Intended for healthcare professionals


The Messenger Review: a missed opportunity for primary care

BMJ 2022; 377 doi: (Published 09 June 2022) Cite this as: BMJ 2022;377:o1427
  1. Becks Fisher, GP, senior policy fellow1,
  2. Judith Smith, professor of health policy and management, senior visiting fellow21
  1. 1The Health Foundation
  2. 2University of Birmingham
  1. Twitter: @becksfisher@DrJudithSmith

The government has published its review of health and social care leadership and management undertaken by Gordon Messenger and Linda Pollard.1 The Messenger Review is the latest in a long line of such stocktakes, often undertaken by “NHS outsiders,” dating back to Sainsbury’s boss Roy Griffiths’ review of NHS management in the 1980s which led to the introduction of general management.2

Healthcare management is a broad, highly complex, and politically exposed discipline, typically under valued by the public, media, and politicians alike.3 Managers are often characterised as bureaucrats who take up resources that would be better spent on frontline clinical care. But there is extensive UK and international evidence that healthcare management matters. Good management is critical to effective delivery of high quality services and improves health outcomes and staff wellbeing.4 In the UK, discussion of healthcare management and leadership typically assumes an NHS trust (or even more likely) hospital context. This is where most resource and development programmes are usually targeted.

There is international consensus that health systems with strong primary care achieve better population outcomes and health equity, when compared with those with greater reliance on hospital specialists.5 Long term investment in infrastructure (including IT and estates), workforce, and leadership is needed to enable primary care to perform this critical role a point underlined by the recent Fuller Stocktake of primary care in England.67 In the NHS, high functioning general practice plays a crucial role in keeping people well, out of hospital and in delivering cost effective care.

General practice has expanded its role and scope extensively over the past 30 years. It runs many more services through diverse routes of access, using the skills of many professions within large multi-disciplinary teams. It has become increasingly networked and “at-scale” with a range of organisational forms, often developed bottom-up.8 The sector has also embraced (or endured) various primary care led commissioning approaches that have been serially reorganised, usually every 4-5 years, in comparison with much greater organisational stability enjoyed by the NHS trust sector.9

There is a vital need for good leadership and management within our struggling primary care sector. Workload is rising quickly, and GP numbers continue to fall.10 Most surgeries have become part of primary care networks (PCNs), delivering expanded services with a broader mix of staff. Simultaneously, Clinical Commissioning Groups—which have provided (often limited) organisational development support for PCNs—are disbanding as integrated care systems form.9 Health policy continues to emphasise primary care’s role in transforming future healthcare services, along with an intention to continue to expand the range and complexity of care and services delivered through general practice, in partnership with other professions and sectors.711

Such intentions are easier to declare than to put into practice. They represent major organisational, professional, and cultural change, which requires sophisticated and experienced management capacity such as HR, finance, IT, estates management, and service improvement skills in addition to the “leadership and transformation” that are often exhorted.71213 These are in scarce supply in primary care. General practice has been moving away from its “corner shop” management approach for many years, gradually becoming more managed and organised. But there is still a stark contrast to the more corporate organisational form of NHS trusts who have the management, professional support, and governance capacity to match.

The culture of primary care is traditionally considered to be nimble, bottom-up, and relatively autonomous, reflecting the fact that general practice leadership has tended to be provided by GP partners, contracted to and not employed by the NHS. But the number of GP partners is declining rapidly, and newly qualified GPs are less likely than their predecessors to want to be partners.1415 Alongside this has been a gradual increase in acceptance of non-GP leaders within primary care, including practice managers, nurses, and general managers employed by “at scale” primary care organisations or PCNs.

In contrast to NHS trusts with better access to internal training departments and many national leadership programmes, there is a startling lack of management and leadership training and development funded for and provided to general practice. NHS management training scheme placements are rarely located in general practice or its “at scale” provider organisations and there is little leadership and management training within GP training. Programmes aiming to address this—such as Next Generation GP—have been developed by and for GPs, with little funding and relying on much goodwill.16

General practice, with its central role in integrated health and social care, needs and deserves excellent leadership and management if it is to fulfil the expectations placed upon it, a point emphasised by Claire Fuller.17 And better leadership and management may improve GP retention. Significant investment is needed to strengthen this aspect of general practice, crafted with, by, and for primary care professionals and teams. Simply adapting training and development programmes designed with NHS trust management in mind will not suffice.

It is disappointing that Messenger’s review of NHS leadership and management largely overlooks general practice, apparently regarding clinical leadership by GPs as the main area for attention, rather than the whole gamut of primary care management expertise. Strong primary care strengthens the NHS and is critical to pandemic recovery. But the sector is precarious and requires bespoke, co-designed leadership and management support, alongside a bevy of measures to recruit and retain clinical staff. Messenger has missed an opportunity with general practice. Eyes now turn to the Government’s response to the Fuller stocktake (which set out a vision) to provide answers about how desired wide scale change in primary care can be resourced, led, and managed.


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not peer reviewed.