Accessibility ToolsMoving More Care into the Community
This winter, health and care leaders across Shropshire, Telford and Wrekin are delivering a major step forward in bringing more care into the community.
The aim is to help more people recover from illness and injury closer to home, in familiar, comfortable surroundings while easing pressure on local hospitals during the busy winter period.
Backed by a £3.6 million reinvestment, this shift will support more joined-up and efficient care, making it easier for patients to access the right support, in the right place, at the right time.
You can read frequently asked questions and answers about this work here.
- NHS Shropshire, Telford and Wrekin (NHS STW)
- Shropshire Community Health NHS Trust (Shropcom)
- The Shrewsbury and Telford Hospital NHS Trust (SaTH)
- Shropshire and Telford & Wrekin Councils
- Primary Care teams
- HealthHero Integrated Care, the new provider of GP Out of Hours Service
Together, these partners are working to deliver more care closer to where people live - improving patient outcomes, supporting recovery at home, and ensuring hospital services are available for those who truly need them.
Key services include:
The Integrated Community Front Door is a service that helps people get the care they need quickly, often without going into hospital. It brings together a range of health and social care professionals – including nurses, therapists, GPs, and social workers – to assess your needs and provide support, usually on the same day. It’s mainly for people who are unwell or in crisis, such as older adults or those with long-term conditions, but who don’t necessarily need hospital care. The aim is to keep people safe and well at home, avoid unnecessary hospital stays, and make sure care is fast and well-coordinated.
This service provides short-term care at home within two hours, helping people stay safe outside of hospital. It’s ideal for those being discharged from hospital or anyone who suddenly needs urgent support in the community. Care workers help with daily tasks like washing, dressing, preparing meals, taking medication, and checking on your wellbeing. The support is temporary and acts as a ‘bridge’ while a longer-term care plan is arranged, helping people return home quicker and remain independent.
Extended discharge planning ensures people with complex needs can safely leave hospital with the right care in place. It’s used when someone needs more than just a standard discharge – for example, they may need equipment, home adaptations, or support from carers. A team of professionals works together to plan everything needed to continue recovery safely, either at home or in another care setting. This reduces the risk of returning to hospital and helps people regain their independence.
A GP-led service at the hospital entrance offers early clinical assessment to help decide whether someone really needs to be admitted. This helps reduce unnecessary hospital stays by making sure people are directed to the right care from the start. It operates separately from regular GP services and focuses on quick decision-making and effective patient streaming.
The Care Transfer Hub helps manage patient discharges from hospital into community care. It acts as a central point for hospitals, community teams, and social care to work together. A new System Manager will oversee the process across Shropshire, Telford and Wrekin, ensuring people leave hospital at the right time with the right support. Weekend therapy cover will also be expanded to keep discharges moving throughout the week and avoid unnecessary delays.
The Urgent Community Response (UCR) service provides fast care at home to prevent unnecessary hospital visits. The service is being improved by extending its hours until midnight and introducing a new medical model to provide better support. With stronger medical oversight, community teams can treat more people in their own homes and reduce pressure on GPs and emergency services.
