Two-hundred years after the birth of Charles Darwin and 150 years after the publication of On the origin of species, we elected to pursue a Darwinian theme in the 2009 MJA annual General Practice issue. “Survival of the fittest” relates to the ability to adapt to the immediate environment, which, for medicine and health care, has certainly undergone some changes! Indeed, the Lancet recently redefined health as the ability to adapt.1 We wanted to explore just how medicine, and general practice in particular, has adapted to changing societal, commercial and political environments.

There is no denying that societal changes, coupled with advances in science and technology, have brought substantive changes in health care. Not only are Australians now living longer than ever before,2 but we also enjoy a comprehensive health system that has made us “a nation free from financial worries that go with illness and incapacity”.3

But it must be acknowledged that there are smouldering tensions both within medicine and in its relationship with society — tensions that may well bring about fundamental change in medical practice. These catalysts for change have been comprehensively explored by Lilford and his colleagues from the Department of Public Health and Epidemiology at the University of Birmingham in an essay entitled “Medical practice: where next?”4

First, there is the rise of consumerism and corporatism. These days, medicine in the developed world is practised in societies consumed by consumerism, individual rights, and a low threshold for litigation. As a consequence, we now practise “defensive medicine”. The very word “patient” is decried by some and replaced by “consumers”, “customers” and “clients”, with their inherent service connotations. In fact, medicine has moved from an environment of individual professionals to one of corporate entities, as the financial lodestones of government subsidies and guaranteed cash flows attract corporate interests. Doctors practising in such environments are no longer considered valued partners, but are regarded simply as workers in a health care team involved in the production cycle.

Second, administrators and accountants now reign supreme, with an emphasis on organisational performance. One of the unforeseen consequences of this corporatisation of general practice, with its production lines accommodating discrete and circumscribed tasks,5 has been the loss of continuity of care.4

The ever-present problem of patients’ access to health care has led to an increasing displacement of doctors by other health professionals.6 Nowhere is this more evident than in general practice. Doctors might still play a very important role in managing an illness, but they no longer exclusively direct the play. The roles of other primary health care providers and coordinators are evolving, and new tensions are being generated as they become involved in decision making, diagnostic procedures, prescribing and the organisation of referrals.

Indeed, the widespread unhappiness and loss of morale among doctors, particularly general practitioners,7 is usually attributed to these and other pressures, especially when accompanied by diminishing autonomy and professional control. When practice frameworks, remuneration and regulations are determined by central bureaucratic commands, disempowerment and loss of professional control will result.

Lilford and colleagues are particularly bleak in their predictions for the future, arguing that medicine may well lose its hegemony:

They go on to argue that intellectual and communication skills will become the most crucial competencies in health care, and that the consultation will reassert itself as the central encounter in health practice.

This special General Practice issue of the Journal contains contributions that explore such diverse topics as the reform of health care policy and general practice (Kidd, Coote, Mara and Sturmberg et al), the development of models of care (Harris et al, Wakerman et al, Phillips et al and Hartigan et al) and medical education in general practice (Laurence and Black, Sen Gupta et al and Sturman et al). Together, they offer some insight into the future direction of general practice.

Coote details the reforms in Australian general practice from 1989 to 2009 (Coote).8 He describes how successive governments enacted reform revolving around remuneration, regulation and accreditation, organisational frameworks, and governance. During this process, governments capitalised on the principle of “divide and rule”. This is not particularly difficult in Australia, given the multiplicity of representative bodies and players in general practice, including such diverse organisations as the Australian Medical Association, the Divisions of General Practice, the Rural Doctors Association of Australia and the academic bodies of general practice and rural and remote medicine. Moreover, the federal government is itself a major powerbroker in the reform process, in that a considerable proportion of general practice income is derived from Medicare, and the government effectively controls both the workforce and the scope and diversity of its practitioners.9 Of even more importance, perhaps, is the federal government’s capacity to create ongoing uncertainty with its endless cavalcade of inquiries and their potentialities for change.

All of this reinforces the notion that reform of general practice should be fuelled by GPs and shepherded by resolute and united medical leadership. Australian general practice has had effective leadership in the past, but if it is to develop further changes in medical care, it will need a multi-representative overarching body. Sir John Tooke’s inquiry into the United Kingdom’s Modernising Medical Careers debacle made pertinent comments on leadership of the British medical profession that may also apply in Australia:

Here in the Antipodes, things are essentially no different. Without such a structure and courageous leadership, the Darwinian evolution of general practice may well be driven by chance alone or, at the very least, a passive or submissive response to the environments imposed by successive governments, as recounted in this issue by Coote8 and Mara.11

If GPs caring for patients 50 years ago were to return today, they would be amazed by the profound changes that have occurred. Yet one constant remains: general practice will continue to be subjected to changing professional, political and social paradigms. In this environment, unless resolute and united leadership ensures its centrality in the process of reform, general practice will no longer be deemed “the fittest” and, according to the basic principles of Darwinian evolution, will not survive.