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

Oral evidence, 27 October 2026.

Witnesses

Dr Darren Mann, Ed Button, and Dr Katie Geary

Chair

I am very pleased to welcome our panellists for the second hour. Dr Darren Mann is a visiting fellow at King’s College London—a very warm welcome to you. We also have Dr Katie Geary, who is a senior medical director at International SOS. It is a pleasure to welcome Ed Button, who is a managing director for government services international at International SOS. Given that we have only an hour, we will crack on with the questioning, beginning with Jesse Norman.

Jesse Norman

Thank you very much for coming. You heard the revelations coming out of the previous session. Dr Mann, one of the questions was about the different nature and location of conflict. If we go back to the present experience in Ukraine, what lessons ought DMS to be taking at the clinical level from those combat injuries? Has it been pursuing them? Has it been looking at how people—civilians and serving solders—have been hurt, on top of the different context for warfare and the implications that that has for casualties?

Dr Mann

I think the context is well known because Ukrainian forces and civilian authorities have made those circumstances perfectly clear.

Jesse Norman

Not at the clinical level.

Dr Mann

Yes, I think at the clinical level. You can find live videos streaming online, and you can see the consequences—

Jesse Norman

Our people have been in touch with their medical counterparts in Ukraine to understand the nature of those stresses and the effects?

Dr Mann

Absolutely, and there have been integrated training programmes between the two and information cross-exchange. As you know, in hospitals to which casualties have been evacuated, some of our personnel—

Jesse Norman

We train their medical doctors, and they train our medical doctors in the armed forces, because obviously it is a two-way flow now.

Dr Mann

It is bidirectional, and whoever is most current does the training. That would be the Ukrainians.

Jesse Norman

What lessons are we drawing from that?

Dr Mann

The fundamental lesson is that the protections that we assumed would apply historically to medical treatment facilities and medical staff no longer apply.

Jesse Norman

You mean the rules of war are different? They are subject to attack in the same way.

Dr Mann

That is the interpretation that you can draw. The traditional conventions—the norms of war—that we have come to rely on are no longer in place.

Jesse Norman

That would imply much more aggressive ruggedisation or protection of some of the near-front medical services that we would be deploying.

Dr Mann

A change in the way that medical support is provided, a change in the amount of time that medical support needs to be provided for in the field, and a loss of ability to transport the injured through the air, so road transport is now routine, followed by rail transport, significantly—80% or so of casualties ultimately transfer by rail. That means we have to adapt our rail facilities and the ability to perform surgery on a train. The whole point, as made by the generals earlier, is that time is not a resource; time is our intervention for saving life on the battlefield.

Jesse Norman

As you go further north, the constraints change more and further adaptation is required. Is that right?

Dr Mann

Yes, but then so is the desolation and the desperation, because the consequences of prolonged in-field care are that certain lifesaving measures ordinarily applied as temporary—for example, tourniquet application—now become a lifesaving procedure. The concept of what many of us call a silver medal mindset comes into place—the idea that you can put a tourniquet on to save someone’s life from catastrophic bleeding, but expect then to remove the tourniquet to save the limb, will probably not be applicable in this situation.

Jesse Norman

But you are doing the best you can under extremely adverse circumstances.

Dr Mann

Yes, according to the conditions.

Jesse Norman

Dr Geary and Mr Button, what adaptations to tactical combat casualty care procedures do you expect to see in the light of Ukraine? Is that something you have thought about at all?

Dr Geary

Yes, absolutely. What Ukraine teaches us is that the distribution of injuries is different. Certainly during Afghanistan and Iraq, casevac was part of our established casualty care pathway. It no longer is; now it is a constraint. Our treatment, application and ethics have to become far forward, much more brutal, and our application to war surgery and so on has to be further forward. As Dr Mann has said, it is a dispersed environment, because the normal rules of war do not apply, and so where our forward operating base or field surgical unit might be are also factors.

Jesse Norman

If you are right, we are talking about a move from a piecework approach to casualty treatment towards an industrialised approach to casualty treatment. Is that right?

Dr Geary

Absolutely.

Jesse Norman

That is a completely different mindset. Are we remotely prepared for that?

Dr Geary

I will defer to my colleague.

Ed Button

I cannot speak for Defence Medical Services—

Jesse Norman

You can speak about the UK. What is your evaluation from an International SOS standpoint? In an international evaluation of the UK, across the NHS and the military, how many out of 10? Where are we? Give me some sense of that.

Ed Button

I do not think we are prepared is the short answer.

Jesse Norman

We are way off the pace.

Ed Button

I believe we are. If I compare it with what we see among our other clients across NATO, the United States, the Australians or Five Eyes, they are far further forward in every aspect of this, in preparedness.

Jesse Norman

I am dying to ask Dr Mann a question about the comparison with covid, when we were woefully ill-prepared for the wrong disease. Is there anything you want to comment on there?

Dr Mann

One major comparator is that we knew covid was coming—we knew that a pandemic was coming—and we understand that there is a general realised threat of a war coming. Our opportunity now is to prepare for that. We need to address several areas of wilful blindness.

Jesse Norman

Current politicians and leaders in the NHS and the other authorities could be held responsible by a Heather Hallett-type future inquiry for failing to prepare. Essentially, that is what you are saying.

Dr Mann

I would not want to be in a position where our efforts are examined after the event; I would like to look at our efforts now.

Jesse Norman

No, I understand. I am just trying to get a sense of the magnitude of the problem. Thank you.

Emma Lewell

Good morning, all. You have just been speaking with my colleague Jesse about how war has changed and the difficulties that that poses for Defence Medical Services. How equipped do you think UK Defence Medical Services are to deal with that? What do you think they would do in the event of an attack on medical infrastructure?

Ed Button

I will answer that in this way: the previous panel talked about capacity, and 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 or systems approach, and that is not what we are seeing at the moment. I think pockets of excellence within the DMS want that to happen, but there is not the funding to get there.

Dr Mann

What I think is key is the whole-of-nation, whole-of-society approach. I believe that the responsibility of Government is to integrate across the capabilities open to us. We spend a lot of time talking about the Defence Medical Services, which obviously have a key role, particularly in the in-theatre piece. We have talked about the NHS and how those two elements adapt and integrate through the reception arrangements. However, I believe that the independent and private sectors—not just private healthcare, but the sectors that hold the transport systems: the ferries, ships, planes and trains—have capabilities that are at the moment invisible to planning. None of that is owned by Government or by defence.

Emma Lewell

Who in Government should be grasping the nettle here and doing all that co-ordination work? Whose responsibility is it?

Dr Mann

In the absence of a Minister for War, my belief is that it should be the Cabinet Office, through civil contingencies.

Emma Lewell

Are you seeing any of that preparation work being done? Are you confident?

Dr Mann

I think there is awareness of it. You will be aware that the UK Health Security Agency held a major exercise a few months ago that modelled exactly what you described: missile attacks on hospitals, a cyber-attack on the red, amber, green traffic light system itself, and a war breaking out in Europe, each developing hundreds of casualties—all that descending. Representatives from core Government Departments were there, so they have the visibility.

Dr Geary

Health is devolved, but EPRR is sort of reserved, isn’t it? I think some of it is falling between the cracks at the moment. Scotland is actually exercising RAMP—it is part of RAMP now—and I sat on the Scottish resilience panel earlier in the year. There are pockets within the NHS that are coming to the table and, as Ed said, pockets in the DMS, but this is also about whole systems. If we look at something like antimicrobial resistance, what happens on the battlefield is exported to the host nation’s health, so we need to think about how what happens externally comes to bear on host nations. Some thinking has to be done at Government level about how all those Departments get together to ask, “What is the best way to create resilience in the UK as a whole, including the devolved nations, that supports the DMS to do the extraordinary things they do with a lean force, and to use the private sector to augment where possible?” We have 41 years of doing that.

Emma Lewell

Do you think the defence readiness Bill should be the vehicle for some of that?

Dr Geary

I think it is a talking point to start the discussions and to accelerate planning and preparedness. However, you will not be able to respond unless you have a common language and a common focus, have started your training and are exercising to deliver. We have to start talking about the hard truths: the reality of the Ukrainian war is having a massive impact on the population.

Dr Mann

The defence readiness Bill is our key opportunity to address some of these very visible needs. For example, covid showed us that it is very expensive to buy your way out of trouble. If you put arrangements in place during peacetime to lease, hire or otherwise set up service level agreements, you will get better reliability and a better price than if you turn up when the disaster has struck. Arrangements with private and independent sector providers are open now, but that will look very different once the whole world is calling on them. The second point for the defence readiness Bill is the healthcare workforce and the regulations that apply to it—particularly the professional regulators: the GMC, the nursing council and allied healthcare. If you remember in covid, medical staff were asked to take on work outside their normal areas of expertise in challenging circumstances. At the same time, they were told to observe the regulations at all times, stay within their competency and make sure that their medical indemnity insurance was in place. That is completely incompatible with the need for a whole-system approach to warfare casualty management.

Emma Lewell

That is helpful; thank you.

Mike Martin

I have two very quick questions. Do you think we should include stipulations in the defence readiness Bill on the requisitioning of transport for casualties, such as trains, planes and all the rest of it? You are nodding, for the record.

Dr Mann

Yes, I am nodding, but I think that “requisition” is a strong term to use.

Mike Martin

With compensation.

Dr Mann

Yes, agreed. For Government to get the best deal, you could make those arrangements in advance, rather than seeking requisitioning.

Mike Martin

Arguably, requisitioning would be the best deal, depending on the level of compensation.

Ed Button

It all comes back to capacity and getting upstream of it. In answer to your question, yes, I wholeheartedly agree that multimodal transport is going to be part of the solution, so we need to get ahead of it.

Mike Martin

And you would need a whole bunch of national security exemptions in health and safety or whether people are acting within their competencies—you just need to make it work. Again, all of you are nodding, just for the transcript. Dr Mann, you said in answer to Jesse earlier that there are “several areas of wilful blindness” when it comes to Defence Medical Services. Can you just list what those areas of wilful blindness are?

Dr Mann

I don’t think these apply only to Defence Medical Services; I am thinking of the nation’s entire healthcare estate, including structure and staffing. For example, let’s look at the healthcare estate we have talked about: the NHS and its conditions of work and occupancy. Let’s now consider the private healthcare sector and private hospitals. The NHS perhaps has 100,000 beds, but private hospitals have perhaps 10% of that, or 8,000 beds. When those hospitals’ service capacity was reserved in covid, only 1% of those 8,000 beds was ever utilised for covid. It was actually the same for the Nightingale hospitals, which was a constructed capacity. The management of that bed stay and occupancy should be visible on a single display or dashboard, as a single visibility status, and I believe there is blindness to that. It is the same for staff, but it is the other way around. Many staff will be double-counted, because many staff working in the NHS will also work in the private sector. We then have the regulars going out and the reserves going out, and potentially a sponsored 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 they would do in the event of hostilities. We have blindness around that at the moment.

Mike Martin

You’d think it would be easier now with the IT systems that we have, whereas they were doing it on clipboards.

Dr Mann

We have an opportunity to make it all visible now.

Mike Martin

To summarise your answer, it is about the data to enable us to drive the operational response and make it most efficient.

Dr Mann

Yes.

Chair

Let’s move on to the role of commercial providers and voluntary organisations.

Graeme Downie

I want to pick up on some of those themes as well, Dr Mann. Something that happens across public services is that they say, “Don’t worry. The voluntary sector or the private sector will take care of that.” However, they do so without an understanding of what they actually deliver, and I suspect we also see wilful blindness in that area. Can you outline exactly what you think commercial providers or voluntary organisations can offer in a large-scale conflict? Crucially, what can they not offer?

Ed Button

If I look at how we integrate with other NATO partners and what they ask of us, as an organisation we do three things. We co-ordinate care, which is the movement of people, we deliver hands-on care and we do training and doctor development—three very simple things. What we offer to them and the way they use us is effectively as a partner. We are not commerce or industry, and we are not treated as such. We are treated as a true partner, and we are 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 from many others in the defence sector, and I talk from previous experience. I believe that to help solve this capacity problem, industry should be looked at through a system of systems approach. If you were to look at a soldier getting wounded in eastern Europe, and their recovery all the way to their return to fighting, there is no one element that is going to solve that entire chain. You are going to have to integrate a variety of different capabilities from both the private sector and the public sector, including defence, to make that work in the most efficient manner.

Graeme Downie

We heard in the last session that the problem was capacity, and you talked about the role of the private or voluntary sectors to fill in those blind spots. Do you feel that you have adequate engagement with Government to know where you would plug in to those areas effectively in the event of a large-scale conflict?

Ed Button

Talking just for DMS, yes—absolutely. We have the conversation with them. They know what we can provide. They are then bound—

Graeme Downie

I sense a “but” coming.

Ed Button

Well predicted. The problem is then actually translating that into contracting for some sort of capability or having the capability to draw on that excess capacity. That is where the bind is. For comparison, I have 304 individual Government agencies as customers, some as far east as Australia and some as far west as the UK, and every single one of them is ahead of where we are in terms of the planning, the understanding of what we can offer and how we integrate. And we are part of that planning process. It is not that defence med does not want to do it; it is that something is stopping them and it is probably around finances and the ability for J&A commercial to get in the way and say, “Oh, you cannot do that.” If we do not get ahead of it now, you are going to be too late. That is because resource is finite, especially in the medical space where everyone is going to be competing for the same thing.

Graeme Downie

Would it be fair to say that they do not know the right question to ask? We know where the blind spot is; we know where we need you, but we do not know if we need 100, 200, five, ten or 20 of whatever.

Ed Button

I think they know the right questions. In the previous session, it was very clear what the UK has outlined in the DIP versus peer competitors, and we are a long way off the mark.

Dr Mann

I would like to go beyond that, though. Of course, International SOS is a recognised and a refined provider, but the potential scale of casualties that we are talking about for the UK—the RAMP Large number—is understood to be about 400 a day. None of us should underestimate, of course, the impact of that on an individual. Four hundred is the current operating number. Germany, as we hear, is operating at 1,000 a day. I believe that those numbers would completely overwhelm even a very capable provider. We have to think in a different way. I am looking at the major logistics providers—the people who own the shipping containers. I am looking at the ferry companies. Who is asking the hospital ships—the mercy ships? Where are they going to be? Who is asking the major ferry providers? Who is asking the airframe manufacturers, many of whom, as we know, are based in Europe? It is just a different scale.

Graeme Downie

I can feel the Chair’s eyes drilling into the side of my head. To flip that slightly on its head again, during covid we saw the reliance on local voluntary charities that just filled in and jumped in because that is what they do. To what extent are we able to plan that grassroots level as well, or is that something that we just kind of assume as well?

Ed Button

I would not be able to speak accurately to that, so I will not. What I would say is this is all about preparation. Until you go out and ask that key question of the local volunteering organisation, and someone is co-ordinating that, you are not going to know the true answer.

Michelle Scrogham

We are talking about capacity, so I will ask how dependent your provision is on the reservists that would be called up and disappear under the normal circumstances?

Ed Button

Broadly speaking, it is not. We of course have reservists, and as a veteran I sit here as one myself—though I am sure I would be called up to the pointy end of things rather than the medical end. But this is about the balance of risk. As for any commercial organisation, we do not rely solely on UK reservists to deliver our capability. It does talk to a very valid point, though, in terms of talking to other nations, and getting ahead around the idea that in order to fulfil the criteria or staffing that is going to be required at scale, you are going to have to make, not necessarily a compromise, but regulatory changes to allow that to happen.

Michelle Scrogham

Are you saying that mobilisation would not have any effect on your capacity?

Ed Button

It would not be significant.

Chair

I wanted to come to your good selves about the work of International SOS. In the event of an article 5 conflict, how would your organisation, Mr Button, manage effective delivery of multiple contracts to both the UK and our NATO allies? How would that operate on the ground?

Ed Button

The way we interact, or what we are asked to do by different nations, differs. What we do for the Department of War is very different to what we currently do for the UK MOD. The short answer is that that is about load balancing our capacity and capability. Until that point is triggered, I would not be able to give you an absolute answer as to how we would do it, but I can give you the reassurances and absolute planning knowledge that we have the capacity to execute every single commercial contract we have. The way you should look at it—this comes back to my point of a system of systems—is that this is not about us providing medical staffing, but about the co-ordination of care into existing network hospitals. It is not like we provide the whole solution; we are part of the solution—sometimes the co-ordination and sometimes the staffing.

Chair

Dr Geary, would you like to add anything to that?

Dr Geary

I also think there is a timing element here. We can say that we can deliver on every contract currently, but there will be a finite number of contracts, even given an extra EU resource pool of medical personnel. There is a time to plan, a time to train, a time to exercise and a time to deliver. The longer there is a delay to acknowledging that we should be a little bit further ahead in the UK, the more that delay costs us access to additional resources. That would be right to say.

Ed Button

I agree. This all comes to getting ahead of it and getting upstream of the actual asks. If the UK follows a pattern of acting when it is too late, there will be resource constraints. From a hospital ship to a container, you are at the back of the line. Then it is too late, and you are not getting the outcomes you require, from both a moral component—the duty of care component—and a force regeneration component.

Chair

So it basically depends on how quickly our Government mobilise to prioritise, otherwise we will definitely be at the back of the queue.

Ed Button

Everyone will be after the same resource. What I think 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, and part of that is balancing the risk of where the resource will come from.

Chair

Dr Mann, I want to bring your perspective into this. There are commercial providers and voluntary organisations. We saw, during both Afghanistan and Iraq, that voluntary organisations such as Help for Heroes provided not only physical rehabilitation but mental health services to injured personnel. How would you compare and contrast and envisage the role of those distinct entities in the event of a conflict?

Dr Mann

I think that we should return to a whole-of-society approach. We understand that, where mental health support is concerned, many people find comfort in the ability to talk with people who understand what they have been through and seen, and who have had a shared experience. That allows you to segregate this into different deliverables. Ultimately, everyone’s experience will resonate.

Chair

I agree with you about the whole-of-society approach. When we were out in Finland and Estonia, the Committee was very impressed with that concept of total security. In terms of the role of voluntary organisations, what sort of emphasis could be placed on them in the event of a conflict, or do you think it would be more toward commercial providers?

Dr Mann

No, I think there is huge role for the voluntary sector. If you speak to St John Ambulance, the British Red Cross and some of the service voluntary organisations, you will hear that it is hard for many of them to find a link point into Government to understand how to set out and cohere what they can deliver. Admittedly, some of those organisations have been witnesses to some of the exercises we have heard being discussed, but they have not been integral to them, which is what requires cohering centrally.

Chair

Thank you. Let us now move on to medical supply chain resilience and other issues.

Mike Martin

I want to dig into stockpiles—pharmaceuticals, medical equipment, blood. Maybe we can start off with where we are on that as a nation and a military.

Dr Geary

Blood stocks are always a cause for concern. There are always calls going out. If you take the German numbers for how many casualties there would be, you would deplete UK blood stocks by 25% a day—and those stocks are managed per devolved nation, by the way; we do not have a centralised blood stock. That is an issue, and General Hodgetts mentioned it as one of the defence medical research issues. It is of paramount importance.

Mike Martin

There would be an appeal and everyone would give blood, but would we have enough medical equipment to get it all out?

Dr Geary

To get it to the front—yes, that is the point.

Ed Button

There is a tendency to focus on the covid experience—we are hostage to the last time we saw this as a nation—when we did not have enough masks and gowns. That is one component of the full thing. As for where I think our weaknesses lie, blood is actually being addressed as best as DMS can, in terms of Blood Far Forward and freeze-dried plasma, and I believe there is money within the DIP for that. The constraining factor comes when everyone needs a stretcher, a litter and all the other ancillary medical equipment to move people back from the frontline. That is probably where we are short. There have certainly been parliamentary questions about whether the current arrangements—the contract to provide clinical equipment to the DMS—are working; I suggest they probably are not. At the moment, attention needs to be on what will be required and how on earth they will get it. I cannot see a contractual mechanism for doing so, nor even an understanding of the magnitude of the issue in terms of supply chain, lead times and critical equipment.

Mike Martin

How many days’ worth of medical supplies should we hold? With ammunition, you are meant to hold three months’ worth. Is that what we are talking about?

Ed Button

I am not a doctor, so I am going to take the fifth on that one.

Dr Mann

My career as a trauma surgeon was interrupted by covid. I was medical director for the Cabinet Office personal protective equipment cell for three years, so I know what a stockpile that has not been kept in date, or in order, looks like. Whichever catastrophe you are managing, you need to understand whether there is a sovereign ownership piece around it—to what degree do you need sovereign solutions? On stockpiles, admittedly, much of the equipment that we relied on in covid—and much that would be relied on for casualty management—saves lives, but it is made in the far east from plastic, rubber and glue. We would face the same supply disruption in the event of a war now as we did from covid. Sovereign supply and actual sovereign manufacture need to be looked at, and there is a case for getting ahead of it now through sovereign import and stockpiling. But how much can you stockpile? Typically, 120 days’ worth, and then you need your service level agreements or home manufacturing coming in. The other thing, especially on supply chain resilience, is that each sector of critical national infrastructure currently has its own supply chain assurance system, and none of them speaks to the others. There is no way of knowing whether there is capacity in one sector that you might be able to use in another or, worse, whether, if all the checks were called in at the same time, all the individual sectors would be drawing on the same individual suppliers underneath. A sovereign supply architecture, with a standard around it to give the UK whole-of-nation visibility, would be very timely now.

Mike Martin

That is a really interesting point. Thank you very much.

Michelle Scrogham

Dr Mann, you said that at the outbreak of covid you were in charge of trying to source and provide PPE. Can you give us a very brief overview of what your worst day in that job looked like?

Dr Mann

Recognising that where there were gaps through failure to order, that was visible to you and you could set about correcting it, the worst feature was when what you actually had on the shelves proved to be out of date, and it required being brought back to life through what is called a re-lifing exercise and tested to see if it was still safe to use. The worst few days were when we were waiting for those tests to come back, knowing that there was no alternative at that time.

Michelle Scrogham

What is the biggest and most appropriate piece of knowledge we should take from that now?

Dr Mann

Decide what you need, order it early, maintain it in date and rotate it into use. For example, clinical equipment has a very good use case, so you stockpile according to your predicted timeline, but you rotate that equipment, as far as possible, through operational use, either within our healthcare system or potentially among allies. You also continue to replace it and maintain it, and a person is accountable for it. I left that job thinking that we needed an equivalent to His Majesty’s Inspector of Prisons—“His Majesty’s Inspector of PPE”—to report to Parliament on PPE stockpile levels for the next pandemic. Perhaps we can talk about that at another Committee.

Derek Twigg

To some extent, you have partly answered this question, as you made it very clear that we have a real problem with domestic resilience. Going back to covid, this was one of the key lessons. That is really worrying. Looking at 2020 and today, given your particular role, Dr Mann—others can come in too if they think it would be helpful—have we significantly moved forward from then?

Dr Mann

Not really, no. I think the national conversation has just started.

Derek Twigg

Which is really worrying. Coming in from domestic resilience, in that case, was complex regulation part of the problem? Has that changed or is that still a barrier and concern?

Dr Mann

Regulations can be part of the problem, but they can also be part of the solution.

Derek Twigg

Which is it at the moment?

Dr Mann

As Major General Hodgetts referred to, it is about derogation, which allows you to relax your regulations, in a calculated and titrated way, to meet the needs of the moment. We have heard how drugs and blood products can be used inter-operationally between NATO allies. The EU did that for covid, when derogation allowed personal protective equipment that was manufactured in another country and to another standard to be used here.

Derek Twigg

Have you seen or heard of any change in that? In other words, have we tried to look at that and make regulation, or deregulation, work better than it did in 2020, for instance?

Dr Mann

Not meaningfully, but that is what the defence readiness Bill should be for.

Derek Twigg

Okay. What about the complexity of procurement systems? Has any significant progress been made on that since 2020?

Dr Mann

In the military, we have seen the introduction of the national armaments director group, to try to unravel some of the complexity around defence procurement. Of course, we saw what happened in covid: if you suspend your public sector resourcing rules and find that direct awards are the only route open to you, you get to dance only with who is on the dance floor, and that leads to its own problems. Getting ahead of the problem is what gives us the opportunity.

Derek Twigg

That is what you keep coming back to. Basically, we are not getting ahead of the problem.

Ed Button

It is all about being upstream of this in the way that our allies are, and we are not quite on the pace. On medical supplies, I would ask DCMS whether, under the current LCST contract and the next generation of the FDSS contract—that is the MOD’s buying power—it is getting what it needs in a timely manner.

Derek Twigg

I come back to an earlier question, when we talked about the estimate of 1,000 casualties from the Germans, and an estimate of 500, say. Given the ability of the healthcare system to cope with pressures today—they are not coping, because we still have corridor care and major delays—and that surely, if there were that number of casualties, the majority of reservists, if not all of them, would have to be called up, a decision on who gets priority for treatment would have to be taken, would it not? That would mean that in war time, service personnel would be given priority.

Dr Mann

Let us talk about that, because—

Derek Twigg

Sorry to labour this, but it is an important point.

Dr Mann

There is an important national conversation to have about this. Essentially, we are reflecting on where reformation can work and where transformation is needed. I like to use the analogy of a parachute: you have jumped out the plane; you have your parachute and are coming down; but it is stretched out, the fabric is a bit old, it has been reused a couple of times and you are not sure who packed it—that is the NHS as it is working at the moment. Now you get a rip in your parachute. You think, “I hope I will get down okay. I’ve not speeded up too much”, but then there is another rip. Reformation would be you trying to stitch the holes in that parachute as you are going down and hoping your descent will be controlled. Transformation is to recognise that tightening up the NHS, redeploying people, putting more people in corridors and putting a temporary thing in the car park will not work. We probably need to consider the scales that we might be talking about: 500 people a day, every day, for as many days as you can imagine—that is transformation. That is reimagining a wartime healthcare system with an honest conversation, including the priorities that you talked about. In an existential war, your first job is to win the war. I would argue that that means the priority is medical treatment of service personnel and returning them to whatever capability they have, so that they can contribute. I am almost thinking not of two tiers, but of two channels of healthcare. This 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, using them for the military. We might use whatever else we need from the NHS, but we would maintain a public service through what is available in the established system. What is needed is a transformation to a wartime healthcare system, not a reformation.

Dr Geary

It is a whole cultural and ethical shift, because even in the military—I have a serving son and a serving husband; someone touched on the military covenant—part of the culture is still that healthcare will get to you and you will be returned home. The reality of Ukraine has changed that. In Afghanistan and Iraq, we saved pretty much everyone we said was T1—you need immediate care now, so we can evacuate—but Ukraine is saying, “T1, you are doomed; T4, you are doomed.” We need to think about palliative care in the battlefield, so T2 and T3, who are the walking wounded and less walking wounded—we can care for them. That is a big ethical and cultural shift for the military to think about, and a big cultural shift for society to start thinking about. In that comes your question, which is well put. It is something that we need to be thinking about. Who are the priorities when it comes to a war footing? What are the societal support priorities? Perhaps that is where the voluntary or third sector comes in. Where is the first aid, the buddy aid and self-aid? Where is wellbeing at home? Where is home support? How can we help accelerate all those great things that are being talked about in NHS transformation? We go back to the system of systems, that actually a war footing means getting our NHS and our home support fit, getting our military fit and bringing in our voluntary sector and not our industry in the round, but bespoke elements of it such as healthcare access and logistics, where needed, to help start that transformation. Dr Mann talked about where we need to get. It is a completely different way of viewing things that we need to be honest and open about.

Ed Button

That interoperability, interchangeability and augmentation only works if you exercise it—or plan it, exercise and train in it, and get ahead of it—otherwise, you are knitting things together at the last minute.

Graeme Downie

Dr Geary, last week the Government talked about what people should prepare for, and different things. Would it be helpful for the Government also to consider training? Essentially, as part of preparedness, should you consider basic medical training? If so, what would that look like? Where is the best place for the Government to say, “You should be prepared to be able to do the following things”?

Dr Geary

I would answer that in two ways. First, if you look at Iceland’s stats—other supermarkets are available—it sold out of all its baked beans, water and other goods. There has been a massive society response, and I think society is actually a little more aware and open than we give it credit for. Secondly, Holland is always awake to the situation that most of their dykes have to pump water 6 metres up to prevent half the country flooding. It is always looking at societal capital and resilience, and it lives with these emergency packs. That has been heightened since the Russia-Ukraine war because of the threat to stability of electrical supplies, which means that some of the pumps may fail. The decision has been, “Where do we let flood? Where do we support in terms of homeland defence? Where do we put the boats?” That society has been talking about it. There is a responsibility for the Government to go out and start having open, non-panic-forming discussions about what we should do. The Government also need to lead by example, potentially.

Chair

In our last section, we want to discuss medical research and innovation priorities. To lead the charge on that is Ian Roome.

Ian Roome

The defence medical research strategy sets out six themes, including combat casualty care, fitness to operate, mental health and infection. To me, the real-life test is whether research translates rapidly into capabilities that save lives on the battlefield. Which two or three research priorities would you accelerate immediately to deliver the greatest improvement in casualty survival and operational effectiveness? What are the principal barriers preventing promising research from reaching the frontlines?

Dr Mann

My first priority would be to reflect the change 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 can be delivered in the event that you are unable to move a casualty back through the chain? What can you take forwards to the casualty? What systems are available for you to deliver equipment, people or information to help them? Under what circumstances do you accept that you may have exhausted your resource allocation to certain severely injured persons, where the greater good for the greater number would be recognised by deploying those resources elsewhere?

Ed Button

If I compare this with other people—other Governments—that we deal with, TCCC, or tactical combat casualty care, has become the priority. There is upskilling to the extent that one of our clients will train 80,000 people over a 12-month period. That is how seriously they are seeing the requirement. That is the decision they made. It is not a huge capital investment for them, but it has the potential to make a significant impact. If you look at this statistically, going back to Afghanistan, the US 75th Ranger Regiment trained its entire regiment in TCCC. Its death rate dropped by 10%, so there is a tangible output.

Dr Geary

There is something about survivability. I know that a lot of the studies out of Ukraine are retrospective and observational, and there are problems with data—General Hodgetts referred back to data integrity—but survivability is a very interesting marker of success. Maybe in a large-scale combat operation we need to talk about return of functionality, which is not linked to survivability. That is an interesting disaggregation of those. Maybe returning to the frontline is a different marker. In short, antimicrobial resistance will be a big problem, because of battlefield contamination—principally gram-negatives, not gram-positives. The area where we should be doing research is point of care testing for the resistant strains. That has use not only on the battlefield but at the bedside in NHS hospitals. That could have direct transferability. Blood is certainly something, as are forward diagnostics. The defence research strategy does not really mention reach-back, telemedicine and the early opportunities to enhance the skills of your frontline troops so that they can do damage limitation and damage control surgery, far forward, when your evacuation chains are in excess of 12 hours on average. On the point about why we do not put research into practice, it is partly regulation and partly because it is not sponsored and adopted. If you have a commitment to research for a reason, and if you have a pathway at the beginning of the research, it is more likely to come to fruition.

Ian Roome

To explore the barriers—the actual problems of getting research implemented—who would you say is accountable for the overall system?

Dr Geary

I think that is the issue: there is not a single accountability, as with many things. If it falls under public procurement, you have NICE in the UK. You have to get funding if it is a novel way of doing things. You have to get policies, and you might have to get a royal college to accept it. There are various routes. This goes back to having a derogation or a sponsored route at the beginning when you set your research.

Ian Roome

Obviously, you have experience of Defence Medical Services. What do you think are the comparables between Defence Medical Services and civil medical services? Are we doing enough to provide good-quality medical care to our service personnel? I am talking specifically about the armed forces covenant. We heard from the earlier panel about the improvements that the CQC recommended. I would like to hear your experience, what you think needs to be done and what the comparables are between civilians and those who serve. Be honest.

Dr Geary

I will start by saying that I think there are individuals working extremely hard in both DMS and the NHS to deliver exceptional care on an individual basis, but the systems they work in often let them down. Sometimes, the system thinking prevents rapid acceleration of good ideas and innovation. The leanness of DMS prevents it from doing good stuff at capacity in an enduring fashion.

Dr Mann

As Dr Geary says, there are highly motivated, committed professionals providing a very high standard of care overall, consistent with the standards available in this country, given the constraints that we face. If we think about the floor and the ceiling of the armed forces covenant, the floor is that you should not be disadvantaged because of your armed forces membership. That seems to be a pretty low floor, when you look at the ceiling that could be achieved.

Ian Roome

I have one further point. I have done some research on the comparables around pay, particularly for consultants and doctors. At one time, the gap was quite high. If you did military service, it was quite a lucrative profession to go into. This is about the retention of personnel. I want your views on what the Government and the Ministry of Defence should be thinking about in relation to pay levels. Are we in danger of losing trained medical personnel? Are they likely to go into civilian careers, rather than do Ministry of Defence work?

Ed Button

Logically, you are always going to run that risk. I am not able to speak accurately about any pay disparity, but that is always going to be a risk. This is systemic—it is a much wider issue. It is not about money; it is about the entire piece. Are we standing up and giving our service personnel what they signed up to, from housing and benefits to the way they are treated as veterans? I would argue that the answer is no. It is not just about money. We probably need to look at the component parts that would retain highly trained medical staff. Pay is probably a significant part of it, but look at the wraparound. That is not just in defence med; it is a well-publicised issue across defence.

Dr Mann

I think most people stay for the purpose, not the pay. I acknowledge of course that people in Regular roles will have certain constraints according to their promotional level. For medics who are reservists, and they are the majority, there are opportunities open to them to supplement their NHS income if they so wish. Their service pay is separate.

Chair

To wrap things up, the Committee wanted to have this session on Defence Medical Services because we want not only to gain knowledge ourselves, as a Committee, but to focus hearts and minds on what has been termed the most hollowed-out part of defence. Given that you have the ear of the Ministry of Defence and the Government, what action would you like to see from the Government regarding Defence Medical Services and the defence medical system, and when?

Dr Mann

I would like to see a clearer organ responsible for integration from defence medical to the NHS, and across to the independent and voluntary sector to cohere a national wartime medical plan.

Ed Button

I will answer your last bit about when: now—you are already a little too late. It is about supporting DMS from a fiscal point of view to allow it to get on and enact changes. The biggest change is not to look at industry or the commercial sector as a horrible thing but to look at it as part of the solution. The sooner the MOD, writ large, and DMS do that, the better the chance of the right outcomes for patients.

Dr Geary

You have not left me much to say. It is about an honest review of what we have currently as a function, including the gaps—which are manifold, unfortunately—against the projected requirements if and when we are faced with a Ukraine-type situation. Where do they want to get to in order to support that and, as Ed says, who is best to support it? The full element of the costs should not fall to DMS.

Chair

Dr Geary, Mr Button and Dr Mann, thank you so much for using your invaluable time to inform our Committee on Defence Medical Services. It has been very thought-provoking and, no doubt, it will have led many to focus in on DMS. With that, I end today’s session. Q97 everity, 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.