If I had my time again, I’d be a travel writer. I finished Bill Bryson’s Down under1 on the plane to Perth, Western Australia, and became inspired again about the west — the vastness and evocative timelessness of the land. As I travelled, I looked forward to catching up with old friends and meeting new ones in general practice. We were due in to do accreditation visits in the city and the Pilbara and Kimberley regions in the north-west of the state. Over the years, I’ve had the privilege of visiting over 400 practices — from Broome to Bondi and from Thursday Island to Tullamarine — for accreditation and other projects, and have been able to watch the evolution of general practice.

After 3 days in Perth, we caught the early flight to Karratha, a mining town in the Pilbara region. We were struck by the isolation and heat and red rocky landscape when we arrived, but were pleasantly surprised by the practice. Corporate private practices in remote WA, established to take advantage of the mining boom opportunities, appear to be well supported. The facilities we surveyed were better than some we had visited in Perth; and the medical staff, practice manager, nurses and reception staff were enthusiastic and very capable.

We interviewed one of the doctors, a Melbourne graduate recently arrived with his family, who was enjoying the work.

Later, we asked another doctor from overseas the same questions.

For some, “the expansiveness” of the landscape, as Thubron puts it, “becomes an obsession”;2 for others it is simply oppressive.

This duality strikes at the heart of the crux of change in general practice. Some doctors and practices embrace it and see opportunities, whereas others believe that the constant changes are all about government and College control.

Graduating in 1978, I “grew up” medically with reform agendas in health (Box). Nothing much changes. Community health centres, the predecessors of GP Super Clinics, were first established in the Whitlam era, when I was a resident in Canberra. When I moved to rural practice in Gundagai in 1982, Medibank had evolved to Medibank “mark 2”, and finally Medicare.

Ten years on, general practice accreditation — along with Divisions of General Practice, a tightening of vocational training and registration and improved uptake of information technology systems — was one of the key recommendations arising out of the 1992–93 Commonwealth Budget.3 Following on from the vocational registration debate, it was a time of intense political heat in general practice. We experienced “crash or crash through” by the Royal Australian College of General Practitioners and opposition from the Australian Medical Association, which was fearful of a nationalised health system and government intrusion into the doctor–patient relationship.

I remember a meeting with the then federal Minister for Health, Housing and Community Services, Brian Howe, shortly after the Budget was released. He said something to the effect of how he would concentrate “this year on general practice, next year specialists and the year after pharmacists”. Of course, we are still waiting for accreditation of specialists and publicly funded and expansive divisions of surgery or other specialties.

The government’s “reform” agenda of the 1990s didn’t go quite as planned. General practitioners weren’t paid more (until pressure was put on the system by falling bulk-billing rates much later), and the planned great reform of the Medicare Benefits Schedule based on the Relative Value Study didn’t eventuate. Governments soon used vocational registration to control entry into general practice, noting that both direct and secondary costs were rising rapidly and were related directly to the number of doctors. The brakes were applied. Medical school intakes were not increased for years and entry into general practice was limited. It was not until recently, when an ageing population, increased demand and more complex management systems brought home the stark reality of medical workforce supply, that governments acted to take their feet off the brakes.

In the late 80s and 90s, the early professional agenda was about recognition of general practice as a unique discipline and addressing perceived or actual differentials between specialists’ and GPs’ incomes. GPs wanted greater recognition and higher pay. There was an expectation that a new (content-based) fee structure, introduced by the federal Minister for Community Services and Health, Neal Blewett, would usher in a brave new world for patients and better rewards for GPs. This naïve expectation appears to persist among the proponents of the new reform agenda, including Super Clinics, fund-holding by Divisions of General Practice, performance-based pay, nurse practitioners and patient registration.

Medicare as a personal insurance scheme is being slowly replaced by fund-holding, grants and government largesse. This takes power away from patients and puts it into the hands of bureaucrats. It will take a lot to convince me that bureaucrats can manage general practice any better than the way they have managed the public hospital system, with its failing infrastructure, difficulties in access, bed block and inadequate mental health services.

The real issue now in general practice is workforce. There are not enough doctors and not enough nurses to do the nursing, let alone become primary care practitioners. The professional, political and bureaucratic focus has been taken off this real problem as we focus on alternative funding strategies or run scared on nurse practitioners. It is far more important for the future of general practice to create vertically integrated clinics with medical students, prevocational trainees, registrars, GPs, rural doctors and specialists, and to support a personal commitment to investment in the practice. Other providers will come.

Bryson would make a great GP. He seems to spend a lot of time in pubs, watching and talking with people, and longitudinal contact with people is the main satisfaction for most GPs. Bryson has a perceptive wit and is a hive of information on the interesting and remarkable. When he visited WA, he didn’t venture as far north as we had, but wanted to ring his wife, sell the house, buy a caravan and wander through the Kimberley.1

General practice has been on a journey. Every day is different. Like the country we live in, it is huge and undervalued. For some, reform in general practice hasn’t gone far enough; for others it has gone too far. There are many with vested interests that don’t necessarily parallel the interests of patients or GPs. We shouldn’t ignore the history of reform in general practice, and any changes should be based on a patient agenda rather than political or other agendas. It may be time to settle for a while and work out where we’ve been and where we are going.

Port Hedland is ringed with red sand beaches. When I asked a local why there was no one swimming, she said, “Luv, if the stingers don’t get you, the sharks, sea snakes, stonefish or stingrays will”. For many GPs it is a case of once bitten, twice shy.