title: Negotiating refusal in primary care consultations: a qualitative study.
abstract: BACKGROUND
  How GPs negotiate patient requests is vital to their gatekeeper role but also a source of potential conflict, practitioner stress and patient dissatisfaction. Difficulties may arise when demands of shared decision-making conflict with resource allocation, which may be exacerbated by new commissioning arrangements, with GPs responsible for available services.
  
  
  OBJECTIVE
  To explore GPs' accounts of negotiating refusal of patient requests and their negotiation strategies.
  
  
  METHODS
  A qualitative design was employed with two focus groups of GPs and GP registrars followed by 20 semi-structured interviews. Participants were sampled by gender, experience, training/non-training, principal versus salaried or locum. Thematic content analysis proceeded in parallel with interviews and further sampling. The setting was GP practices within an English urban primary care trust.
  
  
  RESULTS
  Sickness certification, antibiotics and benzodiazepines were cited most frequently as problematic patient requests. GP trainees reported more conflict within interactions than experienced GPs. Negotiation strategies, such as blaming distant third parties such as the primary care organization, were designed to prevent conflict and preserve the doctor-patient relationship. GPs reported patients' expectations being strongly influenced by previous encounters with other health care professionals.
  
  
  CONCLUSIONS
  The findings reiterate the prominence of the doctor-patient relationship in GPs' accounts. GPs' relationships with colleagues and the wider National Health Service (NHS) are particular of relevance in light of provisions in the Health and Social Care Bill for clinical commissioning consortia. The ability of GPs to offset blame for rationing decisions to third parties will be undermined if the same GPs commission services.
authors.affiliation: National Institute for Health Research, National School for Primary Care Research, University of Manchester, Manchester M13 9PL, UK. alexkmwalter@hotmail.com
authors.forename: Alex
authors.initials: A
authors.lastname: Walter
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
authors.forename: Stephen
authors.initials: S
authors.lastname: Harrison
mesh_terms: D034462:Dissent and Disputes; D005260:Female; D017144:Focus Groups; D058006:General Practice / Q000458:organization & administration; D015276:Health Care Rationing; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D017008:Negotiating; D010817:Physician-Patient Relations; D011320:Primary Health Care; D036301:Qualitative Research; D012017:Referral and Consultation; D016079:Refusal to Treat; D013222:State Medicine; D006113:United Kingdom