Professor Charles Knight OBE is the CEO of St Bartholomews Hospital, and was seconded to be the CEO of the Nightingale Hospital London at the ExCeL as the first wave of the COVID-19 pandemic reached its crescendo. We spoke to him about his experience during this turbulent time, and about what we, as a health system, could learn from these last few months.

Let’s start at the beginning! As the CEO of a London hospital, when was the first time you realised COVID would be a massive issue, on a national scale?

Well, I suppose as in all exponential growth, it sort of sneaks up on you for a while and then explodes. We had been hearing, I guess like the rest of the country, really since December that this was an issue. It wasn't really until early March however that things really starting accelerating and by the end of March, we had done a lot of work here at St Bartholomews to get ourselves ready, in particular making contingency plans that we would be one of the Cardiac Surgical hubs for London.

Barts ran Cardiac Surgery through the pandemic for London and most of the operating was done at Barts and Harefield, because they were sites that did not have A&E departments and therefore had a little bit more control over their intensive care unit beds. The cardiac surgery is entirely ITU reliant, and virtually everywhere apart from St Bartholomews and Harefield were filled up with COVID and Cardiac Surgery ceased. If we hadn't made those plans which Steve Edmondson, our chief of surgery, drew up in a matter of days then the possibility would have been that there was no Cardiac Surgery; no surgery for dissections or whatever so setting that up was really important. Then towards the sort of 23rd of March or so, at that point there was a very substantial doubling rate in intensive care unit admissions, and the modelling suggested that within two or three weeks we would get to 7000 ventilated patients in London - we have an ITU bed base of 800 intensive care unit beds in London. Now that didn't happen, but it was an entirely reasonable model at the time because it was just taking the doubling rate and showing what would happen in two weeks.

It was that moment around late March, when a number of intensive care doctors and NHS London thought – ‘well we have to have a solution to this’ - and that initially was a variety of people looking at different options for sort of ‘barn ITU’.

Once we got to that modelling projection of 7000 - and over a few days it went from ‘you've got plan for 1000’, to ‘you’ve got to plan for 2000’, to ‘you’ve got to plan for 7000’ - once it got to that point then really, the EXCEL Centre was the only place that could conceivably accommodate those sort of numbers of patients. So obviously there wasn’t the staff, there wasn't necessarily the equipment, there was nothing ready - but it was a very reasonable thing to at least build a facility.

Following that, over the next few days, discussions turned whether it should be run as an NHS Hospital. Initially there was a thought that maybe it could be a Military Hospital or have some other governance around it - but I think entirely correctly, it was thought that it has to be an NHS Hospital as it's part of the NHS response. And seeing as it was right in the middle of our [Barts Health] catchment area, with Newham Hospital just miles up the road, and with Barts Health having experience in running a big group of Hospitals, Alwen [Alwen Williams, CEO of Barts Health] was asked to take it on. Alwen asked me to go over and do it which was not exactly what I wanted, because we were all pretty exhausted by that point from having set up everything at each of our Hospitals - so the thought of then going to do this rather extraordinary thing, of setting up an intensive care unit in a conference centre, was obviously incredibly exciting but also immensely stressful!

We had to bring together teams from across London and everyone was wonderful; there were lots of volunteers as well as lots of people seconded there to build the leadership team both clinically and managerially; and you know, we did get ready and we did get to the point where we could accept patients within nine days, which was a colossal feat - absolutely nothing to do with me - it's to do with the clinicians and the military and all the people that were building it.

One of the unique challenges of building, what is essentially a whole new facility from scratch is that you have a lot of people coming from a lot of different areas, with lots of expertise in those areas but who may not have worked together before. How did you find working with this team?

Well I think you’re correct, managing that was the greatest challenge and I think it was a testament to the clinical leadership, the nursing leadership, that that they managed to forge these teams. There was a great sense of purpose and there was a single objective, so it wasn't like running a hospital; they had all come together to do one thing, which you don't maybe get in a normal hospital environment. The clinical leadership set up very quickly a very open, non-hierarchical, sort of structure - a clinical forum happened everyday where people could just input and say; ‘you know this thing happened - we need to change this’ and everyone agreed to change it. It was real-time risk management, real-time governance, which was great to see and a great learning point for us.

I think the single greatest achievement of the doctors and nurses there was that ICNARC, which is the National Audit of ITU outcomes, found the Nightingale mortality as exactly the same as the national average - so for the 54 patients that we treated, in a conference centre, with teams assembled from all over the place, in a completely foreign environment, to have achieved an average outcome is an astonishing achievement.

I think that's probably what I'm proudest of; that we didn't let patients down, they weren't being treated in a field hospital as a last ditch attempt; they got care that was essentially equal to what they what they got elsewhere.

I mean the problem at the Nightingale was juggling our need for equipment; we didn't have much, and there were all sorts of rumours that we had masses of ventilators that weren't being used, but I can assure you that we didn't! We didn't have enough equipment, we didn't have enough staff but I think by the end of April, we were in a position where we actually could have taken substantial numbers of patients. We got ourselves into a good place by then, which again is only sort of a month of really running.

Thankfully, by then the number of patients had started to decline, so we weren't really ever used in the way that it was conceived. I think we could have easily got to a point where we were treating 150 patients; that would have been okay but it didn't happen for the best reason.

During the first wave, across the country we saw a lot of routine surgeries were being put on hold and that’s had huge knock-on impacts moving forwards. How do you think we, as a health system, can move forward from this?

It's really important that the health service did sort ‘snap back’ to as much normal operating as possible, as quickly as possible. That's obviously a lot easier said than done; people had been redeployed, pathways had been changed. We now have to have much more rigorous infection control procedures in every hospital and that has had the effect of reducing our bed base by probably 10% because we have to keep some side rooms for suspected COVID; all our pathways have been altered and changed, to get back to normal. Now, our target for this month is to be at 90% of July 2019’s activity, and we're at about 90% of that targets - over 90% of 90% of last year whatever that is!

So it is a big challenge - we have to keep patients safe, we have to make sure they don't get infected; a COVID outbreak in a chemotherapy ward is just a complete disaster; so we have to be extremely careful. At the same time, as you will be aware, there were multiple studies showing that patients didn't attend hospital when they should have, and they've suffered cardiac arrests at home.

The public health messaging of years which was ‘take notice of symptoms, get to hospital’ was suddenly spun round to ‘protect the NHS’ - for very good reasons, but people I think are still reluctant to come to hospital in a way that they weren't a year ago. I think as we see COVID cases tick up in London that will probably get worse.

So I think you're right - it's going to be a long term issue, we just hope that a reasonable vaccine is on the horizon. I don't think a vaccine is going to be a magic bullet but it's going to be a very important part of restoring normality. If, as is likely when the vaccination programme is rolled out, healthcare workers are near the top of the list - again that's part of giving reassurance to patients if they know that the staff are not capable of giving them the disease. I think I think it's going to be very choppy waters for a while yet, and obviously we went into this as a NHS with large numbers of patients on the waiting list already so it's not like there's a lot of slack. I think there’s learning from that; London has now increased its number of potential ITU beds in hospitals which is obviously much better than being in ExCeL. I think also that more and more, the concept of surgical hubs is really growing; hubs that are not directly linked to a hospital with an A&E Department where they can do high volume, low complexity surgery - be that orthopaedics or ophthalmology. That's probably the only way that the NHS is going to get out of the hole that it's got into with COVID in terms of many, many patients waiting.

Finally, in terms of this whole experience, I was wondering what you thought we have earned as a healthcare system?

On the positives, I think we have learned how really important simple staff welfare is - which we were aware of but it's given a real momentum to that and I think that's highly welcomed. The NHS has not always been a great employer; it needs to look after its staff much better and I think people have got that in the way that they maybe didn't before.

I think it's shown that there is much more need for collaboration between organisations; the NHS is one organisation but it's broken up into independent businesses; Barts Health Trust, GST Trust. There was actually a lot of good system working during the pandemic between people, breaking down those sorts of barriers that the business nature of NHS trusts has erected over the last decade - so that's good.

And lastly stuff like the Nightingale shows that the NHS can react fast; it doesn't have to be the lumbering bureaucracy that it is always portrayed as.

It actually moved pretty fleet of foot - and in many ways faster than a lot of private companies - so it can be done and we need to just reflect on why we can't do that all the time. Obviously there are good reasons why we can't do it all the time, like you should consult about changes, you should involve patients in reconfiguration and obviously we didn't during the pandemic. It is entirely appropriate to regulate medicine tightly because you're dealing with people’s lives - but there has to be a better way of regulating and a better way of making changes to the NHS. Hopefully the balance will be swung a little bit more to a lack of bureaucracy and a bit lighter touch regulation.

This interview was conducted via zoom between Professor Charles Knight and Harris Nageswaran on the 29th October 2020. Some sections have been edited to flow better when reading, such as breaking up long sentences; the content remains the same however.