How Would the UK’s Healthcare System Cope with War?

The UK’s operations in Afghanistan, Iraq, Syria and the Sahel drove military medical innovation and casualty evacuation (CASEVAC) procedures. Tactics, techniques and procedures (TTPs) evolved rapidly due to the need, and timeframes became critical. There was an expectation that casualties would reach a hospital (Role 3) or forward surgical team (Role 2) within the ‘golden hour’. Medical Emergency Response Teams (MERT) – a Chinook with a pre-hospital team in the back – brought the emergency department to the patient, enabling lifesaving care en route. Technology also improved such that hospital-only interventions (such as the administration of life-saving tranexamic acid in trauma) could be carried out at the point of wounding by minimally trained personnel. This systems approach was continuously refined and year-on-year survival increased. By the end of combat operations in Afghanistan in 2014, 99.2% of UK personnel treated at the Role 3 medical facility in Camp Bastion, Helmand, survived.

These dramatic improvements were enabled by the luxuries of the character of these conflicts. Air supremacy allowed essentially unrestricted helicopter extraction from the frontlines, which would be denied in warfighting operations. There was a minimal accurate long-range threat to support elements, allowing large, static medical facilities to operate unconstrained. The Electronic Warfare threat was also negligible.

At the same time, care on the home front also improved. The Role 4 receiving hospital in Birmingham and the Defence Medical Rehabilitation Centre were scaled up to manage the increase in military injuries, supported by a proliferation of forces charities which generated significant societal support for wounded soldiers and veterans. This reflected a renewed military covenant as an increasing number of fatal and non-fatal casualties were repatriated to Wootton Bassett in Wiltshire, granted royal patronage in 2011 in recognition of its unsavoury but valuable role.

Discretionary out-of-area operations have therefore lulled militaries and societies into a false belief that medical processes and resources are fit for purpose and could cope with increased demand. Highlighting growing unease among UK military planners, in a recent House of Commons Defence Committee report into readiness, the Commander of Strategic Command stated that he had ‘concerns over our ability to provide the scale of medical cover that we are going to need in the context of a war-fighting operation’.

Learning from Ukraine

Ukraine is currently experiencing the demands, complexities and brutality of medical provision for its soldiers and citizens during war. European governments must study these insights and trends to assess their own abilities, reassess the risks, and use a whole-of-society approach to find solutions.

First, the scale of casualties in state-on-state war is magnitudes greater than recent modern experience. It is not unreasonable to expect hundreds of casualties per day during periods of heavy fighting, compared to a total casualty rate (military of all nationalities) in Afghanistan which peaked at around 160 killed and 500 injured per month, with a predictable demand curve each fighting season which allowed enhanced preparation year on year. NATO has recognised this reality in its recent Medical Support Capstone Concept, but there is still a gulf between knowing what may be required and delivering it. The UK’s largest declared Role 3 hospital configuration has 10 intensive care and 80 general beds (compared with Camp Bastion’s 12 and 50, respectively) in support of a Division – that is, 60% larger for a many-fold increase in expected casualties. These facilities will also need to be dispersed at a greater range than current doctrine suggests, putting further strain on CASEVAC chains.

Second, mass civilian casualties are a constant of high-intensity war, and valuable and scarce military assets such as air defence must protect both the civilian population and the fielded military force. The trend for increased fighting in urban areas will produce a corresponding increase in civilian and military casualties at the same time, which will not easily be separated, so each will end up in the other’s medical system. This will require a degree of civil-military integration that the UK has not needed since the Second World War. Unfortunately, development of these skillsets is not a priority within an overstretched Defence Medical Services.

Third, well-trained and experienced soldiers are an extremely valuable resource, and every effort needs to be made to get them back into the fight as soon as possible. This will require some resources to be diverted from those who need them most, in order to treat less badly injured soldiers. ‘Reverse triage’ is a well-established concept, but it is unclear how tolerable it would be for wider society, or even what its impact would be on the moral component and will to fight of UK troops.

Fourth, the heavy use of artillery and long-range strike capabilities makes CASEVAC, particularly at scale, very risky and far more reliant on ground movement. The days when Platoon commanders could summon a MERT, along with Apache helicopter escorts, to extract single casualties with non-life-threatening injuries are long gone. The Division, Brigade and Battalion commanders of tomorrow will have been Platoon and Company commanders during Iraq and Afghanistan and could bring false expectations and preconceptions with them that will be passed down through the chain of command. A mindset change is urgently needed. Similarly, hospitals will never be far enough from the battle to be safe. Without significant changes to their TTPs, existing soft, fixed facilities will not survive long.

These considerations raise other critical planning challenges. For example, if it takes longer to CASEVAC, then the standard operating procedures around Combat Application Tourniquets (CATs) must also change. In ‘Care under Fire’ they are applied liberally, with the expectation that casualties will be removed by a trained medic within an hour. In Ukraine, many cases have been reported where CATs have stayed on too long, resulting in unnecessary loss of limbs or amputations far higher than required, with a subsequent reduction in function and the number of soldiers put back in the field. Changing this will be hard as the UK training system (Team Medic, Battlefield Advanced Trauma Life Support) has been overtaken globally by the US’s Tactical Combat Casualty Care (TCCC). While there are obvious advantages of moving to a single model, we must now change a global set of first aid drills, not a sovereign set. NATO must urgently address this.

Strategic CASEVAC in a Denied and Contested Environment

The UK currently has over 1,000 soldiers persistently deployed to Estonia and Poland on Operation Cabrit, 70 miles from the Russian border. If war broke out, it is highly likely that Role 3 medical facilities in Tallinn and elsewhere would be overwhelmed by Estonian civilian and military casualties. Therefore, it would be politically problematic to treat UK or other NATO personnel over Estonians. Moreover, getting casualties to other ‘safe’ destinations, such as medical facilities in Landstuhl in Germany – which the UK has used for years – would be face the same problem. Therefore, it is unclear exactly how CASEVAC from Estonia to the UK would work within this environment. The UK has limited non-air capabilities and currently has no dedicated hospital ships. The Royal Fleet Auxiliary ship Argus has a maximum configuration of 100 beds, which is well below the likely capacity required. It is uncertain whether there are contingency plans to requisition and refit civilian ships in a similar manner to the Dunkirk evacuation, or how these would be staffed if they were extant.

The Multinational Medical Coordination Centre / European Medical Centre is a dual hatted NATO–EU strategic MEDEVAC cell which is mandated to consider these problems. The cell, a German national unit, is underutilised and not yet widely accepted within NATO. It could be the focus for movement coordination, but it is unclear whether it has the capacity, expertise or support to fulfil this role yet.

How Would the NHS Cope?

The NHS is increasingly strained. Post-Covid complications have added to the extant backlog, with several NHS trusts declaring critical incidents. Emergency Departments are experiencing significant problems, with ambulances waiting in car parks as hospitals are too full to unload them. 32% of ambulances arriving at University Hospitals Birmingham NHS Trust (which includes the UK Role 4 at the Queen Elizabeth Hospital) waited over an hour to offload their patients in January 2024. It is not uniquely challenged, though; NHS England has not achieved its Emergency Department waiting time targets since just after UK combat operations in Afghanistan ended in 2014.

Yet Birmingham will remain the focal point for casualty treatment until maximum capacity is reached, according to the NHS–Ministry of Defence (MoD) Reception Arrangements for Military Patients (RAMP) instructions. Given current pressures, this is unlikely to be more than 100 per week. NHS bed occupancy often exceeds 95% (equating to 56 beds available at the Role 4). The logistics burden of receiving and distributing casualties would move rapidly to a centralised NHS response according to the Mass Casualty plan, with the MoD remaining responsible for tracking and reporting on patients. RAMP is a legacy Afghanistan-era contingency and is ill-suited to current scenarios, not least because the NHS response it depends on is designed for a single ‘big bang’ incident. For context, 100 severely injured casualties could require 1,000 units of blood. While blood is one of the services most prepared for significant and sustained surges in demand, this would represent 25% of the total donated in the UK per day. Aside from the physical capacity, there is currently no mechanism in place for scaling up the experience of treating military injuries.

Finally, potential adversaries have shown no hesitation in targeting hospitals directly or in using disinformation to increase pressure on them, and so the whole response may be complicated by a hybrid threat. The 2017 WannaCry ransomware attack, which impacted the NHS, demonstrates how cyber disruption could also hinder an adequate response and compound the standing risks within the system.

Realising an Integrated Approach

Recent warnings on the potential of war have focused on the military’s fighting capability and physical component, rather than the arguably more critical enablers and moral component needed to win a war. The evidence suggests that conflict-driven medical innovation has stalled since the withdrawals from Iraq and Afghanistan; plans need to be updated and centred around potential future scenarios, rather than experience. In a similar fashion to a lack of available munitions, the UK has taken a risk – conscious and unconscious – on medical provision. The government needs to reassess the risk, gauge public appetite, and plan accordingly.

Persuading a government to invest in the redundancy and stockpiling necessary for resilience when there are other cost pressures such as munitions will be difficult, but a strong argument can and should be made. ‘Public Health’ was assessed as Tier 1 – alongside ‘International Military Conflict’ – on the 2010 National Security Risk Assessment, and despite the large-scale Exercise Cygnus in 2016, the UK was not prepared for the Covid-19 pandemic. With a real risk of large-scale conflict in the coming years, the government must learn from past mistakes.

However, the health secretary is not currently listed as a member of the National Security Council (NSC) or its Europe or Resilience sub-committees. Therefore, either the NSC Resilience terms of reference need to be expanded, or a new NSC Medical should be created to prepare. There is an opportunity to capitalise on recent civilian-military planning for Covid-19 and the impact of Brexit on supply chains, and to expand and enhance the Nightingale concept to increase emergency capacity. The solutions are not just procedural – they will also require tough moral choices regarding who to treat and how. To ensure the UK is fully prepared, the government must be transparent with the public on the investments and potential trade-offs required.

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

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