The UK’s National Health Service (NHS) is the publicly funded health care provider in the country. It is the largest non-military employer in the world. Similar to US medical services, it is heavily dependent on migrant doctors to deliver essential medical services. Many accounts, though, find evidence for inequality in their careers and pay.
Twenty six percent of UK doctors have obtained their primary medical qualification overseas, migrating from the European Economic Area (EEA) or further afield (international medical graduate or IMG). Research on the experience of women doctors and on migrant doctors can be located, but with a notable exception. It is less common to see gender and place of qualification considered together. So, we wanted to know – do NHS migrant doctors experience pay gaps compared with their UK-trained counterparts? Are they worse for women? And if so, how can they be narrowed?
Last year, with the permission of the UK’s Department of Health and Social Care, we completed a research study published in the Academy of Management Discoveries journal analysing inequality in career outcomes and the reasons for pay gaps for migrant men and women doctors. We had survey returns from 5,753 medical doctors working for the NHS supplying information about their pay, levels of support and career barriers.
We found that, all else being equal, migrant pay gaps are large especially for women that have taken their medical exams outside Europe. We also found that management support reduces career barriers and pay gaps for all groups except for migrant women doctors with dependent children.
Taken together we take this as evidence that there is inequality and may even be discrimination in the UK NHS migrant doctors’ careers. More positively, we also show that there are ways that line management and human resources practices can overcome career detriment and reduce pay gaps for most groups. But there is more work to do to support female migrant doctors with dependent children. Innovative management practices may be required.
What causes migrant pay gaps?
Most organisations in the US and UK have pay gaps between their male and female workers. There is also evidence of ethnic pay gaps. And some studies show ethnic women experience increased pay gaps which are greater than might be expected as a consequence of gender and ethnicity. However, few organisations collect information on their migrant pay gap, for either men or women, or both.
Migrant doctors, even highly skilled ones, suffer the penalty of other people’s negative evaluation of their performance. They are more likely to experience racialised micro-aggressions, undermining behaviours, bullying, and harassment in comparison to home country-trained doctors. They receive fewer opportunities for career development and are much more likely to be referred for “fitness to practice” assessments. These effects are likely to be compounded by female gender.
We found that migrant doctors pay gaps are primarily caused by their lower rank and shorter length of service. Pay gaps range from 9.3 percent comparing male UK-trained with male IMG doctors, to 19.6 percent comparing male UK with female IMG doctors. Where a group is both female and migrant—e.g., female EEA and female IMG—, pay gaps are the largest, amounting to nearly 20 percent in each case. However, we found that if, in theory, length of service and seniority was equalised, pay for migrant doctors would be higher and pay gaps would be considerably reduced. Even where this happens, pay isn’t equal, leaving a role for possible discrimination, but it was much closer to the UK-trained comparator especially for migrant male doctors. Migrant female doctors are damaged much more by potential discriminatory factors.
Narrowing pay gaps for migrant doctors
The idea that reducing workplace barriers and improving management support in helping the careers of migrant doctors isn’t new, but making a statistical connection to factors that will ultimately reduce their pay gaps is a novel idea. Additionally, if we can understand how perceptions of workplace barriers and experiences of management support differently affect migrant groups, we will be able to recommend targeted solutions within NHS (and possibly wider) workplaces.
We commenced this exploration by using a composite measure of career barriers including the perception of negative attitudes of senior medical colleagues; workplace bullying; lack of role models or mentors; a long-hours culture, and lack of opportunities for professional development.
We also measured the perception of management support deriving a composite measure of using questions about the experience of mentoring, support or encouragement from a senior colleague and organisation leadership.
Positively, our findings are that the perception of management support is statistically proven to reduce the perception of career barriers for all, but this connection is stronger for some groups. Migrant doctors, especially groups of migrant women doctors, perceive the highest career barriers, but also perceived the greatest levels of management support. And management support is particularly effective for them in reducing career barriers to improve their tenure and chances of promotion. Indirectly, of course, this tackles their pay gap. This is good news!
Doctors with young dependents
But will it remain the case after we look at the special case of doctors that have young dependents? We find it remains a significant effect; in fact, we show that management support is most effective in reducing barriers for doctors with young dependents. The exception, though, is for groups of doctors that are trained outside the UK and outside Europe, especially women. For them, the effectiveness of management support deteriorates with dependent children.
The pandemic stretched worldwide medical services to breaking point and reliance on migrant doctors to deliver essential care increased considerably. In order to retain the services of this high-skill workforce, we need to ensure health service providers are attractive and inclusive places to work. As a matter for concern, our study found pay gaps between migrant and locally trained doctors. However, we were pleased to note that most of this gap could be explained by factors that respond well to proactive management support. The group who needs the most intense support, however, are female migrant doctors with young dependents and organisations will need to focus their efforts on supporting the needs of this group.
Carol Woodhams, Dulini Fernando, Yuanyuan Huo and Gabriele Dente. “Exploring the Interplay between Pay, Career Barriers, and Management Support: An Intersectional Study of Migrant Doctors”. Academy of Management Discoveries 2022.
image: NIH Clinical Center via flickr (CC BY 2.0)