Boost to community-based care set to transform patient recovery closer to home

Health and care leaders across Shropshire, Telford and Wrekin have taken the next step in delivering their commitment to expanding community-based care, as part of a wider plan to improve patient recovery and ease pressure on local hospitals.

Backed by a £3.6 million reinvestment, the initiative will see more services delivered at home or within residential settings - helping people recover from illness or injury in more familiar and comfortable surroundings, closer to their support networks.

As part of this shift, the Rehabilitation and Recovery Units currently based at the Royal Shrewsbury and Princess Royal hospital sites will close, with the wards returning to acute use in the near future.

The move towards more care in the community will mean that patients experience faster access to support, with services also designed to reduce waiting times as well as unnecessary hospital stays, and help people get the care they need quickly, often on the same day.

Dr Lorna Clarson, Chief Medical Officer at NHS Shropshire, Telford and Wrekin (NHS STW) said: “Importantly, these changes will help people stay independent at home, even during illness or recovery, with extended hours of support available and more personalised, joined-up care from local health and care professionals.

“More support will also be in place to ensure patients can leave hospital safely, with the right equipment and support, reducing the risk of re-admission and enabling a smoother recovery.

“The changes form part of a wider vision to improve patient outcomes and ensure hospital services are available for those who need them most, particularly through the busy winter months.”

Key community-based services will include:

Integrated Community Front Door (getting the right help without going to hospital)
A single point of access to urgent community-based care, bringing together health and social care professionals to assess and support people quickly, often on the same day, without a hospital visit.

Two-Hour Domiciliary Care Bridging (urgent home care within two hours)
Rapid, short-term home care within two hours, helping people return home safely after hospital or receive urgent support in the community while longer-term care is arranged.

Extended Discharge Planning (safe and well-co-ordinated hospital discharges)
Tailored discharge support for patients with complex needs, ensuring the right care, equipment and home adaptations are in place to avoid re-admission and aid recovery.

GP Support at the Hospital Entrance (early assessment to avoid hospital stays)
A dedicated GP service offering early clinical assessments to help people access the most appropriate care without unnecessary hospital admission.

Care Transfer Hub and System Manager (co-ordinating discharges into the community)
A central co-ordination team supporting safe, timely hospital discharges into the community, with new leadership and expanded weekend therapy cover to keep care moving throughout the week.

Enhanced Urgent Community Response (UCR) (fast care at home and later into the night)
Faster access to urgent care at home, with extended hours until midnight and greater clinical oversight, helping reduce pressure on GPs and emergency departments.

This joined-up programme is a partnership between NHS Shropshire, Telford and Wrekin (NHS STW), Shropshire Community Health NHS Trust (Shropcom), The Shrewsbury and Telford Hospital NHS Trust (SaTH), Local Authorities, and Primary Care partners, including HealthHero Integrated Care, the new provider of GP Out of Hours Services.

The move also delivers on the shared vision for the Government’s 10 Year Plan to strengthen local services and enhance recovery and rehabilitation support.