NHS Nightingale Hospitals: Agile Response to COVID-19 or a White Elephant?

Edna Astbury-Ward

Disclosures

May 01, 2020

In the UK there are a total of 17 field hospitals being built or completed in recent weeks, seven in England (London, Bristol, Birmingham, Manchester, Harrogate, Exeter, Tyne & Wear) eight in Wales (Cardiff, Neath, Abercynon, Llanelli, Llandudno, Flintshire, Denbighshire, Bangor) and one each in Scotland and Northern Ireland. Logistical support from members of Britain’s military COVID Support Force as part of Operation Rescript has enabled building work and creation of these new field hospitals to happen in record quick time. 

Bed Capacity

The total bed capacity of all the proposed Nightingale Hospitals totals could be more than 13,000.

However, Dr David Rosser, chief executive of University Hospitals Birmingham NHS Foundation Trust said Birmingham's Nightingale hospital is "not being used at all" 10 days after it was opened. Dr Rosser claimed this was "a good thing" because it demonstrated that the NHS had coped with the extra pressure put on it by COVID-19.  The temporary hospital, which was built in 8 days and has the potential capacity for 4000 patients over a 75,000 sq ft area, opened on April 10th. However, West Midlands Mayor Andy Street admitted it has 'not needed to be used'. 

Usage

Similarly, the flagship ExCel Nightingale in east London treated just 26 patients last week, down from a peak of 41. Currently NHS critical care capacity in London is holding up well, with existing hospitals managing despite the significant increase in demand for care. NHS England said NHS trusts have already freed up more than 33,000 beds, the equivalent of 50 new hospitals. These successful measures mean hospitals still have sufficient staff, beds and equipment available to deal with Covid-19, but the Nightingales provide an extra reserve of capacity if required. NHS Chief Executive Sir Simon Stevens said: "It will count as a huge success for the whole country if we never need to use them but with further waves of coronavirus possible it is important that we have these extra facilities in place and treating patients."

Staffing Nightingales 

Despite concern that there is a lack of staff to run the hospitals, NHS Nightingale Hospitals in London and Yorkshire & the Humber are currently not accepting any more applications due to the high volumes received. Staff have to commit to working a 48-hour shift over a 4-week rota. Nursing staff ward managers/matrons are paid on NHS band 7 scale and Staff Nurses on an NHS Band 5 pay scale. They receive the same rate as all other NHS employees doing jobs in the same pay band. Doctors pay bands are still to be decided but they are recruiting tiers 1-3 Doctors. 

An Agile Response to the Pandemic?

Professor Charles Knight is a consultant cardiologist and an honorary professor at the William Harvey Research Institute, Queen Mary University, London, he is also chief executive of St Bartholomew's Hospital. Prof Knight is currently seconded to NHS Nightingale Hospital London as chief executive and is leading the management team there. He took part in a debate about Nightingale hospitals for the Royal Society of Medicine (RSM) COVID-19 Webinar series. Prof Knight was interviewed by President-Elect and trustee of the Royal Society of Medicine, Professor Roger Kirby, a retired consultant urological surgeon. 

Vast Halls 

Prof Kirby began by asking Prof Knight what were his feelings at the beginning of COVID-19 and the construction of the ExCel Nightingale hospital. Prof Knight was clear about the enormity of the task that was ahead of him and his team: "When we first came here, and we looked at these vast halls, and we saw the beginnings of the bed base being rolled out, it was a profoundly moving and really awe inspiring and horrific moment, because if you imagine all those beds being full of patients, it was like the apocalypse, so you have a sense of scale that is unimaginable…and it is absolutely wonderful that that hasn't happened." Building work began on ExCel Nightingale on 23rd March, it was officially opened on 3rd April and accepted its first patient on 7th April. He said he found it "truly inspiring".

Prof Kirby asked Prof Knight whether the fact that the NHS has been able to achieve this, in such a short space of time is indicative of a way that the NHS might develop in the future? Prof Knight responded by saying that the NHS has responded very well to profoundly different modelling at the various stages of the pandemic and that the NHS should no longer be seen as a "lumbering bureaucracy". He went on to add that, "we have proven once and for all that is not the case". He also said that he didn't think "there were many private sector companies that could have, or indeed have, responded to the pressures of COVID in the way we did". 

Pride and Agility 

He said that he didn't think that the NHS could, or should, go back to the way it used to work. However, he acknowledged, "one mustn't ignore the fact that for most of one's time in the old NHS you were talking about money and business case approval and we haven't had to do that for the Nightingales. But it would be foolish to think we could go back to a world where there is a blank cheque, that's not going to happen. But what we can do is to take pride in what's been achieved, to the flexibility of the response across the whole country, and also to learn from that to be more agile in the future, not go back to the sort of level of bureaucracy that we're used to."

Staffing 

Many of the listeners asked questions about how the staffing of the Nightingales has been achieved. Prof Knight conceded that, "it was easier to build a new hospital than it is to staff it", hinting at some of the difficulties in recruiting the right staff, to the right place, at the right time, admitting that it would have been incredibly difficult to provide sufficient staff should the thousands of predicted patients have come through the doors of the ExCel Nightingale. 

He said that the team were faced with a very difficult situation where there were people who may die because of the lack of a ventilator so they had to do something. He said, "we would have to find a way, we would have had to stretch staff, skilled staff, supporting them with less skilled staff in a way to try and make that work because, the alternative was unthinkable".
When he talked about stretching staff he said that this situation had turned "decades of intensive care medicine on its head" in that, traditionally critical care meant one-to-one nursing of patients in side rooms but was now being delivered on a current patient ratio of one to four. But if numbers of COVID-19 positive patients increase patient/nurse ratio would go down to one nurse for six patients. He admitted this "would stretch the skilled staff more than they ordinarily would be".

Prof Knight told listeners that this number/ratio of skilled staff to patients, would for a period of time have to be used in normal (non-COVID) intensive care units, because of deployment of ITU staff to the COVID Nightingales. He said: "For a long time at least, we will not have the staff to run those either." Prof Knight was keen to point out that a permanent training legacy was urgently needed to help the NHS step up to the challenges it will face. He said: "We all agree that we will need more beds, more ITU beds going forward and therefore we need more staff. This is probably the most important thing we can do, is to train more staff for what’s to come."
 

Will Nightingales Take Non-COVID-19 patients?

Prof Knight explained how the Nightingales were set up for an immense surge of COVID patients and that hasn't happened, which he said was "amazingly good". But they had an increase in ITU bed usage in London from 800 beds to 1050 COVID positive patients in addition to approximately 250 non-COVID patients - currently about 850 ITU beds are being used in London. He added that all the beds that are currently used over the normal number are "full of COVID positive patients". He made the plea that "there is an increasing need for London and the rest of the UK to get back to some degree of normal operating so that we are not losing patients from heart disease, cancer, and other important conditions that would usually get treated". He said that the Nightingales could provide a bridge to the health service between normal operational service and COVID care. 

Prof Knight suggested that the NHS needed to radically reorganise itself in order to provide some COVID-free hospitals or environments, where patients are not at risk of infection and can have the confidence that they can get in and be treated, and leave without the disease, compared with other centres which will be COVID-positive hospitals. He envisioned using Nightingale hospitals to bridge the gap when more rigorous infection control measures come in to separate and isolate COVID-positive and COVID-negative patients. He repeated the urgent need for London to double its ITU capacity on a permanent basis. Furthermore, he added, "that we must have a system of health care in this country that means if this ever happened again that we wouldn't have to do this, we wouldn't have to build an intensive care unit in a conference centre, because we had enough capacity under usual operating that we could cope with a surge without having to do that."
 

Why Can’t Nightingale Hospitals Take Patients From the Care System?

Prof Knight defended the stance that ExCel Nightingale was commissioned with a specific purpose and a specific patient in mind, ie, unconscious, ventilated patients, and that they couldn't take direct referrals from the community because the decision on whether to ventilate a patient or not has to be made in the usual manner (from a hospital). The exception to the rule was that they can take patients who are conscious only if they are recovering from COVID. The reason for this he explained was that the ExCel Nightingale was not created as a ‘step down’ facility, though other Nightingales which are created later may be commissioned on this basis as they will benefit from the new modelling which shows that a super surge in ITU requirements may not be required. 

Storing Up Health Problems 

Prof Knight said that understandably the public have become "very averse to going into hospital". He added that there is increasing evidence that people are presenting later with symptoms such as chest pain, which normally they would not have ignored. As a cardiologist this caused him great concern. He stressed that presenting very late meant they were at increased risk of much bigger myocardial infarctions, or even an increased risk of dying at home with a cardiac arrest. 

PPE

Asked whether the ExCel Nightingale staff had sufficient PPE, Prof Knight replied: "For the short-term yes, but do we have vast stocks that would give us comfort..? No. So, it has been a hand-to-mouth existence like every hospital in the NHS, with people scrambling around to get enough supplies to keep staff safe. We're not at a level of a comfort where I have a huge cupboard full of supplies that I can gloat over. No. No it's a matter of taking each day as it comes."

Lessons Learnt

Prof Knight said what was important was to retain the agility to keep learning and to be more adaptable and to respond to situations more quickly than we have in the past. He said that it wasn't just the constructions of the Nightingales that has demonstrated agility, but the whole of the NHS of which he said he is extraordinarily proud to be a part of.

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