GPs' experience of difficult decisions in patients with dementia and an acute illness.

Background: GPs are often required to make decisions about the management of acute illness in people living with dementia. These decisions are often complex and involve multiple informants.

Aim: We aimed to explore how GPs made decisions about acute illness in people with dementia using a micropolitics approach.

Design & setting: Qualitative, semi-structured interviews with 13 GPs with a range of years of experience working in South Yorkshire, UK.

Method: Interviews were conducted by phone. Interviews focused on GPs' accounts to reflect their own perceptions and choices as portrayed to the interviewer. The analysis used the lens of micro-politics in the analysis and interpretation of the themes, with a focus on decisions between GP, patient, family and carers, other health and social care providers about the management of acute illness in a person with dementia.

Results: The results showed that GPs act as street-level bureaucrats while carrying out their role, using discretion during decision-making in an environment characterised by uncertainties and work pressures. In addition, GPs use the "soft power" skills of diplomacy such as negotiation, persuasion and engagement in navigating through difficult decision-making situations, while building relationships and partnerships with various actors in the health system.

Conclusion: GPs possess and express power and influence decision-making in people living with dementia when navigating biomedical, social, economic and psychological factors. This power comes in the form of soft power (street level diplomacy) and the more formal power of street level bureaucracy.