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Could ‘Total Football’ be a metaphor for good general practice?

Nick Wooding trained in Oxford, and has also been a medical superintendent in rural Uganda and run a university in Kampala, teaching public health, and is now back working as a GP in Oxford.

In Images of Organization, Gareth Morgan suggests eight organizational metaphors: machine, organism, brain, cultural system, political system, psychic prison, instrument of domination, and finally flux and transformation.1 Another metaphor, inspired by binge-watching Ted Lasso and the BBC’s “Pep Guardiola: Chasing Perfection”, is the football team.

Traditional General Practice: playing 4:4:2

Another metaphor… is the football team.

Using Morgan’s machine metaphor, connected parts produce repeatable outputs. The ball advances from defence through midfield for the striker to score. Staff, clinical and non-clinical, know their roles. Locums (substitutes) replace absentees. This works in stable environments – not the current, constantly changing, NHS. And it is dehumanizing.2 People, with different personalities, strengths and weaknesses, aren’t interchangeable. Doctors aren’t cogs in a bureaucratic machine, but highly educated, self-regulating professionals, which “underpins the concept of an “independent profession.””3 They get injured (burnout). Patients bring multiple, complex problems to short consultations.

Parking the Bus: playing ultra-defensively

This doesn’t mean defensive medicine, avoiding complaints or litigation (or receptionists blocking access to doctors), but defensive management: tightly controlling finances; not being entrepreneurial or innovative; preparation for Care Quality Commission (CQC) inspections taking precedence over clinical care. Mandatory training replaces on-going clinical CPD. Inspections and supervision risk regulating self-regulation out of professionals. Using the football metaphor, CQC regulators are the referee, but shouldn’t be always inspecting the VAR monitor but let games flow freely.

There’s a streaker

Returning to the NHS after four years in Africa, I wondered where general practice had gone. During clinical commissioning group (CCG) meetings, I couldn’t understand why anyone had ever considered certain topics a good idea. The obvious analogy is the boiling frog, not noticing insidious changes and unquestioningly, accepting them.4

The streaker isn’t a frog but the emperor in his new clothes. Does his cabinet really believe that the golden cloth is invisible except to the wise; or do they collude, desiring to keep their positions; or do they just want a quiet, stress-free life. We accept change and moan about it behind its back.

Total football

This is an attacking style where all the team’s players except the goalkeeper are adaptable, changing positions during the game.

This is an attacking style where all the team’s players except the goalkeeper are adaptable, changing positions during the game.5 The healthcare assistant (HCA) does not only take blood or do health checks; they listen to both the patient and their gut, sometimes directing patients to seek further care. Longer appointments would be more holistic.

I remember being called into the HCA’s room. The gentleman there had mentioned in passing that he had lost a bit of weight. He is still alive, his lung cancer caught early, thanks to the HCA’s intuition, communication and observational skills. The HCA (or pharmacist) could follow up results, not the busy GP with their full inbox, and inform the patient of their QRISK and suggest statins. Nurses and HCAs take initiative, ordering extra tests if indicated, without needing to ask. Doctors doing phlebotomy free up time for HCAs to spend more time with patients, who discover things not volunteered to a doctor. Receptionists, seeing the QOF alerts, book smears or vaccinations, and listen out for waiting-room conversations which might alert them to other issues in people’s lives.

There might be medicolegal implications, but could they be another example of parking the bus? Why ask people to book another appointment into the overloaded appointment book? There are other opportunity costs. The self-employed patient takes more time off work, also losing tax to society which could help fund the NHS.

One of Guardiola’s strengths isn’t just his system, but adapting to the players available.6 Teams include personalities, not just functions; what are their personality types (e.g. Myers-Briggs), team roles (e.g. Belbin) and management styles. Maybe a salaried GP is better suited to leadership than a partner. How can the system adapt?

Substitutes

Should a GP do all those interminable time-consuming (but important) forms? Who can be brought on instead? What extended roles would offload work from frontline healthcare workers, whatever their cadre?

Finally…

Who is the manager or goalkeeper – the practice manager or the senior partner? And who is the coach? It’s not one person, but everyone shares their knowledge and experience for training and mentoring. And if people do not want to be a player-coach, should they even be in the team?

References

  1. Morgan G, Images of Organization: The Executive Edition (Sage Publication, CA, 1998).
  2. Morgan G, p. 26, , Images of Organization: The Executive Edition (Sage Publication, CA, 1998).
  3. Irvine, D., 1997. The performance of doctors. I: Professionalism and self regulation in a changing world. British Medical Journal, 314(7093), p.1540. https://www.bmj.com/content/314/7093/1540?sso=  [accessed 28/02/2020]
  4. https://en.wikipedia.org/wiki/Boiling_frog#References [accessed 28/02/2024]
  5. https://dictionary.cambridge.org/dictionary/english/total-football [accessed 28/02/2024]
  6. https://www.bbc.co.uk/iplayer/episode/m001vnm5/pep-guardiola-chasing-perfection, [accessed 06/03/2024.]

Featured Image: created using DALL·E on 23/3/24 by Richard Armitage

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