and inclusive. A comprehensive strategy that deals with these many interrelated dimensions seems more likely to succeed. Focusing on needed changes one at a time is unlikely to be as successful, as indicated by the failure of many prior efforts to advance primary care to have the hoped-for impact. Actions must be focused toward a common objective, and they must be mutually reinforcing. For example, changes in education for primary care are unlikely to bring about desired changes in the practice of primary care unless the changes are reinforced by the organization and financing of services.

The common objective is provided by the committee's definition. The many elements that together can advance primary care toward that objective can be viewed as a system—that is, ''a set or arrangement of things so related or connected as to form a unity or organic whole" (Webster's New World Dictionary, Second College Edition).

Taking a Long-Range Perspective

In addition to this systems view of the challenges of implementation, the committee believes that the strategy for implementation must have a long-range perspective, with action steps that can be taken in the shorter term to advance the strategy. Making intended changes in an enterprise as complex and fluid as health care is neither simple nor quick; continued learning from experience and from the development of new knowledge will be mandatory. The research and data recommendations outlined in Chapter 8 should help provide the means for this continuous learning process over the long term, but in the meantime we believe that we know the direction to take and enough about the needed action steps so that progress can begin immediately.

Taking Advantage of Factors Favoring Primary Care

Many of the actions recommended in this report are intended to shape changes already under way, rather than to mark the start of new efforts. The forces for change at work today can be important potential allies of the implementation strategy. Those forces were described in some detail in Chapter 5.

For example, the growth of managed care and integrated health care systems that emphasize the role of primary care has raised the demand for primary care clinicians thus reducing the differential between the incomes of primary care clinicians and the incomes of medical specialists. Federal and state policymakers have also shown growing interest in the availability of primary care, particularly in rural areas, in the training of adequate numbers of primary care clinicians, and in the removal of legal barriers to the wider involvement of nurses and other types of health professionals in primary care. The rapid development of Medicaid managed care programs, and the likely continued growth of the enrollment of Medicare beneficiaries in managed care arrangements, will continue to merge the



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