Oral evidence: One-off Session on Defence Medical Services, HC 724

Oral evidence, 27 October 2026.

Witnesses

Lt Gen Martin Bricknell and Maj Gen Timothy Hodgetts.

Chair

This is a one-off evidence session of the House of Commons Defence Committee on Defence Medical Services. I am pleased to say that we have with us two esteemed individuals with a great deal of experience in Defence Medical Services, namely Lt Gen. (Rtd) Martin Bricknell, the Surgeon General of the UK armed forces back in 2018-19, and Maj. Gen. (Rtd) Timothy Hodgetts, also a former Surgeon General, as well as being chair of the NATO Committee of the Chiefs of Military Medical Services in 2021-24). Gents, we will get on with the questioning very soon, but I also want to warmly welcome our new member of the House of Commons Defence Committee, the hon. Member for Dunfermline and Dollar, Graeme Downie. Graeme, a very warm welcome to you. We have two different panels today. We have one hour with you, with lots of questions, so please try to be as succinct as possible, because we have a lot of ground to cover in the next hour. Without further ado, I will ask my colleague Lincoln Jopp to kick-start the questioning.

Lincoln Jopp

Generals, thank you very much for your time. When Gen. Sir Richard Barrons was before us in July, he described Defence Medical Services as “the most hollowed-out bit of defence”. How would you describe the current state of Defence Medical Services?

Lt Gen Bricknell

I will start and Tim will add in. We will balance this between organisational aspects, which I will focus on, and Tim talking about clinical. I had the privilege of serving on the SDR panel for the Defence Medical Services. 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. Given the unique nature of the relationship between the military medical services and the civilian medical services, it is possible to take that as a saving in piece, but it means our foundational baseline if we need to expand and mobilise is at risk. From an organisational perspective, I suggest that it is the capacity rather than the capability dimension, but Tim will probably pick up on some specific aspects of risk.

Maj Gen Hodgetts

There are five principal risks for casualties at scale and duration in the contested environment of war. We came to that conclusion after scrutiny within the NATO setting, and we codified in detail what the risk was across the whole NATO alliance. We find broad risks across the alliance; they vary in each individual country, but they do fit into five main categories. First is medical evacuation, having enough protected vehicles to get patients from the point of wounding to timely surgery. 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. Indeed, the majority of avoidable deaths happen in pre-hospital care, not in hospital care. The focus has to be what happens far forward. The second is mass casualty planning, which demands the military theatre-level medical evacuation plan, but a core focus within that plan has to be to return to duty at every possible opportunity as we evacuate—the further away we get from the frontline, the harder it is to get people back to the fight. We need to recognise that the principles are different from conventional civilian major incident planning, and we have to address enduring high numbers. The third issue is medical logistics. Covid taught us—we have seen this from previous military conflicts—that just-in-time logistics do not work. That means we have to hold more stock, and we need decisions and action on what critical consumable items to onshore or nearshore further. The fourth is around regulatory and legal considerations, and we need the necessary freedoms in place, ahead of conflict, to support innovation at pace, and to be able to credential clinicians in a multinational setting—multinationality buys out some of our medical risk—and to use allied blood and drugs on each other’s patients. We must also remember that the enemy will not follow the law of armed conflict, so we have to change our tactics to take that into account. Finally, it is workforce, and I know we will probably go into more detail about workforce, but we simply do not have the existing military medical capacity to deal concurrently with medical force preparation at scale, medical training at scale, and the predicted casualty estimates.

Lincoln Jopp

Culturally, when you were doing the stuff for the SDR, what was your sense? Logistics is always something—you know, amateurs talk tactics, professionals talk logistics and all that, but only then do they think about the medical paragraph. To what extent did you get a sense that this was in any way in the SDR, that people would like to consider this problem or not?

Lt Gen Bricknell

The actual document was published by the Department, and the chapter on the medical services had the key points that we as a panel had recommended to the Department. In terms of the record, I would argue that the Department contained in the SDR the key points that we had put across, but the challenge of course is the delivery and the difficult choices that the Department has against all the pressures for money. We cannot now 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.

Lincoln Jopp

Forgive my ignorance; the DMS used to be under StratCom or CSOC—whatever you want to call it. Is that still the case?

Lt Gen Bricknell

Some of the cultural change has happened. The headquarters is now the Defence Medical Command, and it is definitely under the CSOC. Certainly, we can see evidence that they are trying to shift the behaviours to give the Defence Medical Command authority over the whole of the defence medical enterprise. You could argue that, when compared with other NATO countries, we are a little bit further behind in this cultural shift from distribution across four commands to a medical command owning the whole enterprise.

Mike Martin

Thank you for your time today. Going into workforce in more detail, pinch points probably understates it, but where are the shortages? What are the critical shortages?

Lt Gen Bricknell

From the organisational perspective, medical in defence should absolutely be the exemplar of the whole force model, taking a balance between the cost of active duty, the value benefit of reserve service plus the civilian workforce that provides the underpinning foundations for the generation of the force through defence primary healthcare. Inevitably, there ends up being difficulty around money, attribution of posts, balance of risk, recruiting and, finally, getting the total balance between active or regular duty in the reserve and civilian workforce. Indeed, one of the points we wanted to make in the SDR is about the potential opportunity to consider the commercial sector as an additional sector rather than purely the NHS—I know that the second part of this session is going to consider that. For over 150 years, there has always been difficulty in recruiting and retaining into the regular force. Tim will now probably pick up some points around the individual pinch-point trades that then turn into capability risks.

Maj Gen Hodgetts

Building on those comments, to highlight this at the start, the majority of defence medical capability is invested in its people, not in expensive platforms—it is in the hands and the minds of our clinicians. That is reflected in how the DMS budget is allocated, which is mostly on people. It is why we have accrued vulnerability over time to operational delivery when serial savings have de-enriched, civilianised or deleted operational clinical positions. There are two key priorities. The first is a central priority around ensuring that our people are used as flexibly as possible and to their maximum competence. That is about optimising our current workflow and getting to full deployability as quickly as possible for those who have been injured or who are sick. On the first point, flexibility, I have 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 launched the Royal Army Medical Service, and it was three corps into one—the Royal Army Medical Corps, the Royal Army Dental Corps and Queen Alexandra’s Royal Army Nursing Corps. That was not driven by cost savings; it was driven by ensuring that we could have the best workforce opportunity and adaptability or flexibility for operations, where appointments in the future could be on competence rather than on cap badge. I have to declare a bias or conflict of interest, because I have been the master general for the last four years and have overseen that process. The second positive is that, at the moment, we have 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 lives in the longer period it is going to take to get to surgery. The enhancement in the DIP of £20 million for that—I am sure we will come back to the DIP—is really welcome, but it only supports roll-out to a proportion of the existing Army. A critical pinch point—there is more than one, but I would say that it is really important to address this early—is surgeons. If we are saying we have to get medevac right to get to the surgeon as quickly as possible, we have to have enough surgeons available to then treat the patient. Across the DMS, there are currently around a dozen consultant trauma and orthopaedic surgeons, but there are three times that number within higher training. We will have to do things differently in the future, so that, rather than just being reliant on a consultant-delivered model, we exploit the ability to use our higher trainees to give additional capacity.

Mike Martin

What is the lead time to create an orthopaedic surgeon? What would it be under another model—call it the different model that you are advocating?

Maj Gen Hodgetts

Good point. It is different for different clinical specialities. We have medical school, foundation years and then specialist training. For a surgeon, it is a total of about 15 years; for a GP, it is about 10 years; and for some of the other specialities, maybe 13 or 14 years. It is a long time to start from scratch to develop that capability. Paired with that employment flexibility and adaptability is getting people back to full deployability—the medically downgraded, and the medically non-deployable or partially deployable. There is evidence of effect here: Defence Primary Healthcare—DPHC—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 has had money from the individual services independently, and I think that from the next financial year that is going to be centralised. To give you an example of numerical evidence, which the NHS has from its Further Faster armed forces initiative, ear, nose and throat surgery waiting times—one of our pinch points to get through outpatients and surgery—have reduced from around 17 weeks to 12 weeks in a six-month period. That is a really good improvement. For trauma and orthopaedic care, which is a lot of our musculoskeletal injury of the large joints, that has dropped from around 14 weeks to around 10 weeks. There is definite progress in getting the sick and injured back to full deployability faster than we have been able to achieve in the past.

Mike Martin

This would be wholly inadequate in large-scale combat operations. Can the sponsored reserve model help us out in terms of backfilling?

Lt Gen Bricknell

In the SDR, we recommended that the Department develops a workforce plan for the Defence Medical Services, which has not yet been published. It would be interesting to see the extent to which the Department is now taking this whole-force proposition, including sponsored reserves, to look at how the nation’s health workforce can be balanced across all the different uses, and where the military component fits into this whole national health workforce enterprise.

Mike Martin

Is this document coming?

Lt Gen Bricknell

I do not know. That is a question for the Department.

Maj Gen Hodgetts

I would concur about the sponsored reserves model: there is a real opportunity to consider building clinical teams, whether in organisations such as ISOS, 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.

Michelle Scrogham

Obviously we saw the impact of covid and the pressure that put the NHS under. If we are 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 when the domestic reservists are called up?

Lt Gen Bricknell

The Department has been doing quite a lot of collaborative work across Departments. Just three weeks ago, there was a major concept development exercise that involved many partners. We also have to put this into perspective. The NHS, in overall capacity terms, is huge, so the military demand signal is unlikely to be significant enough in terms of total demand to require anything more than the changes we saw in covid. However, there will be pinch-point areas, such as burns and plastics. Compared with our NATO allies, we are perhaps less advanced, either in regulatory terms or in terms of actually conducting training exercises. We have seen France, Germany, the Baltic states and Norway conducting live exercises, moving military casualties and rehearsing how they would be absorbed into the civilian sector. We have not yet seen that from a UK perspective. However, as a demonstration of national intent, and, indeed, as part of the deterrence information campaign, just showing that the country is capable of handling military casualties might be a significant part of deterrence in the same way as preparing for military operations.

Maj Gen Hodgetts

I would 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. Martin referred to RAMP—the reception arrangements for military patients. That is about how we would distribute casualties across the NHS and the NHS would take the lead on that. But that is not about how casualties would be treated. Civilian clinicians may be quite unfamiliar with blast, ballistic and burn injuries when we spread the casualties far and wide. We are actually ahead of the curve on that. In 2017 in Birmingham, the military and the NHS collaborated within the Royal Centre for Defence Medicine to come up with NHS major incident and mass casualty treatment guidelines. 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 emergency preparedness response and resilience distributed those guidelines to every acute trust. So there is no excuse to say that we have not actually thought about how we are going to treat such patients. With the approval of the NHS, from 2023 those guidelines were made available to NATO allies to draw down on if required. I regularly lecture 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. I am reminded of what Rommel said in the second world war: “The British have some of the best doctrine in the world, but it is fortunate for us their officers do not read it.” While we produce those guidelines, it is really important that people actually read them and exercise them. I am really conscious of there being enough wide space within the NHS, which runs so operationally hot, to be able to run exercises like we run in the military. The 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 am asked what made the biggest difference to the extraordinary outcomes that we got in Iraq and Afghanistan, it was not an individual clinical intervention, it was the data. There is no reason why we cannot collect good data in the future. It is not about scale. It is not about the fact that it has to go across the whole country. It is about having the right architecture that can then draw down that data. We can use modern tools such as AI to interrogate that data in real time and give us the necessary reporting and trends that we would need to see and share with both the civilian and military community to continuously drive quality improvement. 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. Sustaining our military academic footprint in Birmingham is critical if we are going to be able to improve outcomes. Even if we start from a lower point than before, there is no reason why we cannot continue to improve outcomes through the next conflict. It is what has happened in every conflict in the last hundred years. The outcome at the end of the conflict is better than the outcome at the beginning of the conflict. We have some really reassuring research partnerships, for example, with the Medical Research Council to develop a joint centre of research excellence for blood. We also have a very strong multi-site partnership with the University of Birmingham for blast traumatic brain injury. I could identify others, but I will pause there.

Michelle Scrogham

Yes, concise would be better, because we are quite time limited. I want to ask about strengthening co-operation between the MOD and the Department of Health. It sounds like that is quite a weak point at the moment. We only have a few areas in the country where we actually operate in our hospitals. What do you think expanding that—getting the message across to the rest of our hospital footprint and perhaps bolstering some of the gaps in areas within the NHS, so that they are able to draw on the expertise we have in Defence Medical Services, and vice versa—would do to the service?

Lt Gen Bricknell

In the SDR, we recommended consideration of some form of enterprise board that would look beyond the Department of Health and the Ministry of Defence, similarly, for example, to the defence medical board that the US has. Our concern was how this integration was presented from a strategic perspective so that there would be shared commitment between Departments. There are a lot of very positive things happening, but of course the challenge is 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.

Maj Gen Hodgetts

On the clinical side, there is absolutely a role for 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. I would also highlight the British Medical Association; you will 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 has definitely taken leadership on that.

Chair

I will reiterate what I said at the outset. We only have half an hour left, and there is a significant amount of ground to cover. May I ask you to be as succinct as possible; otherwise, many of those areas will not be covered?

Jesse Norman

If you have additional testimony, you can send it to us; you do not have to cover everything in oral testimony now. If the BMA is involved, we can be sure that it would go on strike within a few days of the declaration of war. Which are the three or four leading clinical centres for dealing with military-related injuries in the UK?

Maj Gen Hodgetts

Over the last 25 years, we have very much invested in Birmingham, with the Royal Centre for Defence Medicine. We have specific substantial clusters of uniformed personnel in other joint hospital group facilities, such as James Cook in Middlesbrough. We have the Plymouth-based hospital, and we have quite a lot of people in Frimley Park and people in Oxford. Of course, in conflict, we would be drawing very quickly on our regular staff and deploying them, so we would have to consider the impact on the facilities where those people are now.

Jesse Norman

No kidding. You have talked about the great success of the treatment of injured servicemen and women in Iraq and Afghanistan. What was the maximum number of people who were affected and injured at the peak moments of those conflicts?

Maj Gen Hodgetts

It was small scale. I did four tours of Iraq and three tours of Afghanistan. I cannot necessarily give you a specific number.

Jesse Norman

Was it two dozen? Was it 500? Give me a sense of scale.

Maj Gen Hodgetts

A very substantial burst of casualties would have been 10 casualties at a time. That would have tipped us, probably, into major incident mode in the 25-bedded field hospital in Camp Bastion.

Jesse Norman

So if we get anywhere near anything that could be remotely hot, we are going to be overwhelmed, given the scale that you are discussing.

Maj Gen Hodgetts

Yes. I can cite what the German surgeon general has said, because it is in the public domain: Germany is preparing to deal with 1,000 troop casualties per day.

Jesse Norman

Is that incremental per day? So 1,000 on day one and 2,000 on day two, minus whatever the ones they—

Maj Gen Hodgetts

1,000 per day.

Jesse Norman

Yes, so there will be an extra 1,000, but the sump will be going up by 1,000 minus the ones they have managed to return to service.

Maj Gen Hodgetts

Yes.

Jesse Norman

Okay. That is going to grow pretty quickly.

Maj Gen Hodgetts

And that does not take account of the civilian casualties. Those are military casualties. If you are fighting on your own soil or within reach of indirect fire, you will take civilian casualties too.

Jesse Norman

Drones are flying over and people are being hit; they are not as accurate as you might like; they are possibly being targeted more randomly than you might like; the rules of war are not being obeyed; lots of people are getting hurt. Obviously, the difference between that scale of planning and the scale that you have talked about in Iraq and Afghanistan is at least one and possibly two or three orders of magnitude. What preparation have you done in case we do end up with hundreds of servicemen and women injured every day?

Lt Gen Bricknell

I think that should be asked to the Department—both the Ministry of Defence and the Department of Health.

Jesse Norman

Let me put it this way: what did you see when you were doing work on the review about the Department’s planning?

Lt Gen Bricknell

At the point of the SDR, it was more a conversation of what was intended to happen in terms of planning. In terms of what is now in the public domain, I do not think we yet see a plan. What we have seen is a lot of work to plan to develop a plan.

Jesse Norman

That is not very encouraging.

Lt Gen Bricknell

Again, we cannot speak for the Departments. If you look at our other NATO allies, they are probably further ahead—

Jesse Norman

And you have benchmarked this with those other major NATO allies, along the lines of the German experience, have you?

Lt Gen Bricknell

In the public domain—

Jesse Norman

You know how far short we are, at least privately, even if not in the public domain.

Lt Gen Bricknell

In the public domain, we can see that they have been conducting physical exercises to test systems. We have not seen in the public domain—

Jesse Norman

So any comparison with Iraq and Afghanistan, however brilliant the achievements then, is mad, because in those conflicts it was at least towards a magnitude smaller than what we would expect to see in the kinds of scenarios we are talking about. It is a course of false optimism—that would be the worry.

Lt Gen Bricknell

This is why we are discussing capacity rather than capability.

Jesse Norman

Fine. Final question: what do we do to improve national awareness of this problem? You have talked about running some casualty exercises within the NHS or elsewhere; obviously, local government has a potential role as well. The last Prime Minister completely failed to talk about a national conversation. We now see the Defence Secretary starting to do that. What is your view on how we get people thinking about this seriously?

Maj Gen Hodgetts

I think this is a start. We are exposing the key issues here. I will 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. That is absolutely known.

Jesse Norman

So you are on screaming red alert, given the difference we are talking about, but you are doing it at a classified level, rather than in public with us.

Maj Gen Hodgetts

Yes. What I would say publicly is that the capacity of our deployable hospital capability has shrunk to perhaps 10% of what it was at the end of the cold war and even into Operation Granby in 1990. The unit of currency before was 400 to 800-bedded field hospitals in the British Army of the Rhine, and we put out 500 beds in Iraq in 2003. 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.

Graeme Downie

Thank you both for taking the time to be here this morning. I want to pick up on some of the points that Jesse was talking about, and expand a little into how prepared DMS would be to evacuate and repatriate in a world where you are not going to have air superiority and where helicopter support is unlikely to be available—again, very different from the situation in Afghanistan. What is the level of planning or awareness in the Department on how that would happen?

Lt Gen Bricknell

Back to what we tried to raise in the SDR, we were concerned about theatre-level medical capacity. 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. Clearly, we know that the work to handle the casualties when they arrive in the UK is in train, but there are quite a few hundred miles between the ports of disembarkation here and the points at which our casualties would be injured. There would be some multinational collaboration across NATO.

Graeme Downie

I want to pick up on that, because you talked in the introduction about the collaboration of allies on blood and drugs. You talk about us being at different levels of preparedness from our NATO allies. Are we impacted by being further behind when it comes to that collaboration on blood and drugs, if you are moving from eastern Europe to western Europe as a stopping-off point before coming back to the UK?

Lt Gen Bricknell

From a regulatory perspective, the UK is fully integrated in the discussions with the NATO countries. Part of the challenge is that most of the regulation is in the EU frame rather than the NATO frame, so the actual negotiation around regulation needs to embrace discussion about regulation in the EU alongside working within NATO itself.

Graeme Downie

We have to make sure that we do not think of this purely as a NATO issue; it has to be an EU discussion as well.

Maj Gen Hodgetts

It does. Indeed, there are derogations within EU policy for movement of casualties, blood and drugs across EU partner nations’ borders. I know that we have been looking at how we can access those derogations as well. In terms of where the vulnerabilities or frictions are in the chain from point of wounding back to home, have we got enough of the right casevac vehicles? Casualty evacuation is moving a casualty without ongoing medical treatment, so that would be your unmanned vehicles. Then you are into medevac, which is your armoured ambulances and your protected mobility. Moving back through the European continent, you will get to a strategic hub, and we need to project forward and pull our casualties back to the UK. How would we use ambulance trains, ambulance buses and ferries to get casualties from a channel port back to the UK, or sailing Eurostar into St Pancras and offloading a large number of casualties to redistribute? We have to think of all these elements in that theatre medical plan, and in particular not just focus on the RAMP—the reception arrangements when they get back to the UK.

Graeme Downie

You mentioned the exercises that have taken place in Birmingham and some other sites around England. Not to be the Scottish guy on the Committee, but are there any discussions with NHS Scotland and the Scottish Government about similar arrangements in Scotland? With that kind of mass, large-scale conflict event, presumably you would need to distribute more around the UK.

Maj Gen Hodgetts

I cannot give you the evidence of that definitively, but I know from speaking to colleagues that there is engagement with the devolved Administrations.

Derek Twigg

Drone warfare has completely changed the nature of how we will deal with casualties in the future—is that correct?

Maj Gen Hodgetts

Yes. In particular, it has identified the vulnerability of any facility that puts a red cross on top. No longer will we set up in a field flying a red cross. We will have to look for hard cover and for dispersion, and for smaller units that are more mobile, because that is what gives us protection. But there is a flip side: aggregation gives you sophistication. When you disperse into smaller bits, you lose that sophistication and the ability to treat as effectively.

Derek Twigg

Can I clarify one other thing? You mentioned the German figure of 1,000 casualties. If there were 500 or 300 casualties each day, depending on their severity, is it your view that, given the state of the NHS and the capacity issues and the pressure on it, the Government would have to decide whether priority was given to treating wounded service personnel or civilians back in the NHS, because otherwise the whole thing would collapse?

Lt Gen Bricknell

We saw with covid that when we understood that we needed to look after the whole system, we reinforced the social care component to get patients out of hospital, so that you had more capacity at the front end. 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 that surge.

Derek Twigg

Basically, there is no way, in terms of trauma and urgent medical need, that you will be able to maintain that level of casualties and the NHS at the same time. All your reservists would have to be called up on that basis, surely.

Maj Gen Hodgetts

Clearly, there is a health enterprise risk that if the NHS has to take more military patients and—

Derek Twigg

Sorry, you would have to take, if not everyone, most of the reservists in the NHS to deal with the casualties that you have on the frontline, never mind back in England.

Maj Gen Hodgetts

Yes. There are two issues there: taking the staff out, but also the NHS making the decision that it has to treat those military patients and therefore it cannot treat all the civilian patients. We know from covid that that has a risk and that cardiac patients and cancer patients suffer.

Derek Twigg

We have not discussed the mental health casualties of PTSD breakdown and severe anxiety. Is any work being done on the number of casualties that we will have to deal with, and how we are going to do that? We have not got a lot of time, but I just wonder whether work is going on and whether there is somewhere we can have that information.

Maj Gen Hodgetts

We know that about 20 to 30% of DNBI—disease non-battle injury—casualties will be mental health-related, so a very significant number will have to be managed, and the aim would be, if possible, to deal with those as far forward as we can.

Derek Twigg

Have you done any war-gaming about the number of casualties on that basis?

Maj Gen Hodgetts

I cannot answer that without having to investigate.

Derek Twigg

Okay. Maybe you could let us know. What will the lead command model enable the DMS to do differently, and what problems will it not resolve?

Lt Gen Bricknell

Again, I will speak with 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. That was one of the SDR recommendations, and the Department has announced that it has changed the name so it is now Defence Medical Command, and it is now working out 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 that we are able to make choices about things like investing in protected ambulances so that you can collect casualties off the battlefield, versus any other element of the armour protection that the Army needs in the battlefield. We would hope that the lead command model gives more authority to direct the way in which the military medical services are run.

Chair

Based on the information available to you, what tangible progress has the UK made against the NATO medical action plan, and where are the largest remaining gaps?

Maj Gen Hodgetts

I will start with the history of the medical action plan, because that was under my chairmanship of COMEDS. 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 at the Washington summit in July 2024. 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 the Netherlands in 2025. That is the history behind it. All NATO nations are expected to address the weaknesses within their country against around 30 lines of activity within the medical action plan.

Chair

Very concisely, what progress has the UK made on that?

Maj Gen Hodgetts

A parliamentary question has been asked about that, and the response was that the MOD “has identified activity in all five themes”— the five areas of risk that I identified—“as set out in the NATO Medical Action Plan and the assessment provides the basis for cohering and prioritising activity.” That is the official answer, but the specifics of where there is difficulty in closing with those lines of activity is not in the public domain, and that would be a valuable avenue for this Committee to explore.

Chair

In your opinion, what are the largest gaps? That is what we are interested in.

Maj Gen Hodgetts

Against those five themes that I have already identified: medical evacuation; enough platforms; enough hospital infrastructure—

Lt Gen Bricknell

Essentially, it is capacity across the whole system.

Chair

What lessons can the UK draw from our other NATO allies in preparing both our civilian and our military health structures?

Lt Gen Bricknell

It would be interesting to compare just how much money other countries have put into their military medical services. As an example, Germany has announced a €750 million project to procure protected medical infrastructure—

Maj Gen Hodgetts

It is €570 million, not €750 million.

Lt Gen Bricknell

Sorry—€570 million to put the forward medical services into protected containers, so that if they are attacked by a drone, they have more defence. Australia has culminated a programme called JP2060, which was about completely refreshing its military medical services; that was a $420 million upgrade programme. Canada has announced $75 million investment into partnership between Canadian Blood Services and the Canadian armed forces. The Estonians have announced a €150 million project to develop modular medical systems for forward medical services. As an order of magnitude, it looks like our NATO allies are investing a significant amount of money into their miliary medical services.

Chair

So they are taking it a lot more seriously than we are.

Mike Martin

Is there an opportunity for casualty sharing across NATO, so we treat each other’s casualties? What would that look like?

Maj Gen Hodgetts

Absolutely; that is what we have done in previous operations, and it is what would happen in future operations, particularly where areas of operation overlap. There is also opportunity for multinationality in our field medical treatment facilities to buy out risk. Medical provision is a national responsibility, but we have learned in the last 30 years that multinationality works. For example, we might be deliberately planning a medical treatment facility, perhaps in the enhanced force vigilance area of Estonia, where we are the lead framework nation, and other troop-contributing nations might provide medical capability to the framework nation at a British facility. That might give us, in pinch-point specialities, some freedom to manoeuvre elsewhere. We need to think about multinationality. Yes, we will be treating each other’s patients, which is why, at the core of NATO, is interoperability in the equipment and guidelines that we use.

Ian Roome

Do you think the investment in Defence Medical Services meets the requirements of the SDR?

Lt Gen Bricknell

The only real announcement was in the defence investment plan, which was £50 million over four years—I have just given you some reference points. From an SDSR perspective, the bit that we did not see was any investment into the primary healthcare infrastructure, which was specifically mentioned in the SDSR chapter. I would highlight that the Care Quality Commission, which reviews medical services in defence as well as the wider NHS, has made some significant observations about the quality of the infrastructure in the defence primary healthcare network. I was surprised not to see anything at all about that. On the allocation of £50 million, I will hand over to Tim.

Maj Gen Hodgetts

It is very welcome as a good start; £10 million is for infrastructure and the other £40 million is about improving outcomes far forward. However, I identify clinical capability that is not there for the next conflict. I usefully remember it as non-C ABCDE. The “non-C” is non-compressible haemorrhage. The money for tranexamic acid auto-injectors was great, but we still need the surgeons to do the operation, and the next big development that will disrupt outcomes in pre-hospital care will be from non-compressible haemorrhage in the abdomen, chest or head. That is what we need research and development investment to do. The “A” is about antimicrobial resistance. We are fighting a war in an effectively post-antibiotic era. World war one was pre-antibiotic, but we now have so much antibiotic resistance that we need the solutions—the phage technology and new antimicrobials—to be fighting that antimicrobial resistance. The “B” is about blood far forward. A lot being done about that, and there is a really good relationship between DMS and NHS on blood transplant. The “C” is about cold injury mitigation. The places we have been in the last 25 years have been hot, but all the likely scenarios for where Russia may go next are cold: the Baltics and the High North. We therefore need to adjust our equipment and our guidelines to be able to manage patients effectively in that very difficult situation. The “D” is about data. I have already covered that—the point at wounding, through to the NHS—and the “E”, I have already covered, which is about the right evacuation platforms to get the patient to surgery in as timely a manner as possible.

Ian Roome

How do Defence Medical Services facilities compare with the NHS equivalent?

Lt Gen Bricknell

What I cannot do is more than just highlight the Care Quality Commission report, which this year also reviewed how there has been progress over the last seven or eight years. The Care Quality Commission does highlight that there has been quite a lot of organisational progress, but no real investment across the infrastructure. A number of medical centres have been newly built, but, taken across the entire infrastructure requirement, there are some significant risks in terms of the quality of the primary care centres.

Ian Roome

Given the armed forces covenant, which the MOD is saying it will now bring into law, do you think that we are failing service personnel with the facilities that we are treating them in?

Lt Gen Bricknell

I would think that some visibility of the money allocated to do this would provide some reassurance.

Ian Roome

Has there ever been an analysis of getting service personnel back to fighting fitness versus recruiting new service personnel to do their roles?

Lt Gen Bricknell

What we know, using the armed forces continuous attitude survey, is how much members of the armed forces value their access to healthcare and dental care. In covenant terms, it is really important to maintain the confidence of armed forces personnel in the health and dental services that they have access to.

Maj Gen Hodgetts

I do not know whether you are intimating about medical employment standards there, but there has been very detailed work and two cohort studies—this was published in January 2021, so it may need review now—into the amount of medical risk that was being taken within medical employment standards: was it enough risk? 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 the light of the current geopolitical situation.

Emma Lewell

Going back to the NATO medical action plan, where do we rank alongside our allies in terms of identifying and addressing weaknesses?

Maj Gen Hodgetts

It is very variable across each country, depending on what risks are being carried, so it is a bit like comparing apples with pears. What I can say is that, if you look across the alliance, there are issues in each contributing nation that need to be addressed.

Emma Lewell

So you would not be able to say whether we are near the bottom, the middle or the top in terms of addressing those weaknesses?

Maj Gen Hodgetts

Well, Martin has identified where we are now in terms of investment in modernising our infrastructure. That is £10 million for hospital infrastructure over four years, compared with the hundreds of millions that Germany, Australia and other countries are investing.

Emma Lewell

There is lots of talk about a potential attack on NATO by Russia by 2030. How ready do you think we are, and what more do we need to do to be ready?

Maj Gen Hodgetts

If we had to go out of the door today, we would go out with an effective force. The issue is the volume of patients that we might be presented with. We are ready to go out and fight; I have no hesitation in saying that. What we lack is capacity if we had to do this at huge scale.

Emma Lewell

In terms of defence medical readiness, what worries you the most? If there was an attack and we had to act, I know that we would be ready and would go out, but what is it that causes you the most concern?

Lt Gen Bricknell

We highlighted in the SDR the concern about theatre medical capacity. What has not been put into the public domain is any response to that concern.

Emma Lewell

But you have seen that response.

Lt Gen Bricknell

The Department, to explain what it might—

Emma Lewell

So it exists, but is not in the public domain.

Lt Gen Bricknell

I cannot speak for the Department.

Emma Lewell

Okay, I will leave it there. Thanks.

Chair

As I mentioned before we started the session, there is a lot of ground to cover in an hour. Obviously, we have not been able to draw upon all your esteemed experiences. If there is anything that you feel we have missed in this session, we would be very grateful if you can send that across to us in writing, and that can then inform our future deliberations. With that, I thank you once again for your valuable time.