‘BRAIN CIRCULATION’, THE SPANISH MEDICAL PROFESSION AND INTERNATIONAL MEDICAL RECRUITMENT IN THE UNITED KINGDOM
Brad K. Blitz
Abstract: Macro-level explanations for skilled migration often overlook the importance of organizational structures that facilitate the entry of professionals into specific markets. These same structures play an even greater role in determining whether or not returning migrants can re-establish themselves in their home state. This article explores such challenges by reviewing the concept of ‘brain circulation’ -- the claim that temporary skilled migration enables intellectual resources to be shared across states rather than be permanently transferred. The importance of professional structures for skilled migration is examined in the case of Spanish doctors who have been recruited into the UK National Health Service. Focus groups and semi-structured interviews were held with practicing doctors (n=12), and National Health Service managers and recruiters (n=10) in Madrid, London, and County Durham. The main findings of this study suggest that structural barriers, including the lack of jobs, instigate migration from Spain; these same factors combined with the relatively flat structure of the Spanish medical profession deter doctors from returning and deny the potential for brain circulation. Relocation offers the potential for improved social status which influences both personal and job satisfaction, thus increasing the chances for retention within the National Health Service to the detriment of the Spanish medical profession.
‘The final, definitive version of this paper has been published as Blitz, Brad K. (2005) ‘“Brain Circulation”, the Spanish Medical Profession and International Recruitment in the United Kingdom’, Journal of European Social Policy, 15/4, pp. 363-379 by SAGE Publications Ltd./SAGE Publications, Inc., All rights reserved. ©
‘BRAIN CIRCULATION’ AND INTERNATIONAL MEDICAL RECRUITMENT IN THE UNITED KINGDOM*
Introduction
The movement of highly skilled workers between developed states has given rise to recent studies on ‘international professionals’ and has fuelled debate over the degree to which such movements should now be considered evidence of ‘brain circulation’ and ‘international brain exchanges’ (Cervantes and Guellec, 2002; Gaillard and Gaillard, 2002; Mahroum, 1999; OECD, 2002; Pellegrino, 2001; Salt, 2002). ‘Brain circulation’, in contrast to brain drain1, is premised on the claim that in an increasingly global migration market characterised by temporary movements of skilled labour (Iredale, 2001; OECD, 2003; Salt, 2002), professionals may act as knowledge carriers and thus enable intellectual resources to be shared across states, rather than be permanently transferred from one state to another. The combination of temporary migrations, sustained investment in research and development, and the likelihood of remittances being sent back home, has led proponents of ‘brain circulation’ to argue that the net result of such skilled labour flows may be increased economic growth for both sending and receiving states in the long-term (OECD, 2002). This article examines the claim by considering the case of the Spanish doctors who have been brought into the National Health Service over the past two years. It seeks to understand why medical professional relocate from Spain and what factors influence their potential return. The proposed examination also sheds light on additional trends which are especially relevant to contemporary Europe. The accession of ten new European Union member states and the expansion of the Single Market have now created several specialised
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labour markets and have increased the pool of highly specialised migrants who seek employment in the health sector outside their home country. In addition to the migration of health workers within the European Union, it is important to note that these changes have also affected patients, as health authorities have started to contract out of services between European Union member states, including Britain and France.2 Thus, both health workers and patients must now adjust to increasingly competitive and internationalised medical systems. Initial support for the ‘brain circulation’ thesis is drawn at the macro-level from research on the globalisation of firms and data confirming the multi-directional movements of skilled persons not only from East to West but between advanced economies (Salt, 2002). Recent trends in the career patterns of international nurses working in the National Health Service have given added weight to the argument in favour of ‘brain circulation’. Although the nursing sector has relied on migrant labour for over forty years, current patterns of recruitment suggest a new migratory dynamic. For the first time there are now more overseas nurses than nationals registered with the UK Department of Health and the number is growing (Buchan, 2002, 2003). Experts claim that this shift is the result of an active campaign by the British government and point to the Anglo-Spanish Agreement initiated by former Health Minister Alan Milburn which aimed to recruit 20,000 nurses by the end of 2004 and an additional 35,000 nurses by 2008. Both Spanish and British sources contend that the main motivation for this agreement was the need to replace depleted stocks of indigenous staff in Britain and cater for Spain’s oversupply of nurses (Interview with Pilar Alonso, 18 June 2003).
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Further support for the circulation of nursing professionals between advanced states can be gleaned from the considerable evidence of reverse flows of nurses back to Ireland and Australia as well as transfers to the USA (Nursing and Midwifery Council, 2002). Spanish nurses who have come to the United Kingdom on two-year contracts as part of the Department of Health’s recruitment drive have similarly been able to move between the two nursing systems and have found that by temporarily relocating to Britain on a fixed term contract they can obtain credit from the Spanish Nursing authorities and secure promotion upon their return home (Lissa Perteghella interview, 17 June 2003). This process may be described as ‘professional leap-frogging’ and is understood to apply to hierarchically organised professions, such as nursing, which have a high degree to transferability. This is especially evident for those working as auxiliary nurses lower down the career ladder (Nursing and Midwifery Council, 2002). Thus, possible explanations for ‘brain circulation’ and the temporary integration of professionals lie not just at the structural level, but also at the meso-level where we obtain information about organisational and professional structures, occupational networks and the social contexts of receiving states (Cohen, 1991). The logic of ‘brain circulation’, is not, however, without its critics who note that migrants have less autonomy over their careers and face many barriers as they try to maximise their training by relocating (Castles, 1995; Cohen, 1991). Moreover, other criteria, such as induction programmes, professional networks, community and ethnic structures have considerable bearing on skilled migrants’ chances of accessing the labour market of foreign states (Ballard et al, 2004; Blitz, 1999a; Cornelius et. al, 2003). Then there is the issue of return, a necessary condition for ‘brain circulation’. The suggestion
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that the return of migrants may promote the sharing of knowledge assumes that re-entrants have sufficient control over employment conditions in their countries of origin to maximise their skills. This claim is subject to considerable debate in the literature on return migration which highlights many of the difficulties of re-adaptation (Blitz, 2003, Cervantes and Guellec, 2002; Gmelch, 1980; Findlay, 1995; King, 2000). Further, there is considerable evidence that some highly skilled professions, including specialisations within the medical sector, have largely failed to attract professionals to return (Olsen, 1996). This article seeks to generate understanding of the conditions that facilitate ‘brain circulation’ by reviewing the experiences of Spanish doctors who have recently joined the British National Health Service. It draws on research conducted during Summer and Autumn 2003 which aimed to gather information on the experiences and motivations of Spanish professionals who were currently employed or seeking employment within the National Health Service. I begin by considering definitions of ‘brain circulation’ and the role that states and individuals play in the decision-making process. I then consider explanations for professional mobility between advanced economies before discussing the meso-level and institutional contexts of the National Health Service recruitment drive and the findings generated by the research study. The nature of the medical profession in Spain and the organisational differences between the nursing profession and general medical practice are considered in light of the above definitions of ‘brain circulation’.
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Brain circulation and the return of professionals
The concept of ‘brain circulation’ assumes that highly skilled individuals will seek to maximise their options in a global migration market where states compete to attract talent (Cervantes and Guellec, 2002; Gaillard and Gaillard, 2002; Mahroum, 1999; OECD, 2002; Pellegrino, 2001). From the perspective of the state, the two main drivers of the international migration market are the acquisition of skills and the need to counteract skills shortages (Salt, 2002).3 There is also an important element of international competition between source countries over the pool of talent and the need to manage migration flows which has produced both realist policies, characterised by increasingly restrictive controls on admission (Sales, 2002, Sales and Blitz, 2003), and liberal-institutional responses which seek to coordinate national migration policies (Salt, 2002). Realist responses are identified in the proliferation of controls on the admission of skilled labour, for example the 1985 decisions that curtailed the immigration of medical specialists from outside the European Union (Beecham, 1996; Olsen, 1996), as well as admission policies that rely on special work permits, such as temporary work visas. This is particularly evident in new fields of employment, such as information technology, and areas including medicine, which have failed to recruit and retain sufficient numbers professionals. The attempt to manage migration by means of controls, rather than market forces, has also sponsored a recruitment race, where the most economically advanced states compete with one another to capture talent. The United States, Canada, Australia, United Kingdom, and France, in particular, have created energetic international recruitment campaigns to attract highly skilled medical personnel from South Asia and South Africa, onto their shores (Nursing and Midwifery Council, 2002).4 6
Liberal-institutional responses are suggested by the emergence of intergovernmental arrangements which were compelled in part by the extension of regional trading agreements, such as the General Agreement on Trade and Services (GATS) which established a framework of rules for the trade in services, and the increasing reality of European integration (Blitz, 1999b). In this setting, state and regional policies act as ‘lubricators’ that facilitate the movement of skilled workers into the desired sector (Iredale, 2001).5 There are several explanations for personal and professional mobility that lend weight to the central premise behind the ‘brain circulation’ thesis that highly skilled people will seek to maximize the return on their level of education and training. Ballard and Robinson claim that relocation is not an automatic process but there are various stages characterized by instigating, facilitating and activating factors which operate at the micro, meso, and macro levels, that ultimately determine why highly specialised professionals relocate as and when they do (Ballard et al, 2004). From the perspective of the individual, inter-state competition opens up new possibilities for migration including being able to chose between options which may not simply relate to working conditions and remuneration but also non-wage benefits such housing, provision for families, and quality of life issues (Doudeijns and Dumont, 2002). Further, the creation of national and regional policies that seek to promote international recruitment may have a radicalising effect on individuals, empowering them to take advantage of their privileged status within the global migration market (Ballard et. al. 2004). Instigating factors may create a stimulus, however, for individuals, human capitalbased explanations for mobility which emphasize the exchanges of skills, education and
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training in return for work and wages, are still among the principal reasons given for migration between developed states and the UK.
Insert Table 1 here
Table 1 above, which includes data gathered from the International Passenger Survey suggests that employment-related factors remain the most important reasons for relocation (ONS, 2003) and supports the claims that professionals and technical workers in high status fields constitute the majority of new arrivals to the UK (International Labour Migration Database, 2003). Additional explanations for increased levels of inter-state professional mobility, which focus on the state as a global recruiter and individualistic claims regarding autonomy and improved quality of life also support the human capital argument, outlined above. Recent literature on the way in which professionals assess non-wage factors reaffirms the claim of a global marketplace for the highly skilled and the importance of post-materialist values in the construction of elite careers (Diez Nicholas 1996; Doudeijns and Dumont, 2002; Inglehart, 1971, 1977, and 1990). In this context, non-wage preferences include greater choice, autonomy in the workplace, job satisfaction, diversification, and the attraction of foreign travel (Blitz, 2005).
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However, there are three important empirical challenges to the brain circulation thesis as outlined above. First, the insistence on the primacy of economically defined pull factors, such as wage differentials, is at odds with evidence of large-scale migrations with their emphasis on push-factors where structural explanations have greater explanatory weight (Salvatore, 1977)6. In the case of some highly skilled professions such as medicine-related occupations, structural barriers are characterized by exclusive social networks and institutionalized patterns of racial discrimination (Ballard, 2004; Cornelius et al., 2003). Second, international recruitment drives have frequently failed to match demand for employment with the supply of jobs by means of targeted recruitment initiatives. According to Salt, the rationale for such programmes has been overwhelmingly based on short-term priorities and consequently they have produced mixed results (Salt, 2002). The most successful have been targeted at key professionals in growing sectors, such as Information Technology (OECD, 2002). Overall, governments have found it particularly difficult to introduce immigration policies as a way of achieving equilibrium between labour flows and the availability of jobs. OECD data over the past seven years record significant labour shortages for certain specialised professionals in spite of governmental programmes and recent recruitment drives (OECD, 2002). Efforts to draw skilled refugees back home to non-OECD states have met with considerably less success (Blitz, 2003; IOM, 2000; Sales and Blitz, 2003).7 Finally, the substantial evidence of return migration – which is seen to be a necessary condition for ‘brain circulation’ – may paradoxically undermine some of its claims to promote economic growth. The assumption that people will relocate to secure
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better employment (and then send back remittances) is partially contradicted by the growing trend in return migration, which appears be motivated by other, non-financial, factors such as acculturation, family concerns, and sentimental attachments to home (Cervantes and Guellec, 2002; Findlay, 1995; King, 2000). Elsewhere, it has been suggested that adaptation problems account for many premature returns (Bovenkerk, 1974; Gmelch, 1980; Holt, 1998; King, 1986, 2000; Marx, 2001). The discussion below considers the claims for ‘brain circulation’ in the recruitment of Spanish GPs by examining motivations for relocating to the England including both wage-related and non-wage related factors. It highlights the concepts of autonomy and professional structure, as they pertain to labour market incorporation, retention, and return.
Research Context
The retention of GPs in the UK has been a major source of concern for the British medical profession for the past decade (Baker et. al, 1995; Chapman, 2000; Hastings and Rao, 2001; Olsen, 1996; Sibbald et al, 2000. 2003; Young et al, 2003). Among the most significant problems contributing to lower levels of retention are: changing patterns of work, which include an increasing tendency for GPs to opt for part-time contracts; early retirement; and, fewer newly trained doctors entering the profession as secondary medicine continues to attract many young doctors away from general practice (Olsen, 1996).8 The above patterns also have an important gender dimension since women tend to opt for parttime work within the National Health Service and their career patterns differ substantially from their male colleagues (Sibbald et al., 2000). In addition, the British medical system is still recovering from university admission policies that curbed the supply of students 10
entering the profession, below the level of demand, thus provoking a crisis by the mid1990s (Olsen, 1996). According to Sibbald and Gravelle, the primary reason why many doctors have chosen careers outside of general practice is low levels of job satisfaction (Sibbald and Gravelle, 2003). This was particularly evident after the National Health Service reforms of 1990-91 when the largest number of doctors decided to leave the National Health Service and even more quit general practice (Baker et al. 1995; Olsen, 1996; Sibbald et al., 2000; Young et al, 2003). Low levels of satisfaction are having a particularly devastating impact on some of Britain’s poorest regions where the requirement to work out of hours and the lack of community support in these areas, has only fuelled to the flight of GPs from these deprived areas (Chapman 2000; Hastings and Rao, 2001). At the other end, it has been particularly difficult to recruit doctors in highly specialised areas e.g. psychiatry, radiology, anaesthesiology into the National Health Service. To counteract the above problems, the British government has sought to import doctors from other European countries. Their arrival signals a distinctly new phase in the history of international medical recruitment in the United Kingdom. Previous waves of migrants from India, Pakistan, and the Caribbean found jobs as doctors, nurses and other hospital specialists from the 1950s onwards but from 1985 tighter immigration controls restricted access for this pool of doctors and instead privileged European nationals. According to Hastings and Rao, this policy has had a marked effect on the provision of medical care in the UK, especially in deprived areas (Hastings and Rao, 2001). As nonEuropean doctors found it increasingly difficult to reach the United Kingdom, European
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doctors were able to rely on EC directives that aimed to promote the free movement of highly specialised professionals. In the European context, the potential for organised medical recruitment dates back to the creation of the first doctor’s directive 75/362/EEC of 1975 which was aimed to facilitate the right of establishment and freedom to provide services and its corollary 75/363/EEC concerning the coordination of provisions laid down by law, regulation of administrative action in respect of activities of doctors. These sectoral directives were followed by subsequent amendments in 1986 (EC/457/EEC), the creation of general directives aimed at several liberal professions (98/48/EEC, 92/51/EEC), and the consolidated doctors’ directive 93/16/EEC in 1993. In 2001, the European Parliament and Council proposed a new directive which aimed to amend the general directives for the professional recognition of qualifications and the older sectoral directives. The SLIM directive, as it is called, was introduced in order to ensure a more uniform application and interpretation of the general directives, including the updating of lists for the automatic recognition of formal qualifications and recognition of professional experience acquired in other states.
Insert Table 2 here
As Table 2 demonstrates above in spite of the EU’s commitment to promote free movement, the number of doctors moving to England from within the EEA remains
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relatively low at just over five per cent and consequently, the Department of Health has had to consider additional ways of attracting medical professionals to come to England in order to counteract the skill shortage described above (Department of Health, 2002). The Department of Health has established a number of routes to attract European doctors to National Health Service, including direct recruitment into consultant and GP positions, and entry into supervised positions so that the doctor can become better acquainted with the British system. The three main mechanisms used by the Department of Health are: the global recruitment campaign which seeks individual applications from shortage specialties, targeted recruitment campaigns aimed at specific countries and which are conducted by means of government to government agreements or agreements with appropriate professional bodies in the relevant country, and special arrangements that include an International Fellowship Scheme where experienced consultants take up positions in the National Health Service for up to two years and a Managed Placement Scheme that aims to attract consultants who would like to sample living and working in England before applying for a substantive post (Department of Health, 2002). In addition to the above-mentioned schemes, some National Health Service trusts prefer to work with commercial agencies to attract consultants. These ad hoc recruitment campaigns have proved particularly effective in regions that have a particular draw for certain groups of doctors. For example, in South East London, the proximity of the Eurostar and Channel Tunnel has enabled the Trust to attract and retain French GPs; the Trust is planning on recruiting an additional 250 French GPs by 2005 (AMD, interview with the author, 19 September 2003)
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Structural conditions in Britain and Spain: job availability and graduate output
The rationale for the above mentioned recruitment drives is above all the supply of General Practice posts in the National Health Service. According to the British Medical Association’s (BMA) Health Policy and Economic Research Unit’s GP Vacancy Survey of January 2003 there is now a GP workforce crisis. The survey recorded that vacancy rates among British GPs are rapidly increasing, and there is a growing number of unfilled posts with more than 29% of vacancies being left open for six to twelve months (BMA Survey, 2003). Consequently, the existing pool of GPs9 is now “struggling to cope with the needs of well over a million and a half extra patients” (BMA Survey, 2003). However, increased levels of funding and investment over the past five years which have been reflected in a higher degree of public satisfaction relative to other European systems has drawn Continental European doctors to consider Britain (OECD Health Public Satisfaction Data, 2003; National Health Service Chief Executives Report 2002/2003). As noted above, satisfaction is not simply a matter for the public but also medical practitioners for whom the British medical profession stands out as both a relatively autonomous sector which offers opportunities for post-graduate training and is seen as a desirable place to work (Noble and Young 2003).10 Until recently, self-regulation through peer-review has been the characteristic method of controlling access to the British medical profession (Evetts, 2002: 346). In spite of the recent intrusion of government, doctors remain a selfselected group which is distinguished from other professions by their relatively low numbers (OECD Health Data, 2003). In contrast to the other OECD states, Britain enjoys the lowest density of doctors as measured against the general population (1.8 per 1000)
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(OECD, 2003). This fact gives rise to claims that medicine is an exclusive profession – a factor that is attractive to some foreign nationals in search of status (Ballard et al, 2004). The situation in Spain stands in marked contrast to the picture presented above. There is a surplus of doctors in Spain where an average of 600 doctors per year have been unable to secure placements in family and community medicine, as well as other medical specialties (Gazon, 1999). Consequently this has led to a new ‘pool’ of doctors who have no possibility of working in the national Spanish health system. In addition to the surplus of trained graduates, there are a number of structural impediments that prevent Spanish doctors from obtaining secure employment. Many health services in Spain use contractual labour where doctors work for three months at a time so that the authorities can avoid paying social security (Lissa Perteghella interview 17/06/03). The use of a recruitment system where education and experience are converted into points that determine entry and promotion within the medical sector, has been cited as a further barrier to the mobility of doctors within Spain’s internal market (Lissa Perteghella interview 17/06/03). According to Ballard and Robinson, the dearth of jobs in Spain is an instigating factor which could only be activated following the Department of Health public information campaign about conditions in Britain. The creation of specific agreements serves as a facilitating mechanism for admission to the British medical profession (Ballard et. al, 2004). In this context, the Anglo-Spanish agreements support the liberalinternationalist account of migration (Iredale, 2001; Salt, 2002).
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Methodology
Focus groups and in-depth interviews were held with practicing doctors who identified as GPs (and sometimes former hospital specialists) in Madrid, London, and County Durham (n=12); in addition interviews were conducted with National Health Service managers and recruiters (n=10). Participants were self-selected and included candidates who responded to invitations to interview offered at Department of Health sponsored recruitment fairs and information briefings in London and Madrid in June and July 2003; others participants were recommended to the research team. Semi-structured interviews were used to draw out motivations for relocation and gather background information on the nature of the Anglo-Spanish agreements and the way in which they were being implemented by Department of Health recruiters. Three focus groups were held with 1) young GPs; 2) recent arrivals, and 3) former hospital specialists, to gather further knowledge of key issues including, job satisfaction, the availability of jobs for trained doctors, and personal motives for relocation. The data from interviews and focus groups were then sorted thematically and explanations for migration were then ranked based on the impact they had on primary activating factors.
Findings
The findings presented below were collected following interviews and focus groups with medical doctors and recruiters linked to the National Health Service. The doctors in this study were on average 28-35 years old and had been working for at least three years. 16
Some of the specialists who were returning to primary care in the UK were in their late 30s and early 40s. There was a relatively even mix of men and women. Most came from urban centers including cities and towns in Northern (Barcelona, Zaragosa), Central (Madrid), and Southern Spain (Murcia, the Balearic Islands). Most of the participants came to the UK alone but a significant group settled in Northern England arrived with spouses and children. Multiple explanations were given in answer to the question: what made you consider moving to the United Kingdom? Participants identified a mix of push and pull factors, although push factors had greater weight. Above all occupational and economic barriers to progression in Spain seemed to push the doctors to consider relocating. Participants tended to stress the following four work-orientated reasons for their relocation: 1) structural factors; 2) professional development; 3) personal development; and, 4) financial considerations. In addition, they mentioned two main personal reasons including: 5) the psychological benefits associated with status and the greater acceptance as doctors in the UK; and 6) financial benefits to their families. Structural factors were discussed in the context of the barriers to employment presented by the Spanish medical system although participants were keen to balance their criticism with positive references to UK-specific pull factors, not least of which was the opportunity to work in English and experience living abroad. When questioned further, the participants cited the oversupply of doctors, the lack of professional opportunities, difficult working conditions, and the instability of their jobs as among the most important reasons behind their decision to relocate. For the Spanish doctors consultants and GPs, the lack of job security centred above all on the use of three-month contracts and poor conditions of
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work. Recently-trained doctors stated that they were frequently forced to chose between working out-of-hours for extended periods or time, or as locums, and this simply added to personal and professional frustration, compelling many to look abroad. A young female doctor from Barcelona who attended a recruitment fair sponsored by the Department of Health in London claimed that the Spanish system was not working, that market saturation was the main driving force for relocation. In her view, there were simply too many doctors that had graduated from medical schools and that after years of looking for permanent work she had been forced to look for work outside Spain. She described her situation as to be expected and argued that the only way ahead was to leave:
They don’t give you the opportunity [of work elsewhere], they oblige you. Every country wants Spanish doctors except for Spain. It’s terrible. And they prepare good doctors. After that they tell you there’s no work, now go abroad. The only doctors working in Spain are old and they haven’t any interest in doing anything. The only thing they want is retirement.
Her colleagues noted that for those who chose to remain in Spain, the only course of action was to accept whatever was offered. One recent arrival to England claimed that since there were so many doctors, even locum posts were in demand and one needed to accept whatever offers simply to remain on the books, which is what she had done before her move. “If you don’t work out-of-hours, you have to work as a locum with a mobile and be on call 24 hours. You have to say yes because if you say no, they won’t call you anymore.”
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For the consultants who had hoped to settle in England as a general practice doctor, the situation was just a precarious. A surgeon specializing in facial reconstruction spoke about the attrition rate of highly trained specialists who were forced to leave the public sector for private practice. Out of his graduating class of fifty specialists, only eight were still working in a public hospital. Professional Development was another major factor motivating doctors to seek employment within the National Health Service. Opportunities for practice and skills development, in contrast to the professional barriers mentioned above, were frequently listed as strong pull-factors. Several GPs noted that the limited job market back home made continuity of care particularly difficult and yet, the principle of following up with patients was considered to be a fundamental tenet of primary care. Other professional traditions, such as the fact that consultants did not correspond with patients, were seen as disadvantaging both doctors and their patients back home. The fact that in Britain doctors maintain a relationship with their patients was an important draw for them. One Spanish doctor described how she reached her decision to relocate, based on professional considerations.
I was working as an out-of-hours-doctor and mainly it was holidays and weekend and one evening every two or three days. So it was quite hard being out of home and then I found it very difficult to have any continuity, having follow-ups with the patient which I think is one of the main rules of primary care. So I thought being an emergency doctor was very interesting but it would not let me learn much more from the patients because I would never know what was the treatment, the diagnosis
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when they were at hospital so I thought I would rather go to any country where I could have this follow-up.
Training and development were also identified as a positive reason behind the participants commitment to the National Health Service. For some, the mere act of moving would provide them with additional professional development, as remarked by a young GP: “if you change your country and other ways of working, you can improve your skills.” One gastroenterologist from Barcelona spoke about his desire to improve something within his speciality which promoted him to attend a recruitment fair. The Spanish participants in particular noted that there are many opportunities for training in the UK, and that it is easy to locate information regarding professional development. By contrast, several commented on the barriers that prevented them from enjoying further training in Spain. These barriers included bureaucratic procedures with lengthy application forms and often having to send passports and driving licenses to various agencies. Such hurdles deter people from seeking out opportunities for professional development in Spain, in contrast to the UK where several participants were already enjoying regular access to further training. In spite of the differences described above, the Spanish participants commented that the British and Spanish systems were quite similar and this eased their transition in the United Kingdom. In terms of being a GP, the management of patients and basic professional protocols are very similar. Several added that the Spanish system is based on the UK public system and most doctors were familiar with British medical journals because they are used in medical schools. There are many other practical similarities.
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Personal Development. Several participants commented on the fact that by relocating to the United Kingdom, they were able to secure better professional conditions that affected their personal well-being. These improvements were described in terms of: improved status within the community; more respect and trust; better remuneration, and self-improvement through new experiences. Opportunities for personal growth were often cited along side the negative aspects of their employment situation and the structural barriers they encountered back home. Personal factors were closely associated with professional ambitions. This was evident in the discussions over occupational status and job satisfaction. Socio-Psychological Effects: Other factors mentioned by participants included attitudinal differences between patients and doctors and even within the medical community that made the Spanish doctors feel more welcome in England than in their home environments. The doctors interviewed commented that patients in England tended to have more respect for GPs than Spanish patients, and suggested that in Britain, patients have an opportunity to build a relationship with their doctor. In Spain, where a vast number of doctors are locums, they do not enjoy this possibility and as a result, some of the participants felt that the structure of the medical occupation inhibited the development of trust and respect. The possibility of working in communities where the doctor was treated with respect was especially important for some participants whose professional paths had been marked by frustration. A Spanish doctor added that as a locum in Spain she did not have the opportunity to have her own patients and particularly enjoys that aspect of her work in the North East of England.
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Improved professional status, not least being taken seriously as a doctor, was reflected in increased personal status. The fact that British patients were described as polite and were less likely to challenge the doctors’ authority directly, or switch GPs when their requests for unnecessary prescriptions were turned down, as they frequently did back home, contributed to the doctors’ sense of being respected within their new communities, which they appreciated. Other doctors recognized that although GPs enjoyed greater respect, they also had additional responsibilities. The potential for litigation and claims brought against doctors was far greater in the UK than in their home countries and this contributed to additional worries for some GPs. For others, the personal gains were described in terms of new experiences on offer. One psychiatrist who arrived in Britain before the recruitment programmes were created, spoke about how he was led by his desire for adventure, flexible work, and personal autonomy over his career.
I just came with the idea of completing a specialty, coming and going back [and forth to Spain] and having the capacity to decide which is important for me to preserve. Spain did not offer that.
His views were in part shared by a new arrival who spoke of his long-standing desire to have an experience abroad that was satisfied in part by his relocation to the North of England. “Basically my first motivation was to go abroad because I think this is a very good experience for me both personal and professional.” For others, working in the UK presented a package of opportunities. Another Spanish doctor commented that it was about
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“personal improvement”. Her colleague, who practiced complementary medicine added that by moving he thought he could improve upon his family’s “general condition” which was not simply limited to professional opportunities. Rather, the combination of better working conditions, a change of lifestyle, and country where he could work on his English made the UK a “good opportunity.” The notion that personal motivations could encompass several, non-material factors, was reiterated by another contented colleague who had two school-age children and who together with her self-employed husband was able to settle quickly into English life. Being able to work in English was regularly cited as an important factor that contributed to their decision to relocate and to their choice of country. Some participants had explored opportunities in Scandinavia, France and Portugal but preferred Britain. Although it had some obvious professional benefits, for example the fact that much medical research is published in English, the desire to work in an English-speaking country was often expressed in purely personal terms. One female doctor commented that she and her colleagues had been studying English for years “so I think it is more like an exam coming here and being able to manage on your own without any help from teachers or anybody else. It is more about personal satisfaction.” Her colleague, who had a long-standing interest in English culture, Celtic mythology, and 1970s English rock music spoke about the lure of the English language and how it reflected a tradition of honesty which he valued. “With English, you usually say what you mean and that reflects English personality.” Financial considerations, although not the most important factor, were nonetheless mentioned by participants as influencing their decision to relocate to England. Most of the participants interviewed earned between 1500-2000 Euros per month. One Spanish
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surgeon mentioned that he only earned 2000Euro a month and that was hardly sufficient for his family. For those with families the issue of pay came up more often. Others noted that even though they could earn more than £50,000 working as GPs, and were living in an inexpensive part of England (County Durham), the cost of living was still exceptionally high.
Retention and Return
Most participants who had arrived since 2001 were undecided about the length of time they intended to spend in England. Several doctors commented that although they never felt as if they made a commitment to emigrate, they also had no fixed plans regarding return. One female doctor suggested that the geographical proximity of her native country to the UK put her in the position of not having to make hard decisions regarding permanent settlement and loosening her ties to her homeland. She added that “some think it is brave to leave things behind, friends and family, but you can go back to visit every few months or they can come to visit.” A number of Spanish doctors living in North East England took steps to become more established by buying flats and houses but these were not necessarily seen as longterm measures. With the exception of consultants with families who stated that they were planning on settling permanently in the United Kingdom, most participants were open to the idea of return. However, when questioned about their views regarding the prospect of return, a number of participants commented that by taking up a post in the United Kingdom, Spain would be “finished”. One young doctor currently working in Galicia who
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was considering relocating to the United Kingdom claimed that by “moving to Britain you are closing your doors to Spain”. A colleague expanded upon this statement:
there are a lot of people waiting for jobs and you lose contacts, you lose your contract, the hospital everything. There are very few possibilities in Spain so if you go away, you haven’t any real opportunities to go back to Spain again.
Moreover, the vast majority believed that they would face similar conditions to what they had left behind and in this sense, returning to their home countries would signal a backwards step. One young doctor from Spain described the lack of options ahead and how working in the UK had raised his professional and personal expectations.
If I go back, job conditions will be the same, maybe worse because I spent time here and therefore lost contacts. So I have the impression that it won’t be easy for me to go back to Spain and I would not be happy to go back and do what I did before. And it would be even harder, having spent time here. I don’t think things are going to change.
Instead, he held out the possibility of relocating to a third country, such as the United States or Australia. Others noted that there would be little reason to go back and take up jobs in the state system. For the doctor who planned on working in the growing field of complementary medicine, the most sensible option was in private practice. He admitted that he had “no
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expectation to go back to Spain to work for the public sector, not because it is a difficult issue but because I wouldn’t enjoy that in Spain.”
Discussion
The exodus of doctors from Spain to England demonstrates that professional transfers may be facilitated by liberal-institutional agreements such as the Anglo-Spanish contract but in contrast to the current trends in migration (Iredale, 2001; OECD, 2003; Salt, 2002) this study records that the movement of professionals into the National Health Service is most probably not temporary. The lack of job prospects in Spain may serve as activating factors that encourage emigration from Spain (Ballard et al., 2004), but these same conditions also prohibit return. As opposed to the experience of Spanish nurses who were brought into the National Health Service by means of a similar international recruitment drive, the Spanish doctors face significant obstacles that prevent them from returning to Spain. Macro and meso-level factors, above all, the supply of jobs, structure of the medical profession in Spain, and the existence of social and political barriers such as exclusive networks, frustrate the prospect of return since contacts and connections are the principal means of securing permanent and even temporary employment in the Spanish medical sector. Working abroad denies medical professionals access to these sources of influence and this fact was reflected in the comments made by the research participants. There was no discussion of maintaining professional ties with the medical sector back in Spain and the Spanish doctors were either undecided about the possibility of returning to
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Spain or voiced passive support i.e. they offered vague statements in favour of returning but had no fixed plans. Some of those interviewed were out rightly hostile to returning and could not conceive of going back to Spain given the difficulties they had encountered there. These findings suggest that patterns of professional migration may be explained not only by human capital based motivations but also the prevalence or lack of social capital (Cornelius et al., 2003). The research findings outlined above also call into question some of the principal claims for economic growth associated with the ‘brain circulation’ thesis. In the first instance, the fact that many of the participants had mixed motives for relocating to Britain challenges the human capital based assumption that higher wages drive professionals to seek out better work abroad and gives greater weight to post-materialist and non-financial explanations for migration (Blitz, 2005; Cervantes and Guellec, 2002; Findlay, 1995; King, 2000). Several non-financial factors were cited as influencing the participants’ choices to settle in the United Kingdom, and these included both personal criteria, like working in an English speaking environment, and the opportunity for travel. However, most participants held multiple reasons for migrating and although the doctors were able to improve upon their financial position and were able to acquire new skills by relocating to the United Kingdom, for almost all of the participants, this was not a free choice that they had embraced willingly. Rather, most of the participants saw the possibility of working in England less as an opportunity and more a requirement if they wished to continue in their field of expertise. Another weakness in the ‘brain circulation’ argument, which is borne out by this research, is the claim that even if professionals do not return home, they maintain links and
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send back remittances which ultimately contribute to economic growth in the home state. The fact that many participants in this study noted that the cost of living in the United Kingdom was so much higher than in Spain, suggested that there was little possibility of sending remittances back; although this may not be the case in other contexts. There are two additional findings in this study that warrant further consideration. One of the most interesting findings of this study is supported by Ballard’s research of the migration of French GPs to South East London, namely the social benefits of relocation (Ballard et al, 2004). By relocating to the United Kingdom, many of the Spanish doctors were able to improve their social status and this had a great impact of their sense of personal and job satisfaction which ultimately affects their retention within the National Health Service system (Sibbald et al., 2000; 2003; Taylor and Leese, 1997). For both doctors and patients, there were several important professional and social gains that resulted from the Department of Health recruitment drive. As the above evidence records, the Spanish doctors developed a more professional approach towards referrals and established increased contact with patients, a necessary function of primary care. In this context, not only did the Spanish doctors learn new skills but also worked to provide better services to their patients.
Conclusions
The above study of Spanish doctors presents an insight into the trend in internationalised medical care and intra-European migratory patterns which will have greater relevance as professionals in the new European Union member states start to
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explore their opportunities of freedom of movement and establishment (see. Lipp 1999). While this study was limited to Spanish professionals, Italian, German, and French doctors have all joined the British National Health Service in the past two years and represent a distinct wave in intra-European migration. This article focused on the migration of medical professionals: the flip-side of the coin which was not covered in this study is the growing number of patients who will travel between European Union member states for medical care. As for ‘brain circulation, the findings of this study call into question many of the claims, including the assumption that the Spanish doctors surveyed should be able to move between host, recipient, and even third countries over the length of their career. Structural barriers, such as the dearth of jobs in Spain, combined with meso-level explanations regarding the exclusive nature of the Spanish medical profession, create major impediments to medical mobility. Professional structures, the prevalence of contacts and extensive networks (social capital) may determine the extent to which medical professionals can return home and thus provide evidence of ‘brain circulation’ An additional finding to emerge from this study concerns the degree to which professional mobility between advanced states may influence migrants’ personal status including sense of job satisfaction and other non-financial criteria. Rather than promote brain circulation, these factors are increasingly held out as key indicators of retention in the medical sector and hence may contribute to ‘brain gain’ (Baker et. al, 1995; Chapman, 2000; Hastings and Rao, 2001; Olsen, 1996; Sibbald et al, 2000. 2003; Young et al, 2003). As this study records, the Spanish doctors who relocated to Britain developed a more professional approach towards referrals, established increased contact with patients, and
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learned to provide better services to their patients. Such changes in practice increased their sense of job satisfaction as well as the potential for their retention within the National Health Service.
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Notes *
This article could not have been produced without the research assistance of Shannon Nutting. I am also grateful to Lissa Perteghella and Victoria Rubini of the British Embassy Madrid for facilitating access to research participants in Spain and would like to record my appreciation to the doctors, National Health Service, and Department of Health staff who agreed to be interviewed. Dr. Jose Miralles Garcia was extremely helpful providing access to research participants in the UK. I would also like to express my appreciation to Professor Judith Glover for her encouragement and advice and to three anonymous referees. 1
There are many definitions of brain drain but common to all is the sense of permanent loss of skills. 2 In January 2002, a new trend in sub-contracting between European health systems was made public when nine British patients who were waiting for treatment on the National Health Service were transported to Lille, France for cataract and joint operations. 3 Consider for example the creation of the UK’s highly skilled migrant programme in 2002 which enables eligible migrants to enter the UK to seek and take up work for a 12 month period, supports Salt’s claim. 4 The United States seeks to fill 1 million nursing posts within the next ten years. See: Nursing and Midwifery Council, 2002. 5 For example the creation of the UK’s highly skilled migrant programme in 2002 which enables eligible migrants to enter the UK to seek and take up work for a 12 month period. One month before the visa expires, the migrant can apply for further permission to stay in the UK as a Highly Skilled Migrant. 6 See. Salvatore, D. (1977) ‘An Econometric Analysis of Internal Migration in Italy’, Journal of Regional Science, 17 pp. 395-408. 7 The International Organisation for Migration has developed programmes aimed at facilitating the Return of Qualified Nationals in Africa, Bosnia, Afghanistan, and other parts of the world. These programmes have met with little success and have exposed not only the problems of trying to match skills with the availability of jobs, but also the enormous cost to the organisation in terms of administration time and social support. 8 A 1998 report by the British Medical Association noted that only about 19 per cent of junior doctors planned a career in general practice The drop in numbers has led to a shortage of up to 800 doctors in general practice while approximately 7,500 GPs have chosen alternative medical paths, working instead as locums and assistants, to the detriment of the Department of Health with its required intake of 50% of medical graduates, in order to sustain the workforce. See: Chapman, 2000, p.6. 9 According to the BMA Vacancy Survey, of the 304 Primary Care Trusts (PCTs) in England just under 60% of the 150 PCTs contacted by the BMA responded. Between the 89 Trusts that replied, the number of GPs in post totalled 8,816. Of the 89 respondents, only seven reported no vacancies. The total number of open vacancies stood at 412.When expressed as a percentage of the total number of GP positions available between the 89 PCTs, this equates to 4.7% of the total workforce.” 10 In relation to other European countries, the British medical profession enjoys considerably more autonomy, even though this privilege appears under threat from new 31
corporatist practices and increasing levels of external evaluation imposed by the government. REFERENCES Abrahamson, P., Ellis, S. and R. Inglehart (1997) ‘Research in Context: Measuring Value Change’, Political Behavior 19(1): 41-59. Baker, M., Williams, J. and Petchey, R. (1995) ‘GPs in Principle but not in Practice: a Study of Vocationally Trained Doctors not Currently Working as Principals’ British Medical Journal 310: 1301-1304 (20 May). Ballard, K. Robinson, S. and Laurence, P. (2004) ‘Why do general practitioners from France choose to work in London practices? A qualitative study’ British Journal of General Practice 2004; 54; 747-752. Ballard, K. and Laurence, P. (2004) ‘An Induction Programme for European General Practitioners Coming to Work in England: Development and Evaluation’, Education for Primary Care 2004, vol. 15, no. 4 (November), 584-595(12). Blitz, B.K. (1999a) ‘The Resistant Guild: Institutional Protectionism and Freedom of Movement in The Italian University System’, Journal of South European Society and Politics 4(1): 27-47. Blitz, B.K. (1999b) ‘Professional Mobility and The Mutual Recognition of Qualifications in The European Union: Two Institutional Approaches,’ Comparative Education Review, 43(3): 311-331. Blitz, B.K. (2003) ‘Refugee Returns in Croatia: Contradictions and Reform’, Politics 23(3):181-191 Bovenkerk, F. (1974) The Sociology of Return Migration. The Hague: Nijhoff. British Medical Association (2003) GP Vacancy Survey, January 2003. http://www.bma.org.uk/ap.nsf/650f3eec0dfb990fca25692100069854/8e0cfe8c7812023180 256cbb003fcda5/$FILE/GPvacancy03.pdf Buchan, J. (2002) International Recruitment of Nurses: UK Case Study July 2002. http://www.rcn.org.uk/publications/pdf/irn-case-study-booklet.pdf Buchan, J. (2003) Here to Stay: International Nurses in the United Kingdom, 19 February 2003. http://www.rcn.org.uk/publications/pdf/heretostay-irns.pdf
32
Castles, S. (1995) ‘Contract Labor Migration’ in R. Cohen (ed.) The Cambridge Survey of World Migration, Cambridge: Cambridge University Press. Cervantes, M. and Guellec, D. (2002) ‘The Brain Drain: Old Myths, New Realities’ in OECD Observer May 2002. Chapman, R. (2000) ‘General Practice in the United Kingdom: A New Dawn?’ European Union of General Practitioners. http://www.uemo.org/natsec/uk.htm. Cohen, R. (1991) Contested Domains. London: Zed Books. Cornelius, W., Takeyuki, T. and Z. Valdez (2003) ‘Human Capital versus Social Capital: A Comparative Analysis of Immigrant Wages and Labor Market Incorporation in Japan and the United States’, IZA DP No. 476, Bonn: Institute for the Study of Labor (IZA). Department of Health (2002a) Delivering the NHS Plan: Next Steps on Investment, Next Steps on Reform. London: the Stationary Office. Department of Health (2002b) International Recruitment of Consultants and General Practitioners for the NHS in England: Current Initiatives and Guidance to NHS Employers on an Infrastructure to Support International Recruitment. London: Department of Health. Department of Health (2003a) International Recruitment Global Scheme Recruitment Process. London: Department of Health. Department of Health (2003b) Chief Executive’s Report to the NHS 2002/03. London: Department of Health. Diez Nicholas, J. (1996) ‘Social Position, Information and Postmaterialism’, Revista Espanola de Investigaciones Sociologicas (English Edition) 1996: 153-165. Doudeijns, M. and Dumont, J-C. (2002) ‘Immigration and Labour Shortages: Evaluation of Needs and Limits of Selection Policies in the Recruitment of Foreign Labour’, Paper Presented at The Economic and Social Aspects of Migration Conference Organised by the European Commission and OECD, Brussels, 21-22 January 2003. Evetts, J. (2002) ‘New Directions in State and International Professional Occupations: Discretionary Decision-Making and Acquired Regulation’, Work, Employment and Society 16(2): 341-353. Findlay, A.M. (1995) ‘Skilled transients: the invisible phenomenon?’ in R. Cohen (ed.) The Cambridge Survey of World Migration, Cambridge: Cambridge University Press. Gaillard, A-M. and Gaillard, J. (2002) ‘Fuite des Cerveaux, Circulation des Competences et Developpement: Un Enjeu Politique’, Mots Pluriels, No. 20 février 2002. http://www.arts.uwa.edu.au/MotsPluriels/MP2002ajg.html
33
Gazon, F.P. (1999) ‘General Medicine in Spain’, European Union of General Practitioners www.uemo.org/natsec/spain.htm. Gmelch, G. (1980) ‘Return Migration’, Annual Review of Anthropology, 1980 (9): 135-59. Hastings, A. and Rao, M. (2001), ‘Doctoring Deprived Areas’, British Medical Journal, 323: 409-410 (25 August). Holt, D.H. (1998) International Management. London: The Dryden Press. Inglehart, R. (1971) ‘The Silent revolution in Europe: Intergenerational Change in Post Industrial Societies’, American Political Science Review, 65: 911-1017. Inglehart, R. (1977) The Silent Revolution: Changing Values and Political Styles Among Western Publics. Princeton, N.J.: Princeton University Press. Inglehart, R. (1990) Culture Shift in Advanced Industrial Society. Princeton, N.J.: Princeton University Press. International Labour Migration Database (2003) http://www.ilo.org/public/english/protection/migrant/ilmdb/ilmdb.htm International Organisation for Migration (2000) ‘Evaluation of Phase III of the Programme for the Return of Qualified African Nationals, Office of Programme Evaluation, International Organisation for Migration, Geneva. Iredale, R. (2001) ‘The Migration of Professionals: Theories and Typologies’, International Migration 39(5): 7-26. King, R. (2000) ‘Generalisations from the History of Return Migration’ in Ghosh, B. (ed.) Return Migration: Journey of Hope or Despair, Geneva: International Organisation for Migration and the United Nations. King, R. (1986) Return Migration and Regional Economic Problems. London: Croon Helm. Lipp, T. (1999) ‘The Situation of General Practitioners in Germany in the Run-up to the Year 2000’, European Union of General Practitioners. http://www.uemo.org/natsec/uk.htm. Mahroum, S. (1999) Europe and the Challenge of the Brain Drain, IPTS Report No. 29, Seville, Spain: Institute for Prospective Technological Studies. Marx, E. (2001) Breaking Through Culture Shock: What You Need to Succeed in International Business. Yarmouth, ME: Nicholas Brealey Publishing. 34
Noble, J. and Young, R. (2003) The International Market for Medical Doctors: Perspectives on the Positioning of the UK April 2003. National Primary Care Research and Development Centre. http://www.npcrdc.man.ac.uk/Publications/28.pdf Nursing and Midwifery Council, (2002) Statistical Analysis of the Register, 1 April 200131 March 2002, November 2002. OECD (2002) ‘International Mobility of the Highly Skilled’, OECD Observer Policy Brief, July 2002. OECD (2003), OECD Health Data 2003 Trial Version. Office of National Statistics (2003) Economic Trends No. 598 September 2003, London: Office of National Statistics. Office of National Statistics (2002), Average annual international migration: by main reason for migration, 1991-1995 and 1996-2000: Social Trends 32 http://www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=4960&More=Y Olsen, N.D.L. (1996) ‘Sustaining General Practice: Re-engineering and a New Charter are Needed for the Next Millenium’, British Medical Journal, 312:525:526 (2 March). Pellegrino, A. (2001) ‘Trends in Latin American Skilled Migration: ""Brain Drain or Brain Exchange?’ International Migration (Special Issue International Migration of the Highly Skilled) 39(5): 111-132. Sales, R. (2002) ‘Safe Haven, Secure Borders: A Contradiction in Terms?’ Paper presented to annual conference of Social Policy Association Middlesbrough (July). Sales, R. and B.K. Blitz (2003) ‘Asylum-Seekers: Unwelcome Return’, The World Today 59(4) (April), pp. 20-21. Salt, J. (2002) Current Trends in International Migration in Europe. Council of Europe Document CDMG (2002) 26. December 2002. Strasbourg: Council of Europe. Salt, J. and Findlay, A. (1989). ‘International Migration of Highly-Skilled Manpower: Theoretical and Development Issues’, in R.T. Appleyard (ed.) The Impact of International Migration on Developing Countries, Paris: OECD. Salvatore, D. (1977) ‘An Econometric Analysis of Internal Migration in Italy’, Journal of Regional Science 1977(17): 395-408.
35
Sibbald, B., Bojke, C. and Gravelle, H. (2003) ‘National Survey of Job Satisfaction and Retirement Intentions Among General Practitioners in England’, British Medical Journal January 4; 326 (7379): 22. Sibbald, B., Enzer, I., Cooper, C. Rout, U. and Sutherland, S. (2000) ‘GP Job Satisfaction in 1987, 1990 and 1998: Lessons for the Future’, Family Practice 17(5) 364:371. Taylor, D.H. and Leese, B. (1997) ‘Recruitment, Retention and Time Commitment Change of General Practitioners in England and Wales, 1990-94: A Retrospective Study’, British Medical Journal 314 (7097): 1806-1810. Young, R., Leese, B. and Sibbald, B. (2001) ‘Imbalances in the GP Labour Market in the UK: Evidence from a Postal Survey and Interviews with GP Leavers’. Work, Employment & Society, Vol. 15, No. 4, 699-719.
36
