As the the football season ends, I‘ve been comparing the plight of clubs and managers with that of NHS acute hospitals and their chief executives. After all, their equivalent end of season Armageddon might kick off now the election’s over and spending reviews are in train.
There are 156 acute trusts in England and 92 clubs in the four divisions of the football league. The top handful of premier league clubs coalesce in a highly vocal and influential cabal to assert their own interests. This isn’t dissimilar to the Shelford Group of big teaching hospitals.
Finances
The income of the 20 premier league clubs varies from £20m to £420m, with much (unlike NHS trusts) coming from commercial activities rather than gates (the football equivalent of “patient-related income”). The biggest NHS acute trusts have operating incomes twice that of the football giants. Clubs’ biggest spend is on staff wages, with costs rising. Sound familiar?
Even the wealthiest carry debts even bigger than hospital private finance initiative bills. Though the four in five hospitals predicting major deficits next year won’t have a £5bn TV deal to bail them out.
The financial position for football clubs and hospitals is partly in their own gift, either through growing activities beyond core business, selling land, or efficiencies. Though the NHS can’t generate transfer revenue from selling its top performing employees to rivals (though some stars do move to the private sector or interim roles and double their money). But finances depend far more in both sectors on wider financial and regulatory climate – for instance the new financial fair play rules governing football, government spending plans or tariffs for NHS institutions.
Fans and patients
Most fans don’t choose their football team – it chooses them. Same with NHS hospitals. For all the talk of choice – the vast majority of patients want the NHS hospital on their doorstep to be half decent, look after them and have decent buses and parking. They aren’t going to take their custom elsewhere. It’s much the same for football teams.
So what of that exclusive band of sufficiently talented, brave or foolhardy to lead these organisations – the footy managers or hospital chief executives?
Neither are strangers to chairs who can act capriciously or stray into executive chair territory, nor boards with factions, power struggles or differences of opinion. Both come under intense scrutiny, with scandals and rumours in the media, fan or patient forums and the internet. Both appear in league tables shouting “inadequate” or “requires improvement”.
The consequences of failure are stark in both but ultimately football is just a game and even consecutive season relegation can’t compare with patients’ avoidable deaths or harms. Hospitals are safety critical organisations.
Given all this pressure, it’s no surprise that hospital chief executives last an average of 20 months and premier league managers 13 months.
The players
What of these individuals? The international angle is interesting. Although there are chief executives of NHS trusts from countries such as New Zealand, Australia and most recently Belgium, football seems far more likely to look overseas for expertise – to the extent that British managers often complain they are not given the chance at top clubs to show their worth. However the cultural cringe about all things outside the NHS is mirrored in our tendency to think all innovation worth learning from came from somewhere else and ignore our own strengths and culture/system specific solutions.
In football, it’s now mandatory for managers to have completed their coaching badges yet there is still no requirement for NHS leaders to have any formal qualification or registration. And while most managers have played the game to some level, experiencing the business from youth player up, and most are out on the training pitch every day, it’s still rare in England for chief executives to be former clinicians.
The cult of the heroic individual still exists in both sectors – despite all the literature on public sector leadership. There are several recent examples in football (and hospitals) where sacking the incumbent and bringing in wise turnaround specialist, club legend, expensive parachuted in “interim” or “rising star” has stabilised or saved teams – West Brom, Fulham, Sunderland and Villa spring to mind. It doesn’t always work though – sometimes their effect, their “trick” is short-lived or does little to arrest the slide – Bolton, Wigan or Reading.
All these patterns apply in acute hospitals too. I wonder how well some mega-trust chief executives would do if they had to manage in the circumstances of those in middling organisations with less resource – or vice versa. Or whether external consultants or expensive interims would fare any better than the forced-out incumbents? Where there is a track-record is mixed. And maybe sometimes excellent NHS leaders just get burnt out or stale – they didn’t turn bad overnight.
Ultimately, hospital chief executives win the “who’s got the hardest job” penalty shoot out. Why? Because former footballers or unemployed coaches are lining up to stay in the game – even at teams that don’t pay that well. Every managerial vacancy receives dozens of applicants. And there’s not enough media or youth team work to go round. It’s hard to recruit too many hospital chief executives. It’s hard to hang onto good ones. And their skills are transferable to less high profile and less punishing roles in the sector.
Commentators and politicians should remember this next time they pump out toxic soundbites about cutting bureaucracy or fat cats. It’s a tough job and it requires special people. So come and have a go if you think you’re hard enough.
