Introduction and aim
For patients who pay prescription charges, the cost of these, and these in relation to the cost of over-the-counter (OTC) medicines, are likely to influence their health care seeking and medicine-taking behaviour. However, there is little research which examines how this alters when people are forced to consider cost. The aim of this study was to explore how charges for pharmaceuticals incurred by patients influence their decision to utilise primary care services.

Method
Six focus groups were performed with between two and eight participants. These were condition-specific with patients taking medication, on prescription or OTC, for dyspepsia, hayfever or mild hypertension, and HRT. They were recruited through three pharmacies in Greater Manchester and Cheshire and two GP surgeries in Cheshire. The first focus group was conducted with dyspepsia sufferers who were exempt from paying prescription charges, the subsequent five were all with people who had paid for their medicines either through prescription charges or direct OTC purchase.

Results
Cost was identified as an influencing factor when making medication- related decisions by patients who had to pay for their medication, and this was particularly the case for people who were on a low income. Cost played a different role for patients who did not have to pay for their prescriptions in that their exemption steered them to consult their GP for a free prescription, even when OTC products were available. People who had to pay for their prescriptions had developed a number of strategies to reduce their expense for medicines. They would buy medication cheaper OTC, if they could, and GPs sometimes advised this. Patients on regular multiple prescriptions bought pre-payment certificates, but awareness of these was not high, yet that of the cost of outlay was. Patients also said that they sometimes did not get their prescription dispensed or only in part if there were different items on it. Another strategy that was mentioned by a few patients was that they would make their medication last longer by taking a smaller than the recommended dose. Even though, in previous focus groups, GPs had stated that patients would ask them to reduce medication expense by, for example, prescribing a longer supply, patients said that they did not actually talk to their GP about cost issues.

Discussion
Cost of medicines clearly was an issue for patients who had to pay for their medication, particularly those who were just above the income threshold for exemption. Whether patients used cost-reduction strategies depended on the perceived severity and risk of the condition versus the perceived benefit of the medication (either long- term in the case of, for example, hypertension, or symptom relief for acute conditions). This study raises concerns about equity, but also suggests that income problems may directly impact on the manner in which people take their medicines and comply with treatment.

This work was designed and funded within the BIOMED program (Framework IV) of the European Union and forms part of a national contribution of a multinational study undertaken by ENDEP.