Sources of satisfaction and dissatisfaction among specialists within the public and private health sectors
View Article PDF
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.3,4Factors 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.5There 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.12Overall, 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.7,10,13Job 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.15–17The 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
Summary
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
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
Brekke KR, Sorgard L. Public versus private health care in a national health service. Health Econ. 2007;16:601.OECD. Health at a glance 2009: OECD indicators. OECD: Paris, 2009.Zurn P, Dumont J-C. Health workforce and international migration: can New Zealand compete? OECD: Paris, 2008.Medical Council of New Zealand. The New Zealand medical workforce in 2010. Medical Council of New Zealand: Wellington, 2010.Ashton T. The benefits and risks of DHBs contracting out elective procedures to private providers. NZ Med J. 14 May 2010;123(1341).Ministry of Health. Targeting more elective operations: improved access to elective surgery. http://www.health.govt.nz/publication/targeting-more-elective-operations-improved-access-elective-surgery. Accessed 18 April 2013.Socha KZ, Bech M. Physician dual practice: a review of literature. Health Policy. 2011;102:1-7.Morga A, Xavier A. Hospital specialists private practice and its impact on the number of NHS patients treated and on the delay for elective surgery. Discussion Papers in Economics. York: University of York, 2001.Gonzalez P. On a policy of transferring public patients to private practice. Health Econ. 2005;14:513-27Humphrey C, Russell J. Motivation and values of hospital consultants in south-east England who work in the National Health Service and do private practice. Soc Sci Med. 2004;59:1241-50.Le Grand, J. The Provision of Health Care: Is the Public Sector Ethically Superior to the Private Sector? LSE Health and Social Care Discussion Paper Number 1. London: London School of Economics and Political Science, 2001.Midttun L. Private or public? An empirical analysis of the importance of work values for work sector choice among Norwegian medical specialists. Soc Sci Med. 2007;64:1265-77.Ferrinho P, Van Lerberghe W, Fronteira I, et al. Dual practice in the health sector: review of the evidence. Hum Resour Health. 2004;2:14.Leveck ML, Jones CB. The nursing practice environment, staff retention and quality of care. Res Nurs Health. 1996.19(4):331-43.Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234-242.Pathman DE, Konrad TR, Williams ES, et al. Physician job satisfaction, job dissatisfaction, and physician turnover. Fam Pract. 2007;51(7).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(1):7-19.Kankaanranta T, Nummi T, Vainiom\u00e4ki J, et al. The role of job satisfaction, job dissatisfaction and demographic factors on physicians' intentions to switch work sector from public to private. Health Policy. 2007;83:50-64.Dowell AC, Westcott T, McLeod DK, Hamilton S. A survey of job satisfaction, sources of stress and psychological symptoms among New Zealand health professionals. NZ Med J. 2001;114:540-3.Ministerial Task Group on Clinical Leadership. In good hands - transforming clinical governance in New Zealand. February 2009.Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health and professional survey and site visits to 19 DHBs. Centre for Health Systems: Otago University, 2012.Ministry of Health. Monitoring the regulated Mori health workforce. www.health.govt.nz/publication/monitoring-regulated-maori-health-workforce Accessed 18 April 2013.
For the PDF of this article,
contact nzmj@nzma.org.nz
Sources of satisfaction and dissatisfaction among specialists within the public and private health sectors
View Article PDF
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.3,4Factors 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.5There 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.12Overall, 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.7,10,13Job 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.15–17The 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
Summary
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
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
Brekke KR, Sorgard L. Public versus private health care in a national health service. Health Econ. 2007;16:601.OECD. Health at a glance 2009: OECD indicators. OECD: Paris, 2009.Zurn P, Dumont J-C. Health workforce and international migration: can New Zealand compete? OECD: Paris, 2008.Medical Council of New Zealand. The New Zealand medical workforce in 2010. Medical Council of New Zealand: Wellington, 2010.Ashton T. The benefits and risks of DHBs contracting out elective procedures to private providers. NZ Med J. 14 May 2010;123(1341).Ministry of Health. Targeting more elective operations: improved access to elective surgery. http://www.health.govt.nz/publication/targeting-more-elective-operations-improved-access-elective-surgery. Accessed 18 April 2013.Socha KZ, Bech M. Physician dual practice: a review of literature. Health Policy. 2011;102:1-7.Morga A, Xavier A. Hospital specialists private practice and its impact on the number of NHS patients treated and on the delay for elective surgery. Discussion Papers in Economics. York: University of York, 2001.Gonzalez P. On a policy of transferring public patients to private practice. Health Econ. 2005;14:513-27Humphrey C, Russell J. Motivation and values of hospital consultants in south-east England who work in the National Health Service and do private practice. Soc Sci Med. 2004;59:1241-50.Le Grand, J. The Provision of Health Care: Is the Public Sector Ethically Superior to the Private Sector? LSE Health and Social Care Discussion Paper Number 1. London: London School of Economics and Political Science, 2001.Midttun L. Private or public? An empirical analysis of the importance of work values for work sector choice among Norwegian medical specialists. Soc Sci Med. 2007;64:1265-77.Ferrinho P, Van Lerberghe W, Fronteira I, et al. Dual practice in the health sector: review of the evidence. Hum Resour Health. 2004;2:14.Leveck ML, Jones CB. The nursing practice environment, staff retention and quality of care. Res Nurs Health. 1996.19(4):331-43.Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234-242.Pathman DE, Konrad TR, Williams ES, et al. Physician job satisfaction, job dissatisfaction, and physician turnover. Fam Pract. 2007;51(7).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(1):7-19.Kankaanranta T, Nummi T, Vainiom\u00e4ki J, et al. The role of job satisfaction, job dissatisfaction and demographic factors on physicians' intentions to switch work sector from public to private. Health Policy. 2007;83:50-64.Dowell AC, Westcott T, McLeod DK, Hamilton S. A survey of job satisfaction, sources of stress and psychological symptoms among New Zealand health professionals. NZ Med J. 2001;114:540-3.Ministerial Task Group on Clinical Leadership. In good hands - transforming clinical governance in New Zealand. February 2009.Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health and professional survey and site visits to 19 DHBs. Centre for Health Systems: Otago University, 2012.Ministry of Health. Monitoring the regulated Mori health workforce. www.health.govt.nz/publication/monitoring-regulated-maori-health-workforce Accessed 18 April 2013.
For the PDF of this article,
contact nzmj@nzma.org.nz
Sources of satisfaction and dissatisfaction among specialists within the public and private health sectors
View Article PDF
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.3,4Factors 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.5There 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.12Overall, 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.7,10,13Job 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.15–17The 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
Summary
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
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
Brekke KR, Sorgard L. Public versus private health care in a national health service. Health Econ. 2007;16:601.OECD. Health at a glance 2009: OECD indicators. OECD: Paris, 2009.Zurn P, Dumont J-C. Health workforce and international migration: can New Zealand compete? OECD: Paris, 2008.Medical Council of New Zealand. The New Zealand medical workforce in 2010. Medical Council of New Zealand: Wellington, 2010.Ashton T. The benefits and risks of DHBs contracting out elective procedures to private providers. NZ Med J. 14 May 2010;123(1341).Ministry of Health. Targeting more elective operations: improved access to elective surgery. http://www.health.govt.nz/publication/targeting-more-elective-operations-improved-access-elective-surgery. Accessed 18 April 2013.Socha KZ, Bech M. Physician dual practice: a review of literature. Health Policy. 2011;102:1-7.Morga A, Xavier A. Hospital specialists private practice and its impact on the number of NHS patients treated and on the delay for elective surgery. Discussion Papers in Economics. York: University of York, 2001.Gonzalez P. On a policy of transferring public patients to private practice. Health Econ. 2005;14:513-27Humphrey C, Russell J. Motivation and values of hospital consultants in south-east England who work in the National Health Service and do private practice. Soc Sci Med. 2004;59:1241-50.Le Grand, J. The Provision of Health Care: Is the Public Sector Ethically Superior to the Private Sector? LSE Health and Social Care Discussion Paper Number 1. London: London School of Economics and Political Science, 2001.Midttun L. Private or public? An empirical analysis of the importance of work values for work sector choice among Norwegian medical specialists. Soc Sci Med. 2007;64:1265-77.Ferrinho P, Van Lerberghe W, Fronteira I, et al. Dual practice in the health sector: review of the evidence. Hum Resour Health. 2004;2:14.Leveck ML, Jones CB. The nursing practice environment, staff retention and quality of care. Res Nurs Health. 1996.19(4):331-43.Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234-242.Pathman DE, Konrad TR, Williams ES, et al. Physician job satisfaction, job dissatisfaction, and physician turnover. Fam Pract. 2007;51(7).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(1):7-19.Kankaanranta T, Nummi T, Vainiom\u00e4ki J, et al. The role of job satisfaction, job dissatisfaction and demographic factors on physicians' intentions to switch work sector from public to private. Health Policy. 2007;83:50-64.Dowell AC, Westcott T, McLeod DK, Hamilton S. A survey of job satisfaction, sources of stress and psychological symptoms among New Zealand health professionals. NZ Med J. 2001;114:540-3.Ministerial Task Group on Clinical Leadership. In good hands - transforming clinical governance in New Zealand. February 2009.Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health and professional survey and site visits to 19 DHBs. Centre for Health Systems: Otago University, 2012.Ministry of Health. Monitoring the regulated Mori health workforce. www.health.govt.nz/publication/monitoring-regulated-maori-health-workforce Accessed 18 April 2013.
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Sources of satisfaction and dissatisfaction among specialists within the public and private health sectors
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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.3,4Factors 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.5There 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.12Overall, 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.7,10,13Job 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.15–17The 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
Summary
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
Acknowledgements
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Brekke KR, Sorgard L. Public versus private health care in a national health service. Health Econ. 2007;16:601.OECD. Health at a glance 2009: OECD indicators. OECD: Paris, 2009.Zurn P, Dumont J-C. Health workforce and international migration: can New Zealand compete? OECD: Paris, 2008.Medical Council of New Zealand. The New Zealand medical workforce in 2010. Medical Council of New Zealand: Wellington, 2010.Ashton T. The benefits and risks of DHBs contracting out elective procedures to private providers. NZ Med J. 14 May 2010;123(1341).Ministry of Health. Targeting more elective operations: improved access to elective surgery. http://www.health.govt.nz/publication/targeting-more-elective-operations-improved-access-elective-surgery. Accessed 18 April 2013.Socha KZ, Bech M. Physician dual practice: a review of literature. Health Policy. 2011;102:1-7.Morga A, Xavier A. Hospital specialists private practice and its impact on the number of NHS patients treated and on the delay for elective surgery. Discussion Papers in Economics. York: University of York, 2001.Gonzalez P. On a policy of transferring public patients to private practice. Health Econ. 2005;14:513-27Humphrey C, Russell J. Motivation and values of hospital consultants in south-east England who work in the National Health Service and do private practice. Soc Sci Med. 2004;59:1241-50.Le Grand, J. The Provision of Health Care: Is the Public Sector Ethically Superior to the Private Sector? LSE Health and Social Care Discussion Paper Number 1. London: London School of Economics and Political Science, 2001.Midttun L. Private or public? An empirical analysis of the importance of work values for work sector choice among Norwegian medical specialists. Soc Sci Med. 2007;64:1265-77.Ferrinho P, Van Lerberghe W, Fronteira I, et al. Dual practice in the health sector: review of the evidence. Hum Resour Health. 2004;2:14.Leveck ML, Jones CB. The nursing practice environment, staff retention and quality of care. Res Nurs Health. 1996.19(4):331-43.Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234-242.Pathman DE, Konrad TR, Williams ES, et al. Physician job satisfaction, job dissatisfaction, and physician turnover. Fam Pract. 2007;51(7).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(1):7-19.Kankaanranta T, Nummi T, Vainiom\u00e4ki J, et al. The role of job satisfaction, job dissatisfaction and demographic factors on physicians' intentions to switch work sector from public to private. Health Policy. 2007;83:50-64.Dowell AC, Westcott T, McLeod DK, Hamilton S. A survey of job satisfaction, sources of stress and psychological symptoms among New Zealand health professionals. NZ Med J. 2001;114:540-3.Ministerial Task Group on Clinical Leadership. In good hands - transforming clinical governance in New Zealand. February 2009.Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health and professional survey and site visits to 19 DHBs. Centre for Health Systems: Otago University, 2012.Ministry of Health. Monitoring the regulated Mori health workforce. www.health.govt.nz/publication/monitoring-regulated-maori-health-workforce Accessed 18 April 2013.
Contact diana@nzma.org.nz
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Sources of satisfaction and dissatisfaction among specialists within the public and private health sectors
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