Transforming Community and Out of Hospital care


A key element of the NHS Long Term plan is enabling the shift from care within acute hospital settings to a greater emphasis on people being supported within their communities and in the place they call home.  

The South West Community Health and Care team is supporting all seven Integrated Care Systems (ICSs) in the region to transform how health and care services are delivered in local communities. ICSs are a partnership of health providers, local authorities, the voluntary sector and others who work together to improve the health of the population, reduce health inequalities and enable the cost-effective delivery of care across a local area. 

Areas of focus for community health and care include:    

  • Supporting people to stay well through identifying people in the community at risk of deterioration and offering them proactive personalised care and support 
  • NHS support for people living in care homes and prisons  
  • Investing in community teams to prevent admissions and speed-up discharges, through Urgent Community Response and Intermediate Care services  
  • Using digital technology to help people monitor their health, and appropriately support them to be looked after at home if they become acutely unwell. This includes NHS@Home and virtual wards
  • Promoting a multidisciplinary team approach where people from health, care and voluntary sector organisations work together in an integrated way to provide tailored support that helps people and their carers to live well and independently at home for longer 


We link with many other areas of work to help support a ‘joined up approach’. Examples of these include personalised care, health inequalities, supporting carers, digital innovation, enabling discharges and urgent emergency care.  


More information about specific programmes can be found here: 

NHS England » Enhanced health in care homes 

NHS England » Urgent community response services 

Hospital discharge and community support guidance – GOV.UK ( 

NHS England » Better Care Fund 

NHS England » Virtual wards 

NHS England » NHS @home 

NHS England » Digital transformation