What can integrated care learn from Pep Guardiola´s modern European football?
A midsummer holiday´s read
Arturo Alvarez-Rosete (IFIC Senior Researcher)
The afternoon after the closure of this year´s International Summer School on Integrated Care (ISSIC23), my colleague Edelweiss Aldasoro and I went for a well-deserved walk around Oxford, stopping eventually at the famous Blackwell´s Bookshop at Broad Street. Wandering around the various floors and levels, I happened to stop at the footballing section and ended up with this particular book in my hands, a book that finally became my holiday reading: Zonal marking. The making of Modern European football, by Michael Cox. I must note that I am not really a football fan, so the reasons that moved me to buy and read it are still a mystery to me and they could very much be due to some momentary delusion or mild sunstroke (yes, in Oxford!).
A midsummer book
The book is an entertaining history of modern European football since the 1990s up to 2020. It outlines the crucial innovations developed within Europe, describing the different styles and tactical innovations and tracking the dominance of the different footballing cultures and systems over specific periods of time. It all started with the Dutch ‘total football’ in the 1970’s, followed by the Italian defensive dominance in the 1980s, then the French and the Portuguese. The Spanish dominated the football world between 2008-2012, but their dominance was later replaced by the German world cup winners in 2014. More recently, the English Premier League exerts its dominance with its concentration of most revered European managers and melting pot of all previous football styles.
As the summer holidays progressed and so my diving into the book, I learned how traditional football has very much been a physical game, based on hard tackling, long balls in attack and “defending deep with plenty of last-ditch blocks”.
Instead, the modern innovations of contemporary football have moved towards more possession play through highly accurate short passing, towards zonal marking rather than man-marking and to intense, heavy pressing to win the ball back quickly after it has been squandered. All of these innovations have required a radical transformation and reinvention of all players´ roles:
- goalkeepers are now distributors of the ball, playing almost as outfield players;
- defenders now play in an advanced defensive line or performing new roles such as defensive sweepers;
- midfielders are the ultimate playmakers required to ensure possession;
- wingers play touching the lines to pass the defences at speed and cross the ball, but also now they are encouraged to get into the box and shoot;
- centre-forwards are now required to drop deep and build-up play, rather than waiting for the ball to come to them.
I learned about systems: a defensive minded 5-3-2 [5 defenders; 3 midfielders, 2 forwards], the very popular nowadays 4-3-3 [4 defenders, 3 midfielders, 3 forwards] or even the extremely attack-minded 3-3-4 [3 defenders, 3 midfielders and 4 forwards] that the famous Barcelona team on the last decade played on occasions. But no style is necessarily the best. Its efficacy depends on a number of factors, including your team strengths and weaknesses, the players you have at your display, the context of the game and, of course, the adversary you have to face.
This football jargon and concepts kept resonating with my health system knowledge and integrated care lingo. In my head, the football metaphors and the health system concepts kept amalgamating: isn´t integrated care actually about playing in-between lines, opening up spaces, managing transitions, anticipating (care) challenges, and playing out from the back? What if case managers equated to football playmakers, patient navigators were something like the wingers and hospital discharge coordinators what the sweepers do when patrolling behind the defence line? Could modern football teach something to health system designers and integrated care pundits? Actually, is there anything we can learn from Pep Guardiola, Jürgen Klopp or José Mourinho?
The health system as a football pitch
Health services have traditionally been thought, designed and implemented as self-sufficient units rather than parts of a unified health system. New services are not designed purposefully (tactically) to operate aligned with the rest of the system components.
The metaphor of a football pitch can help visualise this misconception. Imagine a football pitch, divided into two symmetric parts, with two goals facing each other. Traditional health approaches views two horizontal lines of services – primary care and secondary care – operating independently, parallel and mostly static.
Of course, the metaphor goes as far as it can be, and we don´t mean that the service user/patient is the adversary team or even the ball. Although it is true that patients very often feel like they are inside a pinball machine, bouncing from one service to another, while care professionals feel that they are the last-ditch block.
The integrated care vision
Integrated care, like modern football, sees the game differently.
1. Opening up new spaces
Modern football is about space. As famous Dutch player and coach Johan Cruyff explained, the trick is making as much space as possible when you´ve got the ball and minimise the space your opponent has when you lose the ball. Modern football has opened the space horizontally (gaining width) through the new role for wingers, who now play touching the white lines; and it has opened up the space vertically as well, playing out from the back and moving both defence and attack lines up higher.
Similarly, integrated care is about using the care space wisely by closing up on service gaps. But it is also about moving out to new care spaces: going from traditional care venues to reaching out to the home and the community settings… and even beyond, connecting with the hard to reach.
2. Possession play
Modern football is about dominating midfield through possession play, which was epitomised in the Spanish “tiki-taka” approach of the 2010s. Teams seek to maintain the ball at all costs, by passing it as much as needed, instead of the sudden dribbling, the long kicks and the running of the old-style football. It´s about patience and technique rather than physicality and speed. Coach Pep Guardiola set a “15-pass rule” because such “a lengthy sequence was necessary for the players to organise themselves in the correct positional structure”. But possession play is not only a method to create the right chance for a good pass, but also a way of “starving the opposition chances” and hence, it is an effective defensive approach as well.
Integrated care is about services crafting a sequence of care events in a single integrated care pathway, through intense interaction (the “passing”), collective responsibility and commitment. It does not mean ownership (“possession” in football terms) of the patient while it´s within the realm of the care professional or otherwise getting rid of the patient as soon as possible.
Integrated care is not about brilliant one-second dribbling in a tight spot – although we love Lionel Messi every time he does that, of course! But arguably integrated care requires another type of “player” with these shining stars playing collectively. Integrated care requires all care professionals involved to be true playmakers, technically skilled, versatile and able to see the entire pathway as a whole (the shared responsibility).
3. Playing between the lines
If traditional football attributed players strict defence and attack roles, placing them in differentiated and straight lines, modern football is about finding and using the spaces in-between lines. Hence, teams have developed all kind of systems and shapes, forming triangles and diamonds in the midfield, at the back or up front, with players connecting the defence and the midfield or the midfield and the attach (see below an example of a 4-4-2 system with a diamond shape in midfield).
Integrated care is about playing between services, ensuring that service users don´t fall between the system gaps. For that, systems around the world have implemented advanced coordination services and roles that are able to connect health and care services.
4. Pressing high-up with an advanced defensive line
While in old-style football, teams played much deeper into their own side of the pitch, protecting their own goal, modern football look to keep the opponent team on the halfway line by keeping a high defensive line and through aggressive pressing. That has revolutionised the role of goalkeepers, who are now expected to play proactively and much more advanced than previously, because the defensive line is set much higher. The book gives the example of Bayern Munich´s goalkeeper Manuel Neuer who spends the game “adjusting his position in relation to the ball and the defensive line, moving back and forward in unison with his defence” and “sweeping outside the penalty area”.
Similarly, integrated care envisages a much proactive care, with services anticipating care needs and delivering care much closer to home. Primary care has raised the disease severity and complexity threshold that now manages, which was previously managed at the hospital setting exclusively.
5. Man-marking and zonal marking
Zonal marking refers to a defence system by which players defend specific areas of the pitch rather than an opposing player. In zonal marking system, “every player is accountable for a certain zone and once a player enters his zone, he instantly becomes his marker. This means that players don’t have preassigned opponents to cover but rather swap targets according to the opposition’s movement. Once the said player leaves that zone, he becomes another player’s responsibility”. While zonal marking has been an innovation of modern football, many teams combine both marking approaches, either switching from one to another at different phases of the game or marking zonally overall but focusing on some key players to avoid or minimise their involvement in the game.
Health systems have traditionally deployed what we could term “zonal caring”. So, services are fully dedicated to and accountable for patients and users while in their zone, but once they leave that zone, patients and users become the responsibility of another service or unit, breaking up the consistency of care over time. Instead, integrated care takes a combined approach, through case management, patient navigation and other person-focused strategies that ensure continuity of care.
This interlinking of football metaphors and integrated care reflections has never dreamt of being a masterclass of modern football nor an evidence-based study on the key components of integrated care. The ultimate purpose of this blog is to take from modern football one of the most interesting elements, which is the importance of structures. Tactics do matter!
Ultimately, I got interested in football tactics because it reminds us of the need for a system thinking approach when it comes to health services design and implementation. Integrated care advocates for a purposeful (tactical) approach to health services design, thinking of them as parts of a unified health system, which must operate aligned with the rest of the system components.
So, which system shape do you have in place in your own setting?
Would you instead go for a more balanced 5-3-2, with strengthened primary care, deploying advanced nurses and care managers up front, perhaps making use of community pharmacy and other services through a true multidisciplinary team management approach?
Is it still perhaps a 6-3-1, with most services deployed at the hospital level, defending deep with plenty of last-ditch blocks, with very weak primary care and a loner case manager up front?
Is the 4-2-3-1 your tactical shape instead, which I wonder whether it is that of the Enhanced Community Care (ECC) Programme in Ireland, combining resources at the hospital setting (4-), with community specialist teams for older people and chronic diseases (-2-), while promoting primary care networks (-3-) and Community intervention teams (-1-)?
Is the Buurtzorg home-care model in the Netherlands, with the deployment of self-governing nurse teams able to deliver a full range of medical and support services to clients at their own home the incarnation of the Classic Dutch Total Football and its classical 4-3-3 shape?
Indeed, would you ever dare to deploy the 3-7-0 system that Pep Guardiola´s Barcelona team used at the 2011 FIFA World Club Cup Final against Brazilian Santos Football Club, overloading the centre with midfielders… and eventually winning four-nil?
 I am grateful to my IFIC colleagues Niamh Lennox-Chhugani and Edelweiss Aldasoro and to Ben Hawkins and PJ Harnett for their critical eye and comments. Their expertise on health systems, integrated and even football matters (although some prefer rugby to football) has been extremely valuable.