Are we ready for war? Part 2: Preparing our emergency departments and hospitals

St Emlyn’s briefing | October 2026

In Part 1 of this series on NHS war preparedness, we looked at the clinical challenges that modern warfare might present for emergency medicine. Blast injuries, complex extremity trauma, delayed evacuation, infection and the changing nature of battlefield medicine all have implications for the knowledge and skills we may need in the future.

This is another long post (it’s more of a briefing), but please stay to the end as this is important.

However, there is another side to this story that I think may be even more important for those of us working in UK emergency departments. War in Europe can still feel distant (it’s not, but it can feel like that), but it’s entirely possible that a major conflict could have a profound effect on our departments without us ever seeing a military casualty.

Recent events have shown just how vulnerable interconnected systems like the NHS might be. Just this week there appears to be an attempt to raise the temperature in French blood banks (that would have destroyed the product). It would be naive to think that such acts might not happen here, or anywhere. And it’s more than just cyber attacks, if we see large numbers of military casualties they will likely need surgery, critical care, rehabilitation and prolonged hospital admission, that capacity has to come from somewhere. And if we are simultaneously dealing with major incidents, disruption to infrastructure or reductions in workforce availability, the consequences would be profound.

In this second article, I want to concentrate on those wider challenges. This isn’t a prediction of what will happen, nor is it intended to provide guidance on how hospitals should prepare. It’s an opportunity to think about what might happen, identify some of our vulnerabilities and start considering how we might respond. All of this is about thinking about what might happen now and to have those conversations with colleagues (and arguably the public too). As I mentioned in Part 1, national work is already underway involving the NHS, Armed Forces, RCEM, RCS and other organisations. I anticipate that more formal guidance and recommendations will emerge over the coming months. Those will be the appropriate sources for authoritative advice and coordinated action.

In the meantime, here at St Emlyn’s we can hopefully encourage some early thinking and discussion.

RAMP and the reception of military casualties

One of the most important concepts in this discussion is RAMP, or Reception Arrangements for MOD Patients. In their article in the RCSD Bulletin, Horne and Naumann describe how the NHS might need to accommodate military casualties evacuated from overseas conflict. At present, military patients requiring specialist treatment are commonly managed through arrangements centred on Birmingham and the Royal Centre for Defence Medicine. That model works for relatively small numbers of patients, and even took the brunt of casualties from conflicts such as Afghanistan, but a larger conflict could produce casualties on a much larger scale.

The authors describe three levels of RAMP activity.

Those numbers are far in excess of other recent conflicts and much greater than the typical UK civilian major trauma workload. One hundred to four hundred casualties per day is not a conventional major incident. It’s a sustained requirement to receive, assess, treat and rehabilitate large numbers of seriously injured patients, many of whom may require repeated operations and prolonged hospital stays.

Even if those numbers were sustained for only a relatively short period, the cumulative demand on the NHS would be considerable. In October 2026, the Ministry of Defence reported on a joint exercise involving the Armed Forces, NHS and international allies to test how the UK might respond to battlefield casualties. The exercise considered hospital capacity, rehabilitation, mental health and maintaining civilian healthcare. National organisations are already examining how the system might respond.

There is also an important distinction between the direct and indirect effects of RAMP. Some hospitals may be designated to receive military casualties. Others may not receive any, but could still experience significant changes in capacity and service provision as resources are redirected to support the national response. That second group could include a very large proportion of the NHS, the point being that the response to a significant RAMP requirement would not be limited to large centres and/or MTCs.

What happens to normal emergency care?

Healthcare is a finite resource, and if we do more of one thing, then we may struggle to maintain business as usual. We are already working in a system where emergency departments are frequently crowded, inpatient capacity is limited and access to specialist services can be difficult. The additional demands of caring for large numbers of military casualties could place enormous pressure on an already stretched system, particularly in surgery, critical care, rehabilitation and inpatient bed capacity.

The consequences would extend well beyond those hospitals directly receiving military casualties. Resources would inevitably need to be redistributed across the NHS, with potentially significant reductions in elective surgery, outpatient services, diagnostics, cancer pathways and rehabilitation. At the same time, the normal demands on emergency care would continue. Patients would still present with sepsis, myocardial infarction, stroke, acute surgical conditions, mental health emergencies and the full range of illness and injury that we currently manage. Indeed, some of these demands might increase as a consequence of wider societal disruption. We could therefore find ourselves trying to maintain emergency care for the civilian population with substantially reduced access to the specialist services, facilities and resources on which we normally depend.

I’ve heard this potential change described as the NHS having to deliver a silver standard of care rather than the gold standard we normally aspire to. I think that’s a useful, if uncomfortable, way of considering the problem. It reflects the possibility that some aspects of healthcare may need to be delayed, reduced or delivered differently in order to preserve essential services and achieve the greatest benefit for the population as a whole. This is not about accepting poor or unsafe care, but recognising that the standards and pathways we can deliver in normal circumstances may not be sustainable during a prolonged national emergency.

Such a change would have profound clinical, ethical and political implications. Decisions about prioritising services, allocating scarce resources and balancing the needs of military casualties against those of the civilian population would require clear national leadership, agreed ethical frameworks and transparent communication with the public. They cannot reasonably be left to individual hospitals or clinicians to resolve independently. Emergency medicine would inevitably be affected by these decisions, and we need to ensure that our specialty is involved in the planning and discussions that will shape how essential civilian emergency care is maintained.

It’s also worth considering what we mean by resources. Healthcare is very much about people, and our greatest resource is the people who work within it. A significant conflict would likely mean that staff would be moved to support the military effort. We may have to do more with much less (people and kit). Those of us close to retirement, may have to rethink our plans.

We may need to do more ourselves

One possible consequence is that emergency medicine may need to expand its scope of practice. Over recent decades, healthcare has become increasingly specialised. In many respects that’s been a good thing, allowing patients to benefit from expertise, technology and specialist services that simply didn’t exist previously.

However, that specialisation also creates dependencies. In a hospital where surgical teams are managing military casualties, some civilian patients may wait longer for specialist assessment and treatment. Emergency physicians might need to take greater responsibility for conditions that would ordinarily be referred elsewhere. For example, we might need to undertake more wound management, fracture care, procedural sedation or selected minor procedures. We may need to manage some patients for longer, develop alternative pathways or reconsider which conditions genuinely require immediate specialist involvement.

There is precedent for emergency medicine adapting its scope to meet changing healthcare needs. Our specialty has developed precisely because we work at the interface between multiple services and respond to the needs of patients presenting with undifferentiated illness and injury. However, this must not become an excuse to transfer additional work into an already overstretched emergency department.

Any expansion of practice would need appropriate training, equipment, staffing, governance and agreement with other specialties. We should also recognise that emergency physicians cannot replace the expertise of surgeons, anaesthetists or critical care specialists. Nevertheless, I think there is value in considering which additional capabilities might be useful, particularly if specialist services become less immediately available. This is something that could be explored through education, simulation and discussions with colleagues in other specialties, rather than waiting until the need becomes urgent.

Major incidents may look different

In Part 1, we considered some of the clinical consequences of contemporary warfare. We should also think about the possibility of major incidents occurring within the UK. I’m not suggesting that attacks on UK civilian infrastructure are inevitable, but they are credible scenarios that need to be considered in national preparedness planning.

Our existing major incident arrangements are largely designed around relatively discrete events. An explosion, transport disaster or other incident produces a sudden increase in casualties, followed by mobilisation of additional resources and a period of recovery. That model assumes that the wider system remains sufficiently functional to support the response. In a major conflict, those assumptions may not hold. An explosion at a transport hub might initially resemble incidents for which we already prepare. However, if a second incident occurs elsewhere in the region, while neighbouring hospitals are already managing casualties, the availability of mutual aid and specialist transfers could be substantially reduced.

Ambulance services may also be under pressure, and staff may be needed at several locations simultaneously. There are important implications for triage, patient distribution, regional coordination and the ability to sustain a response over time. Our planning needs to consider not only larger incidents, but simultaneous incidents, repeated incidents and sustained periods of additional demand. There is also a potential role for emergency physicians in supporting wider healthcare responses, including casualty distribution, clinical prioritisation and coordination with prehospital services. These are areas where our specialty already has considerable experience, but where the scale and duration of a future challenge could be very different.

What happens when the hospital itself is affected?

Healthcare is a target in war. We’ve seen this across the globe in many conflicts. We should be prepared for out hospitals to be directly attacked in a variety of ways (e.g. cyber attacks, and also physical attacks). Modern hospitals are extraordinarily dependent on infrastructure. Electricity, water, digital systems, communications, transport, oxygen, medicines and supply chains are all essential to delivering emergency care. Most major incident plans assume that the hospital remains functional. We may have more patients than usual, but the systems we depend upon to treat them are expected to continue working.

A compound incident challenges that assumption. Imagine a weekday afternoon when your ED is already crowded and a major incident is declared following an explosion in the city centre. Thirty casualties are expected, but at the same time the hospital loses access to its electronic patient record and prescribing systems following a cyberattack. Communications are disrupted, public transport has stopped and several members of staff cannot get to work. The regional trauma centre is already managing casualties and cannot accept additional transfers. It sounds rather dramatic, but it’s not beyond the realms of possibility/

I suspect many of us have experienced relatively short periods of digital system failure and know how disruptive they can be. Extending that disruption over several days, while simultaneously managing additional casualties, would be a significant challenge. Our emergency planning therefore needs to include circumstances in which the hospital itself is compromised.

That means having workable downtime procedures, access to essential paper documentation, alternative communication arrangements and clear plans for maintaining critical clinical functions.

It also means testing those arrangements. A tabletop exercise is useful, but there is considerable value in actually practising how a department would function without its normal digital systems, communications or access to specialist support. And we should remember that these vulnerabilities are not unique to wartime. Cyberattacks, major power failures, severe weather and other emergencies could produce similar consequences. Preparing for them would improve resilience regardless of whether the UK ever becomes involved in a major conflict.

Lessons from history

One of the three articles that prompted this series was Emily Mayhew’s account of how London prepared its hospitals for the two World Wars. I’ve read her book and I think it’s fantastic. A must read for anyone looking at how war changes healthcare.

It’s a fascinating reminder that healthcare systems have faced similar challenges before, even if the technology and clinical practice have changed enormously. During the Second World War, hospitals were reorganised, patients relocated and clinical services adapted to the threat of aerial bombardment. Surgical facilities were moved into protected areas, and the distribution of patients and resources became part of a much wider national response. Those preparations were substantial, but they also had to evolve as the reality of conflict became clear.

I think there are two important lessons here.

The first is that preparation needs to involve the whole healthcare system. It is not enough to increase trauma capacity if the rest of the system cannot continue functioning.

The second is that planning cannot anticipate every eventuality. We need systems that can adapt when circumstances change, rather than relying entirely on rigid plans built around a single expected scenario.

The NHS is now considerably more technologically advanced and specialised than the healthcare system of the 1940s. That’s an enormous advantage in normal circumstances, but it arguably also creates dependencies and vulnerabilities that deserve serious attention. We are arguably more vulnerable as health service now than we were in the Second World War.

We need to think about the workforce

As I mentioned above, healthcare depends on people, and a major conflict could affect the availability and wellbeing of our workforce in several ways. Some NHS clinicians are military reservists and could be mobilised at precisely the time when the NHS needs additional staff. Others may have family members serving in the Armed Forces, caring responsibilities or personal circumstances that make sustained working during a national emergency difficult.

Transport disruption, school closures, interruptions to childcare and problems with communications could all affect staff availability.

There is also the psychological impact of working through a prolonged crisis, something that we saw a lot of during COVID. It would be no surprise to see similar impacts in war. Emergency medicine staff are accustomed to dealing with difficult circumstances, but there is a considerable difference between responding to a major incident over several hours and sustaining emergency care through weeks or months of disruption. Fatigue, anxiety, moral distress and the cumulative effects of repeated exposure to traumatic events could become significant problems.

Workforce planning therefore needs to extend beyond simply calculating how many doctors and nurses are on the rota. We should consider cross-training, sustainable working patterns, staff welfare, rest facilities and the practical support needed to allow colleagues to continue working.

We should think about this personally, too

We need to think about our professional and our personal lives and the impact on both. If we expect healthcare workers to continue providing care during a national emergency, they need to have some confidence that their families are safe and supported. Sensible personal contingency planning may therefore be an important part of professional resilience. The Government recently recommended that we should have three days of supply at home. Seems sensible to me and something European states have recommended for many years.

On top of that though as healthcare workers we need to think about how we would communicate with family members/work if mobile networks were disrupted, how dependants would be cared for if normal arrangements failed, or how we would manage essential needs during a period of disruption. These are not unreasonable things to think about, particularly for people working in essential services.

I know a lot of people who have military or humanitarian backgrounds and they would consider these contingencies entirely normal and obvious to put together in advance. It won’t take a lot of time or resource, but it’s certainly worth thinking about now.

The role of the Royal Colleges and national guidance

There is already work taking place nationally to consider how the UK healthcare system should prepare for the consequences of potential conflict. RCEM is engaged in these discussions alongside other medical Royal Colleges, including the Royal College of Surgeons, as well as the NHS, Armed Forces and other organisations. I anticipate that more formal guidance, recommendations and educational resources will emerge over the coming months.

When they do, please use them rather than treating this article as guidance.

St Emlyn’s is not attempting to pre-empt that process. Our role here is to encourage people to start thinking about the implications, so that we are better prepared to understand and implement national recommendations when they become available.

So what should we be doing now?

I don’t think we need to wait for detailed national guidance before starting some sensible local discussions. The first priority is to understand how RAMP and military casualty reception arrangements might affect our own organisations. Even hospitals that are not designated to receive military casualties may experience significant changes in surgical, critical care and inpatient capacity.

We should also consider how we would maintain civilian emergency care if specialist services became less available. This might include reviewing existing pathways, identifying opportunities for additional training and considering how emergency medicine could safely adapt its scope of practice. Major incident plans should be reviewed with particular attention to simultaneous incidents, sustained casualty flows and reduced availability of regional mutual aid.

Infrastructure resilience deserves similar attention. Departments should understand their downtime arrangements and practise maintaining essential clinical functions during digital, communications or other infrastructure failures.

Finally, we should think about our workforce and personal preparedness. Sustaining emergency care during a prolonged national emergency will depend on supporting the people who provide it.

Final thoughts

The possibility of a major conflict affecting the UK healthcare system is not something I particularly enjoy thinking about. However, I think we have a responsibility to consider it.

The NHS is already under enormous pressure, and I appreciate that suggesting another area for preparation may not be particularly welcome. But the fact that we are busy does not make the risks disappear. The clinical challenges we discussed in Part 1 are important, but the wider consequences for healthcare delivery may be even more significant. We could find ourselves managing not only unfamiliar injuries, but also a healthcare system with less capacity, fewer available staff and reduced access to the infrastructure on which we depend.

I would much rather we spent some time thinking about these possibilities now, while we have the opportunity to learn, discuss and prepare, than find ourselves having to improvise under extraordinary pressure. We should all be thinking about this personally and professionally. We should be considering how our departments and hospitals might be affected. And we should be starting those conversations now.

I hope that none of these scenarios ever become part of our everyday practice, but it’s never too early to start thinking about them.

So why not add ‘War preparation’ as an agenda item for your next consultant meeting. Start the conversation there.

vb

S

References and further reading

1. Horne SJM, Naumann DN. Preparedness for RAMP: Reception Arrangements for MOD Patients. Bulletin of the Royal College of Surgeons of England. 2026. DOI: 10.1308/rcsbull.2026.111.
2. Mayhew E. Hub City: how London prepared for the wars of the 20th century. Bulletin of the Royal College of Surgeons of England. 2026. DOI: 10.1308/rcsbull.2026.114.
3. Lloyd ER, Naumann DN. Looking after combat casualties in the era of drones. Bulletin of the Royal College of Surgeons of England. 2026. DOI: 10.1308/rcsbull.2026.112.
4. Ministry of Defence. Armed Forces, NHS and allies test UK battlefield injury response. October 2026.
5. UK Government. Strategic Defence Review 2025: Making Britain Safer — secure at home, strong abroad.
6. NHS England. Concept of Operations for the Management of Mass Casualties.
7. Simon Carley, “Are we ready for war? Part 1: The clinical challenges of modern conflict,” in St.Emlyn’s, October 28, 2026, https://www.stemlynsblog.org/are-we-ready-for-war-part-1-the-clinical-challenges-of-modern-conflict/.

Declaration: I am Dean of the Royal College of Emergency Medicine. This article is written in my personal capacity for St Emlyn’s and reflects my own views, not necessarily those of RCEM.