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

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Abstract

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.

Section snippets

Governance and user-responsiveness in the public sector

Hirschman's classic analysis (1970) contrasts exit and voice as two ‘recuperation’ mechanisms making organisations responsive to their users. Health policies in many countries (e.g. USA, much of the EU, Australia, New Zealand) increasingly rely on voice and, still more, exit mechanisms for improving responsiveness to users. Absence of the institutional conditions necessary for these mechanisms would fatally weaken such policies. Using new evidence, this paper considers how far the necessary

Methods

The method for testing the proposition that Hirschman's analysis now requires revision, and for pursuing the other aims list above, is to operationalise Hirschman's analysis and, then, compare it with an empirical account of the relevant UK health polices and their implementation. A preliminary conceptual elaboration of Hirschman's analytic framework (Section 3) enables one to categorise concrete, observed governance structures as instances of exit, voice or neither. The UK policy documents

Voice, exit and governance structures

A preliminary to applying the broad concepts of ‘voice’ and ‘exit’ is to operationalise them in terms of observable governance structures and organisational processes.

Organisational-level examples of ‘voice’ mechanisms include user involvement in health policy and decision making in national-level health organisations or federations (as in Germany) and in sick-funds originating from occupational or religious groups (e.g. in Belgium and Switzerland). Another mechanism is to make health managers

English NHS policy

NHS policies for promoting user responsiveness (Department of Health (2000), Department of Health (2001), Department of Health (2003), Department of Health (2004)) and the Health and Social Care Act, 2001 emphasise democratic accountability (DH, 2001), publication of NHS performance assessments (Department of Health (2001), Department of Health (2003)), rights of redress and patient advocacy (DH, 2001), community empowerment (DH, 2004), choice (DH, 2004) and changing PCTs’ organisational

Policy assumptions

Labour government rhetoric invokes both voice and exit; ‘the voices of patients and the public, together with greater choice, will play an important role in shaping the health service in future’ (DH, 2004, p. 79). During the study period the emphasis was as noted on voice. Indeed, all eleven implementation mechanisms listed in Appendix A concern voice not exit, eight at the organisational level, although one of them (linking NHS complaints procedures to the Commission for Health Improvement

User responsiveness through hierarchical governance

Hierarchical governance structures exist both within PCTs and between a PCT and the higher-level NHS bodies (Strategic Health Authority (SHA), DH) who manage it. Within PCTs, managerial authority rests with a Board (of Directors) which through the Chief Executive line-manages PCT employees (nurses, paramedical, managerial and ancillary workers; and, exceptionally, salaried doctors). As explained, the main voice mechanism within PCT hierarchies was the appointment of lay non-executive directors

User responsiveness through quasi-market governance

PCTs commission providers in three quasi-markets—for acute and specialised mental hospital services; for a large minority of general practices through local (PMS) contracts; and for private primary care services, most often paramedical care and nursing homes.

What these quasi-markets contributed towards user responsiveness can be described swiftly because it was so slight. Each PCT is sole commissioner for its resident population who have no exit to another NHS commissioner. PCTs can decide not

User responsiveness through networked governance

PCTs rely on network governance in their relationships with local government (especially social services); with users’ and other voluntary organisations which also provide primary care; and with GPs.

In each PCT the PEC co-ordinated a local network of all GPs, mediating their relationship with the PCT Board. Irrespective of quasi-market arrangements, these networks were the main link between PCTs and general practices. Persuasion and knowledge management were the means by which PCTs could

An exception

In the PCTs described above, networks favoured local GP voices, quasi-markets gave greatest influence to NHS trusts, and national government almost exclusively influenced NHS hierarchies. For NHS managers the benefits (including penalties avoided) in heeding these non-user voices were far greater than those for responding to users. Other studies (Buckland & Gorin, 2001; Gilbert, 2003; Pickard & Smith, 2001) and at least one policy document (DH, 2004) corroborate this general picture of slow,

Voice and exit in quasi-markets

We found no reports of quality changes in NHS primary care stimulating either exit or voice on any substantial scale. However, Hirschman's theory would survive that finding if the quality of NHS primary care had just not changed much during that period. Users participating in PCT decision making were ‘alert’ to service quality, but few in number (barely into double figures, PCT3-excepted). Neither can we test whether more alert users are first to desert the public sector, because there is so

Policy implications

As revised, Hirschman's analysis suggests certain policies for the design of health system governance structures as recuperation mechanisms. Even when an exit mechanism is used to make providers user-responsive, it would be simplistic to counterpose voice and exit too crudely.

As a first-level mechanism for making professional proxies responsive to user demands, exit appears more practicable in services treating relatively minor, short-term health problems. Voice appears more practicable for

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