England was not alone in pursuing this approach, with countries from Argentina to China also rapidly creating facilities to treat large numbers of patients. And although the quest for more NHS capacity in England involved block-booking capacity in private sector hospitals; adapting existing NHS hospitals to care for more critically ill patients; and developing primary care ‘hot hubs’, long-Covid clinics and (for a brief moment) NHS Seacole centres, it was the Nightingales that often captured national attention and featured prominently in early media reports of the NHS’s response to the pandemic.
The seven Nightingales had different purposes – with some mainly set up as critical care facilities and others designed to deliver step-down care for recovering patients (Figure 1). But the hospitals shared at least one common goal (listed on one of the hospitals own websites): ‘Bring hope’.
Click or tap on the map to learn more about the different Nightingale hospitals.
And in the early days, the Nightingales did just that. Over March and April 2020, the consortia (including NHS, military and private sector experience) that built the Nightingales were rightly praised for rapidly converting conference and concert venues into places that could safely store and deliver oxygen to patients, support infection control and deliver complex critical care. Behind the scenes, a host of activity ensured the wider infrastructure that hospitals need would also be in place – from financing, to clinical governance processes, to ensuring there would be food and drink available to staff.
But over summer 2020, one issue came to define the narrative around the Nightingales – quite simply, they were not seeing many patients (Figure 2). And now, one year after they were built, many of the facilities are either being decommissioned or repurposed as mass vaccination centres or diagnostic centres.
Inevitably then, there have been disagreements over whether the Nightingales – which were created at the cost of more than £530 million – should be seen as white elephants that could never have been used, or as the ‘ultimate insurance policy that were thankfully not needed’.
The ‘five whys’ can be a simple but powerful way of getting to the root of an issue. But two whys may suffice in this case: were the Nightingales a waste of money? Why? Because they didn’t see many patients. Why? Because there weren’t enough staff to run them?
The largest Nightingale hospitals were reported to have 4,000 planned beds and would need 16,000 staff at full capacity (a higher staff complement than any hospital in England barring Barts Health NHS Trust and Guy's and St Thomas' NHS Foundation Trust). For an NHS that entered the pandemic with 100,000 vacancies this would always have been an eyebrow-raising ask – as there were few supernumerary staff who could move to support the Nightingales without their local hospitals falling over.
And although, in extremis, the Nightingale staffing ratios could have been changed to allow a smaller group of staff to care for more patients, delivering sub-optimal care on a mass scale like this would have been a very different proposition to the narrative of an ‘ultimate insurance policy’ that we (thankfully) didn’t need.
An investigation by the National Audit Office (NAO) would be the clearest way to cut through these competing narratives and determine if (a) the Nightingales weren’t needed – because other measures both to contain the spread of Covis-19 and to maximise the use of existing NHS facilities were effective; or (b) the Nightingales were needed but couldn’t be used because of a lack of available staff. An NAO study could also usefully highlight other factors that might explain why the Nightingales didn’t see more patients – including the locations chosen for the hospitals; difficulties in transporting unstable critically ill patients; and the growing understanding that patients with Covid-19 would require multi-organ support and a wider range of hospital services than a Nightingale hospital could offer.
There were undeniably some positives from the Nightingale experience. Staff who worked in these locations speak of less hierarchical working styles and rapid learning and improvement systems (including the use of bedside learning co-ordinators) that they want to take into their home organisations. And the courage of staff who volunteered for these facilities should not be forgotten. But the Nightingales experience also unfortunately highlights the folly of having a chronically under-staffed health service. A properly staffed NHS, which didn’t enter the pandemic in a staffing crisis and with fewer hospital beds than comparable countries, might have been able to make more use of the Nightingales.
But, in the end, the country has been left with relatively unused emergency facilities, hugely overworked existing facilities that were full of patients with Covid-19, and rising waits for routine care. The Nightingales have shown that in an emergency you can build ventilators, you can adapt buildings and you can manufacture personal protective equipment – but unfortunately, there is no magic NHS staffing tree to shake.
We all need to learn from the pandemic and refrain from reacting as if the scrutiny is personal or politically motivated.
We were under-prepared for a pandemic because we as a nation were consumed by things like Brexit. An earlier lockdown would have saved lot of lives and misery.
The nightingales like most other interventions were actioned late. While they give us the confidence that we can set them up if need be, apart from being "positive stories" to share at the time of disastrous mismanagement, they unfortunately did not achieve much.
Having said that lots of clinicians and other professionals worked very hard to set them up. We should salute the great work but learn how we could have done this better.
I disagree - I don't think this reads like a cheap shot at all. Seems like a perfectly valid question to ask why they were under-utilised, and I don't think there's any suggestion in the piece that frontline staff or currently-otherwise-occupied HCPs are responsible.
This is a very interesting read, thank you. It is right to look back at what happened so we can learn and make processes more effective and efficient in the future.
I agree this reads like a cheap shot and also Siva is presumably aware that an NAO inquiry is in the offing and has decided to suggest it here in a bid to appear prescient. If only we'd had his prescience in planning the initial response to the pandemic.
Thanks for the comment & sorry you think I’m taking a cheap shot. Just to be clear – I don’t think it’s unreasonable to start constructing emergency field hospitals when you are facing pandemic (especially in the early days when – as you say – we didn’t really have much info to go on and it was better to err on the safe side). But do we know enough to say that we would follow the same process again? Do we know what each Nightingale was set up to achieve, how it was used and what explains any differences between the plan and reality? I don’t think so….and I think your point about staffing illustrates this. Could more HCPs have been deployed to support the Nightingale clinical model? And if they could have been - why didn’t that call come? As you say – there are questions to answer around the response and how funds were spent – the point of the piece is to say that those questions (from a position of what could be done better rather than assigning blame) apply as much to the Nightingales (and other plans to increase capacity) as they do to TAT, the app, PPE etc.
There was little to no information about the virus and how it would behave and there was a lot of guess work involved in planning. Given what we started with, the Nightingale units made absolute sense.
It's disappointing to read your narrative: "...The ‘five whys’ can be a simple but powerful way of getting to the root of an issue. But two whys may suffice in this case: were the Nightingales a waste of money? Why? Because they didn’t see many patients. Why? Because there weren’t enough staff to run them?"
First up - you can't pose answer a question with a "why", you need an issue to address first. This is basic change management 101 and well below what we expect from The King's Fund...
Second - there's an assumption about the units' role and staffing. There are plenty of registered and very capable HCPs working in the background and not on the front line. Those roles are all important in sustaining health and social care delivery, but if we had been at the point of collapse (currently unfolding in India) we would have all been willingly redeployed. We were ready, we were waiting and, if the call had come, we would have gone in a heart beat. The role we, and the nightingale units, might have played is irrelevant given the devastation that we were planning for.
There are questions to answer around how we responded and how funds were spent (V1 of the test and trace app / NHS test and trace...) but it's a cheap shot to criticize the drive to increase capacity in the face of the biggest health crisis of the last century...