Global Fails Local But Local Focus Succeeds Globally

It takes specific local focus across most of the nation's population to get the health, education, and other societal outcomes that make us a better nation. One of the points made by de Tocqueville in his historical summary of American life over 150 years ago was the local focus of problem solving.

As we have moved away from local to global focus, 
our global attempts appear to fail more and more locally.

Care for Americans most in need of care is not facilitated by those far away dictating, managing, legislating, reorganizing, innovating, or profiting.

Health care outcomes are about local people, local life and home situations, local social determinants, decades of past life experiences, sufficient resources locally for needed care, and local providers best aware of the patient and the context of care who have also shared decades of life experiences locally.

Can Americans balance the local and the global sufficient to the task of health care delivery?

Leaders can lead reform, but apparently not local health access recovery. Is it so difficult to focus on the basics, especially when the basic are most needed?

Many like this classic Churchill quote:

Americans can always be counted on to do the right thing, 
after they have exhausted all other possibilities

After all it does have the happy ending of Americans doing the right thing. But it also indicates that Americans will continue to attempt all other possibilities. What if doing the right thing is what has been done for decades or centuries, such as broadest generalist family practice? Are health educators capable of basic focus to meet the basic needs - the needs increasing most rapidly for the next 3 decades?

Those doing well in health care clearly love innovation, formulas, and reorganizations. The pace of change is incredibly rapid and accelerates in ways that indicate that they may never get exhausted of "all other possibilities" - the ones that consume more resources for little gain in care. Too many possibilities exist.

Those with innovation focus and more global approaches gain attention and funding. They obviously gain the attention of major foundations and government.

Innovation can be seen globally and locally. Global innovation is the current rage. Those delivering essential local health services are innovative and adapt care to meet needs, but not in ways that attract foundation or government funding. Locally innovative is essential, but is difficult due to lack of local support.

Disruptive innovation can disrupt 
when the ability to be locally and personally innovative is disrupted.

For example, primary care experience is incredibly important, but it is difficult to explain why primary care experience is so valuable. Students experiencing continuity longitudinal integrated curricula such as RPAP are overwhelmed after 3 months of rural primary care, neutral at 6 months, and comfortable at 9 months. Experience matters, but it is difficult to capture all the dimensions. What seems obvious to me that just 3 months of primary care in different settings, or the usual primary care experience during medical school, appears just about enough to drive students away from primary care.

Primary care is about ever increasing awarenesses in more dimensions 
applied to the care of local patients. 

This is best developed locally by care experiences and by those experienced in local care.

Until we have an entirely different construct for the care of Americans in need of care, 
the United States will continue another 3 decades of delay as in the last 3.

There is just too much distance and difference in too many dimensions for those at the top designing care to hope to comprehend the specific local care needed, just as the specific local workforce needed has escaped design for three decades.

The recent 16 billion bailout for Veterans care is another example of administrative rather than local. Relatively few sites of care are found. Community Based Outpatient Clinics are already a part of the veterans operation and are distributed, but have few hours of operation, few providers, few types of providers, and limited short notice access. Those who understand the past, present, and future limitations of primary care workforce and CBOC situations, should understand that far more than just money needs to be addressed. The new legislation has been promoted as opening up veterans to private care, but the 40 mile limitation, the CBOC limitations, shortages of clinicians and teams, national shortages of primary care, and centralized focus of spending will prevent much improvement for 50% of veterans - the ones most in need of care.

In 2620 counties with 40% of the population and lowest concentrations of clinicians, the problems are magnified by fragmentation, regulation, restrictions of care, and poor access. These are locations with 45% of the elderly and 50% of veterans and other populations most in need of care - left behind by designs that work where clinicians, people, income, and health resources are concentrated, but not where care is most needed.

Somehow our nation must restore a proper balance 
  • between the needs of most Americans and the expenditures upon a few, 
  • between global distant thinking and much needed local implementation of care
  • between most specialized/concentrated services and basic services/services distribution
  • between administrative and non-delivery expenditures and expenditures on delivery costs
As we focus on more spent for fewer for less overall result, we will fail most Americans by our very design.

Local care needs for those in most need of care, must be focused on local solutions
  • Sufficient workforce accessible in ways addressing hours of need and proximity, particularly for those with acute needs and chronic recurrent needs
  • Sufficient health spending to be able to keep sufficient teams and clinicians to deliver the care
  • Care focus on local needs, not referring patients to a particular system or to different systems dividing up the population
  • Spending specific to clinicians and teams, not more spend on regulation, administration, and non-delivery costs
Large chunks of multiple billions must actually get to those who provide basic services for the 40% of the population most left behind in order to have the workforce to deliver the care.

Stimulated by

Recent articles about the Veterans Bailout and Concerns Raised by NRHA and others

Rural Hospital Challenges

Accelerating Cycles of Primary Care Decline

Recent Works

What Veterans Need Is Family Practice

Domino Decline By Design

Declines in Health Care Delivery Despite Increases in Health Spending

Perverse Health Payment Dividing US

How To Resolve Health Access for 40 States Behind By Design

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Overcoming Barriers to Health Access Including ACA

Will Teaching CHC Sites Deliver on the Promise of Health Access?

How Bad Medicine is Sweeping The Country.

Preventing Rural Workforce By Design

Best of Basic Health Access

Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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