When the UK’s chief of the defence staff Sir Richard Knighton recently described the current state of geopolitics as,'the most dangerous period that I have known’, it is an opinion which should cause everyone to take notice.

Following the end of the Cold War, the popular consensus in the West was that the world had embarked upon an inexorable path towards lasting stability, prosperity and peace.

Sadly, the first quarter of the 21st century has largely put paid to this idealistic vision, with today’s world now arguably more unstable and uncertain than at any time since the 1930s.

Long-running wars such as Russia’s invasion of Ukraine and multiple conflicts in the Middle East have all seen the principle of medical neutrality in war zones eroded and ignored by belligerent nations.

Meanwhile, formerly unshakeable international institutions such as NATO and the UN have been undermined and called into question, making the possibility of a major international conflict ever more plausible.

In addition to conventional warfare, many societies, including our own, contend with threats such as cyber-attacks against state institutions, deliberate targeted attacks on infrastructure and supply lines, online disinformation campaigns and shocks in the global economy, all of which have the capacity to directly or indirectly target health systems.

In response to the growing international tensions, NATO last year published its Medical Action Plan.

Designed to strengthen medical support for collective defence, the plan outlines a series of actions for NATO members including ensuring adequately staffed medical workforces, the development of plans for mass casualty and patient evacuation events and a shoring up medical logistics.

Last year also saw the publication of the UK’s latest SDR (Strategic Defence Review) which, for the first time, dedicated a section to healthcare and made recommendations for the development of integrated crisis planning between the Department of Health and Social Care and the Ministry of Defence.

A year on from the SDR and medical action plan, however, the UK remains ill-equipped to meet the measures in the NATO blueprint, lacking the resources, workforce and financial investment required to respond to a mass-casualty event or sudden national emergency.

The lack of action and disunity around the role of healthcare in UK defence preparations is something BMA treasurer and emergency preparedness GP lead Peter Holden feels compelled to speak out on.

Dr Holden, who recently gave an address to the BMA armed forces committee conference on the issue of conflict preparedness, said that since the NHS has never had to deal with the fall-out of a large-scale conflict in Europe, making health central to any preparedness planning was more critical than ever.

‘We are now in a new era where there is a real risk posed to our shores; from direct physical attack to our hospitals, from cyber-attacks to NHS suppliers and from disruptions to supply chains for food and medicine,’ says Dr Holden.

‘NATO expects us to be able to move civilians and casualties from areas of danger to greater safety – but are the current national evacuation plans prepared for the possible scale?

‘Our trauma, ICU and surgical capacity are vulnerable. Mass‑casualty preparedness, essential to supporting allies, requires depth, capability, and training that we currently lack, [and] the UK has the second lowest ratio of doctors to population compared to OECD countries in Europe.’

Last week saw the resignations of defence secretary John Healey and armed forces minister Al Carns over the anticipated funding settlement for the UK DIP (Defence Investment Plan), with Mr Healey warning it would likely fall ‘well short of what is required’ for national defence.

The DIP, which sets out the priorities for the UK’s defence strategy over the next decade, was criticised by the outgoing ministers who warned that, despite the Ministry of Defence requiring £18bn to meet its needs, it was anticipated the DIP would provide just £13.5bn.

Added to the former defence ministers’ fears any funding settlement for the DIP will prove insufficient, are the concerns that new funding could ultimately be drawn from existing budgets, including those for health and social care.

‘If we expect the health service to act as critical national infrastructure in conflict, then it must be funded as such,’ Dr Holden adds.

‘Resilience cannot be delivered on goodwill, overstretched staff, or expired equipment. It requires strategic, multi‑year investment across training, digital infrastructure, supply chains, and emergency capacity.

‘Without this, the NATO plan will remain a document of good intentions rather than a guarantee of national security.’

Dr Holden is not alone in calling for the Government to act decisively and ensure healthcare and the medical profession are central to the UK’s conflict-preparedness planning.

The UK’s lack of capability to provide an effective healthcare response to an attack or major incident, including the use of nuclear, biological and chemical weapons, will be the focus of a motion at next week’s BMA annual representative meeting in Brighton.

In a motion put forward by the association’s East Yorkshire Division, BMA members are urged to back calls for a comprehensive review of the NHS’ preparedness for a major conflict, and for the development of ‘a transparent national strategy’ on the medical response to an attack using weapons of mass destruction.

The motion will also call for an expansion in training and preparedness programmes for healthcare professionals, and for the establishment of stockpiles of medical resources such as vaccines and personal protective equipment.

Despite uncertainties around the DIP, collaborative working between the Department for Health, MoD and NHS is already under way, with a series of workshops earlier this year focusing on the role of the NHS in major conflict and the potential challenges the health service would face.

One challenge to developing a nationwide medical response within conflict preparedness planning is the devolved nature of healthcare across the UK, a factor that also proved challenging during the pandemic.

Furthermore, with most defence medical personnel also working in the NHS, preparedness planning would need to develop contingencies for a reduction in medical staff at the same time that the health service had to respond to mass casualties or patient evacuation. 

Dr Holden believes that, as a UK-wide professional body representing all doctors, the BMA is uniquely placed to act as a lynchpin in discussions and negotiations around preparedness planning.

‘The BMA recognises our stewardship role within the health system, and we are escalating our concerns to the Government as preparation requires a whole of government approach,’ states Dr Holden.

‘The preparation and thought process required does not need new legislation. However, we recognise that the health service must be supported to build resilience. The NHS has already suffered targeted cyberattacks, such as the Synovis attack in London in 2024 which decimated secondary-care capacity. 

‘Healthcare is viewed as an exploitable, soft target and keeps sensitive information in under-resourced systems, and compromising clinical care affords leverage to hostile actors.

‘As medical professionals, as the BMA, we need to start asking the hard questions about the NHS, how its critical national infrastructure, will be ready. We must hold NHS organisations and institutions to account.

‘Now is the time to develop contingency plans rather than repeat the same haphazard decision making we saw during the COVID pandemic.’