Was building the NHS Nightingale hospitals worth the money?

Florence Nightingale received seven unexpected tributes in the 200th-anniversary year of her birth. In late March 2020, as concerns grew that Covid-19 would overwhelm the NHS’s critical care capacity, emergency NHS ‘Nightingale’ hospitals sprung up from Exeter to Sunderland with the aim of supporting the NHS to cope with surging number of people with Covid-19.

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.