Why Manchester is not following London’s coronavirus plan

Senior leaders in the North West were given more details of their new temporary hospital last night, which is set to open on Monday with 36 “step down” beds.

The plan for the Nightingale North West, at Manchester Central conference centre, is to gradually raise that capacity to 648 beds, for coronavirus patients stepping down from intensive care. It will still be able to provide oxygen to patients who need help breathing, but this will be through non-invasive ventilation.

This is a significantly different approach to the clinical model agreed, initially at least, for London’s temporary facility. The hospital at the Excel centre has the potential for almost 3,000 intensive care beds, fully equipped with mechanical ventilators.

The North West is instead banking on its existing hospitals to ramp up internal capacity to meet the estimated peak of ICU demand, with the temporary hospital helping to enable quick discharges and freeing up capacity.

Why the difference?

Firstly, the virus hit London earlier than the regions, so the capital had less time to prepare its “surge” plans.

The original Nightingale was conceived when some scary predictions of intensive care demand were being made. However, so far at least, the existing hospitals appear to be holding out with the additional beds they’ve managed to create internally. A dramatic fall in non-covid related hospital activity must also have helped enormously.

Secondly, the critical care community has been highly sceptical of treating the sickest patients in temporary facilities with none of the usual support services on hand. There is also emerging evidence that more patients than initially expected can be treated in emergency departments with non-invasive ventilation, which means less demand for intubation in intensive care.

Thirdly, the specialist kit needed for ICU is in high demand and short supply, which could have left the North West Nightingale competing with existing critical care teams for additional supplies.

Will this work?

Most appear supportive of the Manchester model, but there are also concerns.

Public statements around the Nightingale hospitals tend to stress the contributions being made by retired staff and clinical graduates. But they will also rely heavily on skilled staff from existing hospitals.

A letter to senior leaders yesterday, seen by HSJ, said staff from Manchester University Foundation Trust and other Greater Manchester providers will help staff the initial opening of the NW Nightingale.

Project lead Ian Williamson added: “As patient demand increases, we do expect to have a shortage across a range of posts and if so, I will be back in touch to seek your support in filling these roles from across the [North West] NHS community.

“This will be informed by the pandemic modelling and trajectories and the pressures experienced by our NW hospital system.”

Trust leaders will be understandably nervous about this, as it comes at a time when their own workforces are increasingly depleted.

The other key concern is less about the Nightingale, and more about the overall capacity.

While the potential surge beds might have been earmarked within trusts, many are still waiting for the ventilation machines, oxygen supplies and other specialist equipment that is necessary to open the beds.

As I wrote in the last edition, they are largely dependent on the centre to deliver. If the equipment and medical gas doesn’t arrive, the risk is there won’t be many recovering patients available to send to the Nightingale.

According to this government slide, the region has so far added 50 or 60 critical care beds to its normal base (around 490), which is a long way short of the expansion seen in London.

Critical care capacity

Fragility exposed

The pressure being placed on the NHS workforce by the covid-19 outbreak is exposing some of the weakest services in the system, which arguably should have been reconfigured years ago.

Chorley’s accident and emergency department has been temporarily closed, with the staff sent to help out in Preston instead. The paediatric A&E at Ormskirk hospital has also closed overnight.

Campaigners will fight to ensure the units are reopened, which the trusts have both promised.

Wythenshawe’s A&E has also now been closed to paediatric emergencies, although as far as I’m aware, this does not fall into the unsustainable category.

North by North West will focus on the region’s response to the coronavirus until the pressures from the outbreak subside. Analysis of the progress of Greater Manchester’s devolution project will resume at that point.