Australia is about to sell off a large chunk of its primary care, and few are asking who the buyer will be. Around a third of the country's general practitioners plan to retire within five years, according to the Royal Australian College of General Practitioners' annual Health of the Nation survey, and when a GP who owns a practice retires, that practice gets sold or it closes. The quiet default is that it gets sold to a corporate group whose business model is volume, because the people with the capital and the appetite to roll up clinics are, almost by definition, the people who make money from more visits rather than fewer.
This matters more than a changing-of-the-guard usually would, because the thing being sold is the one relationship in the health system that actually produces health. A GP who has known you for twenty years, who remembers that your father died of the thing your blood pressure is flirting with, is doing prevention whether or not anyone pays them for it. Fee-for-service does not reward that relationship; it rewards the six-minute consult and the repeat script, and a corporate owner optimising a spreadsheet will find the relationship and tax it. We are, in effect, about to hand the most preventive asset in the system to the buyers least interested in prevention.
So here is a question worth sitting with: if a wave of practices is going to change hands anyway, who should own them? My answer, which will surprise no one who has read anything else on this site, is the people who use them. A retiring-GP wave is a once-in-a-generation chance to re-own primary care from the bottom up, neighbourhood by neighbourhood, as patient-and-staff co-operatives rather than roll-up targets. The capital to do it is sitting right there in the country's $4 trillion superannuation pool, which is forever hunting for exactly this: long-duration, inflation-linked, defensive income. A registered patient list is about as defensive an income as exists.
The mechanics are less exotic than they sound, and most of the pieces are already lying around.
- Buy the practice, keep the people. A co-operative owned by patients and staff acquires the clinic, and the incoming GPs who want to stay are kept on salary rather than left chasing throughput. The doctor's incentive stops being the next billable consult and becomes, simply, the health of the list.
- Fund it with patient capital. A super fund lends against the acquisition, repaid out of the steady, registered-patient income the practice already earns. Patient money, in both senses of the word, which is the pun I have been waiting an entire essay to make.
- Change what the clinic is paid for. Register every patient through MyMedicare, give each one a prevention plan, and shift a growing share of income from per-visit fees to per-patient contracts that pay more when people stay well. The clinic starts earning more when you stay out of hospital than when you turn up at one.
If this sounds like a utopian rewrite of primary care, it is worth knowing the market has already priced the model, in the other direction. In 2023 the American pharmacy giant CVS paid roughly US$10.6 billion for Oak Street Health, a chain of clinics that does prevention-focused primary care for older patients and gets paid per patient rather than per visit. The capitated, keep-them-well model is not fringe; it is valuable enough that a Fortune 500 company wrote an eleven-figure cheque for it. The only question is whether Australia lets that value accrue to a distant shareholder or keeps it in the community that generates it.
And community ownership of exactly this kind is not a thought experiment here. Australia already runs around 148 Aboriginal Community Controlled Health Organisations, clinics owned and governed by the communities they serve, and they have spent decades demonstrating that local ownership and a prevention focus are not mutually exclusive but mutually reinforcing. Look further afield and the Nuka System of Care in Alaska, owned by the Alaska Native people it serves, has become the case study health economists cite when they want to show that treating patients as owners rather than throughput produces better outcomes at lower cost. The evidence that this works already exists. What is missing is the capital structure to do it at scale in suburban and regional Australia, and the will to point super at it.
There is a deeper logic here that connects this to the other instruments I have been sketching this month. Donella Meadows taught that the highest-leverage place to intervene in a system is the rule about who owns it, because ownership sets every incentive downstream of it. Elinor Ostrom spent a Nobel-winning career showing that communities govern their own shared resources rather better than either the state or the market assumes they can. And Mariana Mazzucato's point about missions needing a committed owner applies as neatly to a GP clinic as to a moonshot: a mission with no owner is a press release, and health produced rather than activity billed is precisely the kind of mission that dies without one. The same instinct runs through the member-owned healthspan tontine and the resident-owned place dividend: own the thing, and the incentive to keep you well finally sits with someone who benefits when it does.
It requires a co-operative structure, a patient-capital lender willing to go first, and five to ten practices in a single Primary Health Network to prove the cluster before anyone scales it. That is a small, concrete, startable thing standing in front of a very large, already-happening one.
The retirement wave is coming regardless; the only open question is who catches it. We can let primary care be rolled up by the buyers who profit from more medicine, or we can use the moment to hand it to the people who would rather have less.