What would it take to prepare the NHS for a war?

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By Michael Marshall

As the threat of war looms larger, experts warn that the UK must start planning now to scale up military evacuations, recruit retired medics and protect hospitals from attack.

After decades of relative peace, the world is entering a more violent time. Russia’s all-out war on Ukraine has raged on for four years. The US has attacked Venezuela, kidnapping its president. In the Middle East, Israel has launched massive strikes against Gaza, and in the last few weeks Israel and the US have attacked Iran, which in response has attacked multiple neighbouring countries and fired on ships that try to pass the Straits of Hormuz.

The UK has so far largely stayed out of these wars: for instance, it has supported Ukraine with weapons and money, but has not joined the fighting. But it no longer seems an impossibility for the UK to become embroiled in a war.

The challenges for the NHS are large, but history suggests that they can be met

What would it take for our healthcare system to cope with such a conflict? Experts say that three challenges present themselves. The first is injured military personnel overseas, who would need to be safely brought home and treated. The second is the potential for mass civilian casualties if the UK itself should come under attack. And the third is the risk that strikes against vital UK infrastructure could impact the NHS, perhaps by cutting off communications or power.

These challenges are large, but history suggests that they can be met. Although individual NHS organisations will have a regular schedule of major incident training and exercises, flicking the switch from a whole system designed to manage stable peacetime demand across to one meeting all of these requirements, with sustained delivery at unknown pace, scope and scale, will need coordinated planning.

Bring them home

The UK already has a system for bringing home injured military personnel. It is called Reception Arrangements for Military Patients (RAMP) and was used during the Afghanistan conflict. The Ministry of Defence, Department of Health and Social Care and NHS England work together to fly injured personnel home. The usual destination is the Queen Elizabeth Hospital in Birmingham, which has a history of caring for injured military personnel.

“The staff at Birmingham understand that this is their legacy,” says Emily Mayhew, a military medical historian at Imperial College London and author of Wounded: The Long Journey Home from the Great War.

However, this system would start to come under strain if the UK found itself in a large, intense war, with high casualty rates. A 2024 analysis for the Royal United Services Institute for Defence and Security Studies (RUSI) estimated that Birmingham could struggle to care for more than 100 military patients per week.

The Strategic Defence Review 2025 called for the government to rebuild the Defence Medical Services, and to “invest in medical evacuation and medical stockpiles at a scale that matches military commitments and deployments”.

To expand NHS capacity in wartime there are two potential solutions: retired staff and volunteers

“We don’t have the capabilities, at the moment, at the correct scale,” says Dr Darren Mann, a military surgeon attached to King’s College London. As he recently told The Times, he wants to create a private-sector partnership of transport companies, logistics providers and private military contractors to conduct large-scale evacuations of military personnel. Arguing that the government is unlikely to be able to scale up its systems, he wants to create a new one that the government can contract for if needed.

Medical evacuation “has always been a problem in the UK, because we’re an island,” says Mayhew. In the First World War, France and Germany evacuated injured soldiers by train to hospitals in towns near the front lines. In contrast, the British had to create excellent field hospitals: these treated soldiers to get them to a point where they could be taken by boat across the English Channel and then by train to hospital. “Most people come into Southampton, and then they come to London as the main hub of hospitals.”

Once people are home, the question then becomes: who will treat them?

NHS capacity

The current state of the NHS is well-rehearsed. There is a shortage of GPs. In hospitals many patients are being cared for in corridors, partly because hospitals are struggling to discharge patients who need ongoing care. People with mental health issues and neurodevelopmental disorders face enormous waiting lists.

“The NHS doesn’t have enough surge capacity for a crisis,” says Professor Martin McKee at the London School of Hygiene and Tropical Medicine. “We’re low on staff. We’re low on equipment. We’ve had virtually no capital investment for 15 years.” This has left the NHS struggling to keep up with normal demand. “We’ve always prided ourselves in having ‘just enough to do’, but that doesn’t provide you with that degree of flexibility.”

A study published in The Lancet in December 2025 highlighted many uncertainties about the NHS’s ability to cope with large numbers of casualties, and called for urgent research to understand where the vulnerabilities are.

There are two potential solutions to the lack of staffing: retired staff and volunteers.

“The solution to it in the First World War was to bring back retired medical staff,” says Mayhew. “People say you can’t get retired people back… Well, if there is a staffing problem, we’ll have to get beyond that.”

Institutions like the Royal Colleges will be crucial for any such recruitment effort. Mayhew says it’s vital for the government and NHS management to start working more closely with them now, to draw up plans to entice retired people back if they are needed. “There are institutions that can help them solve that problem,” she says.

Voluntary organisations like St John’s Ambulance and the British Red Cross Society would also be key. The British Red Cross Society was first used in a big way during the First World War, including on the Western Front, where they helped to evacuate injured personnel. Today, St John’s Ambulance might be relied on more heavily.

Historically, the armed forces have often been wary of the voluntary sector. “It’s a culture thing,” says Mayhew. But the experience of the two world wars shows that volunteers can be highly effective if properly integrated with the military.

There is also a great deal of enthusiasm in the voluntary sector. Mayhew calls St John’s Ambulance volunteers “keen as mustard”.

One of the biggest problems for wartime healthcare would be antimicrobial resistance

The UK could learn some lessons from Finland, says McKee. “Finland did fantastically during the pandemic,” he says, because “they had been rehearsing this whole-of-society response to a potential Russian attack every year.” This meant that the heads of the police, armed forces, healthcare and community groups all knew and trusted each other, and were able to work together. The country has “high levels of social capital” and “things like community centres that people can go to if there’s a natural disaster”.

In contrast, many of the UK’s left-behind towns have a dire lack of social cohesion. “We haven’t invested in youth clubs, we haven’t invested in community support,” says McKee. Much of our local government is dysfunctional and disempowered. “These are places that are extremely fragile.”

The key, argues Mayhew, is to start with what we already have that works. Unlike Finland, the UK hasn’t lived under constant threat of invasion, so our society isn’t oriented towards it. “It’d be better to start with the voluntary sector,” she says, because it is already organised and motivated, and scale up from there through “a staged process” if and when it becomes necessary.

It's also crucial to practice, says McKee. He wants hospitals to run exercises to test their response to large numbers of casualties – and the government to support them to do so.

Worst-case scenarios

Finally, let’s consider the most alarming possibilities.

Along with the usual guns and explosives, a new war could bring injuries from chemical, biological, radiological, and nuclear weapons (CBRN). However, Mayhew is sceptical that these will be a major factor. “If we were going to see effective use of chemical weapons, the chances are we might have seen it by now,” she says. They are too erratic and weather-dependent, and liable to rebound on the army that has deployed them. In Ukraine and Gaza, our two most current guides to modern conflict, most of the injuries are from explosions.

It's possible that a war could escalate to the point that the UK itself comes under attack, perhaps from bombs or missiles, or more insidious methods like cyberattacks or cutting undersea cables. Russian cyberattacks have already hit NHS hospitals.

McKee says our relatively centralised healthcare system is a vulnerability: “If you put all of your facilities in one hospital, you have one big target.” The decline of the international rules-based order, reflected in recent strikes on hospitals by both Russia and Israel, indicates that the Geneva Conventions are no longer being respected and healthcare facilities are no longer off-limits, he says.

However, Mayhew says that centralised hospitals in London kept operating through the Blitz. Even St Thomas’ Hospital, which was bombed in 1940, simply moved operations underground and kept going. She says the advantages of big central hospitals, like large numbers of operating rooms and high staffing levels, should outweigh the disadvantages.

Big, well-equipped hospitals are also likely to be the key to one of the biggest problems for wartime healthcare: antimicrobial resistance. “It is the thing that wakes me up at night,” says Mayhew. Blast injuries lead to burns and soft tissue trauma, which is “a Four Seasons Hotel for bacterial infection”, she says. Many bacteria are now resistant to multiple antibiotics.

This is particularly challenging when injured personnel are being moved through multiple stops before they get to the main hospital. If they are treated with antibiotics along the way, the bacteria may build up resistance and become untreatable. “I’m told that the closest thing to hell is the burns ward in Lviv General” in Ukraine, she says, where many patients have infections that cannot be treated.

Mayhew says the best approach may be to avoid giving antibiotics until the patient is in a major hospital, where their infection can be cultured and identified, and the correct antimicrobial used. “You have to hit it very hard with the one thing that’s going to stop it.”

This will all sound alarming, so let’s give the historian the last word. “We have done this twice before,” says Mayhew. During the First World War, the healthcare system held up – even under the additional pressure of the 1918 influenza pandemic.

Likewise, the Emergency Hospital Service created for the Second World War kept going despite bombing raids and was later transformed into the NHS. “The plan worked both times.”

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