A concordant consultation presumes that prescriber and patient engage in a discussion where each is able to share their knowledge and understanding. Such ‘partnership working' enables a treatment decision to be negotiated. Outside the consultation professionals and patients belong to other groups and networks. Significant others may not be physically present in the consulting room but may nevertheless influence what is said or not said between prescriber and patient. The aim of this presentation is to explore the nature and consequences of the professional hierarchy and inter-professional relationships for concordance in medical consultations.

As part of a larger study on meeting treatment information needs of service users in a complex system of health care 13 mental health professionals and 16 patients/service users were interviewed. Four focus groups with 21 members of local user groups were also held. Professional interview topics included experience of interprofessional working and service complexity, and how this impacted on relationships with clients. Lay interviews and focus groups asked about respondents’ experience of dealing with a range of different health professionals.

Most health care workers acknowledged the existence of a professional hierarchy with psychiatrists at the top, community psychiatric nurses near the bottom and GPs somewhere in between. Several patients also made reference to such a hierarchy and their position at the bottom of it. 

Two types of constraint on exchanges between prescriber and patient as a consequence of professional hierarchy were identified:

1. The professional is restricted in what he discusses with patients out of deference to the views of a professional higher up the hierarchy. For example GPs were disinclined to get involved in discussions about medicines that could be seen to be challenging or interfering with the prescribing decision of the psychiatrist.
2. Patients were reluctant to voice their concerns to professionals who were perceived to be at a much higher level than themselves, and/or higher up the hierarchy than another professional who had raised a concern about their medicines. For example a pharmacist queried with a patient the appropriateness of a medication prescribed for a mental health problem because the medicine could exacerbate her asthma. Though worried by this information the patient felt unable to raise her concerns with her doctor.

The second example suggests a compounding effect of the two types of constraint since it is possible that the pharmacist was averse to approaching the doctor directly because of his subordinate position on the hierarchy. 

The research widens the focus from a consideration of concordance as an accomplishment of dyadic relations between individual patients and professionals to being a property of wider communicative networks and systems. The operation of a professional hierarchy points to organisational complexity as an important feature blocking concordance in consultations between patients and health professionals.