Background Gatekeeper is one approach to efficiently allocating healthcare resources in primary care. In Japan, there has been an ongoing argument that the absence of gatekeeping might have contributed to excess demand in specialist or hospital care. By contrast, general practitioners (GPs) in England have played the role of gatekeeper since the establishment of the National Health Service (NHS). This study investigated how primary care doctors in both countries manage patients’ demands during the consultation while acting as a patients’ advocate.

Method We conducted in-depth interviews with primary care doctors in England and Japan via an online videoconferencing platform or face-to-face between July and December 2021. We elicited participants’ experiences and views about rationing and managing patients’ demands in practice; hypothetical consultation scenarios were also used. Interview transcriptions were thematically coded and analysed in the original language. Emerging codes and themes were constantly compared to develop understanding and build analytic frameworks.

Results In total, 8 GPs in England and 15 primary care doctors in Japan participated in the interviews. Most UK GPs expressed their frustrations over the growing pressure to handle rationing by the NHS. They had to manage patients’ expectations and offer alternative options when expecting a long wait or difficulty in accessing services within the NHS. Some of them shared the local guidance on referral during discussions with patients. By contrast, primary care doctors in Japan rarely mentioned their need to commit to priority setting. However, several physicians reported struggling to decline patients’ requests for unnecessary care and tended to use implicit judgement criteria in the absence of an explicit gatekeeping system.

Discussion Although clinicians in both contexts struggled to manage patient demands, the presence of explicit gatekeeping seemed to increase the prominence of priority setting in practitioners’ minds and give them an additional mandate for action.