Very much the public face of Sligo University Hospital for the past 27 years, Consultant Dr Fergal Hickey has hung up his stethoscope for the last time and talks to Gerry McLaughlin about the many challenges he faced
“Seeing a child pass away is very traumatic, or a family wiped out or seeing young people in the full of their life being killed and especially if their sad passing was somehow avoidable or preventable.
“That is particularly hard and is very hard on the nursing staff, but we have great nursing staff, and they would be devastated especially if a child was killed because they could relate it to children of their own around the same age.
“That was really traumatic for staff, and it brought a black cloud over the whole place and sadly it was not infrequent. You also had children in freak accidents or being drowned or knocked down by cars, deaths in fires.”
But the shootings and murders were also very traumatic for Dr Hickey and his staff who were working under very fraught conditions.
On some occasions gardai had to be called to clear the hospital.
Dr Hickey and his team were trying to save lives sometimes under very stressful conditions.
He added that very significant cutbacks at various times have also increased the level of stress in his department- cutbacks in beds and cutbacks in support staff to name a few, particularly after the financial crash around 2008.
“You often felt you were working with one hand tied behind your back, services that were available normally were not going to be because of restrictions, because people were missing, their jobs had not been filled and those things are very hard on people trying to do their best. It is hard enough to do the job when you have the full resources.”
So, what were the highlights for Dr Hickey-amidst the trauma?
“When I came to Sligo first, I was the only Consultant in Emergency Medicine and we only had two junior doctors whereas we now have five wonderful Consultants and 20 junior doctors who work really hard. In the past the department could become quiet at 10 or 11 at night, but now it is on the go 24/7 and every day of the year.”
The workload has increased enormously, he says and the department was built for 20,000 patientsbut is now seeing 47,000 patients and the infrastructure has not kept pace with it.
In 1995 when Dr Hickey started in Sligo if a patient came in with a stroke they were admitted to a bed and given physiotherapy, occupational therapy and speech therapy.
“Now you can get a clot-busting drug and you can get sent to Beaumont Hospital in Dublin where they can fish out the clot in people that are eligible and that is a huge change.
“In a heart attack you also have clot busting drugs, and they came in around the time of my arrival, but I had to change the system and they were now administered in the Emergency Department and not later, after admissions to the Coronary Care Unit which was then the practice.
He added that the Ambulance Service has improved enormously. When Dr Hickey started in 1995 there was an ambulance driver “who in many cases was just trained to drive and an attendant who had about six weeks training.”
“Whereas now they are highly skilled professionals who are capable of making clinical decisions and many clinical interventions.
“All the ambulance staff are now paramedics, and some are advanced paramedics. Of the two person crew, the minimum is that there will be two paramedics and you might have an advanced paramedic as well to respond to cardiac arrests for example.
“The ambulance service has improved out of all recognition, and they are now more capable when they arrive at the scene of an accident, but they are under pressure both locally and nationally.
“The demand for health care is increasing, the population has gone up, people are living longer, and people are surviving situations they might not have survived in the past.
“They are surviving cancers, heart attacks and strokes they would not have survived in the past but the price of that is that they may have a medical condition which periodically runs into crisis.
“And they need hospital admission and that is a good sign that we are saving people who would not have been saved in the past.
“But there is a price to be paid in that demands on the health service has gone up enormously.”
The population of the Republic of Ireland is now 5.1m which is a significant increase.
“There are lots of deficiencies across the health service which means that the pressure on emergency departments is increasing on a daily basis. General practice is under pressure as demand for care very much exceeds supply and people often feel that if they are given an appointment for a certain day they don’t feel they can wait, so they come to emergency departments.
“It may or may not be something we can deal with, but they add to our queue and they add to our frustrations, especially if we can’t solve their problems.”
He added: “I have said it many times, but our acute bed capacity is way less than it should be. So, the OECD average is to have 4.3 acute hospital beds per 1,000 of the population.
“Our figure in Ireland is 2.7 and that is very low indeed.”
So why do we have such a chronic bed shortage?
Dr Hickey says it is because a lot of beds were taken out of the system including Sligo after the economic crash in 2008.
“When I came to Sligo in 1995, there were around 325 beds and there are now around 267.”
So, what is the solution?
“The solution is that they are going to have to build more ward blocks. At the moment, the reason that people are on trolleys is that their care in the Emergency Department is finished and a decision is made that they need hospital admission.
“So, they need their appendix out or they need their hip fracture fixed or they present with abdominal pain that needs surgical admission or with pneumonia, that needs medical admission.
“And the reason they are waiting on trolleys is that there are no beds for them to go.”
“The shortage of beds also means that there is very little planned surgery because there aren’t any beds for the patients to go into. There is no choice but to build more wards.”
But Dr Hickey believes this will not happen because the government in their naiveté thinks that “Sláinte Care will come along and solve all problems and they make it sound like a knight in a white horse.
“The intention of Sláinte Care is to move a lot of care into the community and into primary care. And that is welcome, but if you need your hip fixed, if you need your fracture repaired, or your appendix taken out, it cannot and will not be done in primary care.
“There was a bed capacity report from 2019 which says that we need 2,000 beds immediately in the country.
“They said we would need 7,000 beds but for Sláinte Care, but the assumptions they made for the effect of Sláinte Care on the need for beds are far too ambitious and that is now generally accepted.
“So Sláinte Care is not going to deliver all the wonderful things they are saying it will deliver. So, we probably need more than 2000 beds and that is how short we are.
“Last year they put in 190 new beds in the country, and they made a big deal about it.”
Dr Hickey believes that Sligo needs another 60 beds at least which only brings the hospital almost back to the 1995 figure and a time when demand on the hospital was much less.
Dr Hickey has long believed that there are actually too many Emergency Departments in the country, and he explains why.
“At present, there are 28 Emergency Departments in the country including two paediatric Emergency Departments.
“Over time the number has fallen, but some of those departments don’t have the expertise, don’t have the consultants, don’t have the hospital that is capable of supporting that Department.
“You can’t have an Emergency Department that does not have surgery, medicine, blood transfusion and operating theatre capability on site and perhaps unbelievably there are some hospitals who are missing some of those facilities.
“Sligo has all of those things and is under no threat and Sligo will continue to develop in terms of an Emergency Department.
“Some of the Emergency Departments under threat don’t have the through put of numbers.
“And you need a certain amount of numbers to make people efficient at what they do.
“If you only see one heart attack a month, you are not going to be as good as a department who sees one a day. There is a relationship between volume and performance in medicine.
Dr Hickey believes that somewhere in the order of 18-20 would be a more appropriate number of Emergency Departments in the country and he believes this number is achievable.
“But this means that those departments that are left need to be properly and fully resourced to do the work that will flow from these changes. But you have a lot of hospitals in Dublin that are only a few miles from each other and hospitals in the Midlands that are less than 30 miles apart.
“Sligo and Letterkenny will continue to exist.”
Dr Hickey is proud that his department is well regarded nationally and that trainees are delighted to come to Sligo and have a good experience there.
“Everyone that has come as a consultant has added value and we have some great nurses as well and I am proud of them all and their diagnostic skills as well. They have that clinical nous, and they are a great team, and I am very proud of that team.
“We do have crowding issues because there are no beds available. The trolley issue really impairs an Emergency Department’s capacity to function as an emergency department.”
He added: “There is an acceptance in the Department of Health and the HSE that there is a capacity problem, but it has taken a long time to get to his point. But the speed at which they are responding to the crisis is not appropriate to the level of the crisis.
“This is important because we know that the 14 day mortality of a person who comes to a crowded emergency department is increased.
“The other thing we know is that if you wait for more than five hours from the time to admit decision is made to getting into a hospital bed, if you are on a trolley for more than five hours you have a 1 in 187 excess chance of dying as a direct result.
“So, this kills people, and everybody knows that this causes clinical risk by which we mean mortality or a worsening condition because of the delay.
“It is affecting people’s chances of survival and there is hard evidence to confirm that fact, yet it is not being addressed quickly enough.”
Just over a decade ago there was a major outcry in Sligo over the withdrawal of the breast cancer services from the hospital sparking street protests but all were in vain.
Dr Hickey is adamant that the decision not to include Sligo as a Centre of Excellence was wrong but is keen to point out that there are still quite a number of cancer services available at the hospital.
“There is still enormous anger in the community about the withdrawal of the breast cancer services but it is important that people understand that cancer care still does takes place in Sligo, in general surgery, in ENT, in Dermatology, in Gynaecology and so on, so it is not the case that no cancer treatment takes place.
“The problem was that there were lots of places around the country that should not have been doing breast cancer surgery, they might be only doing one operation every six months.
“So, it was right and proper that places that did not have the throughput or appropriate comprehensive expertise that those breast cancer services should be removed from those places.
“But Sligo got caught up and if you look at a map of Ireland there is nothing north of a line between Galway and Dublin.
“Now there is a satellite service in Letterkenny which should never have happened and that was pure politics. If you were going to have it anywhere it should have been in Sligo where you had competent, capable clinicians who were providing an excellent service.
“But we should have had a Centre of Excellence in Sligo. They should have just looked at the map and said we can’t just have everything south of this line. I don’t think I was asked for my view on the removal of the breast cancer services at the time but if I had been asked for my view, I would have made the same point I made to you.
“It often happens in Ireland that decisions are made and there is a lack of understanding of distances or the reality of the situation. There was a lot of frustration among medical staff that a good service had been withdrawn for no good reason other than somebody had made a decision in Dublin that was well intended but Sligo got caught up in it.”
A more recent controversy has emerged around the future of the Cath Lab services in Sligo University and Dr Hickey outlined the background to the issue.
“If you look at the map of Ireland, there are a few areas on that map that people can’t get to a Cath Lab within the required national standard of 90 minutes if they have a heart attack.
“Sligo is one of them so north of Tubbercurry to Donegal Town is an area that cannot be covered as you can’t get to Galway University Hospital on time.
“If you have a heart attack, from the time of your diagnostic ECG, you have 90 minutes to get to a Cath Lab and you have 120 minutes until the actual procedure is taking place.
“Sligo has always been problematic, so we give people the clot-busting drug in the Emergency Department and then send them to Galway.
“So, in addition to the immediate need there are also a host of people who needed diagnostic angiograms for chest pains etc and that is what takes place in a Cath Lab.
“We were able to do that up until recently but what happened was that the UK company that was providing a mobile service to a number of hospitals in Ireland, could not do it at what they termed an economic rate because other places got access to Cath labs in nearby hospitals so the mobile service was withdrawn from Sligo University Hospital.
“It was a private provider but if you were a public patient, you had access to it. That has brought this matter to a head and the services have been withdrawn.”
He added: “What has been agreed for a number of years was that Sligo has a strong case for a fixed Cath Lab of its own and have a permanent Cath Lab.
“But that plan got held up because of a hullabaloo in Waterford and the government decided to do a national review of cardiology services under Prof Philip Nolan he but ended up being involved in dealing with Covid pandemic numbers.
“That report never got finished and while I have not seen that report, my understanding is that it does recommend a permanent Cath Lab for Sligo.”
When it is suggested to Dr Hickey that there has been a down-grading of services in Sligo hospital he accepts the point in relation to the withdrawal of the breast cancer services, but strongly disputes it otherwise.
“There are challenges and if Sligo looks for something then the view often taken in Galway or Dublin is that if we give it to Sligo, we will have to give it to other hospitals who are lumped in the same category but don’t justify it as they do not have the same range of services.
“The big issue for Sligo remains beds. There is a plan for a major new hospital block in Sligo, but the plan was drawn up a few years before Covid and would have to be revised now because the infection control needs after Covid are totally different so the new block would have to be bigger and more expensive.
“There is never a date for starting because you have to get about eight levels of approval from HSE central which is a very tortuous process. It’s like pulling teeth.”
But the biggest more recent challenge facing Dr Hickey and the hospital was the outbreak of the Covid pandemic in 2020.
“We were lucky in the early stages as there was not a huge amount of Covid in Sligo-Leitrim compared with Donegal and Mayo.
“I think that was a tribute to local people who actually were probably better at sticking to the guidance that existed.
“That helped us as we would not have been able to cope in bed terms. But Covid admission also put more pressure on the supply of beds.
“So, we were lucky in that the patients we got, the vast majority of them survived and we were lucky that for the first six weeks after the first lockdown, our department was relatively quiet which meant we could get organised and get prepared for what was coming to create space and come up with contingency plans and to make a few renovations.
“The downside was because people were so afraid of going to hospital, we were seeing late presentations people who were coming in a week after they had a stroke, or heart attack and presented with cancer sometimes months after they should have come in.
“Some of those people would have had very bad outcomes as a result. That was a real problem.”
So much so that Dr Hickey ended up having to publicly tell people that emergency departments were open and if people had an emergency they should come to their department.
“It was difficult for people and people were wearing PPE and communication was very difficult”.
But with restrictions lifted, there has been a surge in the numbers attending Emergency Departments.
“They have gone up by 10-15 percent. This year we will end up seeing the equivalent of 14 months of patients in 12 months. Covid is still around and still quite a bit of it in hospitals. People are not dying of it, generally speaking, an odd person sadly still passes away due to underlying conditions, are very infirm or they are unvaccinated.
“It is criminal the number of people who are unvaccinated and that is just crazy stuff.”
Dr Hickey thinks the position taken by “anti-vaxxers” is “mad”, given the strength of the evidence in favour of vaccination.
“If they want to risk it for themselves, that is their decision , however unwise, but the fact that they are sometimes influencing vulnerable people to make the wrong decision is indefensible.
“There is another booster coming out later in the year and it will probably be given at the same time as the flu vaccination so it will probably be an injection in each arm.”
He added: “There are probably around 20 people with Covid in the hospital at present and at its worst there were from 50-55 people in the hospital with it.
“The country made a great response to Covid and Ireland’s death rate from Covid is in the best three in the world and that is despite bad infrastructure, poor infrastructure from the infection control point of view, critical shortage of intensive care beds and a shortage of acute hospital beds”.
Dr Hickey was overwhelmed with the send-off he got on his last day at SUH.
“It was a very emotional occasion retiring and my colleagues had a function in the canteen to mark it on June 30. They set up a photo montage of various things, with video messages from people who could not be there, and it was humbling to listen to a lot of what was said by consultant colleagues, by nurses, by Fr John Carroll and especially the genuine nature of it.
“A number of people have stopped me on the street since to also wish me well. All of that is a reflection of how fast things went in 27 years and they certainly have flown by.
“As well as being President of the Irish Association for Emergency Medicine I am also involved in roll out of the National Trauma Programme and the Emergency Medicine programme which is a chance to shape health care in the future.”
So where does his see the challenges for medicine in the future?
“I think there is a big recruitment and retention problem of doctors and nurses. There is an argument that the HSE is over-administered and under-managed. There are an awful lot of administrators who seem to just move bits of paper around the place.
“There is nothing more infuriating than getting an e mail that has been forwarded to ten different people, in HSE central, none of whom have added any value.
“One of the unfortunate things on the ground is that Australia is opening up as we speak, and we are going to see a lot of doctors and nurses who will emigrate there and they may not come back and that is a real worry.
“So, we produce enough doctors and nurses each year to meet our needs, but we lose large numbers of them because it is perceived as a very difficult system to work in.
He continued: “It is undoubtedly true that the HSE is a very large bureaucracy, and it moves very slowly and the Department of Health and the HSE have a difficult relationship. There is duplication, and the role of the Department of Health should be strategic development, but they don’t do it.
“The role of the HSE should be the operational delivery of health care and they struggle with that, and they have managers spending time putting out fires that should not have happened.
“They have been unfortunate with Covid and that stressed their system, but the HSE responded well and went from being unable to do lots of things to setting up a very good testing and vaccination system almost over- night.
“But they need to fix a lot of obvious problems, but they have been fobbing these off for the past ten years. So, they can do it when they need to do it but somebody needs to put a fire under them to do it and that’s why when there is political focus things happen when government says just do it no matter the cost, they will do it.
“Up to now, on the issue of bed capacity they haven’t done it, on the issue of doctors and nurses leaving they haven’t done it either.
“We are bringing in nurses from all over the world and I have no difficulty with that, but it seems crazy that our nurses are going away in droves. And we are being forced to recruit from abroad from a totally different system that has driven their Irish colleagues out of and that is mad.”
Outside of medicine Dr Hickey is a big fan of Sligo Rugby club for whom his son Ross plays and is currently playing in Brazil.
He also goes to rugby international matches and is looking forward to going to the World Cup next year and he also likes travelling and hopes to do a bit more of that in the days ahead.
Dr Hickey went out to Brazil last Thursday to visit his son so when he comes back he knows that reality will kick in.
“I can’t imagine me doing nothing but as to what that something will be, I am not sure. Sligo is very special to me, and it is home. We have lots of friends here and in good weather it is matchless.”
When asked about the things that make him angry, he said:
“Oh inefficiency, having to do the same job twice and the frustrations of dealing with a lot of public bodies drives me nuts and things which are allegedly there to improve the experience and only make it worse.”
“And IT that makes things harder rather than easier to do.
He added: “I really do enjoy people, social events and the whole interaction of it all”.
When asked what he would like his epitaph to be, he said:
“That I left the place better than the place I found.”