27th September 2013, Volume 126 Number 1383

Toni Ashton, Paul Brown, Elizaveta Sopina, Linda Cameron, Timothy Tenbensel, John Windsor

As in many countries, most medical and surgical specialists in New Zealand have the opportunity of working as salaried employees in the public sector and/or on a fee-for-service basis in the private sector. Because the supply of specialists is fixed in the short to medium term, increasing time spent in the private sector inevitably means that less time is available for specialists to work in the public health system.1 It is therefore useful to understand what factors may influence the decisions of specialists to work in one sector or the other.

The question of what influences specialists’ decisions to work in the public and/or private sectors is especially pertinent in New Zealand because the specialist workforce faces tight constraints. While the absolute number of practising medical specialists has been increasing in recent years, the number of specialists per head of population remains amongst the lowest of the OECD.2 New Zealand also has the highest proportion of migrant doctors (42%) in the OECD countries.3,4

Factors such as the ageing of the professional workforce and the attraction of higher incomes offered in other countries are putting further pressure on this already constrained clinical workforce.3 In addition, some district health boards (DHBs) are increasingly contracting elective surgical procedures out to the private sector5 in an effort to meet the national target for improving access to elective surgery.6 This increases the private sector work that is available to specialists and potentially puts further pressure on the public sector workforce.5

There is a growing body of international literature on the topic of dual practice in which specialists work in both sectors.7 Most studies take a theoretical approach to examine issues such as the impact of dual practice on public sector labour supply1 or on the incentives for dual practitioners to increase public sector waiting lists8 or to ‘cream-skim’ profitable patients.9 A common assumption underlying these theoretical models is that maximisation of income is a key objective for clinicians.

A few empirical studies have explored the factors which influence specialists’ choice of sector or their division of time between the two sectors. One study, undertaken in south-east England, explored the motivations of specialists who work in dual practice.10 It found that, in addition to the financial benefits, reasons for engaging in private practice included greater clinical autonomy and strategic influence, and a greater sense of being valued.

The authors concluded that the values and actions of these specialists diverged from a common belief (perceived to be held in the UK11) that private sector work is driven by professional self-interest while public sector work is underpinned by altruism and public interest. Another study, undertaken in Norway, also emphasised the importance of specialists’ autonomy in their choice of sector.12

Overall, the empirical studies suggest that many motivations other than income influence specialists’ choices of sector including working conditions, type of work, clinical autonomy, status, professional opportunities and a sense of social responsibility.7,10,13

Job satisfaction, including satisfaction with leadership roles and income security, has been found to be a predictor of staff retention.14 Conversely, job dissatisfaction, including perceptions of inconvenient or inflexible work schedules and workload pressures, has been found to be a predictor of intent to leave a job.15–17

The aim of the present study was therefore to explore the sources and extent of satisfaction and dissatisfaction of specialists with the two sectors. Such information can inform health workforce planning and assist public sector managers in developing strategies for improving the recruitment and retention of specialists. The information will also be of interest to doctors and may assist in their career planning.

Method

A directory of registered doctors working in New Zealand was obtained from an international health care management consultancy. From this we selected those specialties that offer work in both the public and private sectors. This provided a population of 1983 specialists from 28 specialties.
Specialties were sub-divided into procedural and non-procedural (see Table 5), although it should be noted that some specialties that we classified as non-procedural (such as dermatology) involve the performance of some procedures. The rationale for this sub-division was that procedural specialists may have greater opportunities to earn a higher income in the private sector. Since increased income has been considered to be a significant factor in deciding whether to work in the private sector, different levels and sources of job satisfaction might be reported.
A questionnaire was developed based on a set of questions used by Kankaanranta et al. (2007) in a Finnish study of satisfaction and dissatisfaction amongst physicians.18 Questions were modified where necessary to reflect the New Zealand environment.
Satisfaction and dissatisfaction were assessed using two separate sets of questions, with levels being measured using a 5-point Likert scale in which a score of 1 ranked low while a score of 5 ranked high. Thus a high score for satisfaction would mean that the respondent was very satisfied, while a high score for dissatisfaction would mean that they were very dissatisfied. The questionnaire also covered personal information including demographic variables, area of specialty, place and time of training, and past and current place(s) of work.
The questionnaire was mailed to the 1983 specialists in October 2009 along with a covering letter explaining the objective of the study, and a stamped addressed envelope for returning the completed questionnaire. A reminder postcard was sent out in November 2009 thanking those who had already responded and requesting others to complete and return the survey. The study was approved by the New Zealand Ministry of Health Multi-Region Ethics Committee.
Summary statistics were calculated of frequency for the categorical variables and means and standard deviations for continuous variables. Two-tailed t-tests were performed to compare satisfaction and dissatisfaction scores between the two sectors. Results were considered statistically significant with a p-value smaller than α=0.05.

Results

Completed surveys were received from 943 (47%) of the 1983 invitees. A majority of respondents were male (78%), aged between 41 and 60 years (66%) and of European descent (73%) (Table 1). No respondents were New Zealand Māori. A majority (60%) were proceduralists, with a larger proportion of proceduralists being male (85%) than non-proceduralists (70%).

Half of respondents (50%) were working in both the public and private sectors, one-third (33%) were working solely in the public sector, and 14% worked solely in the private sector. The mean number of hours worked per week in each sector was 32 hours in the public sector and 23 hours in the private sector (Table 2).

Proceduralists reported spending a higher proportion of their total hours working in the private sector than non-proceduralists (45% v 32%, p<0.005).

Table 1. Characteristics of respondents
Characteristic
Total respondents
(n=943)
Proceduralists
(n=566)
Non-proceduralists
(n=335)
Speciality not-reported
(n=42)
n
%
n
%
n
%
n
%
Gender
Male
Female
Not reported
737
191
15
78
20
2
481
77
8
85
14
1
233
97
5
70
30
<1
23
17
2
55
40
5
Age (years)
31–40
41–50
51–60
60+
Not reported
146
324
272
156
45
15
34
29
17
5
77
193
168
100
28
14
34
30
18
5
57
118
97
51
12
17
35
29
15
4
12
13
7
5
5
29
31
17
12
12
Ethnicity
NZ European
NZ Māori
Pacific people*
Chinese/Indian
Other
Not reported
693
0
4
45
150
51
73
0
<1
5
16
5
436
0
3
29
68
30
78
0
<1
5
12
4
228
0
1
15
72
19
68
0
<1
4
21
6
29
0
0
1
10
2
69
0
0
2
24
5
Workplace
Public and private
Public only
Private only
Not currently working
Not reported
473
306
130
28
6
50
32
14
3
1
362
98
96
7
3
64
17
17
1
1
95
186
32
19
3
28
56
10
6
1
16
22
2
2
0
38
52
5
5
0
*Mostly of Samoan, Tongan, Niuean, or Cook Islands origin.
Table 2. Mean number of hours worked per week in public and private sectors
Sector
Total respondents
(n=943)
Proceduralists
(n=566)
Non-proceduralists
(n=335)
n
Mean
SD
n
Mean
SD
n
Mean
SD
Public
727
32
13.7
451
29
12.8
276
37
13.6
Private
580
23
13.8
454
24
13.6
126
18
13.3

The average mean satisfaction scores (out of a maximum of 5) for all respondents were 3.33 for the public sector and 3.57 for the private sector, indicating a slightly higher level of overall satisfaction with the private sector (Table 3).

Sources of high levels of satisfaction in the public sector were opportunities for further education (mean score = 4.05), interesting work (4.05) and opportunities for professional development (3.99).

In contrast, the private sector is valued for the opportunity to work independently (4.45), the freedom to apply ideas in the workplace (4.28) and the income earned relative to the workload (4.06). Income security scored relatively highly as a source of satisfaction in both sectors (3.92 for the public sector and 3.90 for the private sector).

The average mean dissatisfaction scores were 3.07 and 2.44 for the public and private respectively, indicating a higher level of dissatisfaction with the public sector. Interestingly, workload pressures and mentally demanding work ranked highest as sources of dissatisfaction for both sectors. Contrary to expectations, there were no significant differences between the mean scores of proceduralists and non-proceduralists for any of the 23 sources of satisfaction and dissatisfaction.

Table 4. Mean difference in sources of satisfaction and dissatisfaction between the public and private sectors
Variables
Mean difference#
SD
P value
Sources of satisfaction
  1. Freedom to apply ideas in workplace
  2. Opportunities to work independently
  3. Income relative to workload
  4. Amount of after-hours work
  5. Predictable hours of workload
  6. Prestige or respect for your position
  7. Public recognition of accomplishments
  8. Income security
  9. Leadership role
  10. Interesting work
  11. Regular and appropriate review of performance
  12. Promotion prospects
  13. Opportunities for professional development
  14. Opportunities for further education
1.59
1.54
1.25
0.76
0.69
0.40
0.13
-0.03
-0.12
-0.37
-0.43
-0.48
-0.77
-0.89
1.33
1.21
1.38
1.49
1.46
1.28
1.36
1.47
1.62
1.26
1.42
1.41
1.46
1.45
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.777
0.591
0.035
<0.001
<0.001
<0.001
<0.001
<0.001
Sources of dissatisfaction
15. Managerial interference
  1. Poor employee/employer relations
  2. Inconvenient or inflexible work schedule
  3. Ungrateful or non-compliant patients
  4. Workload pressures
  5. Atmosphere in workplace
  6. Mentally demanding work
  7. Fear of failure in work
  8. Monotonous Work
-1.66
-1.08
-0.85
-0 56
-0.54
-0.41
-0.28
-0.15
-0.07
1.15
1.14
1.16
0.86
1.08
1.25
0.89
0.78
0.96
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.047
# Paired t-test comparing private and public sector mean satisfaction and dissatisfaction scores.

In addition to knowing the absolute levels of satisfaction, it is helpful to know how levels of satisfaction compare across the two sectors. Mean differences in the sources of satisfaction and dissatisfaction between the two sectors are given in Table 4.

In this Table (and also in Table 5), positive mean differences reflect higher scores in the private sector relative to the public sector for both satisfaction and dissatisfaction. The private sector was rated more highly than the public sector for the 6 sources of satisfaction numbered 1 to 6 in this table, while the public sector was rated more highly for the 5 sources numbered 10 to 14.

While the private sector provides specialists with greater freedom to apply ideas in the workplace and greater opportunity to work independently, the public sector is valued more highly for its opportunities for further education and professional development, and for its prospects for promotion. Levels of dissatisfaction were significantly higher in the public than the private sector for 8 of the 9 sources of dissatisfaction (numbers 15 to 22, Table 4) and most especially for managerial interference.

Table 5. Mean difference in satisfaction and dissatisfaction by type of specialty
Type of specialty
n
% of total
Mean difference#:
Mean difference#:
Satisfaction
Dissatisfaction
Difference
SD
P value
Difference
SD
P value
All
943
100
0.24
0.88
<0.001
-0.62
0.56
<0.001
Proceduralists
Orthopaedics
Obstetrics & gynaecology
General surgery
Ophthalmology
Otorhinolaryngology
Cardiology
Urology
Gastroenterology
Plastic surgery
Oral & maxillofacial surgery
Paediatric surgery
Cardiac surgery
Breast surgery
Neurosurgery
Vascular surgery
566
113
92
85
59
45
41
30
29
25
14
8
8
8
7
2
60
12
10
9
6
5
4
3
3
3
2
<1
<1
<1
<1
<1
0.27
0.37
0.35
0.14
0.21
-0.06
0.29
0.39
0.13
0.41
0.65
0.12
-0.06
0.66
0.33
0.39
0.89
0.92
0.86
0.96
0.72
1.02
0.89
0.97
0.81
0.83
0.93
0.59
1.01
0.57
0.64
0.97
<0.001
<0.001
<0.001
0.198
0.038
0.723
0.052
0.056
0.434
0.031
0.021
0.582
0.875
0.022
0.221
0.728
-0.62
-0.73
-0.63
-0.50
-0.61
-0.70
-0.60
-0.55
-0.52
-0.76
-0.56
-0.57
-0.70
-0.41
-0.74
-0.55
0.56
0.54
0.57
0.59
0.53
0.62
0.61
0.39
0.49
0.70
0.63
0.75
0.56
0.30
0.52
0.39
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.005
0.068
0.017
0.011
0.009
No data
Non-proceduralists
General medicine
Emergency medicine
Geriatrics
Endocrinology
Neurology
Dermatology
Respiratory medicine
Rheumatology
Haematology
Nephrology
Sexual health medicine
Paediatrics
Other
377
47
43
33
26
22
22
20
20
19
17
5
2
59
40
5
5
4
3
2
2
2
2
2
2
<1
<1
6
0.23
0.40
0.20
0.36
0.43
-0.06
-0.06
0.16
0.02
0.23
0.17
1.03
0.89
0.21
0.86
0.95
0.68
0.98
0.84
1.09
0.98
0.80
0.88
0.83
0.78
1.05
0.35
0.74
<0.001
0.007
0.075
0.046
0.020
0.825
0.764
0.411
0.928
0.200
0.388
0.398
0.174
0.040
-0.64
-0.55
-0.80
-0.56
-0.56
-0.74
-0.48
-0.77
-0.59
-0.77
-0.52
-0.81
-1.06
-0.67
0.56
0.56
0.60
0.53
0.59
0.59
0.52
0.51
0.53
0.47
0.40
0.68
0.08
0.62
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
0.006
<0.001
0.339
0.033
<0.001
Missing
42
4
-0.01
0.86
0.959
-0.46
0.58
<0.001
# Paired t-test comparing private and public sector mean satisfaction and dissatisfaction scores. Positive mean differences reflect higher scores in the private sector relative to the public sector for both satisfaction and dissatisfaction.

Mean differences in the levels of satisfaction and dissatisfaction by the specialty group are given in Table 5. The results for all specialty groups are presented in this table in the interests of completeness. However the number of respondents in some groups is very low and the results should be interpreted with caution.

The difference in satisfaction levels was statistically significant for only two of the 28 specialty groups: orthopaedics (mean difference = 0.37) and obstetrics and gynaecology (0.35). Four specialty groups rated the public sector more satisfying overall than the private sector: otorhinolaryngology (n=45), cardiac surgery (n=8), neurology (n=22) and dermatology (n=22). However none of these differences were statistically significant.

All 28 groups reported higher levels of dissatisfaction with the public than with the private sector, 20 of which were statistically significant. The mean difference in dissatisfaction scores was greatest for specialists working in emergency medicine (-0.8), respiratory medicine (0.77) and plastic surgery (-0.76).

We also examined whether the sector in which respondents were working affected levels of satisfaction and dissatisfaction. For the 14% of respondents working in the private sector only, the mean difference in satisfaction levels was greater (0.37) than for those working in both sectors (0.25) and those working only in the public sector (0.19).

The mean difference in levels of dissatisfaction was also slightly larger for those working only in the private sector (-0.67) than for those working in both sectors (-0.65) and those working only in the public sector (-0.63).

Discussion

This study suggests that specialists are generally both more satisfied and less dissatisfied with working in the private sector than in the public sector, with differences in the levels of both satisfaction and dissatisfaction between the two sectors being statistically significant for 24 of the 28 sources included in our survey. Nevertheless, for the public sector, high levels of satisfaction were reported for the opportunities that it offers for further education and professional development as well as for the interesting work that it offers.

Key sources of dissatisfaction were workload pressures, mentally demanding work and managerial interference. In contrast, when working in private practice, specialists value the opportunity to work independently and to apply their own ideas in the workplace. They also have a good income relative to their workload and little managerial interference.

Satisfaction levels with income security were similar for both sectors. Moreover, non-pecuniary factors were important sources of job satisfaction. These findings raise questions about theoretical models of dual practice which are based upon an assumption that income maximisation is the key driver of workforce choices of specialists.1 It also suggests that specialists working in private practice may be encouraged to allocate a greater share of their time to the public sector if non-pecuniary sources of satisfaction improved.

Our results support those of an earlier New Zealand study that explored the relationship between job satisfaction, job stress and psychological morbidity amongst New Zealand health professionals.19 It found that overall levels of satisfaction were similar for both sectors but that specialists perceived public work to be more stressful than private practice.

Job stress has been shown to be inversely related to job satisfaction both theoretically and empirically.17 While our survey did not include questions specifically related to levels of stress, dissatisfaction was higher in the public sector for all sources of dissatisfaction. These included factors related to stress such as poor employer/employee relations, workload pressures and mentally demanding work.

The study by Kankaanranta et al. in Finland18 was directed specifically at the question of what factors influence physicians’ intentions to switch between the public and private sectors during the period 1988 – 2003. It found that increased job satisfaction decreased the intention to switch from the public to the private sector for all years except 1988.

Surprisingly, job dissatisfaction was not correlated with intention to leave the public sector except for the year 1988. This suggests that retention in the public sector might be improved if public sector managers focus on ways of strengthening the sources of satisfaction reported for both sectors. Of particular relevance here is our finding that specialists value the opportunity to apply their own ideas in the workplace - a finding that was also reported by Kankaanranta et al.18 While this was ranked second highest as a source of satisfaction in the private sector (with a mean score of 4.28), for the public sector, it was ranked lowest of all of the 14 variables on the satisfaction scale, with a mean score of 2.70.

Since our survey was undertaken, many DHBs have worked towards building clinical governance and leadership following the release of the Ministerial Task Force Report on Clinical Leadership in 2009.20 In a survey undertaken in 2012 of health professionals employed by DHBs, more than two-thirds of doctors agreed that health professionals in their DHB are engaged in shared decision-making with management, and that their DHB had sought to foster and develop clinical leadership ‘to some or a great extent’.21 However, only around one-third felt that their DHB was providing sufficient support for them to engage in clinical leadership activities.

Clinical leadership in the public sector may be more difficult if clinicians are too busy with their own practices, or if they have insufficient training to engage meaningfully with management to provide leadership in system improvement. This suggests that public sector managers need to continue to seek ways to encourage specialists to express their own ideas, and to open up opportunities for them to influence the process and direction of service development.

Unfortunately there are no national statistics which describe the demographic profile of the total specialist workforce in New Zealand against which we can assess the representativeness of our respondents. However, our sample contained a slightly lower proportion of women (20%) than the 27% of specialists reported as female by the New Zealand Medical Council.4

Our sample also contained no Māori, whereas 3% of the specialist workforce identify as Māori.22 Considerable effort is currently being directed towards encouraging increased participation by Māori in the medical workforce in New Zealand. Information about sources of satisfaction and dissatisfaction amongst Māori specialists would be highly valuable for informing this process.

A further limitation to our study is that the numbers of respondents from some specialty groups were too small to produce any meaningful results. It is also possible that responses may have been affected by the fact that our survey included a greater number of questions relating to sources of satisfaction than to sources of dissatisfaction.

Conclusion

The public sector specialist medical workforce in New Zealand currently faces many challenges including difficulties in filling vacant positions, increasing international competition for specialists, and a heavy reliance on immigrant doctors. At the same time, many specialists are working full-time or part-time in private practice.

Developing policies and practices which increase satisfaction and decrease dissatisfaction with working in the public sector should assist in alleviating pressures in the public system and secure a more stable workforce. In particular, allowing specialists more freedom to work independently and to apply their own ideas in the workplace may enhance their recruitment and retention in the public sector.

The findings of this study should also inform the wider debate about the relationship between the public and private sectors in New Zealand and about how the sectors can work together to secure a more efficient use of the specialist workforce.

Summary

This study explores the level and sources of satisfaction and dissatisfaction of medical and surgical specialists with working in the public and private sectors in New Zealand. Overall mean levels of satisfaction were higher in the private sector than the public sector while levels of dissatisfaction were lower. While the public system is valued for its opportunities for further education and professional development, key sources of dissatisfaction are workload pressures, mentally demanding work and managerial interference. In the private sector specialists value the opportunity to work independently and apply their own ideas in the workplace.

Abstract

Aim

As in many countries, medical and surgical specialists in New Zealand have the opportunity of working in the public sector, the private sector or both. This study aimed to explore the level and sources of satisfaction and dissatisfaction of specialists in New Zealand with working in the two sectors. Such information can assist workforce planning, management and policy and may inform the wider debate about the relationship between the two sectors.

Method

A postal survey was conducted of 1983 registered specialists throughout New Zealand. Respondents were asked to assess 14 sources of satisfaction and 9 sources of dissatisfaction according to a 5-point Likert scale. Means and standard deviations were calculated for the total sample, and for procedural and non-procedural specialties. Differences between the means of each source of satisfaction and dissatisfaction were also calculated.

Results

Completed surveys were received from 943 specialists (47% response rate). Overall mean levels of satisfaction were higher in the private sector than the public sector while levels of dissatisfaction were lower. While the public system is valued for its opportunities for further education and professional development, key sources of dissatisfaction are workload pressures, mentally demanding work and managerial interference. In the private sector specialists value the opportunity to work independently and apply their own ideas in the workplace.

Conclusion

Sources of job satisfaction and dissatisfaction amongst specialists are different for the public and private sectors. Allowing specialists more freedom to work independently and to apply their own ideas in the workplace may enhance recruitment and retention of specialists in the public health system.

Author Information

Toni Ashton, Professor of Health Economics, School of Population Health,University of Auckland; Paul Brown, Professor of Health Economics, Health Sciences Research Institute, University of California, Merced, California, USA; Elizaveta Sopina, Research Fellow, School of Population Health, University of Auckland; Linda Cameron, Professor, School of Social Sciences, Humanities and Arts, University of California, Merced, California, USA;Tim Tenbensel, Senior Lecturer in Health Policy, School of Population Health, University of Auckland; John Windsor, Professor of Surgery, Department of Surgery, School of Medicine, University of Auckland

Correspondence

Professor Toni Ashton, School of Population Health, University of Auckland, 261 Morrin Road, Auckland 1142, New Zealand.

Correspondence Email

toni.ashton@auckland.ac.nz

Competing Interests

None identified.

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