This is one of the most commonly cited case types by SCA examiners when they describe what separates passing candidates from failing ones. Not because the clinical content is particularly difficult — it usually is not. Because the consultation dynamic is uncomfortable, and most candidates have not practised it enough to handle it well.

In most consultations, the doctor and patient are moving in the same direction. The patient wants to feel better. You want to help them feel better. The consultation is about finding the best way to do that together.

In a negotiation case, there is a divergence. The patient has decided what they need. You have a different clinical view. And the case tests whether you can hold that divergence — without dismissing the patient, without giving in, and without the consultation becoming an argument.

The RCGP examiner guidance specifically names negotiation and adaptation to patient concerns as higher-level consultation skills. They are not skills most trainees develop through normal clinical preparation. They require deliberate practice in situations that feel uncomfortable.

Candidates who struggle with negotiation cases often make their position clear too quickly. The patient states their request, the candidate forms a clinical view, and within the first three minutes the consultation is already in conflict — because the patient can sense where this is going and has started defending their position before you have understood it.

The request is not the starting point for your assessment. It is the starting point for your curiosity.

Before you decide what you think about the request, find out what is behind it. Why this, why now, why specifically this is what they need. A patient requesting a sick note at the start of the consultation may be asking because they genuinely cannot work. They may be asking because they are afraid to tell their employer the real reason they need time off. They may be asking because they have been told by someone else that this is the route they need to take. Each of those is a different consultation, and the clinical response to each is different.

Slow down the opening. Understand before you assess.

Once you have understood the request and completed your assessment, there will be cases where the clinical answer is not what the patient came for. How you deliver that matters enormously.

The worst version is a blunt refusal: "I'm not going to be able to do that." Said once, said firmly, no rationale, no acknowledgement. The patient feels dismissed. The dynamic escalates. The remaining eight minutes are adversarial.

The best version acknowledges what the patient came for before it declines it. "I can hear that you came in today hoping for X, and I want to explain why I'm going to suggest something slightly different — because I think it will serve you better." That sentence does not change your clinical position. It changes the dynamic. The patient is less likely to push back against a doctor who has heard them than against one who has not.

Give your rationale in plain language. Not "this falls outside the current clinical guidelines" — that is policy language, not clinical reasoning. Explain what you actually think is happening and why the request does not fit. Trust the patient to understand.

They will. In negotiation cases, the role player is specifically briefed to hold their position. The examiner is watching what you do when your first response does not resolve the tension.

The instinct under pressure is often to repeat yourself more firmly. It does not work. Saying the same thing more emphatically does not produce a different response — it produces a more entrenched one.

Instead, go back to the patient. "Help me understand a bit more about why this feels so important to you." That question is not weakness. It is a consultation skill. The answer often surfaces something that changes the picture — a piece of context that either justifies a modified clinical decision or helps you find a different solution that genuinely addresses the patient's underlying need.

Then offer something real. Not a consolation prize and not a vague alternative. A specific, clinically appropriate response to what you now understand the patient actually needs. The patient who came demanding antibiotics and has disclosed they have a job interview in three days might be genuinely reassured by a delayed prescription with clear criteria for when to use it. The patient requesting a sick note who has disclosed serious workplace stress might need a conversation about what support they actually need rather than a form.

Sometimes the patient will not move, and neither should you — if your clinical position is sound. The SCA does not require you to resolve every negotiation case with the patient in agreement. It requires you to handle the disagreement professionally.

If you have heard the patient, explained your reasoning, offered alternatives, and the patient still disagrees — you can name that calmly. "I understand we see this differently, and I respect that. I want you to know my door is always open if you'd like to talk about it further." That is not a failure. That is a GP managing a genuine difference of view with honesty and without rupturing the relationship.

What the examiner will not accept is a candidate who changes their clinical position under patient pressure without a clinical reason for doing so. Prescribing inappropriately, writing a sick note without grounds, or making a referral purely to end the conflict — these are not negotiations. They are capitulations, and they cost CM&C marks.

They are watching whether you understand the request before you respond to it. They are watching whether your position is explained with a clinical rationale or stated as policy. They are watching how you manage the pushback — whether you escalate, capitulate, or handle it with skill. And they are watching whether an alternative is offered that genuinely addresses the patient's underlying need.

Ask your practice partners to hold their position and push back after your first response. Not once — twice. Make them briefed to be persistent. The moment after a second push is where most candidates have no instinct at all, because most practice cases resolve at the first negotiation move.

Practise going back to the patient rather than repeating yourself. That single skill — returning to curiosity rather than doubling down on position — changes negotiation cases.

Related in this series

• How to Structure Your SCA Consultation — the full structure reference
• The SCA is a play: know your consultation type — the series overview
• Why people fail the RCGP SCA — common failure patterns
• The Prescribing Dilemma — contested requests overlap
• The Ethical Dilemma — professional conflict overlap