Two and a half thousand years ago, Aristotle described phronesis, or practical wisdom, as the ability to make good decisions in complex and uncertain situations where no simple rule can fully determine the right course of action (Aristotle, 1999). Modern healthcare education uses a different term for this idea. It talks about entrustment, the point at which a clinician can be trusted to carry out professional activities with decreasing levels of supervision (ten Cate, 2005). Different words, different centuries, but they point towards the same underlying idea: that professional practice is not just about knowledge and skill, it is also about judgement, responsibility, and trust.
This raises an important question. At what point do we trust a clinician to make decisions on their own?
Healthcare education has traditionally focused on competence, whether someone can demonstrate the knowledge and skills required to perform a task safely. Competence matters, and patients deserve clinicians who are knowledgeable, skilled, and safe. However, clinical practice is not simply about performing tasks or recalling knowledge. It is about making decisions, managing uncertainty, prioritising risk, and taking responsibility when there is no obvious right answer.
So perhaps the real question in professional development is not simply whether someone is competent, but whether they are capable and can be trusted.
There is a moment in most clinicians’ careers when the decision is yours. The patient is in front of you, the presentation is not entirely clear, the guidelines do not quite fit, and there is no obvious right answer. In that moment, the question is not whether you are competent; the question is whether you are capable.
This distinction between competence and capability is well recognised in the healthcare education literature. Fraser and Greenhalgh (2001) argued that while competence is necessary, complex healthcare systems require capability, the ability to adapt, learn, and respond to unfamiliar situations. Competence is often demonstrated in structured or supervised environments, where tasks can be observed and assessed. Capability, however, is revealed over time, across multiple situations, often when things do not go according to plan. It becomes visible when a clinician is faced with complexity, uncertainty, competing priorities, or situations where there is no single right answer. In those moments, what matters is not just what the clinician knows, but how they think, how they decide, and how they manage responsibility (Fraser & Greenhalgh, 2001).
Models of professional development support this view. Benner’s (1984) work, based on the Dreyfus model of skill acquisition, describes how practitioners move from rule-based behaviour as novices towards more holistic, intuitive, and context-sensitive decision-making as they gain experience. Importantly, competence is only one stage in that developmental journey. Over time, practitioners begin to see the bigger picture, recognise patterns, prioritise more effectively, and make decisions with greater confidence and judgement. This development does not happen quickly, and it does not happen through knowledge acquisition alone. It develops through experience.
This is why work-based learning matters so much in healthcare education. Much professional learning takes place not only in classrooms, but in the workplace, through participation in real practice, reflection, and feedback (Kolb, 1984; Schön, 1983). Apprenticeship models make this particularly visible, where learners are embedded into clinical environments over extended periods, being exposed to real patients, real decisions, real uncertainty, and real responsibility, all under appropriate supervision. In these environments, learners are not simply demonstrating competence in isolated tasks; they are gradually developing capability through experience, reflection, and the progressive assumption of responsibility (Kolb, 1984; Schön, 1983).
Clinical supervision plays a crucial role in that process. Increasing responsibility without supervision can be unsafe, but supervision without increasing responsibility does not develop capability. Effective clinical education and workforce development rely on a balance between the two. Learners and developing clinicians need opportunities to make decisions and take responsibility, but they also need appropriate support, discussion, and reflection. Through clinical supervision, decisions can be reviewed, reasoning can be explored, and learning can be consolidated. Over time, as supervisors observe judgement and decision-making in practice, trust develops, and with that trust comes greater autonomy.
Alongside supervision, governance also matters. Governance structures such as defined scopes of practice, supervision frameworks, competency processes, and professional regulation are sometimes seen as administrative requirements; however, they serve an important purpose. Governance provides a structure that allows developing clinicians to take on increasing responsibility in ways that are safe for patients and supportive for clinicians. NHS England guidance for primary care and advanced practice supervision emphasises that supervision levels, scope of practice, and responsibility should change over time as capability and experience develop (NHS England, 2023; NHS England, 2025). Within Integrated Care Systems, this progression is increasingly linked to workforce transformation and service redesign priorities, aligning capability development with population health needs and system performance (NHS England, 2022).
This distinction is not only relevant at the level of individual clinicians but also at the level of services and systems. Community musculoskeletal (MSK) services are often designed around processes, pathways, and performance metrics, yet what they ultimately rely on is the capability of clinicians to make safe, timely, and context-sensitive decisions. National improvement work has repeatedly highlighted unwarranted variation in MSK pathways, access, and outcomes across systems (NHS England, 2019; Getting It Right First Time [GIRFT], 2021). These challenges are not solely issues of competence, but of how capability is developed, supported, and trusted within services and across systems.
Increasingly, healthcare education is not just asking whether someone is competent, but whether they can be trusted. This idea is often described as entrustment, the point at which a clinician can be trusted to carry out professional work with decreasing levels of supervision. The work itself is sometimes referred to as Entrustable Professional Activities, or EPAs (ten Cate, 2005). Competence shows what someone can do, but entrustment determines what someone can be trusted to do independently. Professional development, therefore, is not just about gaining competencies; it is about gradually being trusted with greater responsibility (ten Cate, 2005).
Across a clinical career, responsibility gradually increases, with learners developing knowledge, skills, and behaviours, often in relatively controlled environments. New graduates begin to apply those skills with supervision and support, and as clinicians gain experience, they are given more autonomy, more complex patients, and more responsibility for decision making. In advanced and consultant-level roles, decisions often become less about individual tasks and more about managing complexity, leading teams, developing services, and making decisions that affect not just individual patients but systems of care. Across the four pillars of clinical practice, leadership, education, and research, capability is expressed through judgement, the ability to make thoughtful, context-sensitive decisions in complex situations (NHS England, 2025).
This development does not have a clear endpoint. Clinicians do not simply move from novice to expert and then stop. Instead, they move from needing rules to recognising patterns, to managing complexity, and then spend the rest of their careers continuing to learn, adapt, and refine their judgement. In that sense, becoming a clinician is not a single transition that happens at graduation or at the point of promotion; it is an ongoing process that unfolds over an entire career.
So while healthcare systems quite rightly measure competence, what they ultimately rely on is capability. They rely on clinicians who can make safe decisions, manage uncertainty, take responsibility, and use judgment in complex, real-world situations. Developing that capability is one of the central challenges of healthcare education, supervision, governance, and workforce development. It is something that takes time, experience, responsibility, and trust.
Competence can be assessed, capability is developed through experience, but trust is earned, and that takes time.
As always, thank you for reading.
Steve
References
Aristotle. (1999). Nicomachean ethics (T. Irwin, Trans., 2nd ed.). Hackett Publishing. (Original work published ca. 4th century BCE)
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley.
Fraser, S. W., & Greenhalgh, T. (2001). Coping with complexity: Educating for capability. BMJ, 323(7316), 799–803. https://doi.org/10.1136/bmj.
Getting It Right First Time (GIRFT). (2021). Musculoskeletal services: GIRFT programme national specialty report. https://www.
Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Prentice Hall.
NHS England. (2019). The NHS long term plan. https://www.longtermplan.nhs.
NHS England. (2022). What are integrated care systems? https://www.england.nhs.uk/
NHS England. (2023). Supervision guidance for primary care network multidisciplinary teams.
NHS England. (2025). Multi-professional framework for advanced practice in England.
Schön, D. A. (1983). The reflective practitioner: How professionals think in action. Basic Books.
ten Cate, O. (2005). Entrustability of professional activities and competency-based training. Medical Education, 39(12), 1176–1177. https://doi.org/10.1111/j.