Around three-quarters of the London Nightingale’s beds are earmarked for intensive care, in contrast to the “step-down” care model being planned at its Birmingham and Manchester counterparts. As the capital’s capacity concerns shift from ICU to community provision, should London refocus?

The London Excel hospital, which admitted its first patients last night, was the first of the so-called “NHS Nightingale” facilities, and was conceived at breakneck speed amid concerns coronavirus would completely overwhelm the capital’s ICU capacity.

The draft plan, as exclusively revealed by HSJ last week, was for the Excel to house up to 2,900 intensive care beds, in what was described as a giant “ICU barn”. The proportion of planned step-down beds was much lower, at around 700.

However, HSJ understands London’s critical care community and a number of acute trust leaders did not support the ICU model, and made sure the “exclusion criteria” — the conditions under which patients can be admitted — were so stringent as to rule out the sicker and more frail patients from being transferred to the Nightingale.

Meanwhile, emerging evidence is suggesting significantly more covid-19 patients than first expected can be treated on non-invasive ventilators, which means they don’t require full ICU care.

Having benefitted from more time to see this unfold, the temporary hospitals in Manchester and Birmingham opted not to go down the ICU route. Instead, it was felt the existing NHS hospitals in the regions could expand their ICU capacity internally to cope with the outbreak’s peak, so long as they had more step-down beds to discharge patients to.

Shifting goalposts

Several senior NHS leaders — from both in and outside the capital — told HSJ the London Nightingale needs to shift its model to be more in line with its regional counterparts.

One senior clinical figure said: “Continuous positive airway pressure machines [which are non-invasive] seem to be effective in the majority of patients, especially in combination with prone positioning.”

Another senior management figure in London said: “The Birmingham model is much more sensible. It’s basically a step-down facility from acute care. The notion is that you should maximise the critical care capacity of every existing site first.

“Staff will be much more willing to do extra shifts, retrain and redeploy from theatres…. and return from retirement if they are doing so for the hospital that they know and love.”

This second point is not to be underestimated, given finding staff is the main challenge facing all of these facilities.

But, what is the goal?

Some, however, argued that if the Excel does end up being underutilised, this would be no bad thing — the system would have planned for the worst, and avoided it.

No one is counting their chickens just yet and who knows what the coming days and weeks will bring. However, the amount of capacity cleared in London’s hospitals has proven the NHS is far more agile than it is given credit for outside its own parish (warning: this link contains offensive and inaccurate content) .

As chief medical officer Chris Whitty told the daily media briefing on Monday: “If we end up in a situation where we have more ICU beds [throughout the outbreak] than we absolutely need, that will be a success.”

An NHS England source echoed this sentiment, describing the Nightingale hospitals as “insurance policies”.

The source said that while no major changes to the London care model were imminent, it was “an extremely dynamic situation”.

“We need some fixed points [but, equally], we are always looking at if things should change,” the source added.

It is hard to argue with the overarching principle made by Professor Whitty — but it would equally be tragic if the London system became paralysed because a shortage of step-down and community beds meant ICUs were unable to discharge patients, all while rows of ICU beds at the Excel sat empty.

Perhaps, as the goalposts shift, so must the goals.