihood of not repeating the same career choice again, UK physicians scored higher than the other groups, but not significantly so.

Discussion

With regards to the sample population and high response rate, this survey can be seen as representative of doctors in the South Island of New Zealand and the South-East region of the UK. Larger sampling frames would be required to give a fuller account of each national picture. However, the results are inferential for the situation in both countries.
Overall, levels of job satisfaction were high for all groups, with the exception of UK hospital physicians who were found to be significantly less satisfied with their work than NZ doctors. Both UK physicians and surgeons scored higher on parameters of job stress and notions of governmental interference in their work. The implication is that working in the UK is a more difficult and less rewarding experience. Certainly that is the implication for the UK physicians in the study population.
Gender differences were not analysed in this particular study despite their being a roughly equal distribution of male and female doctors. However it was felt to be beyond the scope of this paper to deal with the real and perceived differences in job satisfaction related to gender issues. Also it is important to mention that we have missed the biggest source of potentially dissatisfied doctors in both countries—ie, those doctors who have left the medical profession altogether.
A future study comparing international differences in the reasons behind doctors leaving work would provide much ‘food for thought’.
The results from this survey are consistent with other studies—where job satisfaction for NZ doctors is relatively high,1,7,8 and job stress is average. UK doctors, however, have generally shown to have lower satisfaction and higher job stress.2,3,6
Despite the job satisfaction levels, many of the questionnaire responses are concerning. In all of the doctor groups, significant numbers of doctors had often contemplated leaving the medical profession.10 From the comments and low satisfaction scores (for hours of work and recognition for work performed), clearly many doctors feel they work in an unrewarding environment.11
Both UK and NZ doctors were more likely to be satisfied if they maintained clinical autonomy, were paid what they wanted, did not have excessive bureaucratic interference, and believed they were getting adequate recognition for their work.
This is supported by the extensive research of the Society of General Internal Medicine (SGIM) Career Satisfaction Group who developed a current and comprehensive model of physician job satisfaction in the United States.12,13 That Group highlighted similar concerns, including doctors’ worries about the effects of ‘managed care’ on the doctor-patient relationship (something not touched upon by our own study). The ability of doctors to provide quality care, and the centrality of their relationships with colleagues as well as patients were also considered important.
Whenever doctors are surveyed about job satisfaction, the same issues always emerge and prove contentious. Direct comparison of job satisfaction and job stress levels between NZ and the UK proves extremely interesting because it demonstrates the relative differences in success and satisfaction with work, irrespective of the many similarities in the respective health services.
Certainly, the UK suffers from many sociopolitical factors that exemplify the difficulties of working in the National Health Service (NHS).14,15 These factors may be absent or minimal in New Zealand, hence NZ doctors have relatively greater job satisfaction.
In the UK, doctors’ perceived problems include
  • A notably larger population and more urban centres—with disease and social problems relating to depressed socioeconomic status,16
  • Greater outsourcing of healthcare services to third parties,
  • Longer waiting lists,
  • Larger patient caseload (as inpatients and outpatients),
  • Negative media image and publicity about the National Health Service (NHS),
  • European working-time directives necessitating employment of more non-training grade doctors,
  • Greater governmental interference with medical practice—ie, waiting-list targets and false outcome indicators such as waiting times in accident and emergency (A&E) departments,
  • National disagreement over consultant contracts, and
  • Restrictions on private practice commitments.
The above issues are far less evident in the NZ health service—due to the smaller population pressures, the relative geopolitical isolation of NZ, and the arguably more favourable working environment enjoyed by NZ doctors.17
Compared with doctors in New Zealand, our study demonstrated that doctors in the UK experience greater job stress, particularly the UK physicians subgroup who have a significantly lesser degree of job satisfaction. The reasons for this dissatisfaction are multifactorial but have important implications for the UK NHS in terms of retaining its doctors, helping to reduce stress, and psychological morbidity.17,18
Doctor dissatisfaction affects everyone. In New Zealand, important lessons must be learnt as, although New Zealand may be regarded as a better place to work, increasing numbers of NZ doctors are (paradoxically) leaving to work abroad in countries such as the UK. By tackling the above issues, preventative measures can be explored to help New Zealand retain its doctors and maintain its superior job satisfaction qualities.
Author information: Paul Grant, Department of Medicine, Timaru Hospital, Timaru, South Canterbury. Fax: (03) 368 44000; email: drpaul.grant@orange.net
References:
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  2. Davidson JM, Lambert TW, Goldacre MJ, Parkhouse J. UK senior doctors' career destinations, job satisfaction, and future intentions: questionnaire survey. BMJ. 2002;325:685–6.
  3. Ramirez AJ, Graham J, Richards MA, et al. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet. 1996;347:724–8.
  4. Leigh JP, Kravitz RL, Schembri M, et al. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:1577–84.
  5. Rietveld, J. Strike action by senior medical staff in Timaru—how did this come about? N Z Med J. 2003;116:U352.
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  10. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Health Care Manage Rev. 2001;26:7–19.
  11. Pathman DE, Konrad TR, Williams ES, e al. Physician job satisfaction, dissatisfaction, and turnover. J Fam Pract. 2002;51:593.
  12. Konrad TR, Williams ES, Linzer M, et al. Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Med Care. 1999;37:1174–82.
  13. McMurray JE, Williams E, Schwartz MD, et al. Physician job satisfaction: developing a model using qualitative data. SGIM Career Satisfaction Study Group. J Gen Intern Med. 1997;12:711–4.
  14. Lewis R, Gillam S. Back to the market: yet more reform of the National Health Service. Int J Health Serv. 2003;33:77–84.
  15. Rhodes P, Nocon A. User involvement and the NHS reforms. Health Expect. 1998;1:73–81.
  16. Evans D. 'Taking public health out of the ghetto': the policy and practice of multi-disciplinary public health in the United Kingdom. Soc Sci Med. 2003;57:959–67.
  17. Howell B. Lessons from New Zealand for England's NHS Foundation Trusts. J Health Serv Res Policy. 2004;9:104–9.
  18. Cunningham I, Hyman J. Empowerment: the right medicine for improving employee commitment and morale in the NHS? Health Manpow Manage. 1996;22:14–24.
     
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