Introduction and aim
There is some qualitative evidence indicating that the relatively high prescription charge in the United Kingdom (a flat fee per item) may have an impact on patients' decision not to have their prescription dispensed. However, there is no quantitative evidence that links non-dispensing to reasons for this. This paper presents results from a pharmacy panel study that explored reasons for non-dispensing and focuses on the extent to which the prescription charge featured in the decision.

Method
During a six week period in June to August 2000 16 community pharmacies, located in the North of England, completed a piloted data collection form each time a request or suggestion was made for a prescribed item not to be dispensed. The name of the medicine, strength and amount prescribed, who initiated the interaction, the reason for this and the outcome were recorded. Pharmacists and staff also recorded background information, such as the patient's sex and prescription exemption status.

Results
Forms were completed for 520 pharmacy customers, although data is available on 598 items, since some (12%) customers presented with more than one item for non-dispensing. Cheaper availability of OTC products was the largest (41%) single reason identified for the non-dispensing of prescription items. A further 12% of items were not dispensed because customers were unwilling or unable to pay the prescription charge. A number of other reasons, including that there was a mismatch between current and past medication on the GP records (21%) or that the patient had a supply of the medicine at home (10%), accounted for the remainder. Unsurprisingly, cost-related reasons were encountered almost exclusively for patients who had to pay prescription charges, while non-cost reasons were more commonly seen for exempt patients. Nearly half (48%) of all interactions about non-dispensing were initiated by the patient (or the patient's representative). However, patients unwilling or unable to pay the prescription charge were significantly more likely to initiate a direct request to pharmacy staff for non-dispensing (84.3%). As a result of not dispensing the prescription item, 247 OTC products were sold in place of the original prescription, 236 (97%) of which contained the same active ingredient. There were sixty-two incidents where a prescribed item was not dispensed, or substituted, solely due to its cost, and 10 of these were delayed until the customer was in a position to pay. More than a third of the non-dispensed items (n=23) could be deemed as clinically important (beta-blockers, inhaled bronchodilators and corticosteroids, and anti-infectives).

Discussion
This is the first UK study investigating reasons for non-redemption of prescriptions at the point of dispensing. It has identified the prescription charge and the system of GP prescribing as the two main factors. Even though many non-dispensed items were substituted by a comparable OTC purchase, a small number of essential drugs were delayed or missed altogether due to affordability issues on the part of the patient. This study has also revealed the extent to which patients are willing to discuss cost issues with pharmacy staff.