Exit, voice, governance and user-responsiveness: The case of English primary care trusts

Susan Pickard, Rod Sheaff, Bernard Dowling

Research output: Contribution to journalArticlepeer-review


Hirschman contrasts exit and voice as 'recuperation' mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the 'user exit' described by Hirschman, two new 'exit' mechanisms now exist in quasi-markets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users' demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates. © 2006 Elsevier Ltd. All rights reserved.
Original languageEnglish
Pages (from-to)373-383
Number of pages10
JournalSocial Science and Medicine
Issue number2
Publication statusPublished - Jul 2006


  • England
  • Exit
  • Governance
  • Primary care
  • Quasi-market
  • UK
  • Voice


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