Why do general practitioners from France choose to work in London practices? A qualitative study

Abstract

Background: Growing concerns about the ability to maintain and increase the general practitioner (GP) workforce has led to active recruitment of GPs from overseas. However, little is known about why these GPs choose to leave their countries and come to work in London.

Aim: To investigate the motivations and expectations of French GPs migrating to work in general practices in London.

Design of study: A qualitative study using semi-structured interviews.

Setting: General practice induction programme in southeast London.

Method: Individual interviews with 31 French GPs, who attended an induction programme for international recruits, were taped, transcribed, and analysed using a categorical approach.

Results: Three factors led to the process of migration: instigating factors, creating the stimulus for migration; activating factors, based on the perception that English general practice offered greater opportunities; and facilitating factors, which make migration possible. Particular emphasis was placed on personal and professional instigating factors, with a desire for new cultural experiences and a widespread discontent surrounding the infrastructure of French general practice, playing crucial roles in the stimulus to migrate. Ease of travel and a paid induction programme facilitated the move to their chosen destination.

Conclusion: French GPs' decisions were part of a process of migration influenced by a series of integrated factors. Consideration of these factors will not only enhance recruitment to English general practice, but will also facilitate foreign GPs' transition to work in the National Health Service (NHS) and, ultimately, maximise their retention.

Introduction

THE government's NHS Plan¹ states that between 2000 and 2004 the number of general practitioners (GPs) working in Britain will increase by 2000. Although a recent Department of Health report states that this target has now been reached,² over the past 10 years there have been growing concerns about the ability to maintain the GP workforce size, let alone expand it,^3-5 with a possible crisis if the trend towards early retirement continues.⁶ Southeast London has experienced particular difficulties in recruiting and retaining GPs,³ resulting in a vacancy rate in March 2003 of 10.1% (103 vacant posts).⁷ It has been suggested that factors such as the high cost of living, poor working premises, and large list sizes all contribute to GPs' reluctance to work within London.⁸

These difficulties have led to a need to actively recruit GPs from overseas. To facilitate this, the government launched its Global Recruitment Scheme in 2003, in which overseas health professionals are supported through the transition from employment overseas to working in the National Health Service (NHS).⁹ By April 2003, 89 GPs had been recruited from the European Union (EU), predom-inantly from France and Spain.¹⁰ In order to successfully attract and integrate these GPs into the NHS we need to understand their motivations and expectations of working and living in England. We undertook a qualitative study to investigate why French GPs left their own country and came to work in southeast London. We describe the process of migration, illustrating how a series of integrated factors shape the decision to relocate.

Method

This study is part of a wider project investigating French GPs' experiences of the transition to working in the NHS. Approval was obtained from King's College Hospital's Research Ethics Committee and the Lambeth, Lewisham, Southwark and Greenwich research governance committee. Participants were recruited from five consecutive induction programmes run between 2001 and 2003 by the Department of General Practice and Primary Care, King's College London. The programme runs over 10 weeks, with participants spending around 40% of their time on a clinical placement in a southeast London general practice. The key objectives of the programme are to:

• identify any clinical concerns and support developmental needs,

• ensure that the GP's English language (both written and spoken) allows him/her to consult effectively,

• enhance the GP's knowledge of the NHS infrastructure and to meet any other educational needs, and

• provide a supportive environment that facilitates the transition into employment in general practice, and the social aspects of life in England.

HOW THIS FITS IN

What do we know?

The government have launched an international recruitment programme to increase the number of general practitioners (GPs) working within the National Health Service (NHS). Little is known about what influences GPs to work in England.

What does this paper add?

French GPs' decisions to migrate are influenced by instigating factors, which create the stimulus for migration; activating factors, which generate the perception that there are better opportunities in another country; and facilitating factors, which make migration possible. Although French GPs view the NHS as offering exciting opportunities, personal instigating factors, such as the desire for a new cultural experience, and professional instigating factors, such as widespread discontent with the French healthcare infrastructure, are key to decisions to migrate. The ‘push’ to leave France, therefore, is stronger than the ‘pull’ to go to England.

All participants undertook their medical education in the EU.

Two weeks before the end of the induction programme, participants were provided with written and verbal information about the study and invited to take part. Following consent, data were collected using semi-structured interviews, 27 of which were conducted at the end of the induction programme and four with French GPs who had been working in London for approximately 1 year after completing an earlier induction programme. With responders' consent, interviews were audiotaped and conducted in English by three researchers, two of whom are medical sociologists and one a personal and organisation development specialist. Initial interview tapes were heard by all researchers to check for consistency in content and interview style. At interview responders were asked questions about their experiences of working in France, their reasons for leaving France, why they chose to come to England and their expectations of working and living in London. The topic guide was revised and refined throughout the interviewing process to accommodate emerging themes. Interviews lasted from 35 to 90 minutes.

Interview tapes were transcribed verbatim by an independent person and imported into the software package, ATLAS/Ti 4.1. Analysis followed a categorical approach, whereby codes were assigned to sections of data according to a theme or category, for example, ‘reasons for leaving France’ and ‘attraction of London’. Data relating to each of the codes were then retrieved and analysed for content, focusing particularly on links and variances within the dataset. The coding frame was developed by one researcher and subsequently checked and modified by another. Initial analysis of the categorised data was independently carried out and the explanatory value of the categories against the retrieved data were assessed. All researchers subsequently discussed and agreed the analytic framework.

Results

Overall, 41 French GPs completed an induction programme, but eight did not remain in the UK and were unavailable for interview. The remaining GPs in the programme (n = 33) were invited for interview and of those, 31 (94%) agreed to participate. Twelve responders were female. The median age was 43 years (interquartile range [IQR] = 35–48 years), with a median of 8 years' (IQR = 4–19 years') experience working as a GP. We found that decisions to migrate tended to be influenced by a series of integrated factors, each contributing to a process of migration. This process involved consideration of what we have identified as:

• instigating factors, which create the stimulus for migration;

• activating factors, which generate the perception that there are better opportunities available; and

• facilitating factors, which help to make migration possible.

Presumably, there are also a number of mitigating factors that might prevent an individual from migrating, although we were not able to distinguish these in our interviews.

Instigating factors

Responders tended to place much more emphasis on the many instigating factors that led to migration than they did on activating or facilitating factors. Thus, the impetus to change their current situation appeared to be the main driving force, rather than any immediate desire to work in England. We categorised instigating factors into two broad groups: personal and professional.

Personal factors. The most common personal instigating factors were a general desire for a life change and the chance to experience a different culture. These appeared to stimulate migration in GPs of all ages, including those with young families. Many responders had already lived and worked in countries other than France before coming to England and could be classified as ‘adventurers’ who frequently sought new life experiences. For example, one GP spoke about having worked in Cambodia before coming to England and then finding it difficult to settle down to everyday life in France:

‘When I came back [to France] at the beginning of May of this year I worked as a local GP in France. But you know, because I've travelled a lot it was a little bit hard for me to settle again in another country, another city. For me it's boring … it's more exciting you know to be French and living in London than to be French and living in Paris.’ (GP 12.)

A general feeling of restlessness instigated migration not only for those who had travelled previously, but also among GPs whose career and personal lives were following a more conventional path:

‘I thought, okay, I am 28/29, I've got my children, my husband, a house, a car, you know I've everything and I could actually settle down and live that life for evermore. And it didn't really suit me. I wasn't really happy with that thought, so I just thought it might be a good idea to maybe try and do something else.’ (GP 15.)

Whether these GPs will eventually settle in England or move on to another country is not clear, although at interview they generally expressed a desire to remain for at least 1 or 2 years.

Around a third of responders were from an ethnic minority group. Several spoke about wanting to live and work somewhere that they felt had a more tolerant and accepting attitude towards non-white doctors. Although few responders stated that their ethnic origins alone prompted them to migrate, the following comment suggests that a sense of not belonging to, or being accepted in, French culture might be an important factor instigating migration:

‘The main reason [for leaving France] is … not because of the medical system, but due to the social difficulties. I mean, I am a black man. I was born in France and I grew up in France. But the social way means that I'm not French, even if I have a French passport. So it's quite difficult to stay in a country that you think is yours, but people remind you that it's not really yours. Your country is overseas … In my job, several times I met difficulties to progress.’ (GP 24.)

Professional factors. Professional instigating factors appeared to have a powerful impact on decisions to relocate. They included working long hours, being on call, meeting the demands of patients, and having to deal with the business side of general practice. Most of the GPs interviewed spoke about working some 60–70 hours a week:

‘The problem in France is that you have no time. You arrive in your surgery, you see a lot of patients. It's really a long day and it is 10 home visits per day. I chose to begin at 10:00 in the morning, but I also finish at 8:00/9:00 in the evening and I come back home at 9:30/10:00, so it was very difficult. And it is very common for French GPs to work like that. But the problem was, I have three children and it was too much for me …’ (GP 17.)

There was also little opportunity for GPs to work part time, which was particularly difficult for women who had families, or for doctors wanting to pursue other professional or personal interests:

‘I've got three children and my husband has a lot of time [off from work], but I've never had time. And it's difficult to work part time as a doctor in France.’ (GP 23.)

Specifically, the fee-for-service health system in France, whereby patients pay the doctor directly and later claim back the cost from the government, was viewed as unsatisfactory and frustrating. Doctors often felt the need to comply with patients' demands for treatments, drugs or diagnoses regardless of their professional judgement. This scenario was exacerbated by French patients' ability to change GPs at will and to go directly to specialists without a referral. As some GPs suggested, if the doctor does not comply with the patients' wishes, he or she stands to lose income:

‘There is too much money in [the] relationship with patient[s]. When you see a patient he has his needs and a cheque in one hand, and if you don't answer to his needs you don't have your cheque. By example, if [the patient] wants to stop work he says to you, “I want to stop work,” and he has his cheque, and if you don't want to do what he wants, he says, “Oh, I am looking for another doctor,” so it's not a good relationship. The patients are controlling the system by the money.’ (GP 30.)

‘When patients came to see us, they always wanted a list of medicine and so on and lots of things, and then it's free and they have the right to have nearly everything, and I wasn't agreeing with that. I didn't want to continue in such way … if we would have not moved I think I would have changed my work.’ (GP 21.)

Moreover, although responders did not feel that poor pay was an instigating factor for coming to England, they did cite high rates of taxation in France as a disincentive to earn more money by seeing more patients or working long hours:

‘Income taxes in France are very high. They are very high. And if you work more and more, you pay more and more taxes.’ (GP 30.)

Activating factors

Activating factors crystallised responders' vague goals or hopes about working outside of France. Responders highlighted a number of factors that fostered the perception that England provided possibilities for better working conditions, professional development, and personal opportunities.

In response to the professional instigating factors that they felt ‘pushed’ them away from France, responders enthused about the option to work part time or fewer hours, and to have no on-call commitments in England:

‘[The advertisement] said “No visits, no home calls, no long hours, eight sessions of only of 3.5 hours,” so if you look at all the conditions you realise you're working too hard [in France]!’ (GP 4.)

Of particular importance was the prospect of being salaried as it was seen to remove the business aspect of the work, and by not having to physically take money from the patient within the consultation, it was easier to facilitate a therapeutic, rather than consumerist, dialogue:

‘… a good point for my decision to come, [is that] you will be a salaried GP … when I saw that in England GPs are salaried — and my duty is only taking care of patients and not also bothering with all the money and financial problems and everything — I was very surprised … If it's a private GP I would never come here to work, having all the difficulties too.’ (GP 14.)

Further, the French GPs felt that the opportunity to be salaried freed them from the need to either buy their practices or to work as long-term locums, which usually entailed travelling around the country to fill vacancies as they arose.

English general practice also appealed to responders because they believed it provided an environment where GPs worked together as opposed to the French norm of individual practitioners working in isolation or in competition with their colleagues. Having spoken to other French GPs who had come to work in England and visited London before applying for the induction programme, one GP was motivated to follow through his application as the teamwork environment looked appealing:

‘… one of reasons why I came here was probably because Doctor K [from the recruitment agency] told us that it was teamwork [here in England] and he showed us a surgery … which is a really nice and good one and everyone has a room there. And even in this surgery there [are] … you know midwives, [the] community team, [and] they have their proper room. Some social workers have their proper room — they are working in the community and that sort of team work or network — I would like to work like this.’ (GP 22.)

Likewise, another responder considered this environment of working in a team an activating factor:

‘In France we are alone. We don't work in a team. We can be lots of doctors who are working, but it's not like a team … in England you are a country of community, in France we are a country of individuality, so it makes all the difference.’ (GP 21.)

Activating factors also related to the desire to develop professionally, opportunities for which were deemed scarce in France. These included undertaking further study and doing research either within practice or at an academic institution. On the whole, the English medical education system appeared to be held in high esteem mainly because, within the published medical literature, the UK contribution was felt to be particularly prestigious:

‘In France we have less possibilities than here in London. In England if you want to study and work at the same time, it's possible. If you want to do some research and working as a GP, it's possible as well. It's really complicated in France. You have to find some partner and share the surgery and say “ok, now I want to work part time” and you have to find time to research or study for yourself. There is no support like the NHS that can provide you with some special training.’ (GP 12.)

‘English … Anglo-Saxon books are the best medical books in the world … when I was a student I heard a lot of good things about the whole system in England. There were two things — the books and the medical knowledge. Both are [of] a very good, a very good level.’ (GP 11.)

Responders also considered the opportunity to learn or improve English to be a positive factor for themselves and their families. This aspect was decisive for many responders, as an understanding of English medical terminology was viewed as imperative for those who thought they might subsequently want to work in other English-speaking countries or for organisations such as Médecins sans Frontières:

‘So when I have seen [the advert] I say why not to go in England and see a very big opportunity which is given? And for me when I come here I come for a purpose to see if I understand the English system. Then I will be able to practice anywhere in the world. And I discuss with my wife and my children, and they said, “Oh why not? We can go”. If they come with me they will pick up English. So after that they will be able also to go anywhere.’ (GP 14.)

‘Also, I need to improve my English because when I was in the field working for Médecins sans Frontières they needed you to speak fluent English. It's quite hard to communicate with people and English is an international language.’ (GP 12.)

A further important attraction was the chance to work and live in London, which was perceived to be an exciting city. None of the responders spoke about the prospect of working in a relatively deprived part of London as being off-putting:

‘London, you know, is a vibrant town. Life is in London —everybody says that. It's the main town of Europe … although Paris is working hard.’ (GP 15.)

Facilitating factors

Facilitating factors were highly influential in the final stage of the migration process and helped responders to realise their desire to relocate. Indeed, some responders suggested that without these factors they would not have considered moving to England:

‘For me the best thing [about the induction course] was to do with all the paperwork, because by myself I couldn't do that. Because it was too difficult with the General Medical Council. It was too much … You need jabs and so many forms and back-up details. If they hadn't explained that, we wouldn't know what to do.’ (GP 4.)

The provision of a salaried induction programme appeared to sway the GPs' decisions to come to England rather than go to another country. The length of the programme (currently 10 weeks) appeared to be positively influential; responders expressed reluctance to enter a full 2-year (re)training programme:

Researcher: ‘You've spoken to me about your girlfriend living in Canada. Why not choose there?’

GP30: ‘Yes, but it's very difficult to work in Canada … you have to pass an exam first and if you are [a] success, you are on [an] induction programme [for] 2 years.’

Ease of travel was also an important facilitating factor. Many responders remarked on the speed and low cost of travelling back to France, allowing them to participate in the induction course before bringing over their families.

Discussion

Summary of main findings

This study illustrates that French GPs' decisions to relocate to England are influenced by a series of integrated factors, which contribute to a process of migration rather than being decisive in their own right. We categorised these factors as either instigating, activating or facilitating to represent their place in the decision-making process. Of particular importance in this process, were factors relating to being a GP in France, which was deemed difficult or unsatisfying. The majority of responders, were actively looking to change their circumstances rather than being attracted to working in the UK specifically, at least in the first instance. It is worth noting, however, that many of the responders in this study had also worked in other countries and tended to display a general feeling of restlessness and a desire for new challenges and experiences. The issue of cultural disaffection among non-white responders may also be an important factor, and this is something that would need to be investigated in subsequent work.

Having recognised the impetus to migrate, French GPs perceived England as offering attractive employment and personal opportunities. The basic organisation of the NHS, whereby consultations are free at the point of delivery, was a significant activating factor, as this was viewed as changing the entire tenor of the doctor–patient relationship. Working collaboratively as part of a primary healthcare team was also a key activating factor and one that has been found to influence choice of practice by British GPs.¹¹

A variety of facilitating factors, such as the ease of travel between France and London, supported the decision to migrate. Although British GPs have been difficult to recruit to work in deprived urban areas,⁶ such as south London, none of our responders expressed such reluctance. The most influential factor facilitating their move was the existence of a focused induction programme that provided practical assistance with relocation, help in finding a job afterwards and, crucially, lessons in medical English.

Strengths and limitations of this study

In analysing the data, we have considered their validity with regard to conducting interviews with people whose first language is not English. The majority of responders had a good enough command of the language both to understand the interviewer and to respond with relative confidence; the use of an independent person to transcribe the tapes corroborates this view.

It should also be noted that the study excludes those GPs who may have considered migrating to the UK but decided to go elsewhere, as well as the few GPs who participated in the induction programme but returned to France immediately after completing it. These groups may have provided more information on the factors that mitigated the decision-making process than we were able to obtain from our sample.

Further, all our responders were from France and it is therefore not known if the same factors apply to GPs from other countries. More research is needed regarding this, however, we anticipate that, although individual factors may differ, the process of migration that we have reported will be useful in analyses of other groups.

Relationship to other work

In the early 1990s, the Office for National Statistics reported that the principal reasons for moving in to, or out of, the UK was to join a partner/spouse already in the country.¹² More recently, however, issues relating to employment have been shown to be key in motivating people to migrate.¹² Of particular importance among migrants from non-EU countries is economic improvement, with studies showing that this is the primary reason for doctors migrating to the UK,¹³ USA¹⁴ and South Africa.¹⁵ The findings of our study are in contrast to this, with financial gain being rarely cited as a key reason for migrating to London general practice. Indeed, with the high cost of living in London and the high standard of living in France, most of the French GPs find themselves in a similar financial position to that which they experienced in France. What differs, however, is the significant improvement in quality of life — particular advantages include having more time to pursue personal and family activities, which can be achieved for approximately the same amount of money.

Rather than economic gain being the primary motivating factor that draws individuals towards a more affluent country, we found that French GPs were more concerned with leaving what they considered to be a difficult and unsatisfying working environment. Hence, the ‘push’ factors appeared to be more influential in migration decisions than the ‘pull’ factors. Studies looking at the migration patterns of non-EU doctors, however, generally report high levels of satisfaction with their source country.¹³ What both these non-EU doctors and the French doctors in our study had in common was the desire for career advancement.^13,16 Although we did not find this to be the primary factor instigating relocation, it certainly played a role in activating the decision to move to the UK. As such, it is more accurate to view them as knowledge migrants rather than economic migrants.

Implications for clinical practice

Noting the limitations of this study, we suggest that our findings can help policy makers to understand what GPs from France are seeking from their experience in England and how these expectations can be met within the existing UK primary care framework. Such understanding can be used to attract more French GPs, which may help to relieve the pressure on inner city GPs who currently show high levels of dissatisfaction.^6,17

We recommend the continuation of specialised induction programmes for overseas GPs, as these appear to be a crucial factor in converting the desire to relocate into the ability to achieve it. In order to retain these new recruits, it is important that they are further supported through their transition to the NHS and that they are given opportunities to fulfil their professional education and development needs. Postgraduate deaneries and academic departments of general practice and primary care would seem to be ideally placed to facilitate this.

Further research on the experiences of these GPs' transitions to working in the NHS and whether their initial expectations were realised, will help determine the success of this programme of international recruitment.