Could all the Nightingales be better used?
Yes, they were an essential safety net. But with thousands of beds empty and death rates now waning, frustrated doctors are asking...
The Nightingale hospitals epitomise the ‘ Dunkirk Spirit’ the country has always relied on in times of crisis. ‘ My grandfather was at the Somme,’ said the army commander who helped plan the flagship 4,000bed hospital in east London, which opened to great fanfare at the start of the month. ‘I’m just at a different battle.’
The exCel conference centre in the Docklands was supposed to be hosting the National Wedding Show. Instead, under military leadership, the venue was transformed into the epicentre of the greatest peacetime emergency in memory. It was just the start. Almost overnight, university campuses, industrial parks – even a former homebase store – morphed into medical establishments. Volunteers came forward in their thousands to supplement clinical staff.
At a time when distressing scenes from Italy filled our TV screens – patients slumped in hospital corridors – the Nightingales offered reassurance and comfort; a symbol of a country united in common purpose against an unseen enemy.
The latest Nightingale hospital opened in Bristol yesterday. Yet, even as Prince edward was cutting the virtual ribbon via a video link, questions were being asked, misgivings expressed and criticisms levelled – both in and outside the NhS – about the role and effectiveness of these ad hoc hospitals, in a way that seemed unimaginable less than a month ago.
how could the mood have changed so quickly?
‘Too few nurses at flagship hospital’ … ‘empty Nightingale is shattering staff morale’ … ‘Nightingale hospital yet to see a patient in ten days’ – just some of the headlines in the past few days.
It cannot be denied that the seven Nightingales in england, constructed at a cost of many millions with a total capacity for up to 11,000, are treating just a handful of patients. Probably considerably less than 100, by our calculations.
In Birmingham, the Nightingale set up inside the National exhibition Centre more than a fortnight ago, with the potential to take up to 4,000 patients, has not yet been needed. In Sunderland, a 460-bed, 20-ward facility may never open.
‘We’re seeing a diminishing plateau of Covid cases,’ said consultant Richard Breeze, head of the intensive care unit at Lewisham hospital, South-east London. ‘I would be surprised if there was anyone at all in the [London] Nightingale quite soon.’ There are thought to be 26 patients currently at the hospital.
The ‘empty beds’ narrative has led to unease among some doctors and nurses, as well as managers, who believe the Nightingales have already become ‘white elephants’.
‘They’re a waste of money,’ one nurse told us. Another added: ‘It’s all very well having a buffer but the pressure it puts on NhS funding might mean the money would be better spent on areas more directly involved in fighting the virus.’
The comments are typical of the doubts which have crept in. We seem to have forgotten – or simply failed to understand – what Sir Simon Stevens, chief executive of NhS england, said from the outset, which is that ‘it will count as a huge success for the whole country if we never need to use them’.
So far, though, the Italian experience, where hospitals were overwhelmed by a ‘tsunami’ of Covid victims, has been avoided. The Nightingales have, therefore, remained largely empty.
This is precisely the outcome Sir Simon, chief medical officer Chris Whitty and chief scientific officer Patrick Vallance wanted. As long as there was capacity in hospitals, the Nightingales would not be utilised; there is, so they haven’t been. The success of the overall strategy would be judged not on how many pass through the temporary doors of the Nightingales, but how few.
So there’s a compelling argument that ‘empty’ Nightingales are a ‘good news’ story, not a bad one.
Shamefully, NhS england revealed staff have even been ‘trolled because they aren’t treating enough patients’.
But a second peak, higher than the first, later in the year – when a revival of coronavirus might be compounded by seasonal influenza
– is still a real danger. So they might yet be filled.
however, given that the rate of transmission is currently going down, the Nightingales have come under increasing scrutiny.
One option which was being considered by the Government would be to re-purpose the Nightingales to treat cancer sufferers and cardiac patients, to help clear a mounting backlog of cancelled operations. This has now been ruled out.
There have also been calls for stricken care home residents (more than 7,500 of them are feared to have died since the start of the
pandemic) to be evacuated to the Nightingales. Professor Patrick Pullicino, 70, who came out of retirement to work at the London Nightingale and is himself recovering from Covid-19, is one such voice.
‘If somebody in a nursing home gets Covid you don’t leave them there,’ he said. ‘You monitor them and if they get to a certain point you bring them into hospital. You don’t leave them to die of pneumonia and put them on palliative care in a nursing home.
‘That’s not the way to deal with it but that is what they are doing. It is what the NHS should be dealing with but they’re washing their hands of the whole area.
‘Fill the Nightingale with elderly people. There are enough elderly people to fill the Nightingale within 48 hours.’
At the moment, people with underlying health problems are too frightened to visit hospitals, believing they may get infected – something that will cause more illness and death in the long run.
One way of avoiding this would be to introduce a ‘two-tier’ health system with all Covid patients being treated in the Nightingales and all non-Covid patients being treated in hospital, or vice versa.
WHY can’t more Covid patients simply be transferred to the Nightingales immediately? Critically ill Covid-19 patients often develop multiple organ failure requiring not just ventilators, but kidney dialysis machines and cardiac support. The Nightingales, designed solely for those suffering respiratory problems, were not set up to deal with this.
In plain English, they do not have the necessary equipment. But they were never meant to. Building a fully-equipped hospital in a week would have been impossible.
This is spelled out in a document leaked to the Health Service Journal outlining the clinical model for the London Nightingale.
It states, in the first paragraph, that admissions will be ‘lower-risk Covid-19 patients’, which meant those who are ‘frail or elderly, or have comorbidities [additional conditions], are less likely to be admitted’. One of the key aims was to ‘provide hope’.
Some within the NHS have blamed the PR strategy which failed to highlight the limitations of the Nightingales from the beginning; that they were basic field hospitals and were only ever meant to be a safety net, a last resort.
‘The London Nightingale was never intended to be and never will be as good as the existing London
ICUs [intensive care units],’ said Richard Breeze. ‘It was and should only ever be seen as a fallback of absolute necessity. If every other London ICU bed is full and the patient is otherwise going to die, then the Nightingale gives them a better chance of survival.’
David Rosser, chief executive of University Hospitals Birmingham NHS Foundation Trust, put it even more bluntly: ‘Is [the Birmingham Nightingale] as good as a bed in a hospital? No, not by a long stretch. It remains fundamentally a warehouse with beds in it.’
Taken out of context, his comments could be seen as a criticism, but he was just being honest; both he and Mayor Andy Street went on to praise the ‘Herculean effort’ behind the initiative.
Another particularly damaging criticism was a recent report that patients have been turned away from the London Nightingale due to a shortage of nurses. ‘They were not turned away,’ insisted a doctor involved in staff training at the Nightingale who agreed to be interviewed. ‘We were not meant to take those patients, full-stop. It would be like sending a patient with a breast problem to a hip surgeon.’
In fact, much of the criticism of the Nightingales is ill-informed, he said. Each bay has a doctor, a specialist intensive care unit nurse, one non- specialist nurse and a number of non-specialist nurses.
‘About 100 medical staff are on the “shop floor” at any one time,’ said the doctor.
BUT the crucial question is: Could the Nightingale cope if there was a wave of infections which overwhelmed the NHS?
A warning has already been sounded that a shortage of critical care staff could put pressure on an already overstretched service in the event of a large-scale coronavirus outbreak and that ‘tough decisions’ would need to be made about who should be treated.
‘Fortunately this has not been necessary so far and the reason is because of the behaviour of the British public. If they’d gone out partying, we could well have needed those beds,’ the doctor told me. ‘But if we needed to rapidly increase capacity, we have trained enough staff to man those extra beds.
‘I volunteered for this. I’m here three days a week. But if there was an emergency, I’d just be at the Nightingale. There’s more flexibility in the system than people realise.’
There is a feeling among staff that the Nightingales successes are not being heard. They were the first hospitals in the UK to make it possible for members to visit loved ones with Covid-19, a model picked up by the Government, with the Health Secretary Matt Hancock promising that ‘ no one will die alone without a family member being allowed to say goodbye.’
Moreover, an extraordinarily compassionate culture has flourished at the London Nightingale. Imam Yunus Dudhwala has supported 20 patients at the hospital. ‘In one bed I’m seeing a patient, their hair being stroked and their hand being held. On another, I’m seeing ten doctors and one nurse looking after one patient.’
It is easy to understand why the Nightingales might seem like ‘white elephants’. Seven hospitals treating just a handful of patients would not make economic sense in normal times. But we are not in normal times. One of the reasons they were set up was to ‘provide hope’. Haven’t they succeeded in this respect?