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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 quasimarkets. 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. Keywords: Exit; Voice; Governance; Primary care; England; Quasi-market; UK

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.12.016 Byline: Susan Pickard (a), Rod Sheaff (b), Bernard Dowling (a) Keywords: Exit; Voice; Governance; Primary care; England; Quasi-market; UK 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. Author Affiliation: (a) National Primary Care Research and Development Centre, Manchester University, Williamson Building, Oxford Road, Manchester M13 9PL, UK (b) School of Health Professions, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK