The death of the clinic

Why our misguided attempts at delivery reform stay stuck in traditional thinking

I am old enough to remember going to the movie theatre and seeing Kevin Costner walk into the middle of a cornfield, have a conversation with a ghost, and then build a baseball field. 'If you build it, they will come,' the voice whispered, as if to promise that constructing something grand would naturally draw people in. Without ruining the movie entirely for those of you from a different generation who may not know this movie, needless to say it doesn’t give to much away to say that Costner’s following this advice leads to all kinds of interesting story arcs.

The “If you build it, they will come” quote has been used to justify all kinds of things. It's a phrase that's inspired countless projects, from grand stadiums to sprawling hospitals, and even ambitious health programs. The underlying assumption is that simply by creating something—no matter how grand or well-intentioned—people will naturally flock to it. But this mindset is deeply flawed, especially when it comes to our health.

In the context of health care, this approach has led to the construction of large, centralized facilities. You’ve seen them. Some are towering juggernauts showing off floor to ceiling windows, waterfalls, and beautiful sculptures out front, while others are more run down, a symbol of an era long gone. No matter how they look, what’s undeniable is how much money we’ve poured into these buildings. And sure, while these structures can be impressive, they often miss the mark on achieving health outcomes and cost a lot of money, which is why we have to keep them around - to pay for them.

In one JAMA study looking at features of health care systems in the US and what leads to overuse of health care services, authors found that systems with higher rates of health care overuse tended to have more hospital beds and physician practice groups but fewer primary care physicians. Additionally, these systems were more likely to be investor-owned (read venture capital and private equity) and less likely to include major teaching hospitals. But the kicker is that the authors found that significant investments in certain health care infrastructures, such as hospital beds and specialized practice groups, incentivize the overuse of health care services. If you build it, you have to pay for it!

Deeper though is an argument about power, convenience, and legacy. You see, these clinics and structures ask of a lot of us, and assume that everyone has the ability, the time, and the means to come to them. As our communities have grown, spread out, the clinics that used to be central to us, have now become a drive, an extended drive for some. Our assumptions about clinics now is that people will just come to them. I mean what choice do we have when we need to be seen? However, this overlooks the real-world barriers that many people face—barriers like transportation challenges, work schedules, caregiving responsibilities, and even cultural or linguistic differences.

Moreover, this 'build it and they will come' mentality has also contributed to a one-size-fits-all approach to care, where we expect diverse populations to conform to a system designed with a narrow view of who they are and what they need. It’s as if we’ve been building these grand fields of dreams, hoping that people will come running, without considering whether they even have the shoes to make the journey. And most of the time, we haven’t even asked if what we’re offering is what people want or will help!

It would be a mistake to think that by calling for a shift from the clinic means I am saying all things should shift digital, embracing technology for all that it is, a lower cost service that can more easily reach more people. Nope. That’s not the case at all, and in fact, couldn’t be further from what I think should be done. While there’s a role for technology, it is not the panacea nor the replacement

For me, care isn’t about attracting people to a specific destination; it’s about meeting them where they are. The real challenge—and opportunity—is to rethink how and where we deliver care to make it truly accessible and responsive to the communities we serve. It’s about recognizing that care can’t always be something that exists 'out there,' waiting for people to come to it. Instead, it must be something that integrates into the very fabric of our daily lives, something that is as close and familiar as the corner bodega or the neighborhood school. Something that we all see as a part of our community.

But what if, like Costner's character in Field of Dreams, we've been hearing the voice all wrong? What if the answer isn't about building more centralized, grandiose structures, making them fancier with bigger televisions, more open spaces, but about bringing care closer to where people already are? After all, a baseball field in the middle of a cornfield only works if you're telling a story about ghosts and nostalgia. In the real world, people need care where they live, work, and play. They need care that understands their daily realities, their communities, and their unique challenges. Delivery reform that doesn’t take this into account misses the mark.

Hyperlocal solutions have to be our foundation. These strategies leverage existing community infrastructure and partnerships to address the things that truly matter to people. During the COVID-19 pandemic, we saw the power of community-based interventions in action. In addition, research has underscored the success of these approaches in things like increasing vaccination rates in certain communities. By bringing the care to the people—whether it was setting up vaccination clinics in churches, schools, or community centers—we were able to reach those who might have been left behind by a more centralized approach. This is the kind of thinking we need to apply to all aspects of health care.

What else can we consider?

Integrate, then disintegrate: We need to bring all aspects of care—from mental health to legal and social supports—together in a way that allows us to then push those teams out into our communities. Integration shouldn’t just happen within the walls of a clinic or hospital; it should happen on the streets, in schools, at community events. Imagine teams of professionals working collaboratively, embedded in the very communities they serve, offering comprehensive support that addresses not just health, but the broader social determinants that influence it.

Reconsider what contributes to health: There’s nothing magical about a clinic. It’s merely a box where the people we have relationships with are housed. Yes, there are times when a sterile environment is necessary for procedures and specific interventions, but this is the exception, not the rule. The vast majority of care—especially mental health care—can and should happen in environments that are less clinical and more reflective of the places where people feel comfortable and safe.

Home?!: The potential for home-based care is vast. Home is where we feel safest, where our routines are set, and where our lives unfold every day. Bringing care into the home not only removes barriers but also allows for a deeply personalized approach, where care is tailored to the individual’s environment and needs. By making home a central place for care, we can create more meaningful, comfortable, and effective health care experiences. Plus, there is rich data on how effective this can be on health outcomes.

Get more creative: The possibilities for where care can happen are endless. Barbershops, coffee shops, pubs, Boys and Girls Clubs, churches—the list goes on. These are places that are already trusted and frequented by people in their everyday lives. Why not bring care to these spaces? Imagine walking into your local barbershop and being able to talk to someone about your mental health, or attending a community event at a local pub where you can get information about legal support. These are real opportunities to embed care into our communities, making it more accessible and less stigmatized.

Listen to the people you serve: What’s often lost in a lot of our thinking is who gets to design the solution. Too often, we leave the community out of the conversation, creating systems and interventions that don’t truly reflect their needs or realities. Any meaningful approach to rethinking care must include co-designing and implementing solutions with community input. This ensures that interventions are not only culturally relevant but also effective. By involving the community in every step of the process, we can create care systems that are truly responsive and respectful of the people they serve. Imagine the last time you were in a clinic - was the experience the one you wanted? Was the space designed like you would like it? Chances are the answer is no.

Imagine a system where mental health services are embedded in local schools, grocery stores, or even barbershops—places that people naturally visit, places that are a natural part of our lives. This happens when we lean into a focus on hyperlocal, tailored, and relational solutions. Imagine care that adapts to the needs of the community, rather than asking the community to adapt to the needs of the system. This is not just a dream; it’s a necessity. It’s the new clinic. It’s also the future of care. If we don’t start reimagining care to be as close as the corner store and as integral as the neighborhood school, we’ll miss the chance to truly make a difference on the things that actually matter.