Running on empty: whatever happened to the Nightingales?

On Boxing Day morning, while many of us were blearily contemplating the prospect of turkey sandwiches for lunch, paramedics were responding to the first of nearly 8,000 emergency calls they received that day in London alone.

It was a day when England and Wales recorded 34,693 new cases of covid-19 and more than 20,000 people were being treated in hospital, worse than in the April peak. The figures were alarming, but this was still only the beginning of a second wave of infections that went on to bring hospitals to their knees and frightened a reluctant government into imposing another lockdown four days later.

That same morning, down at the ExCeL exhibition and convention centre in east London, a team of contractors, architects and engineers were gathering in the vast, hangar-like building, their Christmas break brought to an abrupt halt. It was nine months almost to the day since many had first met there, wide-eyed, to try to turn the exhibition centre into the UK’s first coronavirus surge hospital. They did it in 10 days and it was rightly hailed as a magnificent achievement.

This time the task was to reconfigure one of the halls into a step-down and rehab facility for patients recovering from covid and other conditions. Adding ward kitchens, showers and toilets, they were essentially converting the makeshift intensive care unit (ICU) into a community hospital. Again with help from the army and working punishing hours, it took them just two weeks. The other hall was converted into a mass vaccination centre and administered its first shots on 11 January.

Never in a million years would they have been able to staff a unit of that size, even if you took the staff from every intensive care unit in the country

Glynis Meredith-Windle, ArcHealth

James Hepburn, principal at BDP, said his company was “proud to have been part of the team remobilising the Nightingale NHS London hospital. The huge efforts of everyone involved will help relieve the current pressure on the NHS.” He added: “While in a normal design and construction process different parties would become involved at different stages of the project, at the NHS Nightingale hospitals all key stakeholders were on site together working in parallel. This highly collaborative working style was key to the successful delivery of this approach – people left their company badge at the door and became one team.”

It is undoubtedly another impressive feat, but why was it necessary? Sir David Sloman, regional director for the NHS in London, told journalists: “Unfortunately, given very high levels of infection driving very high hospital admissions, we do need to reopen the Nightingale once more.” In fact, the Nightingale didn’t just need to be reopened, it had to be repurposed. As our screens filled with images of ambulances backed up outside hospitals and of nurses in tears, pressure mounted on politicians and health bosses to show that the Nightingales were not expensive white elephants. In a 20 December interview with Sky News, health secretary Matt Hancock was forced to deny they were being dismantled after beds and ventilators were seen being removed from the ExCeL.

We are now hearing plenty about the London Nightingale’s new life administering vaccines, but with patients being treated in ambulances as hospitals in the South-east struggle to cope with a new admission every 30 seconds, and with worst-case projections suggesting London could be short of between 1,932 and 5,422 beds this week, why are critically ill covid patients not being delivered direct to its doors?

Half a billion pounds well spent?

Earlier this month health minister Lord Bethell told parliament, in a written answer you have to hunt for, that while the set-up cost of the seven English Nightingales was the widely quoted £220m, the total bill including running costs, stand-by costs and decommissioning is expected to reach more than half a billion pounds by 2022. Yet, according to analysis by Building, only around 150 covid patients were ever treated in the English Nightingales during the first wave.

The ExCeL shut its doors to patients after six weeks and started offering its space to filmmakers desperate to create fresh drama for locked-down Britain. Many of the Nightingales were used for outpatient services and some have now reopened for covid patients, but two – including the most expensive one, in Birmingham – have never been used and remain on standby (see “UK covid field hospitals”, below, for more details).

So, did we build the wrong things, and if so why? As the second wave reaches its peak, Building talks to some of the people involved in the Nightingales’ creation and other specialists, and asks how the hospitals came about, whether mistakes were made and what the industry can learn from one of the most extraordinary episodes in Britain’s peacetime history.

Beds but no staff

“The first thing to say is the architects and engineers and everyone did a fantastic job to get it up and running in such a short period of time. Credit where it’s due,” says Glynis Meredith-Windle, executive director of clinical planning consultancy ArcHealth and a former nurse.

“But the whole concept has been very problematic,” she continues, as she prepares for her first volunteer shift at her local vaccination centre. “The biggest issue for me was how they got to the number of 4,000 intensive care unit beds.” That is the number originally planned for the ExCeL centre, although only 500 were completed. “Never in a million years would they have been able to staff a unit of that size, even if you took the staff from every ICU in the country,” she adds.

That view is shared by Nicki Credland, chair of the British Association of Critical Care Nurses, who has said that number of beds was “never going to happen” and only existed on politicians’ crib sheets. Each critical patient arriving at a Nightingale by ambulance would need to bring a dedicated specialist nurse with them.

People involved in building the London Nightingale point out that the alarming modelling coming out of SAGE (the Scientific Advisory Group for Emergencies, which provides scientific advice to government decision-makers) back in March showed that thousands of extra beds were needed to stop the NHS being overwhelmed. That is why the ExCeL was picked, BDP’s Hepburn told Building at the time. “It’s the only one that’s big enough,” he said, memorably describing it as “a shed for lots of intubated patients”. People close to the project also point out that staff-to-patient ratios at the worst-affected hospitals are now nearing the 1:6 that people said would be unacceptable at the Nightingales.

Meredith-Windle, who has spent four decades advising architects and clients on hospital projects around the world, suggests a little less haste early on would have saved a lot of money that could have been used to buy PPE.

The success of a normal hospital project turns on the quality of its brief, which begins with a business case from the trust and, she says, should be informed by extensive consultation with future staff, as well as demographic modelling. Almost inevitably with a project of such urgency some of those steps were missed, with procurement rules relaxed by emergency legislation. That did not affect the quality of what was delivered and, in Scotland at least, as Colin Carrie – recently retired director of Keppie Design, the architect on Glasgow’s Louisa Jordan Hospital – argues: “There were no obvious short-cuts.” All the mandatory NHS guidance was followed and everyone involved in the project was already part of the NHS supply chain, he says. “The base rates had previously been agreed so there was no open chequebook – and in fact everyone was working on a not-for-profit basis.”

Even the epic speed of the design stage was not that much faster than some regular clients demand, he says. What was exceptional was the collaboration and the timeframe in which each project was completed because there was none of the stop-start, “Oh, we’ve run out of money” that delays public-sector projects in normal times.

Meredith-Windle’s other main criticism is why intensive care units were created in England instead of step-down care, as happened in Scotland. Better to keep the sickest patients close to the array of other services they require, she argues. “I never understood why they wanted Nightingales for ventilated patients. To my nurse brain it never seemed logical.”

But adding thousands of intensive care beds to existing, often crumbling, hospitals is not something that can be pulled off in a fortnight. Apart from space – which some hospitals have been creating by discharging less-sick patients and hurriedly repurposing wards – treating covid patients requires vast quantities of oxygen. Southend Hospital in Essex was reduced to rationing supplies this month as patient numbers spiked. Health policy analyst Roy Lilley, a former NHS trust chair, says antiquated gas facilities is an issue at a lot of hospitals. “If you do a £50m hospital makeover, you paint it and do infection control but a lot wouldn’t have thought of increasing their oxygen capacity because it involves the pipes – you’d have to rip the whole lot out,” he says.

Increasing ICU capacity

This was one of the dilemmas facing the people who devised the Nightingale concept. “If you add to an existing hospital but don’t upgrade the infrastructure you are not helping,” says a source who worked on the project but who asked not to be named. “We did talk about how do you expand ICU capacity. We were talking about hospital car parks for that reason – but you wouldn’t want to be in a car park now,” he says.

An exhibition hall closer to central London was considered but ruled out because it was too small. Building’s source reflects on whether repurposing four of these smaller buildings might have been more effective. Each could have been twinned with an NHS trust to give a sense of ownership, he says, acknowledging that being “shipped out” to the ExCeL, an alien setting with unfamiliar colleagues – even if you could recognise them behind their PPE – was not an appealing prospect.

It’s a neat idea, but the reality of London’s multi-trust structure and the nature of those frantic, uncertain days back in March would have left the four mini-Nightingales competing against each other for scarce equipment. “It would have been a total nightmare,” says the source. “Maybe you could have centrally co-ordinated it but the trusts were all completely swamped by covid, so you would have had to create this second team to deliver it. It would have been an insane project. The only reason it happened so quickly is because we were all in the same place, all pulling in same direction. In hindsight you can say a lot of things, but the reality is it was a moving challenge.”

Until the current crisis there was a view that the fact the Nightingales had barely been used was something to celebrate. That hospitals were not overwhelmed in April was credited partly to higher than expected compliance with distancing rules that tamed the R rate and partly to the heroics of NHS staff.

When all is said and done, we will find things we might have done better. But it doesn’t matter: this is a once-in-100-years thing

Roy Lilley, former NHS chair

Lilley, a former Tory mayor, says there is a huge amount to be proud of: “We faced the biggest logistical challenge the nation has faced since the war. No one could have prepared us for this. When all is said and done, we will find things we might have done better. But it doesn’t matter: this is a once-in-100-years thing. I don’t think people could have worked any better or harder.”

But Building’s source believes that narrative is not quite right. “They keep saying hospitals are coping. We really need to question what coping means,” he says. “ICU nurses in tears. Is that coping? Stopping cancer surgery. Is that coping? I’m not sure it is. Last time, they said the NHS coped, but it didn’t: it stopped doing everything else. It fell over! But it’s a really challenging thing to say the NHS is failing because it’s so dear to everyone’s hearts. It almost feels like you’re saying the people have failed – when they’re working so incredibly hard.”

He and Meredith-Windle lay the blame ultimately at the feet of the government, accusing it of both poor planning and years of underinvestment. “Everything has been cut, cut, cut to the bone so we’re 40,000 nurses short,” says Meredith-Windle.

Our source questions what the government was doing during the summer when it could have been upskilling non-ICU nurses to better stand in for their sick and isolating colleagues in critical care. It could also have taken time to prepare the ExCeL for its new use instead of making panicky phone calls over Christmas.

“It’s hugely frustrating,” he says. “It’s the fact we did something that’s possibly not quite right but then there were six months of inaction despite lots of discussions about the Nightingales. The government was insisting hospitals got back to normal but you can’t expect an organisation to do that and prepare for a second wave. We knew this was going to happen, but it seems we didn’t learn anything from the first time around.”

NHS England and the Department of Health and Social Care did not respond to requests for comment.