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The first casualty: truth

In Britain, preparations for a major war and for casualties on a massive scale were shrouded in secrecy.

On 3 December, Health Secretary Virginia Bottomley refused to make public the Department’s guidance to regional health authorities on the reception and allocation arrangements for military casualties to the NHS in time of war. This secrecy was compounded because senior health service managers are now required to sign the Official Secrets Act, blocking the flow of information to clinicians and making it difficult to plan properly for emergency admissions.

The immediate effect on the NHS was localised increases in workload as military hospitals in the UK ended or greatly reduced services to local communities, and reservists working in the NHS were encouraged to volunteer for military duty.

On 27th December the Department of Health issued a ‘Restricted’, document ‘Gulf Contingency Planning. NHS Plan and Procedure Guide ‘.

This plan, ‘Operation Granby’, suggested that heavy casualties amongst UK forces were expected, that there would be significant disruption of the NHS, and that it would be necessary to misinform the media about the extent of casualties, their impact on NHS services and the adequacy of medical facilities.

The plan listed NHS Districts close to ‘airheads’ (military and civilian airports) that would receive casualties from the Gulf, and predicted that 65-70 vacant beds per day would be required in each NHS region, to a maximum of 500 per region. This totals 7,500 in England, with hospitals in Wales and Scotland being held in reserve. Some press commentators agreed that this would have only a slight impact on NHS services, given that a Region with 2,500 beds would expect between one and two thousand to become vacant each day.

However, a document giving guidance to senior clinicians issued by the DoH one day after the Operation Granby plan painted a gloomier picture.

Appendix 6 of this clinical guide details chemical weapons injuries and their treatment, and points out that: “The management of CW casualties will present new problems for doctors in the UK... The compounds likely to be used in CW differ from those encountered in ordinary clinical toxicological practice.”

”the period of care needed by CW casualties may be underestimated particularly in the case of mustard gas burns. Casualties with severe burns may require weeks of hospital care and a lengthy convalescence... precise details of how nerve agent poisoning may differ from insecticide poisoning are imperfectly known...”

The document also expected burns casualties to be suffering from skin losses of between 15% and 40% and “massive and complex soft tissue injuries involving skin and muscle, or muscle and bone, or all three” which will need treatment within 24 hours of landing in Britain and commented: “There is likely to be heavy pressure on burns, intensive care and neurosurgery units. Such pressures arise, in part, from staff shortages, particularly of nurses and technicians.

The problem for the NHS, then, was seen to be one of case-mix rather than bed numbers, with the possibility of large numbers of chemical weapons injury and severe burns cases being added to those suffering from more ‘usual’ blast and shrapnel injuries. DoH predictions that war casualties would block NHS beds for no more than 12 days — the average NHS inpatient stay, contradicts the Department’s own advice to clinicians.

Professor Angus McGrouther, a plastic surgeon quoted in The Observer on January 13th, said: “The military are very gung-ho about the ability of the NHS to cope with casualties, but did not adequately consult civilian specialists in planning services...”

”We know that soldiers might get First World War injuries... The fear is that they are going to get First World War treatment.”

Let’s hope he is wrong.