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This article highlights why and how the way in which primary care is organized conditions how the health care system works. A decline in primary care prevents any progress from being made. Primary care is supported by the state, but with no discernible impact, for reasons that are set out by the author.Solutions for improvement do however exist and are proving their worth. What they have in common is their grassroots origins. This article looks at the PAÏS scheme, which focuses on organizing generalists, which it sees as the cornerstone of primary care. Over ten years of results are now available, presented here, based on external assessment that is exemplary in its method and reproducibility.This personal account illustrates the difficulties of implementing solutions developed at the local level, in the face of a state that has reverted to centralization and its regional arm, the ARS (Regional Health Agency).The objective of this article is two-fold: first, to encourage those with new ideas to take them forward, in spite of everything; and second, to argue for local initiatives to be seen as test beds or stepping-stones that can be used to move toward more ambitious solutions, in line with national goals, once they have proven their worth.The current context means there is a burning need to act, giving approaches like PAÏS new relevance.