Introduction and aim
If patients pay a prescription charge the cost of medicines is likely to influence their health care behaviour. This may be particularly so for women on hormone replacement therapy (HRT), where cyclical combination products incur a double prescription charge. This unusual scenario may also have an impact on GP prescribing behaviour. The aim of this study was to explore in depth how charges for HRT products influence patient decision-making and GP prescribing.

Method
Women taking HRT, either for control of menopausal symptoms or as a preventative measure, were recruited through two GP surgeries in Cheshire. Two focus groups with a total of ten women were conducted, one in a deprived area, and one with women from a more affluent background. Five focus groups were also performed with GPs from three Health Authorities in the Northwest of England. Between 10 and 11 GPs participated in each group.

Results
GPs were aware that most HRT products incur a double prescription charge, and acknowledged the inequity this creates for women needing combination products. GPs and patients were concerned that the double charges were particularly problematic when establishing therapy, since many patients had to try a number of different products before settling on suitable treatment. GPs mentioned a number of strategies they used to help reduce the inequity for patients. Several said they would sometimes issue trial packs, but most simply increased the length of supply they prescribed. Unlike for other long-term medication, which GPs would prescribe for no more than three months, the majority of GPs said they would prescribe HRT, similar to the contraceptive pill, for six months. To make it fair for all women on HRT, one female GP favoured a slight variation on this theme, by prescribing six-monthly for women on combination products, and three-monthly for those using single products. How widespread any of these strategies are is uncertain however, since the women in this study had no experience of being given trial packs, and the majority of the women were on three-monthly repeat prescriptions. Some women were even on monthly repeats, highlighting the variability that exists within the repeat prescribing system. The women themselves also reported their own strategies for reducing the cost burden, including making HRT plasters last as long as possible before renewing a prescription. While several did ask their GP for a longer supply those that had felt empowered enough to do this reported being refused the request.

Discussion
Women on HRT cannot use OTC substitution to reduce the cost of their medication, a strategy frequently used by patients where de-regulated products are available. Instead they try to get a longer supply. There is clearly a mismatch between patients' and GPs' perception of the inequity of this situation however, since in practice it appears that requests for a longer supply are ignored. Further research is required to quantify the extent to which this cost issue causes problems with therapy for women on HRT, and policy makers may need to address the inequity by altering the system where a double prescription charge is incurred.

This work forms part of a national contribution to an international study being undertaken by ENDEP, in which Peter Noyce is a partner. The project is funded, in part, by the European Union under Framework IV of the BLOMED programme, contract number BMH1-98-3576