European Medical Provision in Times of War

Russia’s 2022 invasion of Ukraine has driven the largest transformation of NATO’s military strategy since the Cold War with a new ‘family of plans’, under the Supreme Allied Commander Europe’s command, sharpening NATO’s Russia-facing spear.

But the Alliance’s medical provision needs to catch up urgently. If war breaks out, Russia will attack allied health systems – just as it is attacking Ukraine’s – as a deliberate strategy to weaken our will and capacity to fight. Multi-dimensional attacks on the NHS would overload Cabinet decision-making, diverting political attention away from the wider threat. Blatant Russian denial, deflection and disinformation has rendered international law ineffective at protecting healthcare. For those services to continue to function effectively in war, increasing resilience must be a priority.

RUSI’s significant concerns about how the NHS might cope with war were echoed both in the NATO Medical Action Plan, endorsed at The Hague Summit in June, and the UK Government Resilience Action Plan (UKGRAP) launched in July. The latter parses the problem into three core objectives: effective assessment; whole of society engagement; and strengthening the public sector. A recent RUSI-led exploration of these objectives – in partnership with International SOS – identified deep challenges to conflict-related health resilience and developed realistic policy interventions to address them.

Specific Risks Relating to Health System Resilience

Health systems are highly complex ecosystems; a huge market of suppliers and providers, dependent on thousands of IT systems – often outdated, redundant and difficult to secure – to manage their services. They occupy a vast infrastructure footprint, whose buildings are necessarily largely open to the public – making them challenging to protect. Public health-seeking behaviours can be easily manipulated by targeted dis- and misinformation, projected and amplified by malign actors. Exploiting this convergence of physical, cyber, informational and economic vulnerabilities would decrease capacity, reduce efficiency and increase demand on already maxed-out services, precisely at the moment that war casualties begin to return home.

It will happen. Russia uses all these tactics in Ukraine; assaulting healthcare with not only bombs, but ransomware, misinformation, energy and supply chain disruptions. A recent attack on a Ukrainian Children’s Hospital demonstrated it perfectly; a disinformation campaign suggesting that the Ukrainians would execute a false flag attack on one of their own hospitals, which pushed Ukraine to deploy resources for its defence and leaving other sites exposed. As time passed without incident, these resources were eventually repositioned, triggering the Russian bombardment, amplified by a second information campaign asking why a telegraphed attack on children was not prevented. The UK health ecosystem has not needed to consider its vulnerabilities in this way as, with the exception cybercrime and long-ago IRA attacks, it has not been targeted in living memory. In a war, Russia will use the same, highly effective playbook against the UK and its allies.

Several immediate issues must be addressed. First, ownership of risk. The National Security Risk Assessment identifies threats and assigns lead-departments to manage them, but health resilience is not easily compartmentalised. Emergency Preparedness, Resilience and Response is Westminster’s responsibility. Health, by contrast, is devolved, and Health Resilience is a mixture of devolved and reserved responsibilities. Any attack on health is likely to involve several vectors, for example supply (devolved) and cyber (reserved), so the necessary response may fall into the cracks between departments and nations, as was evident during COVID.

Second, this web of responsibility creates indecision. There are two psychological Rubicons to cross: beginning to plan in earnest against the real possibility of war, including adopting a greater risk tolerance befitting the more challenging circumstances ahead; and switching these plans on early, delivering rapid change when it is needed. UK Resilience is still agonising over whether to start seriously planning. The decision to enact those plans will be far harder.

Third, time. The French Health Ministry told its hospitals to be war-ready by 2026 and NATO believes it could be fighting Russia by 2030. The MAP describes what needs to be done, but – sensibly for an agreement between 32 diverse partners – does not specify how to go about it. Unfortunately, the collaborative, iterative approach outlined in the UKGRAP is unlikely to deliver readiness in the short-term. The Nordic nations, who built the societal resilience that the UK aspires to, did so through decades of education and investment. To walk even part of that path in a few short years, the UK would need to drive change hard. Despite initial statements about using this pre-war period to prepare, momentum seems to have stalled, displaced by other domestic challenges. Until politicians are clearly preparing for war, why should society? The comparison with other nations is stark; in two years, and from a standing start, nearly 1000 Estonian Healthcare workers undertook Hospital Major Incident Management (HMIMMS) training, equivalent to 35 new providers in every hospital. This contrasts with nine scheduled courses across the UK this year, potentially adding around 0.1 providers per hospital. Ironically the Estonian project was facilitated by a UK Defence Medical Services capacity-building team, in partnership with a UK civilian organisation.

The UK voluntary and commercial training sector is very strong. Teaching more of the population the essential ways to save a life (CPR, stopping bleeding, choking and the recovery position) would also be a powerful public health measure in its own right, making it a dual-use investment which is a popular concept in security circles at the moment. While the mechanisms exist to co-ordinate an agile network of suitably equipped first responders, their recruitment and training is still overwhelmingly driven by charitable organizations such as St John Ambulance and CitizenAid. The next step, supporting ‘zero-responders’ (the general public) to contribute meaningfully to the outcomes of an accident or attack, would need resourcing. More money would be part of that, but even this is not straightforward. The NHS reputation for inefficiency, alongside its failure to dramatically improve despite enormous investment (three times the budget allocated to defence), means there is little political or societal appetite to throw more cash at the problem.

Resource is also not enough; there needs to be direction and intent to match it. Resilience relies on clear legal frameworks, ideally agreed and communicated pre-crisis. The General Medical Council defined acceptable changes in practice during COVID, included promoting final year medical students to ;doctors early. These are exactly the kind of measures that might be required should healthcare workers be pulled en masse from the NHS to support a large-scale conflict; the UK should be planning for those scenarios and others like them now and putting the necessary statutory instruments in place. However, there is currently no national standard for what a public access emergency trauma kit should contain. Standard-setting organisations such as the National Institute of Clinical Excellence (NICE) could easily resolves such issues but currently have no mandate or resource to do so. The political direction to implement these changes is currently lacking.

Priorities to Harden Resilience

There are several urgent areas that government must address, if resilience opportunities are to be seized ahead of a crisis. First, political buy-in. The Strategic Defence Review (SDR) told the UK to prepare for war, while adopting a ‘whole of society approach.’ However, an effective whole-of-government approach is a pre-requisite for both, and there is currently insufficient coherence between defence, health and other key departments. There is a real opportunity to bring the MoD and Department for Health and Social Care closer around resilience. The respective secretaries of state could forge a relationship bound in preparing the nation for war and co-lead the Parliamentary push for a Defence Readiness Bill and cross-department Medical Action Plan. Special consideration needs to be given to the powers of Westminster and those of the Devolved Administrations and the seams and handoffs that will need to be mitigated as health is a devolved competence, while defence is not, and resilience spans multiple jurisdictions.

Second, be explicit about funding resilience. At The Hague NATO Summit, allies agreed to spend 5% of GDP on defence by 2035; with 3.5% on hard military capabilities and a further 1.5% on security related spending, including resilience. As a new policy designed to win over Trump, NATO has yet to establish guidance on what can be accounted for. A solid case could be made that increasing health capacity would be valid resilience expenditure, especially if assured through meaningful cross-government and regional exercises. It would be a productive way to meet NATO targets: setting a good alliance example; adding real value; and removing the need for clever accounting tricks.

Third, concentrate on dual purpose solutions. Supply chains and IT hardened against attack are also resilient to day-to-day disruptions. This represents high quality business continuity planning. Resilience is currently delivered on a shoestring, and so important activities are only paid lip-service; back-up generators are routinely tested, and ‘pass’. But these tests are often done at 2am under minimal load instead of during a busy day – and so provide only minimal assurance. Similarly, the UK demands only minimal cyber standards in NHS suppliers. Investment and legislation in this space will reduce system failures and downtime and so should make the NHS more efficient in its day job. This can only help with delivery of political targets that are very much front and centre – such as waiting times – as well as health outcomes in general, which will knock onto employment and growth.

Fourth, prepare for the fight. Enhancing societal readiness – for example extending first aid training in schools, cadets and other youth organisations, and in the workplace – prepares the second and third echelons by fuelling wider conversations about why people need to be trained. This increases the perception of the proximity of conflict and drives cultural shifts in risk tolerance. This should translate into more people considering reserve service. If they do, that same first aid experience could even shorten their pre-deployment training pipeline. Clearly there is a dual purpose here too – improving trauma outcomes brings huge economic benefits, as more people suffering workplace accidents or road-traffic collisions return to work.

Finally, exploit commercial interest and economic potential. Private and voluntary organisations have vast experience in both providing training at scale and the manufacture of associated equipment. Clear political engagement would rapidly translate into self-sustaining economic activity – both UK-centred and export-ready. This whole sector could readily switch from civilian trauma to a more military focus (or even a pandemic one) as needed. It would also stimulate innovation, leveraging learning from Ukraine into strategic advantage on the battlefield and thence to the roadside, creating further growth. There is also the opportunity to boost sponsored reserve numbers in the process.

Time is Running Out

The time has come not only to ‘think the unthinkable’ but to act on it – treating war as a real and imminent threat. As our adversaries will target societal cohesion and health systems, resilience must be moved from an aspiration to a political priority: through strong leadership; targeted investment (using the 1.5% security-related spending commitment); preparing our people; closer partnership with the private and voluntary sectors; and forward-thinking legislation to pre-empt crisis strained bureaucracy amid the fog of war.

This commentary was produced in collaboration with International SOS for a RUSI project on European medical resilience.

© RUSI, 2025.

The views expressed in this Commentary are the authors', and do not represent those of RUSI or any other institution.

For terms of use, see Website Terms and Conditions of Use.

Have an idea for a Commentary you'd like to write for us? Send a short pitch to commentaries@rusi.org and we'll get back to you if it fits into our research interests. View full guidelines for contributors.