Defence Committee
Tuesday 27th October 2026
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10:37
Tanmanjeet Singh Dhesi
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Tanmanjeet Singh Dhesi
Order! Order a court order! Today's House of Commons Defence Committee one off evidence session on defence medical services. I'm very pleased to say that we have with us two very esteemed individuals with a great deal of experience in defence medical services, namely Lieutenant General retired Martin Bricknell, who is a former surgeon general of the UK Armed Forces back in 2018 2019. And also we're very, very pleased to have with us Major-General retired Timothy Hodgetts, who was also the former Surgeon General of the UK Armed Forces, as well as being the chair of the NATO Committee of the Chiefs of Military Medical Services in 2021 to 2024, gents will get on with the questioning very, very soon.
But I also want to very warmly welcome our newly elected member of the House of Commons Defence Committee, the honourable member for Dunfermline and Dollar, Graham Downey Graham, a very, very warm welcome to you. Without further ado, we've got two different panels today, so we have one hour with yourselves. There's a lot of questions, so please do try to be as succinct as possible, because there's quite a lot of ground to cover in the next hour. And without further ado, I'd like to ask my colleague Lincoln Joffe to kick start the questioning.
But I also want to very warmly welcome our newly elected member of the House of Commons Defence Committee, the honourable member for Dunfermline and Dollar, Graham Downey Graham, a very, very warm welcome to you. Without further ado, we've got two different panels today, so we have one hour with yourselves. There's a lot of questions, so please do try to be as succinct as possible, because there's quite a lot of ground to cover in the next hour. And without further ado, I'd like to ask my colleague Lincoln Joffe to kick start the questioning.
10:38
Lincoln Jopp
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Lincoln Jopp
10:39
Speaker 1
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Speaker 1
So I'll start and then Tim will fill it. We'll add in and we'll balance this out between organisational aspects, which I will focus on. And Tim will talk about about clinical. I had the privilege of serving on the SDR panel for the Defence Medical Services, and we wanted to put on record that the UK Defence Medical services had been hollowed out as a result of a series of pressures on the Ministry of Defence over the past decade and a half, and that because of the unique nature of the relationship between the military, medical services and the civilian medical services, it's possible to take that as a saving in piece, but it means your foundational baseline if you need to expand and mobilise, is at risk.
So from an organizational perspective, I would suggest it's a capacity rather than a capability dimension. But Tim will probably pick up on some specific aspects of risk.
So from an organizational perspective, I would suggest it's a capacity rather than a capability dimension. But Tim will probably pick up on some specific aspects of risk.
10:40
Speaker 2
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Speaker 2
Thank you. So there are five principal risks, I would say, for casualties at scale and duration in the contested environment of war. And we came to this conclusion after scrutiny within the NATO setting and codified in detail what the risk was across the whole of the NATO alliance. And what we'll find is that there are broad risks across the alliance, but they vary in each individual country. But they do fit into five main categories. So the first would be medical evacuation, having enough protected vehicles to get patients from the point of wounding to timely surgery.
Now, we can mitigate that in part by advances in prolonged field care when evacuation is delayed, but be under no illusion. When medevac is not effective, avoidable deaths will occur and we have to accept poorer outcomes. And indeed, the majority of avoidable deaths happen in pre-hospital care, not hospital care. So the focus has to be what happens far forward. The second is around mass casualty planning, and it demands the military theatre level medical evacuation plan. But we have to have a core focus within that plan to return to duty at every possible opportunity as we evacuate, the further away you get from the front line, the harder it is to get people back to the fight.
And we also need to recognise that the principles are different to conventional civilian major incident planning, and we have to address enduring high numbers. The third issue is medical logistics and what Covid taught us, and we've seen it from previous military conflicts, is that just in time, logistics don't work, and that means we have to hold more stock, and we need decisions and action on what to further on shore or near shore in terms of critical consumable items. The fourth is around regulatory and legal considerations, and we need the necessary freedoms in place ahead of conflict to support innovation at pace, but also to be able to credential clinicians in a multinational setting.
And multinational buys out some of our medical risk, and also to use allied blood and drugs on each other's patients. But also remember that the enemy will not follow the law of armed conflict. So we we have to change our tactics to take account for that. And finally, it's workforce. And I know we're probably going to go into more detail about workforce, but we simply don't have the existing military medical capacity to deal concurrently with medical force preparation at scale, medical training at scale, and the predicted casualty estimates.
Now, we can mitigate that in part by advances in prolonged field care when evacuation is delayed, but be under no illusion. When medevac is not effective, avoidable deaths will occur and we have to accept poorer outcomes. And indeed, the majority of avoidable deaths happen in pre-hospital care, not hospital care. So the focus has to be what happens far forward. The second is around mass casualty planning, and it demands the military theatre level medical evacuation plan. But we have to have a core focus within that plan to return to duty at every possible opportunity as we evacuate, the further away you get from the front line, the harder it is to get people back to the fight.
And we also need to recognise that the principles are different to conventional civilian major incident planning, and we have to address enduring high numbers. The third issue is medical logistics and what Covid taught us, and we've seen it from previous military conflicts, is that just in time, logistics don't work, and that means we have to hold more stock, and we need decisions and action on what to further on shore or near shore in terms of critical consumable items. The fourth is around regulatory and legal considerations, and we need the necessary freedoms in place ahead of conflict to support innovation at pace, but also to be able to credential clinicians in a multinational setting.
And multinational buys out some of our medical risk, and also to use allied blood and drugs on each other's patients. But also remember that the enemy will not follow the law of armed conflict. So we we have to change our tactics to take account for that. And finally, it's workforce. And I know we're probably going to go into more detail about workforce, but we simply don't have the existing military medical capacity to deal concurrently with medical force preparation at scale, medical training at scale, and the predicted casualty estimates.
10:43
Lincoln Jopp
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Lincoln Jopp
Culturally, when you were doing the stuff for the SDR, what was your sense? I mean, a logistics is always, you know, amateurs talk tactics, professionals or logistics and all that. And then and then they think about the medical paragraph. To what extent? I mean, to what extent did you get a sense that this was in any way, you know, in the SDR that people would like to consider this problem or not?
10:43
Speaker 1
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Speaker 1
So the actual document was obviously published by the department, and the chapter on the medical services had the key points that we, as a panel recommended to the department. So in terms of the the record, I would argue that the department contained in the SDR the key points that we put across the challenge, of course, is the delivery and the difficult choices that the Department has against all the pressures for for money. And obviously, we now can't speak for the department, but we can perhaps highlight areas that might be worth considering. If you wish to ask for the department's response.
10:44
10:44
Speaker 1
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Speaker 1
Yes. So? So some of the cultural change has happened. The headquarters is now the Defence Medical Command, and it is definitely under the Csoc. And certainly we can see evidence that they're trying to shift the behaviours to give the defence medical Command authority over the whole of the defence medical enterprise. And you could argue that when compared with NATO, other NATO countries, we are a little bit further behind in this cultural shift from distribution across four commands to a medical command, actually owning the whole enterprise.
10:45
10:45
Speaker 1
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Speaker 1
If I may start off just a bit on the organisational perspective. So medical and defence absolutely should be the exemplar of the whole force model, taking a balance between the cost of active duty, the value benefit of reserve service plus also the civilian workforce that provides the underpinning foundations for the generation of the force through defence, primary healthcare. But inevitably there ends up being difficulty around money, attribution of posts, balance of risk recruiting, and then finally getting the total balance between the active duty or regular, the reserve and civilian workforce. And indeed, one of the points we wanted to make in the SDR is potentially the opportunity to consider the commercial sector as a additional sector, rather than purely the NHS.
And I know that the second part of the session is going to consider that. So. Over 150 years, there's always difficulty in recruiting and retaining into the regular force. And Tim will probably now pick up some points around the individual pinch point trades that then turn into capability risks.
And I know that the second part of the session is going to consider that. So. Over 150 years, there's always difficulty in recruiting and retaining into the regular force. And Tim will probably now pick up some points around the individual pinch point trades that then turn into capability risks.
10:46
Speaker 2
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Speaker 2
So thanks, Martin. And building on those comments, just to to highlight at the start that the majority of defence medical capability is invested in its people, not in expensive platforms. It's in the hands and the minds of our clinicians. And that's reflected in how the DMs budget is allocated, which is mostly on people. And it's why we've accrued vulnerability over time to operational delivery. When serial savings have d-enriched civilianized or actually deleted operational clinical positions. Now, I think there's two key priorities. The first is a central priority around ensuring that our people are used as flexible as possible and to their maximum competence.
So this is about optimizing our current workflow , and also that we get to full deployability as quickly as possible for those who have been injured or who are sick. So on the first point, flexibility, I've got two positives and one critical pinch point to identify. The first positive is that in November 2024, the largest structural change in the Army medical services for 125 years concluded when we actually launched the Royal Army Medical Service, and it was three cores into one, the Royal Army Medical Corps, the Royal Army Dental Corps and the Queen Alexandra's Royal Army Nursing Corps.
And that was not driven by cost savings. It was driven by ensuring that we could have the best workforce opportunity and adaptability and flexibility for operations where appointments in the future could be on competence rather than on capbadge. Now I have to declare a bias, a conflict of interest, because I have been the master general for the last four years and overseen that that that process. But the second positive is that we have at the moment a further contemporary revolution in combat casualty care, very much driven within the army to empower soldiers and vocational medics with additional skills to sustain life in that longer period it's going to take to get to surgery and the enhancement in the dip of 20 million for that, and I'm sure we'll come back to the dip is really welcome, but it only supports rollout to a proportion of the existing army, a critical pinch point, and there is more than one.
But I would say that this is really important to be addressed early is surgeons. If we are saying we have to get medevac right to get to the surgeon as quickly as possible, we've got to have enough surgeons available to then treat the patient. And across the DMs, currently, there are around a dozen consultant trauma and orthopaedic surgeons, but there are three times that number within higher training. So we're going to have to do things differently in the future. And rather than just reliant on a consultant delivered model that we do exploit the ability to use our higher trainees to give additional capacity.
So this is about optimizing our current workflow , and also that we get to full deployability as quickly as possible for those who have been injured or who are sick. So on the first point, flexibility, I've got two positives and one critical pinch point to identify. The first positive is that in November 2024, the largest structural change in the Army medical services for 125 years concluded when we actually launched the Royal Army Medical Service, and it was three cores into one, the Royal Army Medical Corps, the Royal Army Dental Corps and the Queen Alexandra's Royal Army Nursing Corps.
And that was not driven by cost savings. It was driven by ensuring that we could have the best workforce opportunity and adaptability and flexibility for operations where appointments in the future could be on competence rather than on capbadge. Now I have to declare a bias, a conflict of interest, because I have been the master general for the last four years and overseen that that that process. But the second positive is that we have at the moment a further contemporary revolution in combat casualty care, very much driven within the army to empower soldiers and vocational medics with additional skills to sustain life in that longer period it's going to take to get to surgery and the enhancement in the dip of 20 million for that, and I'm sure we'll come back to the dip is really welcome, but it only supports rollout to a proportion of the existing army, a critical pinch point, and there is more than one.
But I would say that this is really important to be addressed early is surgeons. If we are saying we have to get medevac right to get to the surgeon as quickly as possible, we've got to have enough surgeons available to then treat the patient. And across the DMs, currently, there are around a dozen consultant trauma and orthopaedic surgeons, but there are three times that number within higher training. So we're going to have to do things differently in the future. And rather than just reliant on a consultant delivered model that we do exploit the ability to use our higher trainees to give additional capacity.
10:50
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10:50
Speaker 2
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Speaker 2
To that? And it is different for different clinical specialties. But we've got medical school, we've got foundation years and then we've got specialist training. So for a surgeon, it's a total of about 15 years. For a GP, it's about ten years. And for some of the other specialties, maybe 13 or 14 years. So it's a long time to start from scratch to develop that capability. So just paired with that employment flexibility and adaptability is getting people back to full deployability the medically downgraded, the medically non-deployable or partially deployable. And there is evidence of effect here that defence Primary Healthcare Dfk has championed multiple new clinical pathways in the last couple of years, and it has been able to reduce a number of the NHS waits.
It's got money from the individual services independently, and I think from the next financial year that's going to be centralised. But to give you an example of numerical evidence, which the NHS has from its further, faster Armed Forces initiative, the ear, nose and throat surgery waiting times, which is one of our pinch point to get through outpatients and surgery, has reduced from around 17 weeks to 12 weeks in a six month period. So that's a really good improvement. And for trauma and orthopaedic care, which is a lot of our musculoskeletal injury of the of the large joints that's dropped from around 14 weeks to around ten weeks.
So there's a definite progress in getting the sick and injured back to full deployability faster than we've been able to achieve in the past.
It's got money from the individual services independently, and I think from the next financial year that's going to be centralised. But to give you an example of numerical evidence, which the NHS has from its further, faster Armed Forces initiative, the ear, nose and throat surgery waiting times, which is one of our pinch point to get through outpatients and surgery, has reduced from around 17 weeks to 12 weeks in a six month period. So that's a really good improvement. And for trauma and orthopaedic care, which is a lot of our musculoskeletal injury of the of the large joints that's dropped from around 14 weeks to around ten weeks.
So there's a definite progress in getting the sick and injured back to full deployability faster than we've been able to achieve in the past.
10:51
10:51
Speaker 1
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Speaker 1
So in the SDR, we recommended that the department develops a workforce plan for the Defence Medical Services, which hasn't yet been published. But I think it would be really interesting to see the extent to which the Department is now taking this whole force, including sponsored reserves proposition, to look at how the nation's health workforce can be balanced across all of the different uses, and where the military component sits into this whole national health workforce enterprise.
10:52
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10:52
Speaker 2
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Speaker 2
But I would concur about the sponsored reserves model that there's a real opportunity to consider building clinical teams, whether it's in organizations perhaps such as ISIS, to to follow on the next panel or in institutions such as the NHS, to give us functional additional teams that might reinforce some of our reservist hospitals.
10:53
10:53
Michelle Scrogham
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Michelle Scrogham
Thank you. Chair. Obviously, we saw the impact of Covid and the pressure that put the NHS under. But if we're talking about a large scale combat operation, what planning and preparation would you like to see put in place now to avoid that undue pressure being put on the NHS, with the reservists being called up?
10:53
Speaker 1
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Speaker 1
So the department has been doing quite a lot of collaborative work across departments. And just three weeks ago there was a major. Sort of concept development exercise that involved many partners. We also have to put this into perspective. You know, the NHS in overall capacity terms is huge. And so the military demand signal is unlikely to be significant in total in terms of total demand to require anything more than the changes we saw in Covid. But there will be pinch point areas such as burns and plastics. What I would say is, compared to our NATO allies, we perhaps are less advanced in either regulatory terms or in terms of actual conducting training exercises.
So we have seen France, Germany, the Baltic states, the we've seen Norway conducting live exercises, moving military casualties and rehearsing how they would be absorbed into the civilian sector. We haven't yet seen that from a UK perspective, but as a sort of demonstration of national intent and indeed part of the deterrence information campaign, just showing that the country is capable of handling military casualties might be a significant part of deterrence. As well as preparing for preparing for military operations.
So we have seen France, Germany, the Baltic states, the we've seen Norway conducting live exercises, moving military casualties and rehearsing how they would be absorbed into the civilian sector. We haven't yet seen that from a UK perspective, but as a sort of demonstration of national intent and indeed part of the deterrence information campaign, just showing that the country is capable of handling military casualties might be a significant part of deterrence. As well as preparing for preparing for military operations.
10:55
Speaker 2
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Speaker 2
And yeah, so I'd like to pick up three clinical related issues, which are around collaboration on the clinical guidelines to treat patients on data integration, and then perhaps on research and development collaborations within the military civilian enterprise. So Martin's referred to ramp the reception arrangements for military patients, which is about how we would distribute casualties across the NHS, which the NHS would take the lead on. But that's not about how casualties would be treated, when the civilian clinicians may actually be quite unfamiliar with blast ballistic and burn injury when we spread the casualties far and wide.
But here, actually we are ahead of the curve because in 2017 we collaborated in Birmingham, the military and the NHS within the Royal Centre for Defence Medicine to come up with mass NHS major incident and mass casualty treatment guidelines. And we took the military's clinical guidelines for operations, which have been developed from 2003 and then serially enhanced. We took that as the baseline and then NHS EPR for emergency preparedness response and resilience, distributed those guidelines to every acute trust. So there's no excuse to say we haven't actually thought about how we're going to treat such, such patients.
And indeed, from 2023, those guidelines, with the approval of the NHS, were made available to NATO allies to draw down on , if required. But I lecture regularly around the country about medical preparedness for war. And when I ask the audience, how many of you have seen and are familiar with these NHS guidelines, very few hands go up. So I am reminded of what Rommel said in the Second World War, that the British have some of the best doctrine in the world, but it's fortunate for us, their officers don't read it. So it is really important that although we produce these guidelines, people actually read them and exercise them.
But I am really conscious of there being enough white space within the NHS, which runs so operationally hot, to be able to run exercises like we run in the military. Second point was about data and the requirement for data from point of injury all the way through the clinical pathway into the NHS and beyond, into rehabilitation. When I'm asked what made the biggest difference to the extraordinary outcomes that we got in Iraq and Afghanistan, it wasn't an individual clinical intervention. It was the data. And there's no reason why we can't collect good data in the future.
It's not about scale. It's not about the fact that it has to go across the whole country. It's about having the right architecture that can then draw down that data. And we can use modern tools such as AI to actually interrogate that data in in real time and give us the necessary reporting and trends that we would need to see and share with both the civilian and the military community to continuously drive quality improvement. And the third aspect I wanted to cover was about research and development and the relationships that we have between our defence medical services, academics and the wider civilian academic community.
And I think sustaining our military academic footprint in Birmingham is critical if we're going to be able to improve outcomes, even if we start from a lower point than before, there's no reason why we can't continue to improve outcomes through the next conflict. It's what's happened in every conflict in the last hundred years. The outcome at the end of the conflict is better than outcome at the beginning of the conflict. And we have some really reassuring research partnerships, for example, with the Medical Research Council to develop a joint centre of excellence, Centre of Research Excellence for blood, and a very strong multi-site partnership for the University of Birmingham for blast traumatic brain injury.
I could identify others, but I'll pause there.
But here, actually we are ahead of the curve because in 2017 we collaborated in Birmingham, the military and the NHS within the Royal Centre for Defence Medicine to come up with mass NHS major incident and mass casualty treatment guidelines. And we took the military's clinical guidelines for operations, which have been developed from 2003 and then serially enhanced. We took that as the baseline and then NHS EPR for emergency preparedness response and resilience, distributed those guidelines to every acute trust. So there's no excuse to say we haven't actually thought about how we're going to treat such, such patients.
And indeed, from 2023, those guidelines, with the approval of the NHS, were made available to NATO allies to draw down on , if required. But I lecture regularly around the country about medical preparedness for war. And when I ask the audience, how many of you have seen and are familiar with these NHS guidelines, very few hands go up. So I am reminded of what Rommel said in the Second World War, that the British have some of the best doctrine in the world, but it's fortunate for us, their officers don't read it. So it is really important that although we produce these guidelines, people actually read them and exercise them.
But I am really conscious of there being enough white space within the NHS, which runs so operationally hot, to be able to run exercises like we run in the military. Second point was about data and the requirement for data from point of injury all the way through the clinical pathway into the NHS and beyond, into rehabilitation. When I'm asked what made the biggest difference to the extraordinary outcomes that we got in Iraq and Afghanistan, it wasn't an individual clinical intervention. It was the data. And there's no reason why we can't collect good data in the future.
It's not about scale. It's not about the fact that it has to go across the whole country. It's about having the right architecture that can then draw down that data. And we can use modern tools such as AI to actually interrogate that data in in real time and give us the necessary reporting and trends that we would need to see and share with both the civilian and the military community to continuously drive quality improvement. And the third aspect I wanted to cover was about research and development and the relationships that we have between our defence medical services, academics and the wider civilian academic community.
And I think sustaining our military academic footprint in Birmingham is critical if we're going to be able to improve outcomes, even if we start from a lower point than before, there's no reason why we can't continue to improve outcomes through the next conflict. It's what's happened in every conflict in the last hundred years. The outcome at the end of the conflict is better than outcome at the beginning of the conflict. And we have some really reassuring research partnerships, for example, with the Medical Research Council to develop a joint centre of excellence, Centre of Research Excellence for blood, and a very strong multi-site partnership for the University of Birmingham for blast traumatic brain injury.
I could identify others, but I'll pause there.
10:59
Michelle Scrogham
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Michelle Scrogham
Yeah, concise would be better, but we are quite time limited. I was going to ask about strengthening cooperation between Mod and Department of Health. It sounds like that's that's quite a weak point at the moment. We've only got a few areas in the country where we actually operate in in our hospitals. What do you think expanding that would do to the service to actually get that message across to the rest of our hospital footprint, and also to maybe bolster some of the gaps in in areas within the NHS to, to be able to draw on the expertise that we've got in defence medical services and vice versa.
11:00
Speaker 1
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Speaker 1
So, so in the SDR, we, we recommended consideration of a, of a, some form of enterprise board that would look beyond the Department of Health and beyond the Ministry of Defence in something similar to a Defence medical Board that the US has as an example. So our concern was how this integration was actually presented from a strategic perspective, so that between departments there would be shared commitment. There's a lot of, I would say, very positive things happening. But the of course, the challenge is of getting government departments to have shared agendas and then transferring that all the way down to individual NHS trusts through the architecture of the NHS.
And you might want to sort of pick that up.
And you might want to sort of pick that up.
11:01
Speaker 2
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Speaker 2
Just on the clinical side, I think there's absolutely a role of medical schools and royal colleges in picking up how the civilian clinical community can have increased understanding of having to treat casualties of war injury. And I would also highlight that the British Medical Association, yes, you'll be very familiar with its role as a union, but it has a very strong history of developing the military medical ethical framework for use in war. And it's definitely taken leadership on that.
11:01
Tanmanjeet Singh Dhesi
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Tanmanjeet Singh Dhesi
Thank you. Arch. Right. I will reiterate what I said at the outset. We only have half an hour left. There are lots there's a significant amount of ground to cover. My request to your good selves would be to be a succinct as possible, because otherwise many of those areas will not be covered within the next half hour. Right, on to Jesse Norman.
11:01
Speaker 3
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Speaker 3
Thank you. Chair. Obviously, if you've got additional testimony, you can just send it to us. You don't have to cover everything in oral testimony. Now the BMA is involved. We can be sure they'll go on strike within a few days of the declaration of war. What is the which of the three leading or four leading clinical centres for dealing with military related injuries in the UK?
11:02
Speaker 2
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Speaker 2
So over the last 25 years, we've very much invested in Birmingham within the Royal Centre for Defence Medicine. But we have specific, substantial clusters of uniformed personnel in other joint hospital group facilities such as James Cook in in in Middlesbrough than we have the Plymouth based hospital. We've got quite a lot of people in in Frimley Park we have people in in Oxford now, of course, in conflict. We will be drawing very quickly on our regular staff and we would be deploying them. So we would have to consider the impact on those facilities where those people are now.
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11:04
Speaker 3
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Speaker 3
Drones are flying over, people are being hit. They're not as accurate as you might like. They're possibly being targeted more randomly than you might like. The rules of war aren't being obeyed. Lots of people are getting hurt. Obviously, the difference between that scale of planning and the scale that you've talked about in Iraq and Afghanistan is at least one order, possibly 2 or 3 orders of magnitude. What is the what what preparation have you done in case we do end up with hundreds of servicemen and women being injured every day?
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11:06
Speaker 3
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Speaker 3
So any comparison with Iraq and Afghanistan, however brilliant the achievements then actually is, is mad because it's at least two orders of magnitude smaller in those conflicts than what we would be expecting to see in the kinds of scenarios we're talking about. It's just to cause a false optimism. That would be the worry.
11:06
11:06
Speaker 3
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Speaker 3
One final question. What do we do to improve national awareness of this problem? You've talked about running some casualty exercises within the NHS or elsewhere within local government. Obviously, local government has got a potential role as well. The the last Prime Minister completely failed to talk about national conversation. We've now seen the Defence Secretary starting to do that. What's your view on how we get people thinking about this seriously?
11:06
Speaker 2
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Speaker 2
Well, I think this is a start. We're exposing the key issues here. And if I can just say that privately, we do know exactly what the capability shortfalls are because we codified that at a classified level and presented it within the medical manifesto and the medical action plan. So that's absolutely known. Just as a as a yardstick, I would say that.
11:07
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11:07
Speaker 2
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Speaker 2
So but what I would say publicly is that the capacity of our deployable hospital capability has shrunk to perhaps 10% of what it was in the end of the Cold War and even into Operation Granby in 1990, that the unit of currency before was 400 to 800 bedded field hospitals in the British Army of the Rhine and then in Iraq. In 2003, we put out 500 beds, and today our unit of currency is a 48 bed field hospital that can be disaggregated into smaller units if required.
Because we adapted to counterinsurgency operations.
Because we adapted to counterinsurgency operations.
11:07
11:07
Ian Roome
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Ian Roome
Thank you very much. And thank you both for taking the time this morning. I want to pick up some of the points Jesse was talking about, but expand a little bit into how prepared DMs would be to evacuate and repatriate in a world where you're not going to have air superiority, and where helicopter support is unlikely to be available again, very different than what the case was in Afghanistan. Where is the levels of planning or awareness that you're aware of inside the department on how that would happen?
11:08
Speaker 1
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Speaker 1
So back to what we tried to raise in the SDR. We were concerned about theater level, medical capacity, and it might be helpful for the department to show even graphically, how a casualty would move from the point of wounding on the eastern edge of Europe to arrive at a port of disembarkation in the UK, because we do know clearly that the. The work to handle the casualties when they arrive in the UK is in train, but there's quite a few hundred miles between the ports of disembarkation here and the points at which our casualties would be injured, and there would be some multinational collaboration across NATO.
11:09
Ian Roome
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Ian Roome
But I'll just pick up on that, because you mentioned in the introduction about collaboration around blood and drugs of allies. When you talk about us being at different levels of preparedness from our NATO allies, are we impacted by being perhaps further behind when it comes to that collaboration of blood and drugs? If you're moving, say, from Eastern Europe to Western Europe as a stopping point before coming back to the UK.
11:09
Speaker 1
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Speaker 1
I'd say from a from a regulatory perspective, the UK is fully integrated in the discussions with the NATO countries. Part of the challenge is most of the regulation is actually in the frame rather than the NATO frame. And so the actual negotiation around regulation needs to embrace discussion about regulation in the EU, alongside working within NATO itself, you.
11:10
11:10
Speaker 2
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Speaker 2
It does. And indeed there are derogations within EU policy for movement of casualties, blood drugs across EU partner nation borders. But I know that we've been looking at how we actually sort of access those derogations as well. But in terms of sort of where the vulnerabilities are or the frictions are in that chain from point of wounding back, back to home. Have we got enough of the right CAS evac vehicle? So casualty evacuation is moving a casualty without ongoing medical treatment. So that would be your unmanned vehicles. Then you're into the medevac. So that's your armoured ambulances and your, your your protected mobility moving back through the European continent.
You'll get to a strategic hub and we need to project forward and pull our casualties back to the UK. So how would we be using ambulance trains, ambulance buses, ferries to get casualties from a channel port back back to the UK or sailing Eurostar into Saint Pancras and offloading a large number of casualties to the to then redistribute. So we've got to think of all of these elements in that theater medical plan, and particularly not just focus on the ramp, the reception arrangements when they get back to the UK.
You'll get to a strategic hub and we need to project forward and pull our casualties back to the UK. So how would we be using ambulance trains, ambulance buses, ferries to get casualties from a channel port back back to the UK or sailing Eurostar into Saint Pancras and offloading a large number of casualties to the to then redistribute. So we've got to think of all of these elements in that theater medical plan, and particularly not just focus on the ramp, the reception arrangements when they get back to the UK.
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Ian Roome
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Ian Roome
And I just and I want just pick up one further point from earlier on, you mentioned the exercises that are taking place in Birmingham and some of the other sites around England, not to just be the Scottish guy on the committee, but is there any discussions with NHS Scotland and Scottish Government about similar arrangements being held in Scotland again, with that kind of mass, large scale conflict event, presumably you'd want you'd need to distribute more around the UK.
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Speaker 2
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Speaker 2
And particularly it's identified the vulnerability of any facility that puts a Red cross on top. And no longer will we set up in a field flying a Red cross will have to look for hard cover. We'll have to look for dispersion and and smaller units that are more mobile because that's what gives us protection. But there is a flip side that aggregation gives you sophistication. When you disperse into smaller bits, you lose that sophistication and the ability to treat as effectively.
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Derek Twigg
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Derek Twigg
Can I just just also just clarify one other thing, because you said based on the German figures, there was 1000 casualties. So if it was 500 or 300, depending on the severity of casualties each day, basically, is it your view that given the state of the NHS and the capacity issues and the pressure on it, that basically a decision would have to be made by government about whether priority is given to treating wounded service personnel or civilians back in the NHS, because otherwise the whole thing would collapse.
What's your view about that?
What's your view about that?
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Speaker 1
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Speaker 1
Well, we saw with Covid that when we understood we needed to look after the whole system, actually we reinforced the social care component to get patients out of hospital so that you had more capacity at the front end. Well, I think many of the observations from Covid can apply. And then we just need to adjust the clinical services according to the needs of.
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Derek Twigg
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Derek Twigg
And just quickly, very finally on, on that side of things that we haven't, we discussed the mental health casualties or PTSD breakdown and severe anxiety. Is any work being done on a number of casualties that will have to deal with? And how are we going to do that? Again, I haven't got a lot of time, but I just wonder, is work going on and is there somewhere we can have that information?
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Speaker 1
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Speaker 1
So again, by reference to our NATO allies, most NATO allies have a much more powerful central defence or joint medical command that has authorities across the enterprise. This was one of the SDR recommendations. And the department has has announced that the change the name. So it's now Defence Medical Command and they are now working out the. The meaning of lead command and what that means in terms of authorities. I think the most important element of that is ensuring that the aggregated risk across the whole of Defence's health enterprise is properly presented , so that balance of investment decisions are balanced against all the other forms of risk in defence, and then being able to.
Again, make choices in regard to things like investing in protected ambulances so that you can actually collect the collect casualties off the battlefield versus, you know, any other element of the armour protection that the Army needs in the battlefield. So we would hope that with the lead command model, it gives more authority to actually direct the way in which the military medical services are run.
Again, make choices in regard to things like investing in protected ambulances so that you can actually collect the collect casualties off the battlefield versus, you know, any other element of the armour protection that the Army needs in the battlefield. So we would hope that with the lead command model, it gives more authority to actually direct the way in which the military medical services are run.
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Speaker 2
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Speaker 2
Right. So firstly, the history of the the medical action plan, because this was under my chairmanship , within comments that after we had identified and codified that risk across the alliance, we pushed forward through NATO headquarters, the medical manifesto, which was signed off by heads of state and government in the Washington summit in July 2024, and then the supporting detail of the plan behind the medical manifesto, which has become known as the Medical Action Plan, was signed off by NATO at the summit in in the Netherlands in 2025. So that's the history behind it. And then all NATO nations are expected to address the weaknesses within their country against around 30 lines of activity within the medical action plan.
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Speaker 2
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Speaker 2
So there has been a parliamentary question asked about that. And the response to that was that. Mod has identified activity in all five themes, which are the five areas of risk that I identified as set out in the action plan, and the assessment provides the basis for cohering and prioritising activity. So that's the official answer. But what I would say is that the specifics of where there's difficulty in closing with those lines of activity isn't in the public domain and would be a valuable avenue for this committee to.
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Speaker 1
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Speaker 1
So for the forward medical services to put them into protected containers so that if they are attacked by a drone, they've got more defence. Australia has culminated a program called JP 2060, which was completely refreshing their military medical services. And that was a $420 million upgrade program. Canada has announced a $75 million investment into partnership between Canadian Blood Services and Canada and the Canadian Armed Forces. The. The Estonians have announced €150 million project to develop modular medical systems for forward medical services. So as a sort of order of magnitude, it would look as though our NATO allies are investing a significant amount of money into their military medical.
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Speaker 2
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Speaker 2
Well, absolutely. And it's what we have done in previous operations and what would have happen in future operations, particularly where there's overlap of areas of operation. There's also opportunity for multi nationality within our field medical treatment facilities to buy out at risk. Now medical provision is a national responsibility. But we've learned in the last 30 years that multi nationality works. So where we might be deliberately planning a medical treatment facility, perhaps in the enhanced force vigilance area of Estonia, where we're lead Framework nation, there are other troop contributing nations who might provide medical capability to a framework nation British facility.
And that then perhaps would give us in pinch point specialities some freedom of manoeuvre elsewhere. So we need to think about multi nationality. And yes, we will be treating each other's patients, which is why at the core of NATO is interoperability in terms of the equipment and the guidelines that we use.
And that then perhaps would give us in pinch point specialities some freedom of manoeuvre elsewhere. So we need to think about multi nationality. And yes, we will be treating each other's patients, which is why at the core of NATO is interoperability in terms of the equipment and the guidelines that we use.
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Speaker 1
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Speaker 1
Well, the only real announcement was in the defence Investment plan, which is £50 million over four years. And I've just given you some reference points. The bit from a CSR perspective that we didn't see was any investment into the primary healthcare infrastructure, which was specifically mentioned in the CSR chapter. And I would just highlight that the Care Quality Commission, which reviews medical services in the in defence as well as in the wider NHS, has made some significant observations about the quality of the infrastructure in the Defence Primary healthcare network. So I was surprised not to see anything at all about that.
But in terms of the allocation of money for the 50 million, I'll hand that over to Tim.
But in terms of the allocation of money for the 50 million, I'll hand that over to Tim.
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Speaker 2
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Speaker 2
Yeah. So it's very welcome in terms of of a of a good start, 10 million infrastructure. And then the other 40 million is about improving outcomes far forward. But what I identify isn't there in terms of clinical capability for the next conflict. I usefully remember as non C a, B, C, d e. So the non c is noncompressible hemorrhage. The money for tranexamic acid autoinjectors great, but we still need the surgeons to be able to do the the operation and the next big development that will disrupt outcomes in pre-hospital care will be from noncompressible hemorrhage in the abdomen, in the chest, in the head.
That's what we need research and development investment to do. The A is about antimicrobial resistance. We are fighting a war in effectively a post-antibiotic era. World War one was pre-antibiotic. But now we've got so much antibiotic resistance. We need the solutions, the phage technology, new antimicrobials, to be fighting that antimicrobial resistance. The B is about blood far forward. And there's a lot being done about that and a really good relationship between DMs and NHS blood and transplant. The C, though, is about cold injury mitigation. Where we've been in the last 25 years is hot. All of the likely scenarios for where Russia may go next is cold.
It's the Baltics and the high north, so we need to adjust our equipment, our guidelines, to be able to effectively manage patients in that very difficult situation. The D is about data. I've already covered that point of wounding through the through to the NHS. And the E have already covered , which is the right evacuation platforms to get the patient to surgery in a timely manner as possible.
That's what we need research and development investment to do. The A is about antimicrobial resistance. We are fighting a war in effectively a post-antibiotic era. World War one was pre-antibiotic. But now we've got so much antibiotic resistance. We need the solutions, the phage technology, new antimicrobials, to be fighting that antimicrobial resistance. The B is about blood far forward. And there's a lot being done about that and a really good relationship between DMs and NHS blood and transplant. The C, though, is about cold injury mitigation. Where we've been in the last 25 years is hot. All of the likely scenarios for where Russia may go next is cold.
It's the Baltics and the high north, so we need to adjust our equipment, our guidelines, to be able to effectively manage patients in that very difficult situation. The D is about data. I've already covered that point of wounding through the through to the NHS. And the E have already covered , which is the right evacuation platforms to get the patient to surgery in a timely manner as possible.
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Speaker 1
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Speaker 1
Well, I can't do is is do more than just highlight the Care Quality Commission report that that this year also reviewed how there's been progress over the last 7 or 8 years. And the Care Quality Commission does highlight that. It's been quite a lot of organisational progress, but no real investment across the the infrastructure. There have been a number of medical centres that have been newly built, but we've taken across the entire infrastructure requirement.
There are some significant risks in terms of the quality of the primary care centres.
There are some significant risks in terms of the quality of the primary care centres.
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Speaker 1
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Speaker 1
What we do know using the Armed Forces Continuous Attitude Survey is how much members of the armed forces value their access to health care and access to dental care. And in covenant terms, it's really important to maintain that confidence of armed forces personnel in the health service and dental services that they have access to.
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Speaker 2
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Speaker 2
I don't know whether you're intimating about medical employment standards there, but there's been very detailed work and two cohort studies, and it was published in January 2021, so may need review now into the amount of risk, medical risk that was being taken within medical employment standards. Was it enough risk? And in fact, the conclusion at that point, when the guidelines had changed a lot, was that we were taking as much risk as we possibly could at that time. But that will need reviewing in light of the sort of current geopolitical situation.
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Speaker 1
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Speaker 1
We are and what is it we need to do more to be ready. If we had to go out the door today, we would go out with with an effective force. But the issue is the volume of patients that you might be presented with. But, you know, we are ready to go out and fight. I wouldn't be any. hesitation to say that, but what we lack is the capacity.
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Tanmanjeet Singh Dhesi
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Tanmanjeet Singh Dhesi
The department. All right. Okay, I'll leave it there. Thanks. Thank you very much, general. As I mentioned before, we started the session, that there is a lot of ground to cover within an hour. Obviously, we wouldn't have been able to draw upon all of your esteemed experiences. So we would be very, very grateful. If there is anything that you feel that we have missed out in this session, for you to send that across to us in writing, because that can then inform our future deliberations. And with that, I thank you once again for taking out your valuable time.
And I'll call to order very briefly before we .
And I'll call to order very briefly before we .
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Tanmanjeet Singh Dhesi
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Tanmanjeet Singh Dhesi
The House of Commons Defence Committee evidence session on the Defence Medical Services. We've just concluded on our first panel, and I am now very, very pleased to. welcome our. panellists for the second hour, namely Doctor Darren Mann, who is a visiting fellow at King's College London. A very warm welcome to yourself. We also have with us Doctor Katie Geary, who is a senior medical. director at the.
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Speaker 4
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Speaker 4
Beginning with Jesse Norman. Thank you very much indeed, chairman. Thank you very much indeed for coming. You all have heard the previous session and some of the revelations coming out of that. Doctor Mann, just starting, if I may, with you. One of the questions that was asked was about different nature of and location of conflict. So if we go back to the present experience that is happening in.
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Speaker 5
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Speaker 5
For example, tourniquet. application that becomes now a life saving. procedure and a concept of what many of us are calling silver medal mindset now comes into place. The idea you could put a tourniquet on to save someone's life from catastrophic bleeding, and then expect to remove that tourniquet and save the limb.
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Speaker 5
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Speaker 5
Woefully ill prepared for the wrong disease. I don't know if there's something you want to comment on there. Well, I think that one major comparator is that we knew Covid was coming. Just we knew a pandemic was coming. And we understand that there is a general realised threat of a war coming. So it's our opportunity now to prepare for that. I believe that there .
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Emma Lewell
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Emma Lewell
Get a sense of the magnitude of the problem. Thank you. Thank you so much, Emily. Thank you very much, chair. Good morning all. You've just been speaking with my colleague Jesse there, about how how war has changed and the difficulties that poses for defence medical services. How equipped do you think UK is defence medical services are for dealing with that, and what do you think they would do in the event of .
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Speaker 10
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Speaker 10
An attack on medical infrastructure? I think if I answer it this way, which is it's already been talked about in the previous panel around capacity, that is where the issue is. That is not unique to the UK. That is, everyone in continental Europe and across the world. The answer to capacity is a system of systems approach, and that is not what we're seeing at the moment. I think there are pockets of .
excellence within .
excellence within .
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Speaker 5
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Speaker 5
The whole of society approach, and I believe that the. responsibility of. government is to. integrate across the. capabilities open to us. We spend a lot of time talking about defence medical services. They obviously have a key role, particularly in the theatre piece. We've talked about the NHS and how those two elements are adapt and integrate themselves through the reception.
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Speaker 5
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Speaker 5
But I believe the independent sector in this country and the private sector, and not just the private healthcare sector, but the sectors that hold the transport systems, the ferries, the ships, the planes, the trains. None of that's owned by government, none of that's owned by defence. And there are .
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Speaker 7
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Speaker 7
Is a sort of reserved, isn't it? And so I think what what's happening at the moment is some of it is falling between the cracks. I know. Scotland is actually. exercising ramp. It is part of ramp. Now. I haven't sat on the Scottish Resilience panel earlier in the year, so there are pockets within the NHS that are coming to the table. As Edda said, there are pockets in the DMs but also this is whole systems and if we just looked at something like.
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Speaker 7
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Speaker 7
What happens in the. battlefield is. exported to the host nation health. So we need to think about what happens. externally will come to bear on host nations. And so there is some thinking that has to be done, I think, at government level about how do all of these departments get. together to think, what's the best way to create resilience in the UK as a whole, including devolved. nations that support the DCMs to do the extraordinary things that they do with a lean. force and use the private sector to. augment where we can do it. And we .
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Speaker 7
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Speaker 7
Readiness Bill should be the vehicle for some of this? No, I think it's a talking point to start the. discussions and to. accelerate the plan and the preparedness. But you're not going to be able to. respond unless you've got a common language, a common focus. You started your. training and your. exercising to deliver. And we have to start talking about the hard truths that the.
reality of the Ukrainian war had a .
reality of the Ukrainian war had a .
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Speaker 5
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Speaker 5
I think Covid showed us it's very expensive to buy your way out of trouble, so arrange works that you can put in place to lease higher. Otherwise, put service level agreements in place during peacetime, you'll get better reliability and you'll get a better price than you will if you turn up when the. disaster has struck.
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Speaker 5
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Speaker 5
At through the private sector independent sector providers are open. Now that will look very different once the whole world's calling on them. The second point, I think, for the Defence Readiness Bill is around the healthcare. workforce and the. regulations that apply to it. And I'm thinking now, particularly of the professional.
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Mike Martin
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Mike Martin
Health and safety. You know, are people acting within their competencies? You just need to make it work as well. And again, all of you are nodding as well just for the transcript. And then Doctor Mann, if I may, you said in an answer to Jesse earlier that there are several areas of willful. blindness when it comes to defence medical services.
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Speaker 5
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Speaker 5
I believe there's blindness to that. The same for staff, but it's the other way round. Many staff would be double counted because, of course, many staff working in the NHS will also work in the private sector. Then we've got the then we've got the regulars going out, the reserves going out, potentially a sponsor reserve coming in. In previous wars we had a war medical. committee that accounted for every single medically qualified person in this country to understand where they were, what they were doing, and what would they do .
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Speaker 12
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Speaker 12
Starting off with Graham Downey. Thank you very much. I actually pick up on some of those themes as well. Doctor man, something that happens across public services where the voluntary sector or the private sector will take care of that, but without an. understanding of what they actually deliver on, I suspect we see willful blindness in that area as well. Can you outline exactly what you think commercial providers or voluntary.
organisations can offer in a large scale conflict?
organisations can offer in a large scale conflict?
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Speaker 10
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Speaker 10
Can they not offer? So, so yes, so so if I look at how we integrate with other NATO partners and what they ask of us, so as an organisation, we do three things. We coordinate care, which is movement of people. We deliver care, hands on care. We do training, doctrine and development. Three very simple things. The what we offer to them and the way they use us is effectively as a partner. We're not commerce, we're not industry, we're not treated as such. We're treated as a true partner, and we're integrated to. augment their blind spots.
And that is what I think industry can do. When I talk of industry, the medical industry is slightly different to many others in the defence sector. And I, you know, I talk from previous. experience the way I believe that industry should be looked at to help solve this capacity problem is through the system of systems approach. If you were to look at a soldier getting wounded on Eastern Europe somewhere and all the way back to recovery and then return to fight, there is no one element that's going to solve that entire chain. You're going to have to.
integrate a variety of different. capabilities from both the private sector and the public.
And that is what I think industry can do. When I talk of industry, the medical industry is slightly different to many others in the defence sector. And I, you know, I talk from previous. experience the way I believe that industry should be looked at to help solve this capacity problem is through the system of systems approach. If you were to look at a soldier getting wounded on Eastern Europe somewhere and all the way back to recovery and then return to fight, there is no one element that's going to solve that entire chain. You're going to have to.
integrate a variety of different. capabilities from both the private sector and the public.
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Speaker 12
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Speaker 12
Including defence. In order to make that work in the most efficient manner. We heard in the last session that the problem was. capacity as well. And you talked there about, you know, the role of the private or voluntary sector is to fill in those blind spots. Do you feel you have adequate engagement with government to know where you .
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Speaker 10
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Speaker 10
That excess capacity. That is where the bind is. If I compare it to what you know, I have 304 individual government agencies as customers, as far east as Australia and as far west as the UK. Every single one of them is ahead of where we are in terms of the planning, the understanding of what we can offer, how we integrate, and we are part of that planning process. It's not the defence med don't want to do it, it's that something is stopping them and it's probably around finances and the. ability for a commercial to get in the way and say, oh, you can't do that.
And if we don't get ahead of it now, you're going to be too late because resource is .
And if we don't get ahead of it now, you're going to be too late because resource is .
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Speaker 5
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Speaker 5
But I think the scale, potential scale of casualties that we're talking about now, we understand that for the UK the ramp large number is about 400 a day. None of us should underestimate, of course, the impact of that on an. individual 400 is current operating number. Germany, as we hear, is operating at 1000 a day. I believe that that those numbers would completely. overwhelm even a very capable provider. So I think we have to think in a different way. I'm looking at the major. logistics providers, the people that own the shipping containers. I'm looking at the ferry.
companies who's asking the hospital ships, the mercy ships, where are they going to be? Who's asking the major ferry providers? Who's asking? The airframe.
companies who's asking the hospital ships, the mercy ships, where are they going to be? Who's asking the major ferry providers? Who's asking? The airframe.
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Speaker 12
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Speaker 12
Whom, of course, as we know, are based in Europe, just a different scale. The chair's eyes kind of drilling into the side of my head as well. To flip that slightly on its head again, we saw during Covid the reliance on local. voluntary . , charitable who just filled in and jumped in because that's what they do. To what extent are we able to plan that .
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Speaker 10
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Speaker 10
Under the under the normal circumstances. So broadly speaking, it's not. So we while we of course, we have reservists and and I sit here being one myself in terms of as a veteran, I'm sure I'd be called up probably to the pointy end of it rather than the medical end. But this is about the balance of risk, right. And so for, for any commercial. organisation relying solely on UK reservists to deliver our capability is not what we do. So what it does talk to, though, is a very valid point in terms of talking to other nations, getting ahead around right in order to fulfil the criteria or fulfil the staffing, it's going to be required at scale.
You're going to have to make not necessarily a .
You're going to have to make not necessarily a .
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Speaker 10
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Speaker 10
And our NATO allies? How would that actually operate on the ground? So the way we interact, or what we're asked to do by different nations differs. So the Department of War, what we do for them is very different to what we currently do for the UK mod. The short answer is that is about a balance of of load balancing our capacity and. capability until until that point is triggered, I wouldn't be able to give you an absolute sort of answer as to how we would do it, but I can give you the. reassurances and the absolute planning knowledge that we have the capacity to execute every single commercial contract we have.
And, and the way I think you should be looking at it is this comes back to my point of system of systems. This isn't about us providing medical staffing. This is about the coordination of care into existing network hospitals. It's not like we provide the whole solution. We are .
And, and the way I think you should be looking at it is this comes back to my point of system of systems. This isn't about us providing medical staffing. This is about the coordination of care into existing network hospitals. It's not like we provide the whole solution. We are .
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Speaker 10
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Speaker 10
To additional resources. I think that would be right to say. I agree that there's a this all comes to sort of getting ahead of it and getting upstream of the actual ask, because if the UK sort of follows a pattern of acting when it's too late, the resource constraints from a hospital ship to a container, you're at the back of the line and then it's too late and you're not getting the outcomes that you're going to require for, you know, both from a moral .
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Speaker 10
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Speaker 10
Otherwise we will definitely be at the back of the queue. There's everyone's going to be after the same resource. What I think actually should be happening is the full. integration of various elements of industry into the. conversation now, because the sooner you talk, the sooner you can make educated decisions.
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Tanmanjeet Singh Dhesi
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Tanmanjeet Singh Dhesi
And part of that is then balancing the risk of where the resource is going to come from. Doctor, I want to bring your perspective into this. We've got commercial. providers and there are volunteer voluntary organizations. We saw, for example, voluntary organizations like help for heroes. during both. Afghanistan and Iraq.
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Speaker 5
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Speaker 5
Entities in the event of a conflict? I think that we should return to a whole of society approach. What we do. understand for where mental health support is concerned, many people find. comfort in being able, in the ability to talk with people that understand what they've been through, that understand what they've seen, that have had a shared experience, perhaps. So that allows you, I think, to segregate this into different .
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Tanmanjeet Singh Dhesi
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Tanmanjeet Singh Dhesi
But ultimately everyone's. experience will will resonate. I agree with yourself. And does the whole of society approach as the Finns and Estonians, the defence committee were out there, you know, we were very, very impressed with that concept of total security. But in terms of the role of voluntary.
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Speaker 7
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Speaker 7
Doctor Kate, you're you're nodding. So do you want to. Well, I yeah, I mean, blood stocks are always of course of concern aren't they. There's always calls going out. If you look at if you take the German. numbers for how many. casualties and the percentage of blood stocks you would deplete the UK blood stocks, which by the way, are managed per devolved nation. So we don't have a centralised bloodstock.
25% per day. Right. But that. So this is an issue. And General Hodgetts mentioned that as one of the. research defence medical.
25% per day. Right. But that. So this is an issue. And General Hodgetts mentioned that as one of the. research defence medical.
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Speaker 10
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Speaker 10
Have enough medical equipment to get it all out? Yeah. I mean, I think there's there's a tendency to focus on the sort of Covid experience. I mean, the hostage of the last time we saw this as a nation, which is we didn't have enough masks, gowns. That is one component part of exactly of the full thing where I think our weaknesses lie. Blood, I think, is actually being addressed as best as I can in terms of blood forward, forward, frozen plasma, freeze dried plasma, rather. And I believe there's money within the dip to help address that.
Where I think the constraining factor is, is that by the time everyone needs a.
Where I think the constraining factor is, is that by the time everyone needs a.
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Speaker 10
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Speaker 10
Certainly there's been parliamentary questions asked about around whether the current. contract that's held to provide clinical equipment to DMs is is working or not. I suggest it probably isn't, but I think that you know, where the attention needs to be pulled at the moment is what is going to be required, and how on earth are they going to get it? Because I can't see a contractual mechanism for them to, to get that at the moment, or even understanding the magnitude of .
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Speaker 5
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Speaker 5
Talking about? I'm not a doctor, so I'm going to take the fifth on that one. Perhaps I'll come in there because my career as a trauma surgeon was interrupted by Covid, and I was medical director for the Cabinet Office personal protective equipment cell for three years. So I know what a stockpile that's not been kept in date looks like. And I know what a stockpile that's not been kept in order looks like. Managing . Whichever catastrophe you're managing, you need to understand is there a sovereign ownership piece around this? So to what degree do you need sovereign.
solutions stockpiles? Yes. Admittedly, we know much of the. equipment that we relied on in Covid and much that would be relied on for casualty. management and pieces of equipment. They save lives, but they're made of plastic and rubber and glue. They're made in the Far East, and we would be faced with the same supply. disruption in the event of a war now as we were for Covid. So the place for sovereign supply, actual sovereign. manufacture is something that needs to be looked at. The case for getting ahead of it. Now. sovereign import and stockpiling. But how much can you stockpile for.
120 days typically. And then you need to have your service level agreements or home manufacturing coming in. The other thing, especially on supply chain.
solutions stockpiles? Yes. Admittedly, we know much of the. equipment that we relied on in Covid and much that would be relied on for casualty. management and pieces of equipment. They save lives, but they're made of plastic and rubber and glue. They're made in the Far East, and we would be faced with the same supply. disruption in the event of a war now as we were for Covid. So the place for sovereign supply, actual sovereign. manufacture is something that needs to be looked at. The case for getting ahead of it. Now. sovereign import and stockpiling. But how much can you stockpile for.
120 days typically. And then you need to have your service level agreements or home manufacturing coming in. The other thing, especially on supply chain.
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Speaker 5
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Speaker 5
Is that each sector of critical national. infrastructure currently has its own supply chain assurance system. None of them speak across each other. So there's no way of knowing if there's capacity in one sector that you might be able to use in another, or worse, if all of the checks were called in at the same time that all the individual sectors are pulling up and there might be the same individual. suppliers underneath it.
So a sovereign supply. architecture and a standard around it to give the UK .
So a sovereign supply. architecture and a standard around it to give the UK .
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Speaker 5
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Speaker 5
The worst. feature of that was. recognizing that where there was. gaps through failure to order, you could. recognize what was visible to you and set about to correct it. But when what you actually had on the shelves proved to be out of date and required to be brought back to life through what's called a.
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Speaker 5
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Speaker 5
But you rotate that equipment as far as is. possible through operational use, either within our own healthcare systems or potentially amongst allies, and continue to replace it, maintain it and have an accountable person for it. I left I left that job thinking that we need the equivalent of a His Majesty's Inspector of Prisons, His Majesty's Inspector of PPE to report to Parliament on PPE stockpile levels .
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Derek Twigg
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Derek Twigg
Thank you much. Right on to Derek Twigg. Yeah, I mean, to some extent you've you've partly answered the question because, I mean, I think you made it very clear that we have real problems with domestic resilience. And this is one of the key. lessons going back to Covid. And that's really worrying in that sense. I mean, can I just ask you, do you think going back to. 2020 and today, and given your particular role, and please, if you think it would be helpful that we have .
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Speaker 5
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Speaker 5
Be part of the solution. And which is at the moment, right. General. General Hodgetts referred to this derogation. Derogation allows you to, in a calculated and titrated way, relax your regulations to meet the needs of the moment. We've heard how drugs blood products can be used. inappropriately between NATO allies. The EU did it for Covid when. derogation allowed personal protective.
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Speaker 5
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Speaker 5
Significant progress has been made since 2020? And then. Well, I think we've seen within the military the introduction of the National Armaments Director Group to try to. unravel some of the complexity around defence procurement. But. We saw, of course, what happened in Covid. If you. suspend if you suspend some of your public sector. resourcing rules and then find direct awards as the only route open to you, you only get to dance with who's on the dance floor that leads to its own problems.
So .
So .
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Speaker 10
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Speaker 10
You keep coming back to. It's basically we're not getting ahead of the problem. That's yeah, it is. It's all about being upstream of this in a way that your allies are or our allies are. We're not quite on the pace. I think, when it comes to medical supplies. The question I'd ask DMs is, under the current Lxt contract and then the next generation of DS contract, which is the .
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Derek Twigg
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Derek Twigg
MoD's buying power, are they getting what they need in a timely manner? So just finally, so I come back to my my earlier question to the panel. And again, you touched on it. I mean, we talk about 1000. casualties from the Germans estimate of, say, 500. I mean, the ability of the healthcare. system to cope with the pressures. And I'll put the same question, the pressures that they have to do today, which are not consistently up corridor curve. We've got major you know, delays were surely if that many casualties, the majority, if not all of the reservists would have to be called up, then clearly the decision would have to be.
taken on who gets priority for treatment, wouldn't it? So I think that would .
taken on who gets priority for treatment, wouldn't it? So I think that would .
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Speaker 5
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Speaker 5
Let's talk about that because again, there's I think there's an important national conversation to have around this. And essentially we are reflecting on where can. reformation work and where is. transformation needed. And I'd like to use the analogy of a parachute. You've jumped out the plane, you've got your parachute, you're coming down. It's stretched out. The fabric's a bit old. It's been reused a couple of times. You're not sure who packed it. That's the NHS as it's working at the moment. Now you get a rip in your parachute and you're thinking, oh well, I hope I'll get down okay.
I've not speeded up too far. Then there's another rip Reformation would be you trying to stitch the holes in that parachute as you're going down and hoping your descent is going to be controlled. Transformation is to. recognize that tightening up the NHS. redeploying people, putting more people in.
I've not speeded up too far. Then there's another rip Reformation would be you trying to stitch the holes in that parachute as you're going down and hoping your descent is going to be controlled. Transformation is to. recognize that tightening up the NHS. redeploying people, putting more people in.
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Speaker 5
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Speaker 5
And it might even go through the private sector estate because the beds are there and only 1% of them were used in Covid. We might redeploy clinical staff, use those for the military, use whatever else you need from the NHS, but. maintain a public service through what is available to you in the. established system. So I think what's needed is a. transformation to a .
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Speaker 7
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Speaker 7
You know, to home. The reality of. Ukraine is that in Afghanistan and Iraq, we saved pretty much everybody that we said was T1, i.e., you need immediate care . Now we can evacuate. Ukraine is saying T1, you're doomed, T4, you're doomed. We need to be thinking about palliative care in the battlefield. T2 two three, which are walking wounded and less sort of walking wounded, we can care for. It is a big ethical, cultural shift for the. military to think about. And it's a big cultural shift for the, I think, for society to start thinking about.
And within that comes your question, which is well put, and I think is something that we need to be thinking about is who are the priorities when it comes to a war footing? What are the. priorities in terms of. societal support to that? And maybe that's where the voluntary or third sector comes in. Where is the buddy buddy self first aid? Where is wellbeing at home? Where is home support? All of those great things that are being talked about in NHS transformation. How can we help accelerate that? And we go back to the system of.
systems that actually war footing means getting your NHS and your home.
And within that comes your question, which is well put, and I think is something that we need to be thinking about is who are the priorities when it comes to a war footing? What are the. priorities in terms of. societal support to that? And maybe that's where the voluntary or third sector comes in. Where is the buddy buddy self first aid? Where is wellbeing at home? Where is home support? All of those great things that are being talked about in NHS transformation. How can we help accelerate that? And we go back to the system of.
systems that actually war footing means getting your NHS and your home.
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Speaker 7
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Speaker 7
Getting your. military fit and bringing in your voluntary sector and not industry in the round, but bespoke elements of industry such as, you know, your healthcare access, your logistics, where it's needed to help start that transformation. As Doctor Mann's talked about, about where we need to get, it's a it's a completely different way of .
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Speaker 12
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Speaker 12
Things together at the last minute. Thank you much. Graham Downey It was a very short question, just picking up on that. Doctor Geary, we've seen the government over the last week talk about what people should prepare for in different things. Would it be helpful for the government to also consider training essentially as part of your preparedness? You should consider basic medical and if so, what kind of things would. What would that look like? Where's the best place for government to say?
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Speaker 7
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Speaker 7
Prepared to be able to do the following things. Yes, I would answer that two ways. One, if you look at. Iceland stats, you know, other supermarkets are available, but they sold out of all of their, I think, baked beans, goods and water. So there's been a massive society response to that. I think society are actually a little bit more aware and open than we give them credit for. The second thing, Holland is. always awake to the.
situation that most of their.
situation that most of their.
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Ian Roome
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Ian Roome
On that is Ian Rue. The Defence Medical Research Strategy sets out six themes from combat. casualty care, fitness to operate, mental health. infection and so on. And the real, real life test would to me would be whether research trans translates rapidly into. capabilities that saves lives on the battlefield. So which. 2 or 3 research. priorities would you accelerate immediately to deliver the greatest.
improvement in casualty. survival and operational effectiveness? And what are the principal. barriers to. preventing promising. research from reaching the front lines?
improvement in casualty. survival and operational effectiveness? And what are the principal. barriers to. preventing promising. research from reaching the front lines?
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Speaker 5
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Speaker 5
Whoever wants to turn up my first, my first priority would be those that reflect the changes on the battlefield for injured persons, and that is their requirement to be managed for a prolonged period of time at the point of wounding. What can be. managed far forward? What? What can be. delivered in the event that you're unable to move a casualty back through the chain? What can you take.
forwards to the casualty? What systems are available to you to to. deliver either.
forwards to the casualty? What systems are available to you to to. deliver either.
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Speaker 10
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Speaker 10
Recognised by deploying those elsewhere? If I looked at this, comparing it to other people that we deal with other governments T, triple C so tactical combat care has become the priority, i.e. you're upskilling to the extent that one one of our clients, we're training 80,000 people over a 12 month period. So that's how serious that they are seeing the requirement. And that's a decision they made. That is not a huge capital investment for them, but it is.
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Speaker 7
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Speaker 7
But the point that where we should be doing some research is point of care. testing for the resistant strains. Now that has use not only on the battlefield, but actually at the. bedside in NHS hospitals. That is something that could have direct. transferable blood is certainly. something for diagnostics. It's not really mentioned in the.
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Ian Roome
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Ian Roome
The defence medical services and the, the civil medical services? Do you think that we are doing enough to provide good quality medical care to our service personnel? And I'm talking specifically around the Armed Forces Covenant now, and we've heard earlier from the earlier panel about the the improvements required recommended from the CQC, for example. So I'd just like to take your get your experience and what you think needs to be done and what the comparables are between the civilians and those serving.
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Speaker 5
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Speaker 5
That are providing, I think overall a very high standard of care and consistent with the standards available in this country, given the constraints that we that we face. But I note that if you think about the floor and the ceiling of the Armed Forces Covenant, what would the floor be? The floor be with you. You should not be. disadvantaged because of your armed forces membership. And that seems to me to be a .
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Ian Roome
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Ian Roome
Pretty low floor. When you look at the ceiling that could be could be achieved. Just on one further point, what do you think some research that I've done is, is the. comparables around peer, particularly around. consultants and doctors and the peer comparables. So at one time the gap was quite high that if you did military service, you, you know, you was it was quite lucrative to profession to go in. What the government should be thinking of going forward, the Ministry of Defence around the pay levels, because are we are we in danger of losing trained medical.
personnel to go into civilian professionals? Career sorry, rather than. Ministry .
personnel to go into civilian professionals? Career sorry, rather than. Ministry .
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Speaker 1
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Speaker 1
But that's always going to be a risk. I think actually what should be looked at is, is it's a it's a systemic, much wider issue. It's not about money. It's about the the entire piece. And are we standing up and giving what our serving personnel signed up to from a housing benefits the way you treated as a veteran? And I would argue the answer is no. So I don't think it's just about money. I think you need to probably look at the component parts that would retain medic. Highly trained medical staff pay is probably a significant part of it.
But look at the wraparound. And I think that's not just in defence. That's a it's .
But look at the wraparound. And I think that's not just in defence. That's a it's .
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Speaker 2
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Speaker 2
A well. publicised issue across defence. Well, I think most people stay for the purpose, not the pay. Acknowledged, of course, that people in regular roles will have certain constraints according to their promotional level for medics that are reservists. And that, of course is the majority. There are there are opportunities open to them to, to to supplement their NHS income if they so if they so wish to. And their service .
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Speaker 3
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Speaker 3
Pay of course, is is is separate. Thank you. Thank you very much. And just to wrap things up at the end, look, we as a committee wanted to have this session on defence medical services because we not only want to gain knowledge ourselves as a committee, but we also wanted to focus hearts and minds on what has been termed as the most hollowed out part of defence. So given that you've got the air of the Ministry of Defence or Government, what action would you like to see from the.
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Speaker 1
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Speaker 1
Cohere a national wartime medical plan. Mr. Morton, I think I'll answer your last bit, which is when which is now. You're already a little bit too late. I think it's the support to DMs from a fiscal point of view, to allow them to actually get on and make these enact changes. And the biggest change is don't look at. industry or the commercial sector as as a horrible thing.
Look at it as part of the solution. And the sooner the mod writ large and DMs do .
Look at it as part of the solution. And the sooner the mod writ large and DMs do .
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