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Patient co-payment for general (family) practice services occur in many countries. In both New Zealand and Australia the pros and cons of universal versus targeted co-payment are openly and robustly debated. It appears that much less public and professional debate is occurring in the UK, despite a widespread recognition of the increasingly unsustainable mismatch between supply and demand for primary care services. There is currently neither sufficient NHS funding nor personnel to meet this demand, and national surveys show the ever-increasing workload is causing burnout and demoralisation in general practice.1 While some policy discussion documents are now beginning to be considered,2 there appears to have been relatively little discussion, either in public, among the rank and file of the profession, or in the mainstream primary care literature, on the relative merits and harms of introducing targeted point-of-care co-payment. This seems odd, given the many co-payments already present in other parts of the NHS, for such things as sensory aids, dental care, and prescription medicines.Is universal zero cost at point of general practice care a time-expired and unaffordable NHS sacred cow? Is it time to question the unquestionable?International observers of the NHS note increasing despondency within the general practice workforce, with much talk of a broken system tracking an unsustainable trajectory. The increased patient demand is exacerbated and compounded by the burdensome opportunity and transaction costs of a powerful, centrally orchestrated, and financially-incentivised framework. This framework is designed to drive (or buy) ‘quality’ through a complicated and time-consuming matrix of accountability measurements. As the columns of this Journal and many others (both popular and academic) have detailed, the combination of increased demands from patients and an onerous …

Patient co-payment for general practice services: slippery slope or a survival imperative for the NHS?