Sociologists tell us that "Autonomy is the acid test of professional status ... all other characteristics of a profession flow from it".1 Poor Dr Zen* has no professional autonomy. Mr Unger's management is determined, not by her, but by an electronic decision system which then reduces her pay for taking too long and directs her continuing education. How did Dr Zen get into this thankless situation? Let me answer that with some more of her story.

Dr Zen's dream is to become a Clinical Controller with Corporation Enterprise. Competition is intense as the status and salary are so much better than those of the general practitioners who labour in the corporation's clinics. To be considered she has to obtain an MBA from the Corporation Enterprise School of Business.

One cold, wet night in 2020, Dr Zen is at a taxi rank waiting for a fare, correcting her first draft of an assignment for the subject HX101 "History of Corporation Enterprise". The assignment topic is a challenge: "Why did the GP leaders of 2003 call for policies to dramatically increase the number of general practitioners?" The course notes suggest that in 2003 the policies pursued by GP leaders undermined real opportunities for GPs.

Dr Zen has undertaken extensive research. Her essay hypothesises that the key mistake in 2003 was not to pursue policy and structural changes so that general practice could adapt in a positive way to changing community expectations. GPs ignored opportunities flowing from technological developments and changes elsewhere in the health system. They concentrated on defending the status quo and, behind a smokescreen of rhetoric, lobbied government for higher pay for each consultation and for more doctors.2 This maintained short-term cash flow but further entrenched structural problems.

The cash flow of most GPs depended on habits developed between 1984 and 2007 under a financing system called Medicare. Medicare rewarded "down-market" activities, not "up-market" skills. The highest incomes came from providing many short consultations and not providing services requiring the very skills that differentiated GPs from other "healthcare workers". The seriously ill and those requiring minor procedures or time-consuming care drained profits and, under Medicare, could be deflected to specialists or emergency departments.

The network of corporate clinics already emerging across Australia before 2003 grew rapidly following the increase in GP numbers between 2003 and 2007. These clinics were based in the cities and absorbed most new GPs. In 2008, the government admitted that the policy of expanding numbers to get GPs into rural and outer urban areas had failed.

A retired bureaucrat, Gletkin, was commissioned to review the situation. He concluded the government was simply underwriting the profits of a few large GP corporations: the GP workforce was less evenly distributed than in 2003; GPs were being paid for work that could be undertaken more cheaply by others; and the government's commitment of millions of dollars to educating GPs through six years of university and three years of vocational training was of doubtful value because GPs were not using the skills taught.

The government of Mustapha Mond adopted radical measures recommended by Gletkin. Medicare was abolished and Corporation Enterprise established as a government-owned monopoly. This entity compulsorily acquired all GP clinics and rigorously implemented its charter of ensuring an even distribution of GPs across Australia and providing primary care at the lowest possible cost, using protocols designed to refer all serious cases to specialist polyclinics or hospitals.

The company operated to a strict formula of one GP per 1750 people. With a population of 25 million, only 14 250 out of 30 000 GPs were contracted. Minimal incomes were offered. GPs had to agree to adhere strictly to the corporation's treatment protocols.

The education of GPs was rationalised. School leavers, after five years administrative and assistant experience with the Corporation, could apply for entry to the GP course at the Corporation Enterprise School of Medicine, a three-year web-based course supported by "on-the-job" training. Dr Zen was in the first graduating class.

Dr Zen now understands the sadness on the faces of the elderly couple in the next flat to hers in the Housing Commission complex. They commenced careers as GPs in the early 1980s, full of hope and expectation, but were bankrupted in 2007, when found personally liable for a medical indemnity claim. Since then they had been unemployed. Dr Zen hopes she can afford to buy them a hamper again next Christmas.

Dr Zen is pleased it is a quiet night on the taxi rank. She can think about the conclusion of her essay. Students are asked to imagine a different scenario for general practice after 2003. She will argue that GPs, rather than squabbling with government over a few dollars, should have thought more deeply about what the community wanted from general practice and how GPs could "add value". They should have lobbied for policy and structural change so that simple tasks could be delegated to other staff, while the highly (and expensively) trained doctors used their skills managing acute medical conditions and common chronic conditions; coordinated the care of patients with complex conditions; enhanced the procedural aspects of their practices; and established arrangements of value to others, such as early hospital discharge. Such a role would have required fewer GPs, but those GPs would have had much more rewarding careers.