What does ‘place’ mean to us as clinicians?

Before I started working at The King’s Fund, my approach to care delivery as a mental health nurse was based on health outcomes; focused on providing person-centred care, rather than thinking about how wider system mechanisms support my work. One of these mechanisms is ‘place’, a level within ICSs, covering populations of 250–500,000 people. Although place has taken several forms over the years, there has been a renewed focus since the enactment of the Health and Social Care Act 2022 to foster integration at a local level. This is further amplified in the present government’s mission-led approach to transform healthcare in England.

Despite working in secondary care for several years, I was unaware of these policy developments; ‘place’ did not mean much to me. At The King’s Fund, I’ve been involved in research into the development of place-based-partnerships and their progress so far. The idea of a local integrated health system seemed intriguing, but the ‘what, why and how’ left me feeling quite frazzled. This was partly due to my limited knowledge, but also because the term place doesn’t come up in my clinical practice often. It’s hard to see how political rhetoric or health policies affect my role on a micro level, so there wasn’t an urgent need to understand them.

So how do the government’s priorities affect my work day to day? To give one example, I work in mental health, where it is known that people with severe mental illness have a lower life expectancy. Place and prevention have a clear role to play in improving outcomes here, but the voice of place can get lost in the layers of system bureaucracy. In the media, there have been ongoing discussions on the future of place, with Wes Streeting’s announcement on ‘a neighbourhood health service’ providing renewed hope for local integration. It is important that place, neighbourhood and system maintain a symbiotic relationship, which I’ve realised in practice, is quite difficult.

Every clinician works within a place, and our insight, along with data and insight from patients, can and should inform the shape of health care in our individual local pockets. An example of this can be seen where I work in Derbyshire. One of the places within Derbyshire Integrated Care System, Derby City South, has a high prevalence of late-stage upper gastrointestinal cancer; approximately 7% of all referrals. Local partners and the NHS have piloted a new campaign to increase awareness on heartburn, a risk factor for oesophageal cancer; showing the power of a collaborative approach to targeting population health. But one singular place strategy for place cannot be implemented across the board, so guidance from government and providers is key.

Being a clinician working in health policy, I find myself in a unique position. Having a bird’s eye view of the health and social care landscape has redefined the way I think about health care. The opportunity to sit with researchers within a think tank has simplified a complex system, and I still learn something new about the NHS every day. In my clinical role, the link between policy and my practice hasn’t always been clear, but I’m now thinking about what value I can add within my role – what can I do differently to foster integration, and better serve my patients?

Currently, there are multiple moving wheels, with significant re-organisations and a major 10 Year Health Plan on the way. The range of new policies can feel quite overwhelming to most clinicians. Having a working knowledge of place has been helpful for me in deconstructing the challenging realities within health and social care, but given the scale of the proposed reforms, understanding the direct link between system pressures and my clinical practice is daunting. How will the developments affect my role, and do I really need to know about all the changes taking place?

Despite the challenges, I do believe ‘place is the heart of integration’, and getting this right will help with the government’s three shifts. As a clinician, I see the challenges lack of integration and prevention presents daily. I work in acute care, and my mandate for care delivery usually ends when a patient is discharged. But I came into mental health nursing to make a difference to people’s lives, and I worry sometimes about a patient’s wellbeing when no longer under direct care. Successful prevention would see more patients being cared for in the community, and possibly never needing hospital care. But for this approach to work, it needs to be collaborative and responsive, with buy-in from the various system partners, including staff working with patients and the local population to truly understand what would work.

As we await the 10 Year Health Plan, it’s important that the system continues to value the role of place. With the recent abolition of NHS England and plans to cut ICB funding by 50%, there is more uncertainty; not only for places, which are directly funded through ICBs, but also the workforce involved in integration and prevention. Listening to people at working at place level has strengthened my belief in its unlocking power, but the role of clinicians in delivering the change should not be underestimated. We need support to understand how the changes will impact us, and the role we can play in implementation. I’m hopeful that clarity on this will be shared in the coming months.