Defence’s Understanding of Medical Risk and its Impact on UK Capability

Policymakers and allies alike have expressed concerns that the UK would struggle to project or sustain enough force to deter adversaries. Such question marks over the UK’s ability to exert hard power will weaken its conventional deterrent, encouraging competitors and undermining the resolve of its alliances. While the dwindling size of the UK’s forces is undoubtedly a contributing factor, many believe the availability of enablers underpins the problem. Although far from the most concerning deficiency from a warfighting perspective, medical support is commonly cited as one such rate-limiting factor – with frustrated planners heard referring to health as a ‘dis-enabler’. This commentary considers the extent to which medical support genuinely constrains UK operations, as opposed to organisational and cultural attitudes to risk tying the UK’s hands.

Military safety systems, including healthcare support (which both screens out risks and mitigates the harm from them as they manifest), are astonishingly effective. In 2023, a soldier’s risk of death in service was 59% lower than the wider British population (even after standardisation for age). The ‘healthy worker effect’ probably contributes, but as a disease-based phenomenon, it should not especially affect deaths at work (US soldiers die there 62% less often than civilians) or violent/accidental deaths; service personnel suffer these as rarely today as Whitehall civil servants did last century. Yet this safety record becomes a problem when the cost of delivering it (whether financial, time or logistical) constrains operations.

So, what is it that makes medical support a constraint? Could it just be capacity? Although pinch points are no longer reported, the Defence Medical Services (DMS) has been under-recruited for decades. There are significant shortfalls in many employment groups, and there is no doubt this will be an enormous issue if the UK is called upon to fight at scale. That said, between 2004 and 2016, regular DMS doctors (including junior doctors in training) increased from 960 to 1,287, while the number of troops they supported dropped 25% ­– so the capacity versus demand picture is not deteriorating, all other things being equal. The DMS is also clearly able; it has recently deployed facilities to South Sudan, Mali, Afghanistan, Sudan and Turkey, for example. So why is a demonstrably capable support element, severely understaffed but not newly so, increasingly seen as a problem?

First, the goal posts are moving. The Afghanistan campaign – fought from well-established, near-impregnable bases with unchallenged aerial reach – established expectations of ‘NHS levels of care’ on the battlefield. Care should always be the best we can possibly manage, but this benchmark is nonsensical on many levels. NHS standards are missed in the UK, despite enormous resources, in stable and uncontested systems, meeting a largely predictable demand; 20,000 major traumas a year across the UK (compared with 80,000 currently estimated in Ukraine). The intentional disruption of a modern battlefield makes for an utterly different context, but even benign operations have so many factors outside the UK’s control that NHS-quality care is often unrealistic. Afghanistan also saw commanders electing to cut activity (‘Patrol Minimise’) whenever medical capacity was limited, compensating for the risk it normally bought out. That approach, under exceptional wartime conditions, seems to have become the norm – commanders and medics are now habituated to expect NHS-level support to operations and exercises, or constrain activity if it is not available.

Worse, we often voluntarily exceed these NHS standards, as epitomised by pre-hospital care. After a Pre-Hospital Diploma and an Afghanistan MERT tour I am classed as a level 6 (‘specialist/senior’) practitioner, and worked as such on a civilian air ambulance. But 8 is the highest level in Defence, and soon became the standard for many overseas activities. With only 12–15 Level 8s trained annually across the UK, including civilians, this over-egging generates an artificial medical pinch point. Similarly our adherence to NATO evacuation timelines (two hours to a capable surgical facility) whenever possible on exercise, despite the 470,000 residents of the Outer Hebrides living their whole lives without that level of cover.

Second, NHS-based clinical improvement systems often, unsurprisingly, recommend emulating the NHS more closely – even if that is inappropriate in deployed environments. Both the coronial and traditional lessons learned processes treat risk as a simple product of controllable systems, and fare poorly when applied to operational complexity. This focuses us on previously identified risks persisting despite high-safety systems (see the death in service statistics), driving an endless chase for diminishing returns, inconsiderate of harms done to the wider system. Typically the ‘improved’ deployed healthcare system becomes heavier, slower and lower capacity, to the detriment of the force it is supporting. Consider RUSI’s paper exploring protecting medical facilities from enemy targeting; one early proposal, simply hiding them in underground car parks, seems a near-perfect solution. But that only displaces the threat onto the vehicles continually bringing casualties and supplies to that (fixed) location. Privileging individual medical outcomes may increase threat to the whole force.

Third, there is a problem around the articulation of risk. Healthcare thresholds do not align with either public understanding or military yardsticks. Defence is, under normal conditions, far more tolerant of risk than the NHS; a 1% lifetime risk of cancer from an exposure is ‘high’ in healthcare, but a ‘remote chance’ in intelligence. This linguistic (and cultural) disparity may artificially inflate defence’s perception of operational risk – making reasonable activities sound more dangerous than they are.

Finally, society and government waver in their appetite for deploying personnel into areas of risk. As deployed medical director when the first UK soldier was infected with Ebola, I heard that a complete withdraw of all troops was being considered. The pre-deployment planning had predicted half a dozen cases by that stage (still less than 1%), but the tolerance of reality was clearly very different from the hypothetical. While every death in service is a tragedy, they attract far more public attention (and political scrutiny) than ‘normal’ deaths. For context, nearly 200 people drown annually while swimming in the UK. By contrast, six service personnel die annually on collective training exercises. Few, if any, training areas see a single genuine medical emergency in any given year, let alone one that would not survive without immediate treatment. Yet typically at least one medical team is deployed providing cover. Are these judicious attempts at keeping risk ALARP (as low as reasonably practicable) or overkill? Other organisations’ approaches would suggest the latter; the British Antarctic Survey operates at such distances that an emergency evacuation under ideal circumstances takes over 12 hours, but does not deploy a surgeon. Similarly, while the UN was delighted when UK engineers built a hospital to support its mission in South Sudan, lack of such a facility had not stopped it operating there for the previous 12 years. Nor did it deter the hundreds of unarmed, unprotected humanitarians working outside ‘the wire’. Perhaps ‘medical risk’ is, at least in part, simply a euphemism for ‘losing our bottle’.

Regardless of the cause, over-playing medical risk invites several immediate problems. The first is obvious; under pressure, most people revert to the behaviour patterns they are used to. Can commanders used to slow-time, process-driven, multi-layered risk management really be expected to be bold? And if the UK’s decision-makers are not used to taking appropriate medical risk in peacetime, how can it ever win a war when faced with the kind of casualty rates seen in Ukraine?

Second, it blunts our competitive edge below the threshold of conflict, convincing us that we cannot risk deploying our forces to the areas where they are needed, or at a scale that matters. Undermining our persistent engagement strategy may reduce our options if it comes to war, or by our absence encourage our adversaries – so increasing the likelihood of escalation. In this pre-war period, failure to engage is itself an enormous risk.

‘Fortune favours the bold’ was the motto of RUSI’s founder, but boldness and safety are unnatural bedfellows. How can defence balance running into the danger so that everyone else stays safe and meeting its duty of care to its people? First, policymakers need reminding that taking risk over and above the civilian norm is defence’s raison d’être, so they need a clearer understanding of what ALARP should mean in a deployed context. This will require transparent societal engagement and thoughtful ethical analysis to set appropriate expectations of the risks that troops should face. Once defence’s tolerance is clearly established, its articulation of risk must be harmonised across the organisation. Simultaneously, government must ensure the necessary statutory permissions, especially engaging with coroners and professional bodies, so that health support continues to improve but without compromising our ability to protect the UK.

Currently, a justifiable reluctance to incur casualties, exacerbated by a poor organisational understanding of medical risk, makes it hard for defence to be bold when projecting UK forces. But in a time of increasing instability and uncertainty, surrounded by assertive competitors, timidity is not a sustainable position. Only when commanders understand medical risk in the same way they understand the risk of being outflanked or outgunned will they be empowered to make the calls necessary to meet defence’s objectives.

The views expressed in this Commentary are the authors’, and do not represent those of RUSI or any other institution.

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