John Goldie is a retired GP and medical educator
It is Monday morning at 9am. A patient with multimorbidity calls asking for an appointment. Knowing how the system works, he describes it as an emergency. In reality, worsening osteoarthritis is threatening his ability to manage everyday life. He is seen by a locum at 4.30pm. During the consultation, the EMIS screen highlights an overdue diabetes review and blood pressure check. By the end, his blood pressure has been measured, a diabetes appointment arranged, and his analgesia changed.
The question that has prompted him to seek help—what his declining mobility means for his future—remains unexplored.
This is not simply a communication failure but a consequence of how healthcare is organised. Modern systems increasingly treat medicine as a series of standardised transactions. Yet clinical practice is an evolving process in which knowledge, judgement, relationships, and action continually shape one another. Understanding does not precede the consultation; it emerges through it as patient and clinician make sense together.1,2
If general practice is an ongoing achievement rather than a mechanism for completing tasks, organisational design becomes a clinical issue.
If general practice is an ongoing achievement rather than a mechanism for completing tasks, organisational design becomes a clinical issue. Systems built around throughput privilege what is measurable over what is meaningful, often neglecting the patient’s experience of illness.³
1. Continuity is infrastructure, not nostalgia
The factory model of ten-minute appointments, access targets and centralised triage treats patients as interchangeable tasks. Yet meaning develops through repeated encounters, accumulated knowledge and shared experience. When patients repeatedly see unfamiliar clinicians, understanding must continually begin again.
Continuity is therefore a clinical technology for managing complexity, associated with lower mortality, fewer hospital admissions and better patient experience.4-6
Practices should be organised around stable micro-teams responsible for defined patient populations. Their role is to preserve narrative continuity even when individual clinicians are absent. The key question should not be “Who is available?” but “Who knows this patient?” Appointment length should also reflect clinical complexity. Patients with complex problems need sufficient time for sense-making, not simply task completion.
2. Make tacit knowledge visible enough to use
Current digital systems prioritise templates, coding and data extraction. Yet much of expert generalist practice depends on tacit knowledge: recognising patterns, understanding context and sensing that something is wrong before it can be articulated. A gradual change in gait or mood may only become significant when compared with years of previous encounters. As Polanyi observed, “…we know more than we can tell.”⁷
Electronic records should therefore support narrative and uncertainty rather than forcing premature diagnostic closure. Coding should support, not dominate, clinical reasoning.
3. Create structures for collective sense-making
Understanding is rarely achieved by clinicians working alone. As multidisciplinary teams expand, there is a risk that patients become fragmented into separate professional perspectives.
Brief team huddles, informal discussions and shared case reviews are not administrative overheads but essential clinical work.
Brief team huddles, informal discussions and shared case reviews are not administrative overheads but essential clinical work. They allow different forms of expertise to contribute to a shared interpretation rather than disconnected interventions. Routing straightforward transactional work to the wider MDT also releases generalists to focus on complexity and uncertainty. This is not inefficiency but a safety-critical investment in coherent care.⁸
4. Measure the Health of the Process
Industrial systems measure industrial outputs. Activity targets capture speed and biomedical processes but overlook continuity, trust and adaptive capacity. Organisations inevitably value what they measure.
General practice should therefore complement activity measures with indicators of relational continuity, such as the Usual Provider of Care Index and the St Leonard’s Index of Continuity of Care.6,9 These measures make relationship-based practice visible, encouraging organisations to preserve rather than erode it. The important question is not simply how many consultations occurred, but whether patients and professionals reached a deeper understanding of complex problems.
The core realisation
Patients are not static objects with isolated faults to repair but people whose lives continually unfold. Clinical understanding develops through relationships, dialogue, interpretation and time.
The patient in the opening vignette does not primarily need a blood pressure check or a change of analgesia. He needs help understanding a life that is beginning to change. Care must attend to biography as well as biology.¹⁰
The challenge for the NHS is therefore not simply to make general practice more efficient, but to create organisational conditions in which this ongoing sense-making can occur.
Medicine is not the execution of a fixed plan. It is a continuing achievement, renewed in every encounter between patient, clinician and system.
References
1. Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press; 2006.
2. Greenhalgh T. One scale too far? Br J Gen Pract. 2013 May;63(610):261. doi: 10.3399/bjgp13X667268.
3. Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books; 1988.
4. Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract. 2020 Aug 27;70(698):e600-e611. doi: 10.3399/bjgp20X712289
5. Freeman G, Hughes J. Continuity of Care and the Patient Experience. London: The King’s Fund; 2010.
6. Jee SH, Cabana MD. Indices for continuity of care: a systematic review of the literature. Med Care Res Rev. 2006;63(2):158–188.
7. Polanyi M. The Tacit Dimension. Chicago: University of Chicago Press; 1966.
8. Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey Bass; 2012.
9. St Leonard’s Practice. St Leonard’s Index of Continuity of Care (SLICC). Edinburgh: St Leonard’s Practice; 2018. [accessed 31/7/26]
10. Scottish Government. Realistic Medicine. Edinburgh: Scottish Government; 2016. [accessed 31/7/26]
Photo by Bruno Figueiredo on Unsplash
