Integrated care was not just a structural reform – it was a cultural shift that ensured patients and communities were at the centre of every decision, Dr Richard Lewanczuk, Senior Medical Director, Health System Integration, Alberta Health Services, Canada andGlobal expert in healthcare integration told the HSE National Integrated Healthcare Conference 2025.
“From Canada to Ireland, the lesson is clear: when hospitals, community services, and primary care work seamlessly together, outcomes improve and systems become more sustainable. Ireland’s commitment to Sláintecare shows the courage to move from vision to reality, and I commend today’s delegates for the progress they have delivered,” he said. “The challenge now is to continue pushing forward, embracing innovation and collaboration, to ensure that every patient receives the right care in the right place at the right time.”
The HSE said this annual Integrated Healthcare conference themed, “Empowering People through Transforming Care,” showcased the spectrum of change and innovation underway in the healthcare services and highlighted the steady reform of the Health Service in delivering better outcomes for patients and service users.
HSE CEO Bernard Gloster welcomed almost 2,000 delegates from across Ireland, representing the breadth of the health service with staff, service users, patient advocates and policy makers, who attended the Conference which was opened by Health Minister, Jennifer Carroll MacNeill and the HSE Chairman Ciarán Devane
Government fully committed to vision of a universal health and social care service
In his address to the Conference, An Taoiseach, Micheál Martin said the Government was fully committed to the vision of a universal health and social care service, where access was determined by need, not by ability to pay,
“The implementation of Sláintecare is one of the most significant reform programmes in the history of the State, supported by the largest health and social care workforce in our history and record levels of investment in our system. Since the establishment of the HSE in 2005, life expectancy in Ireland has risen from 77.8 years to 82.6 years, one of the highest in the EU. Just as importantly, Ireland is now among the top three nations in Europe for healthy life years at 65. This progress reflects sustained investment, social change and, above all, the extraordinary commitment of our health and social care workforce,” he said.
Integrated care is a living framework guiding how services are joined up, how care is delivered, and how outcomes are improved for patients
Opening the Conference, Health Minster, Jennifer Carroll MacNeill, said, “Integrated care is much more than a policy ambition of Sláintecare. Integrated care is now a living framework guiding how services are joined up, how care is delivered, and how outcomes are improved for patients. Today, there are over 300 posters showing how people’s lives are being improved through the delivery of innovative services. This conference demonstrates the very best of our health service – innovation, collaboration, and determination to build a system that truly works for people and communities.”
The Minister said there must also be a focus on productivity, ensuring that investment delivers better access and higher-quality care for patients. “Sláintecare envisages care increasingly being planned and delivered around the needs of people and communities, with GPs, community care, hospitals and national programmes now working together as part of a single, regionally led system. These reforms are reshaping services, expanding workforce capacity, and embedding new ways of working that will strengthen our health service.”
Integrated care at the heart of our move to a population-based approach to service planning and provision
HSE Chairman Ciarán Devane, who also opened the Conference, said, “This year marks the 20th anniversary of the establishment of the HSE. In that time we have seen many improvements in the health of the nation. Life expectancy has increased, mortality rates have decreased, heart attack and stroke patients have better outcomes, cancer patients are being treated with new medicines and surgeries, our workforce is dedicated and highly skilled.
“Now we have the Health Regions which are integrating hospital and community care, putting patients and service users at the centre of all we do, whereas before decisions were being made too far from the patient and resources are less efficiently allocated. Integrated care means supporting people of all ages across the continuum of their lives closer to where they live, including a re-orientation towards general practice and primary care. This is at the heart of our move to a population-based approach to service planning and provision.”
HSE CEO acknowledges vital contribution of all health service staff in driving transformational change
HSE CEO Bernard Gloster said, delegates were gathered to acknowledge significant progress made across the last 20 years, while recognising areas of the Health Service where continued work was required to achieve fully integrated care provision.
“I want to acknowledge the vital contribution of all health service staff in driving transformational change and commend their leadership and commitment. I’m encouraging you to continue embracing healthcare provision with agility and flexibility, ensuring that the health service consistently delivers better outcomes while placing patients firmly at its centre,” he said.
Building a health service of which the community is proud
Building a health service of which their community was proud involved Care Compassion, Trust and Learning, Dr Andy Philips, REO HSE SW, told the Conference.
Speaking on HSE South West Integration & Commitments he said. “We value the time of those we are privileged to serve. We live our values every day. We put ourselves in the shoes of those we are privileged to serve. We support each over to be the best we can be. We involve those we are privileged to serve as equal partners. We are one system,.one team and one budget. We will avoid harm to patients and staff and will continually work hard to improve our services seven days a week. We govern our services with Transparency, Accountability, Participation, Integrity and Capability.”
Dr. Phillips said their Waiting List Action Plan required Waiting List Management, Making Every Slot Count, Productivity, Enhancing Pathways, Surgical Optimisation and Enablers.
The key actions of Waiting List Management were to Schedule Chronologically, Manage Patient Target List, Implement Coding Changes to Separate Consultant and ANP/HSCP Waiting Lists, Centralise Referral Management, Validate Waiting Lists and removing duplicate referrals.
Key actions of Making Every Slot Count were to reduce DNA/CNA levels, overbook strategically aligned to clinic, ensure compliance with DNA policy, increase the number of Telehealth Clinics and implement cancelation Lists for all services.
The key actions of Increasing Productivity were to maximise insourcing and outsourcing opportunities, achieve a new return ratio of 1:2, extend operational hours/days, remove any activity of low clinical value and ensure compliance of pocc.
the key actions of Enhancing Pathways were to implement modernised care pathways, continue clinical team strategic reviews, implement a regional integrated operational hub for referral and scheduling management and expand enrolment into Patient Initiated Reviews pathway.
The Key Actions of Surgical Optimisation were to implement additional Blitz sessions, extend operational hours, increase utilisation of private providers, optimise theatre utilisation through efficiency improvements and convert inpatient to day case procedures.
The key actions of Enablers were to use insights from data for decision making and understanding opportunities, Implement Text messaging and patient self-booking, engage S38 hospitals in data solutions maximise telehealth solutions and utilise AI and robotics.
Improving Access to Healthcare for individuals irrespective of all barriers
Access to healthcare encompassed the availability, affordability and utilisation of healthcare services by individuals irrespective of their socioeconomic status, geographic location or other barriers, Grace Rothwell, HSE National Director, Access & Integration told the Conference.
She said this access supported individual wellbeing and societal health, enabled prevention, timely diagnosis and treatment and promoted overall health, improved health outcomes and reduced health disparities.
“Improving access to healthcare is about breaking barriersto ensure everyone can receive the necessary care they need, when they need it.”
Ms. Rothwell said there were three key areas of focus -Operations Management, Reducing Delayed Transfers of Care and Joining the Dots – so that there was an integrated patient journey across the healthcare system.
Operations Management.
A person should be in Charge of Operations every day – a single point of access and authority seven days a week.
Management should know who was in the house, ensuring a ‘Plan for Every Patient’ and no delays in the patient journey. This also involved knowing daily demand and creating capacity on and off site to meet that demand – every bed counted.
Diagnostic Capacity should be ensured to meet daily demand
The range of Community Services to support acute flow should be optimised.
There should be Collaboration in place with colleagues to support safe and timely discharge from the acute hospital.
There should always be a plan in place.
Reducing Delayed Transfers of Care
PDDs assigned within 24hrs of admission
- Weekly meeting, ward by ward, identifying patients that will likely require some support on discharge
- Active DToC List & Background DToC List
- Visibility of community capacity & status of closed beds & new beds coming on stream
- Daily linkage with community colleagues regarding capacity available & planned
- Weekly formal meeting on the Active DToC List to agree Discharge Plans & Discharge Dates
- Access & Integration Support Programme, September – November 2025
JOINING THE DOTS
- Injury Units to support ED Avoidance x 7 days
- Rapid Access Clinics to support Admission Avoidance x 7 days
- In-reach to Nursing Homes to keep residents well at home x 7 days
- CAMHS & Mental Health Services Liaison Teams – 24/7
- GPs able to talk to Consultants & Consultants able to talk to GPs x 7 days
- Accessing Diagnostics – Radiology, Endoscopy etc. x 7 days
- Admissions to Community Beds x 7 days
- Timely access to Community Supports post acute episodes of care x 7 days
- Signposting & Connecting Services !
“This all starts with us and our people. We must have Patient-Centred Culture, Can do’ Mindset, Integration & Collaboration, Leadership and Teamwork.”
Admissions from ED to the AMHU reduced by 20% in first year of Consultant Psychiatrist Crisis Resolution Team
Admissions from the ED to the AMHU had been reduced by 20% in the first year of the operation of The Sligo Leitrim Mental Health Services Consultant Psychiatrist Crisis Resolution Team, Consultant Psychiadtrist, Dr Elizabeth Gethins told the Conference.
She said the Team was about providing the Right Care in the Right Place at the Right Time
It had been launched in December 2022, at a time when there had been a 50% increase in Mental Health attendances at the Emergency Department. They had made sure to include the service user voice in establishing it.
Dr. Gethins said a Crisis Resolution Team was a Community based MDT, rapid assessment and intensive support. It was an alternative to inpatient admission, it facilitated an early discharge option from acute inpatient wards. Support was time-limited, up to six weeks. It was service user centred and recovery focused. Its operational Hours were from 8am – 8pm, 7/7. Referrals were from Monday to Friday and there was a handover every morning. It had one phone number and one email address. The service covered Sligo, Leitrim and Cavan
Describing the service impact, she said it provided whole catchment area cover – no one had been denied a service because of where they lived. There had been a reduction in admissions from ED to AMHU of 20% in year one, GPs were referring to CRT rather than ED, 100% of referrals were seen within 24 hours, 2/3 of referrals were taken onto the caseload, 1/3 were discharged back to GP and there was no use of the MHA.
Dr. Gethins said in two thirds of patients, the reasons for referral were linked to suicidality.
Turning to the impact for Service Users and Carers, she said the team worked with people in their homes, provided for a rural catchment area with long distances, it supported people out of hospital and sometimes into hospital and supported the Service User in learning through experience and building resilience.
Digital for Care 2030 a major milestone in Ireland’s health journey
Digital for Care 2030 would be a major milestone in Ireland’s health journey, Derek Tierney, Head of Health Infrastructure, Department of Health, told the Conference.
He said the strategy was significant because it:
- Unified fragmented systems through a shared vision for digital integration, replacing siloed workflows with connected care models (e.g., Shared Care Records, EHR systems).
- Aligned with Sláintecare’s goals by shifting focus from hospital-centric to community-based care, enabled by telehealth and remote monitoring.
- Prioritised patient empowerment through tools like the HSE Health App, which grants direct access to personal health data and from next week, appointment management.
- Secured buy-in, sustained support and sets out governance for delivery of long-term digital infrastructure, ensuring continuity.
Importantly, was about engaging and empowering people, those that provided care and those that receives care.
“Digital for Care” balanced long-term digital ambition with the immediate needs of patients and clinicians through short term and longer-term changes.
Mr. Tierney said the short-term aims were:
- Launching the HSE Health App (2025) for immediate patient access to records and appointment scheduling.
- Implementing Shared Care Records to reduce duplicated tests and improve care coordination.Implementing ePrescribing to replaces traditional handwritten prescriptions/use of health-mail with a digital readable format, streamlining the process and improving accuracy.Widening the use of telehealth and virtual care models to push the shift of care towards the community and home.Rolling out modern office software and clinical applications to support our staff.
- Continuing to automate repetitive process and trial AI for safe and responsible use to support how we delivered care.
Long-term ambitions included:
- Procuring a national EHR system to unify health data across regions.
- Developing a digital workforce strategy to upskill clinicians and reduce administrative burdens.
- Hybrid care models: Further combining in-person and virtual services (e.g., remote monitoring) to address current capacity issues while building future-ready infrastructure.
Mr. Tierney said Digital for Care targeted critical challenges that we currently faced:
For services:
- Fragmented systems: Legacy IT systems hindered data sharing; the strategy mandated interoperable platforms (e.g., National Imaging Solution), Shared Care Record.
- Hospital overcrowding: Digital triage, virtual care to reduce hospital demand pressures and community-based care aimed to reduce unnecessary admissions.
- For patient/staff experience:
- Inefficient workflows: Clinicians spent approximately 30% of time on admin tasks; automation tools freed up capacity for patient care.
- Access inequity: Vulnerable groups risked exclusion from digital services; the strategy emphasised inclusive design and hybrid care options.
- Data security concerns: Robust governance frameworks ensured compliance with EU regulations (e.g., GDPR) while enabling cross-border health data exchange.
“In summary, I believe the strategy’s significance lies in its systemic, patient-centred approach to modernisation, while its phased implementation ensures tangible benefits alongside ambitious structural reforms.
“A standout theme in Digital for Care is collaboration. From the outset both the Department of Health and the HSE worked to make sure that any Digital for Care Strategy was co-designed with patients at the centre, a strategy that could be communicated and understood by all stakeholders who both receive and deliver healthcare and ultimately one that can be delivered with the support of all stakeholders. Collectively we recognised the need for both the Department, the HSE and the wider ecosystem to be aligned behind one vision and to allow everyone speak with ‘one voice’ on digital health.
“What excites me most is the potential for truly integrated, patient-centred care enabled by digital technology. For example, the roll-out of the patient app and shared care records will be foundational to enable coordinated and connected care. A national Electronic health records system will empower patients, streamline workflows for clinicians, and make healthcare more accessible and equitable across Ireland. These advances look to transform how care is delivered, making it safer, more efficient, and more responsive to the needs of every citizen.
“You will have often heard said that Digital for Care is Clinically, led, service driven and technology enabled. To the forefront of minds of the wider delivery team, is the recognition that to deliver Digital for Care requires actively engaging and supporting the workforce and patients, drawing from their lived experience. This ensures that those delivering and receiving care are informed, empowered, and aligned with the goals that Digital for Care seeks to deliver. By fostering collaboration, building digital confidence, and addressing concerns early, we want to address concerns early, enhance adoption, deliver consistency and more sustainable, patient-centred innovations.
“Digital for Care represents transformation in digital health with an aim to deliver a fundamental shift in how healthcare is delivered, managed, and experienced—moving from fragmented, paper-based, or siloed systems to integrated, data-driven, and patient-centred models enabled by technology. This implies change and change that needs to be properly explained and communicated repeatably, owned, planned, managed and delivered.
“My message to all across the system is – Let’s continue working together, united by our shared vision, to build a digital health ecosystem that delivers seamless, safe, and connected care for everyone—because collaboration and commitment will drive our success and make a real difference in people’s lives.”
“Digital for Care looks to bring about changes where we will collectively make Ireland’s health system more responsive, efficient, and patient-focused. I have no doubt that we will strengthen trust and confidence in the health service, accelerate the realisation of digital benefits across the health system and ultimately improve health outcomes.”
HSE’s Core Message – We Cannot Be Complacent
The HSE said a core message to those attending the conference was that while Ireland was improving life expectancy and performing well overall in delivering health services we could not be complacent. An ageing population, growing demand, and workforce pressures were real challenges. To meet these, record levels of capital investment to modernise hospitals, expand community care, and accelerate digital transformation were being made. While these would make care more accessible, efficient, and responsive to patient needs, the greatest impact on the health of such individuals came from community and social initiatives. These initiatives were typically inexpensive and therefore provided significant value for money (value-based care) and return on investment.
Core reforms highlighted included the Enhanced Community Care Programme, which was founded upon Community Healthcare Networks (CHNs) that enabled the provision of multidisciplinary care, supported by Community Specialist Teams (CSTs), closer to people’s homes, a central tenet of Sláintecare. The CHNs formed the basis for local Integrated Healthcare Areas (IHAs) and the six HSE Health Regions. These renewed regional structures were wholly supportive of the provision of healthcare in local communities. Teams were empowered through these structures, with specialist input and consultant governance enabling local leadership in the delivery of both acute and community care.
One example of progress in handling complex health needs was the Chronic Disease Management (CDM) Programme. This programme was run by General Practitioners together with CSTs. In the first half of 2025, GPs completed nearly 350,000 patient reviews – 10% more than in 2024 and ahead of target. The CSTs also had over 220,000 patient contacts, which was 34% more than last year and ahead of target. Most patients with chronic diseases (92%) were being cared for directly through their GPs. Those who needed more help were referred to the CSTs.
Waiting times for patients had improved significantly in this area. In the past three years, there had been an approximate 60% drop in “long-waiting” patients and a 50% decrease in average waiting times for outpatient appointments. This showed the progress made so far, while highlighting the importance of continuing to strengthen integrated care to meet growing needs and ensure patients receive seamless, high-quality services.
Photos – Photocall Ireland
