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Mobile Army Surgical Hospital

Volume 568: debated on Wednesday 9 October 2013

Motion made, and Question proposed, That this House do now adjourn.—(Mr Evennett.)

I never thought I would see the day when the words “Mobile Army Surgical Hospital” would be the title of a debate of mine. I grew up watching the television series “MASH”, which partly inspired me to become a doctor. I want to make a serious proposal about a capability that this country should be able to deploy abroad. I started thinking about the issue following the Syria vote in August. I voted against both motions before the House that day. After that, I thought that I should come forward with a constructive suggestion for our engagement with the crisis in Syria. This is my suggestion.

I will present a history of field hospitals in general—just a brief one; don’t worry—and discuss the humanitarian response capability that we need. I shall then mention the challenges of bringing that about and, perhaps more importantly, the details of the facility.

I became a doctor for a number of reasons, but a couple of things spring to mind. One is a book called “The Red and Green Life Machine” written by a commander in the Royal Navy, a chap called Rick Jolly. The title refers to a field hospital in the Falklands war, set up in a disused abattoir in San Carlos bay. I read the book when I was about 13. I watched every single episode of “MASH” and developed desire and ambition—initially, to become a trauma orthopaedic surgeon. I subsequently went to medical school and decided that I would be a GP. What inspired me was the desire to do something to help people in distress.

However, I stress that I am no pacifist. I did not vote in August against the intervention lightly; in fact, I am in favour of quite significant intervention if it is well thought through, coherent and backed up with a strategy for the region. However, I am against the wilful, somewhat reckless destruction of assets in a small way because that can breed more problems going forward.

We are experiencing the ongoing crisis in Syria through our TV screens. I first visited the country in 1998 and I went back as vice-chairman of the Conservative middle east council in February 2011, about three weeks before the civil war started. I have a sense of association with the country. I enjoyed both my visits—particularly the first one, when I was backpacking around as a medical student. I visited Homs, Hama and the beautiful parts of Aleppo that I fear are no longer intact. When I came back from my second visit, I was gripped with a sense of foreboding that trouble was about to start, although not as quickly as it did. I also felt the sense that Britain’s engagement with the country in its crisis should be constructive and trying desperately to bring about a peaceful end to the war.

The problem is that since then there have been more than 100,000 deaths and more than 2 million people have migrated away from the chaos. There has been one public use of chemical weapons, and it has been suggested that there have been others. We have all had to endure some pretty appalling footage of death and destruction, primarily affecting innocent civilians—women and children. It is pretty shocking to have to endure it.

Our response should be multi-pronged. We could foresee a situation in which hard power is wielded, but soft power should also be considered. This is where I come to the MASH or mobile surgical hospital facility that I envisage for Britain. The history of field hospitals goes back to the Napoleonic wars and the gentleman called the father of combat medicine, Baron Dominique Jean Larrey. From that concept of forward surgical hospitals bringing medical support to combatants at the front line, things developed slowly. I guess that the fastest development took place during the Korean war in the early 1950s; the “MASH” TV series is based on that war, although it was always associated with the Vietnam war because of when it was made. During the Korean war, major developments were made in pushing field hospitals closer to the front line. There was the famous image of a Bell helicopter with two casualties strapped into stretchers on either side, with the purpose of bringing people back to be treated very quickly. The dictum was, “Life takes precedence over limb, function over anatomical defects.”

Since then, there have been massive advances. I have not yet visited the hospital at Camp Bastion in Afghanistan, but I am told that it is a remarkable facility delivering the very best trauma care. Of particular note to Britain is our experience in Kosovo in 1999, where the British Army managed to create, in effect, a tented village for a load of refugees as well as medical facilities. It was a fantastic success, and proof of what our military are capable of.

I congratulate the hon. Gentleman on bringing this innovative idea to the House for consideration. I have a Territorial Army ambulance unit in my constituency and they are renowned for the good work that they have done and can do. Does he see the MASH unit being staffed by regular soldiers or TA soldiers, because I believe that both could do the job equally well?

I was going to come to that. I see it as being a reserve force, not part of the regular Army, although I suspect that there will be some logistics staff maintaining the kit and the facility.

I had a field surgical team under my command in Bosnia in 1992-93. It was absolutely vital, and it was operated by a mixture of regulars and territorials. We must not think that this is necessarily soft power, because it needs security and it needs to be guarded.

I thank my hon. Friend, who of course has a wealth of experience in the field in this matter. I was also going to come to the need for security. In the discussions I have had since I first mentioned this at Defence questions, there has been some disagreement about the level of security required.

The broader point is that this is about the re-tasking of our armed forces. Clearly a lot of change is going on at the Ministry of Defence and there are some cuts to regiments and to forces, but there is also a need to reconfigure forces so that they are interested in delivering not just hard power but softer power. Ultimately, in any response to a crisis—it could be a natural catastrophe such as an earthquake as well as the civil war in Syria—there needs to be joined-up thinking across all the parts of Government that would be involved.

I congratulate my hon. Friend on securing this debate and on the excellent idea that he is putting forward, which has my full support. There have been big increases in the budget for our international development funds but quite severe decreases in the defence budget. Perhaps this is a question for the Minister rather than my hon. Friend, but is there not a strong argument that when the Army is deployed on humanitarian grounds the money should come out of DFID’s budget rather than the Ministry of Defence’s budget?

Yes, I was going to come to that. There should be a DFID-funded capability.

The capability needs to be constructive. A friend of mine has talked about having blue overalls, not blue helmets. In other words, we have a United Nations force with blue helmets, so why do we not have a force of people in blue overalls? Our intervention should not necessarily be military in appearance—we can also intervene in other ways. The capability should be resourceful. We are good at this stuff. We can draw on our experiences in the Balkans and the Falklands—I mentioned Rick Jolly’s field hospital—and prior to that. We are very good at this; we have the clinical expertise, in particular. The capability should be able to be expeditionary—that is, to go abroad. In the case of Syria, I foresee a situation where it could be located in a friendly country such as Jordan. It should also have a domestic application. God forbid that there is ever a chemical attack in this country, but the facility could also be deployed here.

The core goal should be to try to develop a stable world that we all appreciate, and that can be brought about by making friends and influencing people. The Arab street is not necessarily with the British or the Americans. We need to persuade civilians on the ground that we do not always have a malign, vested interest—a sense that we are just doing it for ourselves—in our approach to the middle east, but that we are there to do constructive and good things and to genuinely help people.

Turning to details and capacity, as a result of the conversations I have had I envisage a facility with at least 50 beds, perhaps more. If it is as successful as I think it will be I suspect we will extend it, but 50 beds is a good starting point. I think it should include a CT scanner, which is often not available in more rural areas and far-flung destinations. It is possible to put CT scanners in containers and companies such as Marshall Land Systems in Cambridge make container hospitals. There is no reason why we cannot do this. We need to consider whether the facility should also have paediatric and obstetric services, because it is not just soldiers such as those in the “MASH” television series who will be coming in, but children who have been affected by a neurological agent—such as those we saw in that dreadful footage—and pregnant women who have sustained injuries.

Cost is always relevant when it comes to Government spending and there are some figures available. Apparently the Finns purchased a hospital for deployment for about £5 million. I envisage that my proposal will probably cost between £5 million and £10 million. I think it should be a military asset, because the military is best placed to run it, but it should be staffed primarily with reservists, not regulars. Military logistics are important: the army are the best people to get this facility quickly into the field, and Kosovo is an example of that. The army’s command and control systems are relevant.

My hon. Friend the Member for Beckenham (Bob Stewart) has rightly referred to the facility’s security, which is of paramount importance. I think it would be a target. The facility would focus on hearts and minds and on delivering care on the ground, and if I were an Islamist jihadist I would think, “We need to knock that out, because it’s going to start changing minds and attitudes.” The facility’s security would need some thought. For example, RAF Akrotiri is stationed close to Syria and the deployment of troops may need to be considered in exceptional circumstances.

Clarity of funding is clearly important, as my hon. Friend the Member for Woking (Jonathan Lord) has said. The politics of international aid are tough on the doorsteps of Bracknell—trust me: I experience it quite often. This proposal would be one way of using DFID funds for something that is demonstrably humanitarian and of leveraging in some funds to a defence asset that would be used primarily for humanitarian purposes, but—this would always be at the back of my mind—that could also be deployed if we ever go to war.

We are discussing examples of armed conflict in places such as Syria and Kosovo. Does the hon. Gentleman also see this MASH unit playing a role in responding to humanitarian crises or disasters?

Yes, I do. In fact, the last American MASH unit was deployed in response to the 2006 earthquake in Pakistan and it was then given to the Pakistanis. I would hope that the facility would be used less for military purposes. There are likely to be future crises and I think it should be used in response to them.

I am sorry to intervene a second time, but it strikes me that, if this facility is going to work, the way to demilitarise it would be for it to be connected to the British Red Cross or the International Committee of the Red Cross. That way it would certainly get some kind of international protection in terms of security.

I have detected in conversations that there are difficulties with non-governmental organisations being associated with military assets, so that needs some thought.

I am personally not against it, but I gather that there are difficulties.

Why do we not have such a facility? I wonder about that. DFID has global respect and does good work. There are issues with DFID funding—I am thinking of audit trails in sub-Saharan Africa and the like—and concerns have been expressed on where the money eventually ends up. In this situation, we can spend the money here at home for humanitarian aid. As I understand the definition of international development funding, that is acceptable. Indeed, we could use Marshall of Cambridge—my hon. Friend the Member for North East Cambridgeshire (Stephen Barclay) has joined us in the Chamber. We could buy the facility new at home, and DFID money could, as I understand it, be used for such a humanitarian purpose.

Why is that not happening? Is it silo thinking? Is it to do with DFID not talking to the Ministry of Defence or the Foreign Office? If that is the case, we have a responsibility to try to overcome such bureaucratic hurdles. I recognise that the MOD has concerns about the long-term liability of cost and staffing. I am sure the NHS will have questions, such as, “You’re taking my orthopaedic consultant. Who’s going to do his list?” There are problems, and I have not come to the Chamber with a perfect project outlined and ready to go, but I see no reason whatever why the project cannot be brought about. If we could establish a British MASH unit with a Union Jack on the side of it, it would be fantastic for this country. Our reputation would be enhanced, and such a facility is clearly desperately needed in Syria and the surrounding countries. We are dealing with a significant humanitarian crisis. I know the Minister and his Department are responding in a good way, but that added capability would be much valued. We can do it and do it well.

I shall conclude with a quote which, of course, has to be from “MASH”—I was expecting to turn up in the Chamber to hear hon. Members humming the tune. The quote is from Hawkeye Pierce, the primary character in the series.

“I’m very impressed now with the terrible fragility of the human body and the unbelievable resiliency of the human spirit.”

By creating such a capability, we would display the best facets of that human spirit—we are all human beings. The quote comes from an episode titled, “Our Finest Hour”. If we were to bring that capability about, it would play a part in creating a further finest hour in the history of this country.

I thank my hon. Friend the Member for Bracknell (Dr Lee) for introducing this debate on such an interesting topic. Put simply, I entirely agree that military field hospitals could play a vital role in any international humanitarian response. Indeed, the Department for International Development has collaborated with UK forces in humanitarian responses over many years, for instance in Bosnia, which is well known to my hon. Friend the Member for Beckenham (Bob Stewart), East Timor, Kosovo, Iraq, Afghanistan, Pakistan and Haiti, to name some of the more notable examples.

DFID, the MOD and the armed forces continue to co-operate closely. Since 2007, that co-operation has been codified in a memorandum of understanding that sets out how DFID and UK forces will work together. Its main principles are that DFID will lead the UK response to overseas disasters, that it can ask the MOD for military support if necessary, and that the MOD will charge DFID only the additional operating costs for, for example, ships or aeroplanes, and not the full capital costs. In requesting military support for overseas disasters, it is clearly understood that UK defence requirements will always take precedence.

Alongside that established framework of co-operation, the two Departments have made explicit provision to use military field hospitals if required. DFID has agreed with senior military medical colleagues that, subject to defence priorities, military field hospitals may be deployed as part of a humanitarian response by DFID. To that end, DFID has visited the Army’s 34 Field Hospital at Catterick garrison, which is the MOD’s designated rapid response field hospital. DFID has held detailed practical discussions with it and has contributed to its humanitarian training and preparedness.

Importantly, it must be understood that the deployment of a military field hospital requires substantial logistical support. It might also require a considerable force protection package, which would have a bearing on the location and appropriateness of the facility. Our experience is that the use of any military asset is expensive. Issues around permission to operate and the command and control of such a facility would need to be agreed with the receiving nation, which would inevitably prove more complicated with a military facility than a civilian one.

The Marshall facility in Cambridge specialises in building modular medical equipment. Is it not a key point that the initial funding for the equipment could come from the DFID budget under the existing definitions, which might ease the concerns of other countries about the military aspects of the facility?

Spending on humanitarian matters is official development assistance, so in that respect my hon. Friend is right. However, we must also show that there is value for money and we must know that the assets can be appropriately deployed. I will discuss that issue further.

DFID has worked on the ground alongside UK forces in Bosnia, Kosovo, Sierra Leone, Iraq and Afghanistan. DFID has also used Royal Air Force aircraft and helicopters in earthquake and flood relief in Pakistan, and in sending search and rescue teams to Indonesia. The Royal Navy was able to make its Royal Fleet Auxiliary Largs Bay ships available to help with relief after the Haiti earthquake.

So far, UK military field hospitals have not been deployed under the auspices of DFID. However, the way it would work is that DFID would request the support of the MOD in response to a natural disaster, in accordance with United Nations guidelines known as the Oslo guidelines. Those guidelines stipulate that support should be provided in line with the humanitarian principles of impartiality, neutrality, humanity and independence. They also state that military assets should be requested only where there is no comparable civilian alternative. That implies that the military asset must be the only way of meeting the particular need and that its use should be a last resort.

DFID has to design its humanitarian responses carefully according to the specific humanitarian needs that they face and based on what responses are best provided by the UK and by other donors. Very often, what works best is help to restore and rebuild an afflicted country’s own health system. If a field hospital is needed, there are already well established civilian organisations that are used to providing such hospitals in humanitarian crises, notably the International Red Cross, which has been mentioned.

A civilian response will usually be what is needed in a delicate and complex situation, rather than a foreign military presence which, however well intentioned, is still military and may not be welcomed. For example, in Pakistan, which has also been mentioned, it was a difficult, finely balanced, decision to include RAF aircraft in the NATO relief airlift, when extremists had explicitly threatened the foreign relief effort and relief workers if NATO were to operate in that country. Like other international donors, therefore, while we are glad to have military field hospitals available, we will use them as a last resort, when it is too difficult or dangerous to use civilian measures and if the circumstances permit a military medical unit to be deployed.

DFID has also been building a UK civilian medical response capability. UK surgeons and other medical staff performed heroically in Haiti after the earthquake in 2010, saving lives and limbs which might otherwise have been lost. Building on that experience, DFID is supporting a programme of training and regional workshops for NHS doctors and other medical staff to equip them to deal with the additional challenges of surgery in a conflict zone. That is underpinned by an arrangement with the Department of Health and the national health service to deploy surgical trauma teams drawn from the British health service. Many of those personnel will also be military reservists, thus further exemplifying good civilian/military co-operation across Government.

My hon. Friend specifically mentioned the Syria crisis. As the House is aware, the UK Government’s relief response is considerable. The UK has so far pledged £500 million, making us the second largest donor. Much of that relief is to provide health and medical care. Through our funding we are supporting vital medical help on civilian channels and with civilian medical personnel, not all details of which can be openly revealed. I can say, however, that the range of services provided by DFID is wide and big. It includes ensuring the running, supply and necessary specialist training for a large number of emergency surgical facilities, including in remote areas. For example, we are supporting primary health care centres to help look after vulnerable groups such as women and children, as well as the elderly, who often have chronic unmet health needs. In Syria’s neighbouring countries, which now host more than 2 million refugees between them, DFID-supported health programmes provide medical evacuations and ambulance services, widespread primary health care facilities, mental health and psycho-social services, and highly specialised facilities for victims of sexual and gender-based violence.

We provide specialist training courses for health professionals, many of whom are specialist staff seconded into emergency departments to reinforce their capacity and specialist care. We provide health services for refugees, as well as for vulnerable resident populations that are hosting huge numbers of refugees in their communities. DFID and MOD officials are in frequent touch in London and the region, and the need for and suitability of mobile field hospitals is often discussed. While options remain open, it is agreed that deploying a mobile field hospital at the moment would not be the most effective way to reach the diverse needs faced by so many people in so many different locations.

DFID’s new civilian surgical trauma facility also remains an option, but so far it has not been necessary to deploy a surgical team in any of the refugee-hosting countries. Inside Syria, the level of conflict makes access to health care difficult in many areas, and unfortunately the security challenges also prevent the deployment of a field hospital or a civilian UK surgical team. DFID will therefore continue to support existing health facilities on the ground, and constantly review the situation.

Does DFID have the capacity to deploy not just a surgical team, but the equipment and some primary buildings in support of that team? Is that what my right hon. Friend is referring to?

I like to think that DFID is well prepared always to procure and lay its hands on any such equipment, to which end many framework contracts permit us to draw at short notice on many companies’ equipment so as to do whatever is appropriate in whatever humanitarian situation we face, be that an earthquake, a tsunami or a conflict.

In conclusion, the Government value their ability to deploy military surgical teams as an important option, additional to other means of response. DFID’s response is based on the needs of the affected population, and so far the need for a UK military field hospital has not arisen. If it does, we remain ready to respond as required in the best and most appropriate way.

Question put and agreed to.

House adjourned.