Francis Hegarty is the Chief Healthcare Technology Officer at Children’s Health Ireland (CHI). He is a founding member of the Medical Physics and Bioengineering Department in St James’s Hospital, Dublin, where he worked for over 30 years. A maker, artist and composer, Francis currently chairs the CHI Arts in Health Advisory Council.
Francis was the project manager on Open Window at St James’s Hospital, a five-year art intervention on the ‘health-related quality of life’ of patients undergoing a bone marrow transplant for the treatment of leukaemia. Transplant patients spend long periods of time in protective isolation. A ‘virtual window’ projected contemporary and classical artwork, audio-visual media and other visual stimuli onto patients’ walls. The impact of this art intervention was assessed using the methodology of a clinical randomised control trial. Patients with the ‘virtual window’ showed significantly reduced rates of depression and anxiety before the transplant compared to the control group and were more than twice as likely to report the experience of stem cell transplantation as better than expected. One of the most significant arts in health interventions to have come out of Europe, Open Window took place between 2004 and 2009 in the National Bone Marrow transplant unit at St James’s Hospital.
This conversation was recorded in autumn 2019 and has been edited for clarity and length.
Your background is in engineering. What does that entail within the hospital environment?
I trained in electronic engineering in the eighties. At that time there was an increasing number of items of medical equipment coming into Irish hospitals and a corresponding need for people who understood electronics and were prepared to learn how technology is used in medicine. People like me are called clinical engineers or medical physicists.
Initially the role was all about repair but then as equipment became more reliable and a lot more complex, the job changed to be more about helping clinicians to use advanced technology. Then in the 2000s, with a lot of ICT tech coming into hospitals, the role expanded to include managing the convergence of medical equipment and ICT. As the technology has changed we’ve changed our role but the one thing that would define it through the years is that we manage that interface between medicine and the application of technology. We tend to be interdisciplinary people.
You’ve been making things since you were a teenager, beginning with sound systems. Your creative solutions in the health space have often been influenced by ideas from music technology and vice versa. Could you give an example of how they have influenced each other?
A lot of what I do creatively in engineering I would define as more “maker” than engineering. For example colleagues were trying to measure these small and fast movements of the eye. At the time, we didn’t have access to computers and digitisation so it was very hard to record high frequency signals. I was working in recording studios and it occurred to me that the eye signal frequency was in the sound range. So we started recording these signals onto audio tape. It was insights like that which arose from working in different environments that informed creative solutions.
Over the years, you’ve collaborated on a number of arts interventions within healthcare. How did you become involved in this area of work?
As a clinical engineer I worked in a very interdisciplinary space in the hospital. It was relatively easy to bring in thinking from outside of your day job into that space. During evenings and weekends I was writing music and working in recording studios so I was around musicians, writers, filmmakers, creatives who had a different mind-set.
When I hit problems in hospitals I would think, is there a way that we can ideate and create a solution by thinking differently? Then a big spark for me would have been when Media Lab were here.[i] They were very good at actively bringing engineers and artists together to try and solve problems. When somebody big like MIT is doing it, I felt it was okay to have a go. So it just kind of fell into place.
MIT were involved in the Open Window RCT at St. James’s Hospital. What was your role on the project and what was the approach to the design of the virtual window system?
It was a big team effort. In was instigated by Shaun McCann [retired Consultant Haematologist at St. James’s Hospital], who articulated the problem. He started a project group with curating artist Denis Roche and the guys from Media Lab’s Human Connectedness Group. Shaun saw an article about me – I had just composed music for a Dance Theatre of Ireland show. He knew me as a techie but he didn’t know I did that and he just caught me and said, I have this problem down in Burkitt’s [Haematology/Oncology ward] with patients in long-term isolation and I think the arts will help solve it, I must get you in at the meeting. That’s how it started.
And the problem was these patients have to be in protective isolation during their treatment. They understand and accept the need to be isolated by the way, because it was really good for their care. But there were lots of associated challenges for them obviously, such as disconnect from family and friends and this project was happening at a time before we all had mobile phones and Zoom.
We brainstormed it and said: what if we made a virtual window in the room that could go somewhere? We initially thought to the patient’s home. But at the time people were afraid that would cause more upset. So we pointed the window towards artists, so artists started making work for this virtual window into patients’ rooms.
My role was hospital manager of the project and engineer, making sure that whatever technology the team developed and deployed was safe and okay to install in clinical rooms. Once we had the virtual window working a lot of issues came up around what is appropriate to put onto this platform. Everyone was sensitive to the patients’ situation and aware that some of the people who will be viewing this work aren’t going to have a good outcome from this procedure. It’s a really charged space, very emotional for them and for their families. It’s not like going into a gallery where you can take it or leave it or be offended and walk out. It’s a space where the curation had to be carefully executed. Denis Roche was extraordinary in developing a curatorial practice for this project that engaged with not only the arts and hospital people, but also the patients themselves. His process supported careful selection and constructive engagement with artists so together the hospital staff and artists set limits on what they thought was appropriate to put up. Most artists engaged really positively with that and trying to work out where that line is but it was really hard.
I often think about the project. It brought every possible issue associated with art and health into sharp focus, from infection control, to raising money, to consent issues, to how to do you curate for this healthcare space. All of that played out over the course of the project.
In terms of appropriate artwork for the space, you yourself created one of the pieces. What was the thinking behind your particular artwork?
When the rooms were being built, I spent about a week in the unit before any patients moved in, wiring the rooms ready for the projectors and speakers. So I had the experience of what that felt like. It’s very clinical, the surfaces on the walls, the floors, everything has to be the way it is and that’s the right thing to do. However, the fluorescent lighting, the materials, the sound of it was all very oppressive I felt.
My response was to try and bring nature into the room, that’s where I started off. My wife is from Roscommon so there was a piece of land going down to Lough Key which I could get access to. I went down there really early in the morning and started trying to record that space with a mind to how can I get some of this quality into the room?
I intended to make video with music and it started to become about waves and wave motion. Everywhere I looked everything seemed to be moving very gently, a gentle to and fro movement of the reeds. When I composed the music, I set the tempo around the frequency of the water movement and that became the basis of a kind of ambient Brian Eno type of music. It basically became about stillness and trying to capture that quality of stillness, that quality of sitting on the edge of a lake and staring out.
The Open Window RCT took place over five years. That level of resourcing and funding is beyond the scope of most arts in health interventions.
A lot of the credit goes to Denis Roche. Denis was really passionate about it and worked at it tirelessly for years and raised awareness and money. Together Denis and Shaun framed the approach to the investigation of Open Window’s effectiveness. They approached it using the same methodology you would use if you were testing a drug, a clinical trial. In doing so we were able to access money through institutions who fund clinical research as well as art funding.
We were really testing an intervention – we set out what we hoped to achieve before we started, we recruited patients to it, we randomised them to either the intervention or control. We couldn’t blind it obviously because everybody knew whether you were getting the intervention or not. Catherine McCabe led on most of that, she designed and conducted the study, and undertook the analysis.[ii] There were nearly 200 people in the study, so the results were statistically significant.
Open Window was significant in exploring how people in isolation can feel connected to the outside world and also to their sense of self. Ten years on, where do you see art and technology in terms of building those connections within acute care?
Most of what the Open Window technology did, you can now do it on a mobile phone and laptop. Using tech to bring art-type experiences into hospital is one way to do it and I still think it can and should be used to do that. The legacy for me is related to the more interesting challenge of valuing art in a hospital environment because hospitals are highly regulated and they have their own politics with a small ‘p’ and their own culture and it can be really hard to protect the value of an art invention in the hospital setting.
On Open Window, I remember bringing senior managers into the boardroom and throwing up on a projector a big picture of a chrysanthemum or something. And the whole colour in the room changed and everyone went, oh that’s lovely. In that moment they all appreciated how an image that luminous can change the atmosphere of a room. Everyone got it in a nanosecond. Then we said, okay, we’re looking for €50,000 for the next year to do that. Within I would say three seconds, everyone was back into a mindset where they were asking for evidence of the value for patients and questioning whether it was appropriate for a hospital to spend €50,000 on an art project.
I kind of feel hospitals are art-hostile spaces. It’s very hard for art to exist because hospitals are about duty of care to the patient, there’s never enough money to do everything you want to do and they’re highly regulated. If you have to negotiate along those three axes, you’ll always be told that money could be used better if we hired another physiotherapist or another nurse. And then if you’re doing something, people will be fearful that by putting up the artwork you’ll cause some harm. So you have to fight all three in parallel if you’ve to get something through.
It’s sometimes easier to bring in something like a new clinical intervention because usually some team will have conducted research and published a peer reviewed paper, so there’s evidence. But you come along and you say I want to do an interventional work in health and it doesn’t hang onto the framework of the hospital which is a temple to medical science, it’s very hard to argue for it. So that’s where most of the work is now, rather than around the technology, it’s being able to argue for art in health and hold a vision for that. That’s what I think is the real challenge now in art and health.
That need to argue for the arts within the health space, I believe that you advocated for the Children’s Health Ireland arts programme.
Having managed Open Window for so long in James’s and being on the art committee there for about 10 years and then chairing it in the last two, I was very clear that arts in health needed to be something that was positioned within the hospital, not a trust on the outside of the hospital or a voluntary committee. Having seen up close the importance of the curator role which Denis provided in Open Window it was clear to me we needed to resource good curators and make them part of the hospital organisation.
I had done a lot of work about proposing that to the board in James’s and it didn’t get over the line before I left. When I came onto this project I proposed that approach to the CEO here Eílish Hardiman and she got it and said, yes, this should be something that’s central to a children’s hospital. Thankfully Mary Grehan, CHI Arts in Health Curator, joined us. It is now a department within the hospital structure so it’s embedded. It’s more a side interest for me but I do end up being an advocate for it quite a bit.
You raise a very good point. If the work isn’t embedded within the hospital, it’s easier to let it go.
Absolutely. If it’s embedded then people have to be employed, they have to be given offices, they have to have a budget, they have to report back on what they’ve done with their budget and over time it becomes part of the beat of the hospital. I think over longer periods it becomes really accepted as an important part of the hospital. In my opinion it is part of that wider realignment that hospitals are doing which is about taking a much more holistic view of the care of the patient rather than just prioritising the medical science and the body.
What does an art friendly hospital look like for you?
It would be an executive that understands the value that art plays in the holistic care of the patient and the staff. It’s an environment that’s prepared to take risks safely, but to take risks, around what the art and the artists can offer. Art practice in hospital is a way of knowing and finding out about that world. If that’s valued and funded and people publish their experiences more, then I think that’s an art friendly hospital space.
It is inevitable and productive that the many disciplines in a hospital come together, within the overarching framework of medical science, to solve problems and promote care. I believe it is also beneficial if these same people can come together around a creative challenge. In doing so I suspect teams get better at open mindset thinking, communication and promoting empathy. It is interesting what can happen when you disrupt constructively or create a different focus.
That was a big thing we learnt during the Open Window project. The virtual window was the one thing in that isolation room that was not about the patient’s illness. When the docs came in and there was some work by Barrie Cooke up on the wall, the doctors were no more an expert on that than the patient, so it was a leveller. There was something in the room that the patient had control over and it wasn’t about their illness and it just gave them power. So a hospital that’s confident enough to let that happen would be art friendly, wouldn’t it? St James’s is to be commended for supporting the Open Window project.
There’s a lot of people with experience in conducting qualitative research in hospitals, not everything we do is down to measuring something that has a data point measurement associated with it. Consequently hospitals are a rich space for conducting qualitative and experiential research. An art friendly space would value all that, it wouldn’t be all down to hard outcome as I would call it or cost.
I hope it moves towards a more consumer-driven health service rather than a health service delivering what it thinks the population needs. I think that would be good for the health service, to have to respond to what the citizens want. I suspect if that was truly happening, citizens would be expressing the desire for hospitals to be more open spaces that deal with the needs of the whole person and that would include design principles that prioritise natural light, the aesthetics of the environment, providing spaces and opportunities for reflection, art practice… everything we talked about I guess.
[i] MIT’s Media Lab Europe was based at the Guinness Hopstore until 2005.
[ii] Dr. Catherine McCabe is currently Associate Professor with the School of Nursing and Midwifery at Trinity College Dublin. McCabe completed her PhD on Open Window in 2008 titled “A mixed methods research design evaluating the psychological effect of ‘Open Window’ and exploring the experiences of people undergoing stem cell or bone marrow transplant for the treatment of haematological malignancies.” http://www.artsandhealth.ie/wp-content/uploads/2011/09/The-Open-Window-Study-C-McCabe.pdf