Phil Whatling is a GP partner in North Devon with interests in continuity, system behaviour and the everyday realities of general practice. He is on LinkedIN
Before considering changes to our appointment system in our practice, we tried to understand where capacity was being lost. We expected to find a shortage of appointments. What became clearer was something less visible: work was not consistently reaching resolution.
This was not a formal study or an evaluation of a redesigned service. It was a review of how work moved through our practice, undertaken before any changes were made. The focus was not on the volume of activity, but on whether episodes of care were reaching a clear end-point without generating further avoidable contact.
By mid-morning practices may recognise a familiar pattern. Routine appointments have gone. The urgent list is already heavy. Reception staff are repeating the same steps, often to patients who have already tried another route. Clinicians are reviewing results, responding to online consultations, arranging follow-ups that cannot be booked, and managing messages generated by earlier encounters. The waiting room may appear calm, yet the system already feels full. There is often a sense that nothing is really finished.
The waiting room may appear calm, yet the system already feels full. There is often a sense that nothing is really finished.
It is often described in terms of demand. What is less visible is how much of this activity relates to work that has already begun but has not fully resolved.
General practice, in this sense, can feel less like it is running out of appointments and more like it is running out of resolved work. Resolution here means that an episode of care reaches a clear end-point without generating further contact that arises because earlier steps did not fully complete. When this does not happen, activity returns rather than closes. You see the same problems back again a few days later, often through a different route. This shifts attention away from access alone and towards how reliably care is finished.
What we noticed when looking at workflow
We reviewed the appointment system using process mapping, staff discussion, continuity review and workflow analysis. Across these views, the same pattern appeared. Capacity did not feel fixed. It seemed to depend on how often work finished within a single episode, and how often it did not.
When episodes resolved cleanly, capacity returned to the system. When they did not, capacity was absorbed by follow-up activity, clarification, re-contact and administrative tasks generated by earlier steps.
The patterns are familiar across general practice. Patients often re-contact the surgery after submitting an online consultation or after a phone call if the issue has not been fully addressed. Results are chased when patients are unsure whether anything has happened. Follow-ups that cannot be booked at the point of care generate repeat contact. When continuity breaks, the same issue is often revisited more than once, sometimes several times.
Individually, none of these contacts represent new demand. They are more accurately understood as work returning because it has not fully resolved.
A practical way of seeing this is to notice where episodes repeatedly stall. In day-to-day work, these are familiar points: follow-ups that cannot be booked when they are needed, results that require chasing because the next step is unclear, administrative tasks that pause for missing information, and patients returning because earlier contacts did not fully address the issue. These are often the places where capacity quietly drains away without being visible in any single workload measure.
Over time, unresolved episodes generate additional workload. That workload then occupies routine capacity, leaving less space for new or unrelated need. The system feels pressured even when the number of new presentations has not changed much in practice.
Why appointments alone do not describe capacity
Appointments are easy to count and therefore often used as the main measure of capacity. They are also limited in what they show. They do not capture how many contacts precede an appointment. They do not show how many follow-ups arise after it. They do not reflect how often care fragments into multiple episodes. They also do not show how frequently patients are unable to maintain continuity with the same clinician, even when they want to.
Appointment numbers describe activity at the point of entry, but not what happens within or after the episode of care. This may help explain why practices with similar appointment availability can experience very different levels of pressure, and why increasing appointments does not always reduce workload elsewhere in the system. Appointments describe throughput. Resolution determines what happens next.
What the system looks like when work does not resolve
When work does not resolve, it tends to return. Returned work consumes capacity. As capacity tightens, patients are more likely to use urgent routes of access. Care fragments. Continuity breaks. More follow-up activity appears in the system.
The pattern is not dramatic. It is made up of routine, familiar events: a follow-up that cannot be booked, a result that needs chasing, a task that pauses for missing information, a patient returning because the earlier contact did not fully address the issue, or simply no clear next step being visible at the time. These are the points at which capacity is often lost, although it rarely shows up in any single queue.
Why access redesign does not always reduce pressure
Where work resolves reliably, systems tend to feel more stable even under pressure.
Much of the current focus in general practice redesign is on access: appointment numbers, triage systems, digital routes and same-day models. These change how patients enter the system, but do not always affect how work is resolved once it has entered it. Where work resolves reliably, systems tend to feel more stable even under pressure. Where it resolves less reliably, systems can feel full regardless of the number of available appointments.
In practice, changes to access routes often redistribute work rather than remove it. Work that does not resolve in one place may reappear in another form or at another stage in the system. It often feels like the same workload returning with a different label. Understanding where work fails to complete may therefore be as important as understanding how it enters the system.
A more accurate description of pressure
General practice is often described in terms of rising demand. A more precise description, at least in our observation, is that it is frequently managing a high level of unresolved work. This represents activity that has already entered the system but has not reliably reached resolution. The effect is a sense of persistent workload pressure, even when the number of new presentations appears broadly stable.
From this perspective, appointment numbers describe access. Resolution describes what actually happens to the work afterwards.
Featured Photo by Hans Tilstra on Unsplash
