Driving forces of GPs’ migration in Europe: an exploratory qualitative study

Summary

This multi-country study was carried out to explore the driving forces influencing GPs’ migration in Europe. The main reasons for migrating to another country, to stay in the new country, to return, or migrate further were grouped under the following three themes: professional development; personal reasons; and the situation in their home country or organisation of health care. Professional development was mentioned by the participants as the driving force of migration; at the same time, the decision to stay or to leave seemed to be influenced by the personal factors the most.

Comparison with existing literature

A lot of literature has tried to explain the migration of doctors using the terms push, pull, and plant factors. Better and safer working conditions, smaller workload, higher remuneration, the existence of a national public health strategy, political instability, personal insecurity, and future prospects are just some of the factors for the migration of doctors identified in various studies.^10,12,16,18 The same reasons were mentioned by the participants of the present study (Supplementary Tables S4 and S5). In this study, the focus was laid more on the phases of migration: migrating, staying, or leaving. In all these phases, the same reasons tended to come back and can be seen simultaneously as a pull, a push, or a plant factor. So, while this study can agree on the use of pull, push, and plant factors to describe reasons to migrate, one should be cautious when describing one reason for migration as only a push, a pull, or a plant factor. The terms should be used in the right context.

This study described reasons why GPs, as a specific group within the healthcare workforce, tend to migrate back or migrate further. Gauld et al used a similar approach, but only studied the reasons why doctors from the UK did not stay very long in New Zealand after migration. Those who went back to the UK initially migrated for professional development and gaining experience, which was also mentioned by some of the present study participants.²⁴ This study also described various factors preventing GPs from going back to their home country. Some of them could be seen as plant factors, while others could be seen more as barriers, such as the difficulty of re-entry after a time abroad, or the fear of facing the same problems that motivated their migration in the first place. The ease of re-entry after being away is briefly mentioned in the study by Sharma et al.²⁵ Brugha et al described that some GPs who wanted to migrate further seemed to be pulled or pushed by the same reasons for they were migrating initially: professional and personal reasons, which was another recognisable phenomenon.¹³ These migrants were called 'backpacker migrants' by Brugha et al; they were always in pursuit of better career opportunities, salaries, or overall conditions, hopping from one country to another. This phenomenon is also seen in the study by Gauld et al.²⁴

In the present study, there was an overrepresentation of GPs from Eastern Europe compared with Western Europe, which accords with the previously described findings from literature that doctors tend to migrate from lower-income countries to higher income countries.^4,7–10

While some literature underlines the need for retention strategies to combat the shortage of doctors owing to migration, few studies propose specific strategies. McAleese et al stated that developing retention strategies is required in order to stop the need of some countries to actively recruit doctors.⁸ Both Humphries et al and Taderera emphasised that understanding the reasons why doctors migrate could eventually contribute to much-needed policy changes in service of more robust retention strategies.^26,27

Ibrahim et al described some pull factors that could result in better retention of expat doctors in the UAE.²⁸ These could be described as the earlier mentioned plant factors too. Sharma et al briefly addressed the fact that easing re-entry policies in the UK could encourage doctors to come back.²⁵ Brugha et al also focused on factors influencing the decision to migrate, to stay or to return, focusing more on the specific situation in the Ireland.¹³ Although none of these studies focused on GPs, the same factors were also mentioned in the present study. There are factors contributing to migration and the will to stay in a country instead of returning — mostly personal factors, such as the so-called plant factors and the will to gain experience abroad — which policymakers cannot do anything about. There are, however, pull, push, and even some plant factors — such as a higher remuneration, better career opportunities, easier ways to return after being away for a longer time, and in general an improvement of the healthcare system in a country — that could contribute to the retention of GPs and even the return of emigrated GPs.

Strengths and limitations

For this study, an open call was made to participate in individual interviews and only 15 GPs agreed to participate. There was an overrepresentation of participants from Eastern European countries and some countries were represented by only one GP. It is not possible to report on the viewpoints of GPs who did not participate in the study. Because of these factors, it is difficult to establish actionable points for the entirety of Europe.

The first two authors involved in interviewing the participants and analysing the data have backgrounds in family medicine and general practice, which helped in understanding experiences and terms used by participants, but could also potentially influence the neutrality. Several participants from Estonia were familiar to one of the researchers and were therefore interviewed by the second author. All of the interviews were analysed by the first two authors, bringing together the complex theme structure. By using the same topic guide and having both interviewers conduct the first interview, the two authors created a similar pattern and approach, minimising possible differences between the interviews.

Implications for research and practice

This study adds further information on the driving forces of GPs migration in Europe. Migration caused by dissatisfaction with the organisation of health care, especially primary health care and living environment, is something countries could potentially work on in order to retain their GPs. The focus needs to be on improving work conditions, education, career opportunities, and progression in order to be able to retain domestically-trained GPs, as well as on motivating emigrated GPs to come back by eliminating barriers for returning home. Once GPs have migrated and are experiencing satisfying working and living conditions elsewhere, it is more difficult to attract them back. Some countries in Europe rely more and more on international recruitment to combat the GP shortage, which in turn worsens the situation in other countries; as such, a more unified Europe-wide approach to GP shortage and migration is needed to help diminish the discrepancies between the countries, and limit the ‘brain drain’ from Eastern Europe to Western Europe. However, as there is not much focus yet on evidence-based retention strategies for GPs, more research on this topic is needed.