NHS working conditions: Exit, Voice, Loyalty, Neglect
NHS working conditions including but not limited to pay are deteriorating.
Exit, Voice, Loyalty, Neglect is a model first published by economist Albert Hirschman in 1970. It outlines four routes to handling a dissatisfying situation where there is a power imbalance. The framework can be applied to the behaviour of workers towards an organisation.
When dissatisfied with their working conditions an individual faces four choices
1) Exit: Voting with their feet. Leaving to a new role with better working conditions.
2) Voice: Voicing their concerns to the organisation with the aim of improving the situation.
3) Loyalty: Persisting with the status quo even though working conditions are challenging, passively hoping things improve.
4) Neglect: Staying in the role despite the poor working conditions but with deteriorating effort and care.
The options of loyalty and neglect will not drive change or improvement in NHS working conditions nor, linked to this, the care the NHS workforce is able to deliver.
This leaves exit and voice.
Many NHS workers are choosing to exit. This can happen when their commitment to the organisation fades because leaving is the only way they can protect themselves from poor working conditions and the consequences including work-related stress, burnout, and moral injury.
Can exit lead to change?
Exit resolves the working conditions for the individual. But unless this exodus is heard it will not improve the working conditions for the remaining workforce. There are examples of exit leading to change when exceptional individuals leave the workforce then return to drive change. Or when those leaving the workforce join or start an organisation that creates competition for the original organisation, driving improvement. Most examples of exit driving change come from corporate environments or settings where there are strong market forces. So far, exit has not driven change in the NHS.
This leaves voice.
Voice may not always be a choice. Hirschman explained that ‘voice feeds on the lack of opportunity for exit’. For most of the workforce in training, NHS pathways are the only route to clinical career progression. Staff early in their careers may not be able to exit if they want to develop their practice. They are uniquely invested in improving their working conditions and the care the NHS can deliver. Their professional futures depend on it.
Workforce voice is the main hope for the future of the NHS. If they are not speaking up… or are not being heard, NHS workers will passively wait for things to change in a situation that is deteriorating with time until they eventually vote with their feet and leave.
Workers speaking up, and the organisation listening to the voice of the workforce is essential for progress in the NHS. The alternative is that working conditions will continue to deteriorate at great cost to patient care.