The UK should invest in a dual use ‘hospital ship’ but not necessarily in the manner everyone thinks
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A UK Hospital Ship has been a recurring theme in the media and over the years, accompanied by much online discussion, but it has never really gained much traction in Government. Comments from the Secretary of State for International Development (Penny Mordaunt MP) reported in the Daily Mail would seem to have improved its prospects.

Tens of millions of pounds in foreign aid money could be used to build ships to provide humanitarian relief – and help the Royal Navy. International Development Secretary Penny Mordaunt believes this dual role will quell concerns about Britain annual £14billion foreign aid budget. Critics often claim it is used to help nations wealthy enough to run their own space programmes, such as India and China. However, Miss Mordaunt claims the vessels’ dual role – by assisting in military operations when they are not needed as hospital ships in disaster zones – will allay those fears. In addition, the ships could even be used to host trade missions and promote Britain to the world, much like the Royal Yacht Britannia did before it was decommissioned in 1997.

Without seeing the letter the article reports on or understanding the full background it is difficult to determine the staff work that underpins the suggestion or indeed, the basics of ENDS >> WAYS >> MEANS that results in a hospital ship being the logical end-point.

That said, it is not unreasonable to see how the motivation for the suggestion has roots in making better use of the UK’s significant and politically difficult Overseas Development Assistance (ODA) budget, reinforce the post BREXIT ‘Global Britain’ vision and provide some relief to a defence budget that is in permanent crisis. At a high level, a ‘hospital ship’ ticks all the boxes so would appear at face value to be a no brainer, but like many subjects, scratch the surface and you find significant challenges that might be cause for pause and reflection.

This article takes a look at those issues, and of course, has a broad stab at a few alternatives!

Before We Start, Terminology

Although hospital ship is often used as a generic term and is arguably much easier to understand than Primary Casualty Receiving Facility (or Ship), there is a very big difference so it is important that this is understood, we need to get this out of the way early in the article.

Ships dedicated to providing medical support have a long history but the term Hospital Ship was first defined in the Geneva Convention and Maritime Law (3rd Hague Convention) of 1899 and additionally in the Tenth Treaty of the Hague Convention of 1907. It was very specific about restrictions, marking and rules of use, read it here but as an example, they must not be used for any other purposes, all belligerents have the right of search and must be painted white with a green band. After WWII, the Geneva Conventions of 1949 further enhanced and updated provisions for Hospital Ships, specifically Convention (II) for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea. Geneva, 12 August 1949, Chapter III. Link here

The comprehensive 1949 Convention has also been subject to two sets of ‘commentary’, one in 1960 and the latest, in 2017, again, links above. Needless to say, the legal definition of a hospital ship is a serious matter for anyone thinking they might want one.

Now if you read that and thought, bloody hell, that is a complex business, can I introduce you to the 280 pages of AJP-4.10 Allied Joint Doctrine for Medical Support? It is not possible to summarise such a comprehensive document easily but of most relevance is the concept of different types of facility role, we often hear terms like Role 2 or Role 3 in relation to medical facilities.

A Role 3 Medical Treatment Facility is defined as;

A hospital response capability provides secondary health care at theatre level.  A Role 3 MTF must provide all the capabilities of the Role 2E MTF and be able to conduct specialized surgery, care and additional services as dictated by mission and theatre requirements. In a Maritime context, Role 3 support is provided by the primary casualty receiving facility fitted to Royal Fleet Auxilliary Argus when it is designated as the primary casualty receiving ship.

RFA Argus is often called a hospital ship but she isn’t, instead, she is a primary Casualty Receiving Facility as defined by AJP 4.10 and UK specific doctrine. Painted grey, armed and able to conduct other non-medical tasks, she is most definitely not a hospital ship, even though her primary role is medical in nature.

More on this later, but we need to be very clear about the differences.

We might want a hospital ship, we might not, which leads on to a question…

What do We Actually Want?

Accepting that a Hospital Ship is not a Primary Casualty Receiving Facility we need to try and define what it is we might actually want, what doctrinal or strategic context any such facility would exist in and examine a range of options for delivering against the requirement.

  • A medical capability for disaster response i.e. in the aftermath of a Caribbean hurricane or African Ebola outbreak
  • A medical capability that supports deployed forces in a military operation i.e. a deployed Bastion hospital
  • A multi-purpose capability that can be used for both the above, and potentially other roles in support of both civilian and defence operations

You might note I described these as capabilities, not ships.

Payloads not platforms is perhaps a hackneyed phrase but it does provide the opportunity to look at other means of providing the effect. For example, could a combination of air deployment and ship deployment be optimal, or even developing and supporting local responders as a valid alternative.

We should really look at them all.

There must be some reference to the span of capability, capacities, threats and potential locations.  When the need/requirement has been established, the thorny problems of manning and finance will also need to be addressed. The answers to these questions might make one path or the other preferable, there may be some answers that also close off options and force a compromise in one area or the other. A civilian manned hospital ship paid for by the DFiD budget might be just what DFiD wants, but it would have very little utility for the MoD and still leaves the replacement of RFA Argus to be discussed.

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Establishing the Need

We can place the requirement for a hospital or HADR ship/capability in the wider context of the MoD’s approach to stability.

Conflict prevention is a simple concept that at its core seeks to make the UK safer by providing help to unstable nations such that they can help themselves to stabilise. The theory is that an Ounce of prevention saves a Pound of cure. Getting in early, de-escalating early-stage conflict and supporting overseas development efforts are all seen, quite rightly, as effective means of preventing wider and much more expensive conflict.

The Army’s Adaptable Force as part of Army 2020 continues to evolve, the August 2015 Joint Doctrine Note 1/15 describes the MoD’s defence engagement approach and (although it is a few years old) the International Defence Engagement Strategy provides additional information.

Our collective experience from operations tells us that Defence Engagement activity is a constant: it rises and falls in volume and extent as situations evolve and events happen but the boundaries are blurred.  There may sometimes be a fine line between Defence Engagement and combat operations – equally Defence Engagement may continue inside a country or region during combat operations. Therefore, when understanding Defence Engagement, consensual flexibility in both scale, metrics and effect is needed.

JDP 05 Shaping a Stable World: the Military Contribution pulls these together and provides a good diagram that illustrates how they all fit together. Defence engagement is therefore designed to build understanding and develop capacity with the objective of preventing conflict. The Building Stability Overseas Strategy (BSOS) is a joint Foreign and Commonwealth Office (FCO), Department for International Development (DFID) and MOD strategy for conflict prevention. BSOS also outlines three main mutually-supporting pillars of the Government’s stability strategy; Early warning, Rapid crisis prevention and response and Upstream conflict prevention.

All these documents are tremendously useful in trying to understand the UK’s approach to conflict reduction and building stability, and for the purpose of this document, humanitarian assistance. The 2015 SDSR included a provision for the £1.5 Billion Joint Security Fund and other changes to overseas development assistance parameters. From the Commons Library a description of the funding landscape for conflict prevention, Changing parameters of Overseas Development Assistance

An area where the scope for flexibility has been identified in supporting the budgets of ‘non-protected’ government departments like the FCO is through increased counting of their spending as Overseas Development Assistance (ODA – as defined by the OECD). The UK’s ODA budget has reached the UN target of 0.7% of Gross National Income and the Government is committed to maintaining this level of spending.

In a significant move, ODA was now to be used to serve the national interest.

The Conflict, Security and Stability Fund starts…

The Conflict, Security and Stability Fund (CSSF) became operational in April 2015. A beefed-up version of the tri-departmental (FCO, MOD, DFID) Conflict Pool but now managed and controlled by the National Security Council, it represents an attempt to fulfil the long-standing aspiration for a ‘whole of government’ approach to national security. The CSSF has become the main mechanism for the implementation of the 2011 Building Stability Overseas Strategy (BSOS), which sets out the conflict prevention agenda originally called for by the 2010 NSS. A key element of the UK’s conflict prevention agenda during the last parliament was a greater focus through UK ODA on fragile and conflict-affected states. This has been achieved: the target set was to spend 30% of UK ODA on them by 2014-15. In 2013, 43% of UK ODA was spent on them. This upward trend looks likely to continue over the next five years.

It is clear that the UK sees ‘stability’ as a significant part of the remit of Overseas Development Assistance (ODA) and that funding will follow. It also demonstrates that it is well established; organisationally, doctrinally and financially. With the Modernising Defence Programme, new National Security Objectives and the emergent Fusion Doctrine, there is a conscious effort to provide even greater alignment and direction across departments, or joined-up government in the old fashioned vernacular. A less well-known aspect of the recent changes to the UK’s strategic outlook has been work completed on Cross Government Funds, if there is cash for a hospital ship, it may well find its roots in this work.

Click here to read more.

We can, therefore, place the requirement for a hospital or HADR ship/capability in the wider context of the Governments strategic approach to stability but dropping down to the operational level we should have another look at the medical support and disaster response doctrine publications published by the MoD.

Disaster relief operations (JDP 3-52) provides guidance for planning and conducting military support to humanitarian relief efforts overseas.

This text is particularly important;

UN guidelines, commonly known as the Oslo Guidelines state that civilian assets are to be preferred over the military when providing humanitarian assistance; this is linked to the principle of last resort.  Therefore, DFID will normally only request military assistance when there is an acknowledged gap between humanitarian needs and the civilian resources to meet them, and where the response is acceptable to the local population and in support of the wider relief effort.  The military response must have a comparative advantage over civilian options; such advantage may be: speed of reaction, the scale of effort or availability of specific resources.

It also describes the generic phases of disaster management and establishes the military response element to the lower right quartile of the cycle, perhaps reasonably.

As fusion doctrine matures, potentially, these distinctions and dividing lines will blur. There is no doubt that military medicine has progressed significantly during recent operations, as have expectations. Upon the closure of the Role 3 Hospital at Camp Bastion, Lieutenant Colonel Jaish Mahan, Commanding Officer UK Medical Group, said;

The campaign in Afghanistan, for us as medics, has been the defining operation of our military generation. It has catapulted us to the forefront of battlefield trauma care worldwide. Huge medical advances have been achieved, with a survival rate unrivalled in history

The three diagrams below show the complexity of patient pathways and general approaches, you will note they include the UK as a key element, in a HADR context, this may not be viable.

Medical care is organised on a role or echelon basis, read more at the Allied Joint Doctrine for Medical Support.

The medical doctrine describes the UK’s modular approach to medical care.

Core Modules

  • Emergency Area
  • Initial Surgery Response Capability
  • Specified Diagnostic Capabilities
  • Patient Holding Area
  • Post OP (high/medium dependency)
  • C4I (including telemedicine support)
  • Medical Supply

Enhancing Modules

  • Imagery
  • CT-Scan
  • Surgery
  • Dental
  • Sterilization
  • Ward (general)
  • Primary Healthcare
  • Intensive Care Unit (long-term ventilation)
  • Pharmacy
  • Laboratory
  • Mental Health
  • Internal Medicine
  • Isolation Ward
  • Hospital Management

Complementary Modules

  • Additional Clinical Specialists
  • Specialist Surgery
  • Oxygen Production
  • Preventive Medicine
  • Hyperbaric Medicine
  • Telemedicine
  • Transient / Response Ambulances
  • Magnetic Resonance Imaging
  • Frozen Blood Product
  • Animal Care
  • Mortuary
  • CBRN (Decontamination & Treatment)
  • Physiotherapy

These are represented (or not) at the care echelons. There are two Role 2 variants, Basic and Enhanced, and Role 3, a hospital response capability that provides secondary health care at the theatre level.  A Role 3 MTF must provide all the capabilities of the Role 2E MTF and be able to conduct specialized surgery, care and additional services as dictated by mission and theatre requirements. It can be seen from this that there is some degree of flexibility and scalability within the UK’s approach.

The diagram below shows the span.

The MoD has also recently taken delivery of a modular deployable Role 3 Hospital from Marshall. The Queen Elizabeth aircraft carriers will have Role 2 facilities and Role 3 is currently provided by RFA Argus when designated in the role.

Medical echelons

Health support to Joint Operations

The image below shows a deployable Role 3 Medical Facility

And below, the medical facilities at Camp Bastion in Afghanistan, also a Role 3 facility


Role 3 facilities required include resuscitation, operating theatre, intensive care wards, advanced diagnostics (X-ray, MRI etc), recovery wards, sterilisation, pharmacy, hyperbaric facilities, blood/blood component storage, medical waste disposal, command and control, laboratory, dental, isolation, medical gas handling, power generation, uninterruptible power supplies, storage space, catering, mortuary, laundry, extensive communications for telemedicine and a computing environment that supports the secure generation, storage and processing of large volumes of data. As can be seen from the image above, the Role 3 field hospital occupies a single layer but is approximately 120m by 60m. The Camp bastion diagram clearly shows a substantial layout and RFA Argus has an equally voluminous installation.

The doctrine also includes specific references to disaster relief operations.

This is a fairly long-winded (sorry about that) way of saying a handful of very simple things;

  • The UK benefits from global stability
  • The UK is invested across multiple departments with significant budgets in contributing to this stability
  • Disaster prevention and response is a fundamental part of the UK’s approach to contributing to global stability
  • The UK has done a great deal of thinking about this, and its thinking continues to evolve
  • The UK is doing a great deal
  • Defence has an enduring and evolving need for medical treatment facilities of various types including a Role 3 deployable facility
  • The Role 3 deployable facility can be land or sea-based, or even air deployed, but if we have a deployed force and that if that force is on or near the sea, it pretty much makes sense to have an afloat capability

Existing Capabilities and Previous Examples of Use to Guide Discussion

Perhaps the most well-known hospital ship was the SS Uganda and her service during the Falklands conflict. She was converted from an educational cruise liner into a three ward hospital ship in a very short period of time and served with distinction throughout.

More recent examples include…

RFA Argus

During the 1982 Falkland Islands conflict, the Contender Bezant was utilised as an aircraft transport, ferrying helicopters and Harriers south to the Falkland Islands.

Following purchase by the MoD in 1985 for £13million, she was converted to an aviation training ship at Harland & Wolff, Belfast, with the addition of extended accommodation, a large flight deck, aircraft lifts, naval radar and communication equipment. A Primary Casualty Receiving Facility was added before Argus deployed in 1991 to the Gulf War.  Another role of RFA Argus was that of RORO vehicle transport with vehicles carried in the hangar and on the flight deck, a role she performed in support of United Nations operations in the former Yugoslavia.  During the 2003 invasion of Iraq, Argus was again present in the Persian Gulf as an offshore hospital for coalition troops, earning the nickname ‘BUPA of Baghdad’. More recently, RFA Argus participated in OP GRITROCK, the UK’s response to the Ebola outbreak in Sierra Leone, and of course, a star turn in the Brad Pitt film, World War Z.

The 1998 Strategic Defence Review stated that the MoD would ‘acquire an additional 200-bed primary casualty receiving ship’ with a second available on contract at longer notice (up to a year) when required. The assumption was that the second vessel could be a conversion project, completed on demand. An IPT was formed in 1998 to start the project and scoping contracts let for initial concept and requirement work with BMT and Atkins, this initial work also envisioned JCTS would be delivered through a PFI rather than outright purchase but after it was shown there would be little scope for alternative revenue generation the requirement was changed. After some progress on JCTS, the project was shelved in 2005. There was also some discussion and a proposal to convert one of the Bay class vessels to a JCTS at a reported cost of £360m in 2005 but this didn’t proceed either. At 28,000 tonnes, RFA Argus is a very large vessel and it is the space that allows it to have such flexibility and capability. RFA Argus has a range of extremely impressive medical and support capabilities, improved over a number of years and refit periods.

In 2009, a £37m programme, for example;

This has encompassed major equipment upgrades to safety and evacuation systems, sewage treatment, refrigeration, ventilation, reverse osmosis, fire and watertight integrity; the removal of the forward aircraft lift; the extension of the PCRS with a new access ramp and two new lifts; new PCRS equipment [including a CT scanner, sterilisation equipment and an oxygen concentrator]; and a series of structural modifications including new steel bulkheads, watertight doors and a new bridge front. There was also a major accommodation upgrade, plus extensive painting, mechanical and electrical packages.

The Role 3 medical facilities can flex but in the largest configuration is designated as 4/4/10/20/70 which means 4 resuscitation bays, 4 operating tables, 10 intensive care beds, 20 high-dependency beds and 70 general beds (in two wards).

Other facilities include dental surgery, imaging (Ultrasound, 64 slice CT and X-Ray), pathology, pharmacy and physiotherapy. She has an oxygen concentrator and various laboratories.

The Maritime Aviation Support Force often deploy support teams to RFA Argus on a demand basis and the 180 medical personnel are drawn from the joint defence medical service and wider NHS. Regular training and exercises not only ensure the professional medical standards are maintained but also that they can be exercised on board the ship, with the various unique factors that this involves, something often overlooked by many when discussing this.

She will eventually need replacing.

Other Nations

Other nations have their own variation on hospital ships, from very large to very small.

The largest of the modern hospital ships is the US Mercy Class, USNS Mercy and USNS Comfort. Both are converted San Clemente class tankers, displacing approximately 70,000 tonnes. With a 1,000 bed capacity and 12 operating theatres, they are also equipped for the widest range of medical treatment options. Mercy is home based on the Pacific coast and Comfort, the Atlantic. Both are activated in response to need rather than being permanently in operation and they have a number of design flaws that are often the subject of much discussion; lack of aviation facilities, poor patient movement routes, relatively low speed and their sheer size makes them unsuitable or overkill for many situations.

Russia and China also have hospital ships, the former with the 11,000 tonnes 100 bed Ob class (Yenisey)

…and China with 30,000 tonnes 400-bed Daishan Dao, alternatively known as the Peace Ark.

China also has an interesting ‘medical evacuation ship’ called the Zhuanghe which is a converted 30,000-tonne container ship. She can be equipped with various combinations of containerised shelters although it does seem the range of facilities is relatively limited.

There are also a few other interesting designs to consider, the Spanish Esperanza del Mar is a civilian vessel used to provide medical cover for Spanish fishermen off the coast of Africa, the Brazilian Navy Soares de Meirelles which is a riverine vessel used to provide healthcare to remote communities and the Indonesian KRI Dr Soeharso, a converted LPD. The 21 million Euro (part-funded by the EU) 5,000 tonne Esperanza del Mar is a custom-built vessel and quite modest compared to those above.

The Soares de Meirelles has a very shallow draught to enable it to navigate Brazils numerous rivers

…and the KRI Dr Soeharso is a multi-purpose vessel that has a great deal of flexibility for getting patients on and off with small craft and helicopters.

What is interesting about these last three examples is how they are very specifically designed for their requirement and environment.

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A Proposal

There is any number of options available; do nothing and gap the capability when RAF Argus is withdrawn, convert one of the BAY Class LSD(A) vessels, wrap it up into potential future replacements for Albion/Bulwark, contract a civilian provider for a HADR only hospital ship, or most simply, replace RFA Argus with something like for like, a civilian merchant vessel conversion. What makes this so difficult is a Deployable Role 3 PCRF is so rarely needed so it becomes subject to conversations on likelihood v impact and cost savings. For many years those conversations have confirmed the post 98 SDR status quo of keeping RFA Argus in service, but she cannot last forever.

Converting one of the Bay’s would be simplest, but it would result in a tangible capability loss and doesn’t solve the RFA’s and DMS manning issues, and we would be converting a ship that is likely over 15 years into its lifecycle. I can’t see gapping the capability has many merits either, that would send all the wrong messages to service personnel and their families. This means the most likely would be to design and build a bespoke vessel (less likely) or simply convert a second hand new(ish) merchant’s vessel. The former would be good from a UK prosperity perspective, probably look something like HMS Ocean, and produce the most optimal solution, but it doesn’t solve any of the issues about use rates v cost.

The proposal is in the form of three activities, each in ascending order of likely cost but all within an overall framework that improves the ability of the UK and its overseas territories to both prepare for and respond to natural disasters. Proposals two and three also have a dual role aspect, being applicable to medical support to military operations and HADR.

ONE – Build Local and Civilian Medical and Disaster Response Capabilities

Fundamentally, the ultimate goal of any overseas development organisation must be to make themselves redundant. The more we can enable, support and develop local responders and civilian organisations the more they can look after their own and the more we can spend money elsewhere.

Mercy Ships is a UK based faith charity that operates the M/V Africa Mercy, a hospital ship with 82 beds and a full range of modern diagnostics and support facilities. They also operate a screening and minor surgery facility on land whilst ensuring that multiple training and infrastructure development activities are delivered during their stays at various locations.

Although not nautical, Orbis is a similar UK charity that specialises in eye care. They operate in a capacity of both doing, training and capability development, including some very advanced telemedicine, but with the obvious difference of operating from an ex Fed-Ex DC-10, rather than a Danish railway ferry.

These are not responding organisations, they work on a planned basis to both deliver services and develop local organisations.

Although there is a benefit to overseas basing and defence obligations will remain, an alternative might be to share and expand existing facilities where appropriate. A good example of this is in the Caribbean where there has also been some speculation about basing for defence, counter-narcotics and disaster response. The recent operation to render assistance to the hurricane-hit islands in the Caribbean was a textbook example of response at range and demonstrated the very finest qualities of the UK armed forces, civil servants and voluntary sector, but the irony of UK taxpayers paying for infrastructure restoration on an island that is a significant part of the offshore finance industry cannot be ignored. The issue of being unable to qualify assistance as part of the UK’s official ODA funding has also been controversial. For the future. Instead of a response, the UK should focus the Caribbean British Overseas Territories on infrastructure resilience and local/regional response, a key lesson from Op RUMAN now being implemented. Counternarcotics smuggling is also a role carried out by RN/RFA vessels on a regular basis, again, we should question whether this can be delivered in alternative and lower-cost ways to reduce RN/RFA workloads.

For the Caribbean BoT’s, some have suggested a permanent presence like that of the Dutch support ship HNLMS Pelikaan but there is an alternative.

The Royal Bahamas Defence Force have recently completed their $200m ‘Sandy Bottom’ project which has delivered a number of patrol vessels, a large RORO craft, containerised disaster relief equipment and a significant port facility.

The 600 tonne, 52 meters, multi-purpose cargo vessel (in the last video above) has a landing ramp and 25-tonne crane. It can carry 42 containers on deck with water and oil in fitted tanks. These will be used for logistic support and disaster relief and included in the deal are a number of containers specifically for the disaster relief mission. As an alternative to responding and regular deployments, the UK could fund an expansion of Sandy Bottom or do the same somewhere else to include hurricane hardened relief supplies storage, improved command and communications facilities and another RORO vessel to create a sustainable regional capability. This is just one example, other locations with better proximity to suitable airports may well be more suited but the concept would remain, work with local civil resilience organisations (like the Caribbean Disaster Emergency Management Agency) and build up local capability.

The first proposal is, therefore, to fund from DFiD (and perhaps a small bit from the MoD) UK based charitable organisations and local responders. This is arguably the most cost-effective path and certainly, the best from a long term perspective. And it is absolutely possible within the DFiD budget, with little or no impact on the MoD

TWO – Air Deployable Rapid Response

Within 5 days of the 2010 Haiti Earthquake, Israel had a joint team on the ground conducting a blend of rescue and medical activities. It was a hugely impressive display of rapid response in a disaster context.

They flew there, 3 days after the earthquake.

The first Israeli delegation landed in the capital of Port-Au-Prince on Friday evening (15 January) and established its operation center in a soccer field near the airport. On Tuesday night (Jan. 19), an additional team joined the IDF forces operating in Haiti since the earthquake, consisting of GOC of the Home Front Command, Maj. Gen. Yair Golan, CEO of the Ministry of Health, Dr Eitan Hai-Am, and the Chief Medical officer, Brig. Gen. Nahman Esh. After landing, the team arrived at the IDF field hospital and was updated on the current situation regarding the treatment of victims.

As impressive as it was, it would not have been possible without the efforts of a handful of people from the US 1st Special Operations Wing’s Joint Special Operations Air Component. 26 hours after the earthquake, two MC-130H’s from the 15th arrived at the airport, flying from Hurlburt Field in Florida. Within 30 minutes of arriving the combat air controllers assumed command of air movements, setting up shop in the open air using a couple of folding tables. Aircraft were guided to their parking spots using motorcycles.

These combat air controllers were absolutely instrumental in enabling the inflow of aircraft.

The UK actually has a very good similar capability, we have very high readiness force protection airfield engineering, medical and logistics forces across 16 Air Assault Brigade and the Royal Air Force, backed with various teams of specialists including those that can parachute in if necessary. Where airfields are available, the first priority should be ‘enabling’ them to follow on military and civilian capabilities. The very same capabilities have broad utility across the spectrum of operations, there is no need to dedicate them to HADR or combat operations, it’s all there, it’s all good. Where time is available, and infrastructure not damaged, as per the Ebola response in Sierra Leone, medical facility design and build are also sensible options to exploit,

Where the response is HADR and not solely in support of military operations there are a number of charity rapid-response organisations that could be integrated with the MoD and DFiD’s capability framework.


Serve On

Rapid International


UK Med

Team Rubicon

This proposal is less about any new capability but one of integration, exercise and selected equipment improvements to improve capacity and capability to respond to medical emergencies

THREE – A Multi-Function Vessel and Role 3 ‘Super Module’

Proposals Two and Three have nothing whatsoever to do with a ‘hospital ship’, the subject of this article, but they do place a ship in a wider context that I think is important to note. When we look at a multi-function vessel we can easily envisage RFA Argus, or one of the Bay’s, both being excellent examples of course. Going to the second-hand market reveals several bargains can be had, whether using Container ships, CONRO’s, Vehicle Carriers or those like the current Point class strategic RORO vessels. A similar vessel to the Strategic RORO’s has been converted by the US for SF support, look up the M/V Cragside for further information.

Options might include;

ROPAX; RORO and passenger, perhaps most used in the short sea crossing routes with accommodation for cars/trucks, foot and car passengers. The image below shows a ROPAX design from Flensburger for Caledonian MacBrayne, built at a cost of £43 million. They are usually equipped with stern and aft ramps and extensive passenger facilities.

PCC/PCTC; Pure Car Carrier and Pure Car Truck Carrier are specialised vessels that are designed to carry new vehicles. They have close-spaced decks to maximise carrying capacity but arguably, provide the greatest potential due to their large internal volume and inter deck pathways.

CONRO; a CONRO that combines container and RORO cargo, the Atlantic Conveyor was a CONRO and the Atlantic Conveyor Line continue to specialise in this type of vessel. The upper deck is fitted with container guides and the lower decks, used for RORO cargo. Open deck conventional RORO vessels can also usually accommodate containers and reefer containers on their upper deck.

RORO/LOLO; In addition to RORO vehicle decks, the LOLO part of the combination adds high capacity cranes for outsize or hazardous cargo, in addition to containers. Technically, the Point Class Strategic RORO vessels are RORO/LOLO vessels as they can self-load using a deck crane.

RORO; the classic RORO, used mainly for vehicles and trailers, the trailers can also be substituted for cassettes or devices used specifically for certain cargo types, bananas and paper for example. They can have their superstructure forward, aft or at a midpoint. The superstructure usually contains accommodation for drivers and other passengers but in most designs, this is relatively limited, as drivers do not travel usually internationally. Some might even be tempted by the ‘fastcat’ type short route ferries but just to show a couple of alternatives, a new RO-CON design by Knud E Hansen for the former National Shipping Company of Saudi Arabia (now Bahri) and a concept for a banana carrier, from the same company.

Bahri has taken delivery of six vessels of this design, all built between 2013 and 2014, for the princely sum of £49 million each, no, that is not a spelling mistake. They are designed with RORO, container and heavy lift on cargo in mind, the flexibility built-in.

They would have to be inspected, transported, faults rectified, modifications made, re-inspected and accepted into service, but when your starting point is between one and twenty million Pounds, it is easy to see the attraction of dabbling in the second-hand market. The main problem with a merchant conversion is just that, you have to convert, permanently. This means you are always carrying around the medical facility because just putting ISO container modules is highly unlikely to meet the demanding needs of a Role 3 MTF. You don’t solve the utilisation problem so, in reality, the ship isn’t multi-function at all. When the ship isn’t doing the medical thing, it needs to earn its keep doing something else. Traditionally, we would look at this and think aha, the ISO container module is the answer, in this case, it isn’t.

Role 3 Super Module

Several years ago BMT looked at the options for replacing RFA Diligence under the Operational Maintenance and Repair (OMAR) study. It concluded that the optimum solution was an unpowered barge carried to the area of operations on Float On Float Off (FLOFLO) heavy lift vessel. The barge was 120m x 30m and displaced approximately 3,500 tonnes.

OMAR Barge

Modularity is the answer, but like the Operational Maintenance and Repair (OMAR) study, we need to think big.

Now bear with me, because I will grant you this might sound a bit insane, but this is a post to promote discussion, not provide definitive answers so being a bit radical is not a bad way to start!

Simply put, we build a Role 3 medical facility as a ‘supermodule, not dissimilar to the image above.

When not deployed, the Role 3 MTF Module(s) would simply be stored onshore, they would also provide an excellent training environment or emergency capability. They can be designed from scratch, optimised for patient flow and with all the facilities required. Medical personnel accommodation (which always seems to be a problem) could be built-in or configured as another large module, each self-contained from the other. Aviation or boat handling, again, is built according to specific requirements, possibly including facilities for handling landing craft or hovercraft to enable a quicker ship to shore transfer.

Where could we store modules?. A lot would depend on the availability and proximity of medical and maritime personnel but potential locations could include Marchwood, Glasgow, Belfast, Teesport or Liverpool.

Module Transport Vessel

The BMT OMAR study suggested using a FLOFLO vessel of opportunity or one on a long term charter but I think the type of vessels available has broadened since then and we might be able to look at extracting more value from such a vessel, especially if it were rolled into the strategic RORO contract that provides a number of Point Class RORO vessels for UK Government needs.

Putting aside heavy lift barge/tug combinations, there are three basic configurations for a heavy lift ship

Lift On Lift Off; the ship has a large open deck area onto which outsize and extremely heavy cargos are lifted on and off using dockside or integral cranes. If based at Belfast, the module could be lifted onto the ship at the Harland and Wolff facility.

Roll On Roll Off; the payload is moved on-board using multi-wheeled heavy lift platforms called Self Propelled Modular Transporters (SPMT). Ballasting allows a straight path to be established between the ship deck and quayside.

Float On Float Off; the deck area flooded after ballasting down to an appropriate depth and the cargo manoeuvred in, usually with tugs, although when transporting smaller vessels, they can self-load. The ship is ‘re-floated’ and secured for the journey.

Some of the newer vessels provide all three options, and whilst marginally more expensive, provide the greatest flexibility and overall utility. These types of vessels are operated by a relatively small number of organisations, Jumbo Maritime, Roll Group and Boskalis for example. A typical example is the Roll Dock ST class. Moveable deck panels are used to create a deck at one of six levels and a temporary bulkhead can also be installed to allow the vessel to be submerged without flooding the cargo hold. The ships own cranes can perform all these configuration activities.

The cranes can be used together for a tandem lift of approximately 700 tonnes. The hold has enough space for 1,383 TEU.

One could reasonably argue that the heavy-lift capability would be limited to the Role 3 Super Module but when not being used by the UK Government, there may be some commercial opportunities that can be explored.

The M/V Combi Dock cost €100m to build, these are not hugely expensive.

Interestingly, the later vessels in the Combi Dock series have been purchased and converted for use in the offshore industry. The OIG Giant II, formerly Blue Giant, formerly Combi Dock IV, is just such a conversion. The work included modifications to the cranes (anti heave and lift extension) and adding a helideck, moon pool, accommodation module, additional generators and a Dynamic Positioning system using azipods and thrusters. The 500 tonnes 13mx18m accommodation module is built across seven decks and includes facilities for 86 personnel, including leisure, sleeping, workspaces and water/waste treatment.

Something for a Role 3 MTF would need at least triple that in terms of crew space.

A new build contract at the same ‘offshore’ specification for two was reported €200m for the pair.

Having one or two of these massively flexible vessels would provide the ability to embark for training or deployment, a Role 3 MTF module(s) but when not doing this, and this is the key attraction of this approach, they could do something else. What that ‘something else’ actually is could include all manner of operational and logistic support activities. At a very basic level, over 1,300 TEU’s could be carried by vessel like the Combilift. Using 20ft tank container, for example, would mean the ship could transport 24,000 Litres of water, fuel or other liquids (regulation permitting).

At 4m width, there is 528 Lane Metres, with vehicles using a shore-based loading ramp or lifted in and out. This would be across two decks using the standard hatch covers only, each deck just over 4m high. There would also be space on the hatch covers if it were permissible to carry vehicles exposed to the elements. The USMC used the MV Combi Dock III for just such a deployment

As with containers, the vehicles could be easily lifted onto lighters whilst at sea, in reasonable sea states.

Stretching the concept, they can be used to transport small craft and patrol boats, and even submarines. Smaller craft such as patrol boats or MCM unmanned boats could simply be lifted from the deck into the sea. Using the two-deck approach, the vessel could comfortably transport 110 Pacific 24 RHIB’s, more than we have in service. Larger vessels could also be transported, right up to an MCM or if a new fleet configuration were envisaged, lots of large uncrewed vessels.

More complex large modules could perhaps be developed. An MCM command module, for example, could include UUV/USV storage, aviation, command and workshop spaces all within a single structure. For repair, maintenance and salvage, a module could be arranged to include heavy, electrical and composite workshops, electronic workshops, stores, personnel accommodation, helicopter landing facilities, stores lifts, power generations, compressors, extensive diver support. Would it need a higher speed, thrusters or positioning equipment to negate the need for tug support, potable water or oxygen generation, how would medical gasses be managed and would vibration-damping be sufficient for complex diagnostic equipment, how would it operate alongside or offshore, what about inshore access, patent transfer, medical resupply and a million other questions would need to be answered.

But the biggest question is that of crewing, (and cost, obvs). One option might be to make this a multinational capability, operate it through the JEF or other NATO/Multilateral structure, take personnel from Norway or Poland or Italy for example. We should certainly not discount any options or discount the difficulty of crewing what actually is a very complex and demanding capability that must meet a variety of standards, safety and certification demands. This is not necessarily about a specific design, but a design approach that decouples the infrequently used medical treatment facility from a vessel that could be used for many other tasks when the medical element is not required.

Finally, look beyond the narrow scope of having a Role 3 ship and incorporate that into a wider matrix of capability, using a multi-function heavy lift vessel and Role ‘Super Module’


I honestly think there is an enduring demand for an afloat Role 3 Medical Treatment Facility for defence operations and that the UK has obligations and desired outcomes in terms of responding to disasters globally. Can we combine these in such a way that is not so flawed by compromise that makes the chosen solution useless for either? There is money, as one look at the ODA and MoD budgets would confirm, is this enough of a priority though, again, a tough question>

My proposal is in three parts, help others to help themselves, maintain a rapid response air deployable capability (together with general medical design, build and operate), and finally, do something floaty. That floaty element is the main subject of this article and no doubt many options exist, my slightly bonkers suggestion of a multi-thousand-tonne large module attached to a heavy lift vessel tries to address the perennial problem of infrequent use v specialised nature of the requirement.

Does it make any sense, dunno, see you in the comments.

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This Post Has 15 Comments

  1. MSR

    Super sized modules.


  2. Andrew J Boulton

    Do we need to own the Heavy Lift Vessel(s), that would/can carry the various Large Modules? If so how would the HLVs “earn their keep” when not needed to carry/operate with one of the various Large Modules?

    Or, could/would we just own the various Large Modules, and when required deploy/move them aboard Heavy Lift Vessels “taken-up-from-trade
    ( STUFT) ?!

  3. Jed

    Great article Matey ! A fantastic analysis, of course…..

    So where to begin. I think as you tried to point out, we need to start with what capability is exactly that we think we want ? Is it an actual single role hospital ship, a multi-role civilian disaster response ship, or a multi-role Naval auxiliary to take on the Role 3 PCRS tasking (among other things) ?

    All are capable of providing one or elements of the UK’s “disaster response” and “humanitarian aid” capability set.

    1. Single role, civilian (DfID) hospital ship – you state this bothers you as what does it do when it’s not responding to a disaster ? Well it uses up more of DfID’s aid budget and provides significant “soft power” by moving from African port to African port, hosting MoD,, NHS, MSF or medics from any other organisation, doing surgery that local health systems can’t, down to industrial scale cataract fixes etc. Yes it may be badly positioned when a disaster strikes some place else, but probably easy to get underway quickly than it is to crane the giant modules onto the mother ship.

    2. Civvy multi-purpose HADR capability. Something less hospital-y but with some lane meters for useful rescue stuff like bulldozers, JCB’s , cranes, even fire trucks and ambulances. Engineering kit to help open or create an airfield, containers full of relief supplies, and the ability to generate clean water and power to pipe ashore. Depending on the size, this could indeed by your modular concept. Keeps the budget down through all the key points you mentioned in the article. Military roles you mentioned, such as moving a repair and support barge to theatre etc.

    3. Naval Auxiliary. A full on RFA as a like for like replacement for Argus. This could be a merchant conversion as you discuss, It could be a new build based on the Bay class or one of the Damen Enforcer derivatives (of which the Bay class is one): – or it could be a simplified version of HNLMS Karel Doorman, in other words a variant of the Damen Joint Support Ship design – maybe with a bigger hospital and without the RAS capabilities.

    Such a vessel might be “overkill” for once a year hurricane relief in the Caribbean, but what is stopping us from using it elsewhere ?

    So the question is, how much do we need the military capabilities afforded by RFA Argus ? If an RN / Marines / Army amphib “squadron” consists of a single unit of Albion class, Bay Class and Strategic lift Ro-Ro, then even if we are indulging un-opposed landings in your port opening and force protection scenario as discussed in previous articles, the extra flight deck and aviation capabilities of an Argus replacement based on a Bay or the Karel Doorman , as well as the PCRS capabilities would appear to be extremely useful in the absence of an LPH. Similarly such a multi-role vessel provides for other elements of HADR, not just the medical facilities, but the C3, vehicles carrying, cargo carrying capabilities etc.

    So what end of the spectrum do we think we need the most, a vessel with military utility to replace the one we have, or a white painted civvy manned flag flying good will machine oozing with soft-power capabilities ? Once we have figured that out, we can figure out how to deliver the capability because one way or another they could be both be based on your heavy lift ship plus modules concept.

  4. accattd

    Great to have the good old TD std – rather than just back and forth (I won’t mention “the” Brexit! – as a corollary)

    Anyway, here the ‘shorthand’ for it would have been University-level Hospital, with an A&E specialisation?
    “The Role 3 medical facilities can flex but in the largest configuration is designated as 4/4/10/20/70 which means 4 resuscitation bays, 4 operating tables, 10 intensive care beds, 20 high-dependency beds and 70 general beds (in two wards). Other facilities include a dental surgery, imaging (Ultrasound, 64 slice CT and X-Ray), pathology, pharmacy and physiotherapy. She has an oxygen concentrator and various laboratories.”
    – how doesthe above compare with what was set up in Camp Bastion, btw?
    – that was for one brigade (3000 frontline, with another 6000 in a supporting effort)

  5. Rocket Banana

    There are only two options in my mind: 1) Bay Conversion, or 2) Flo-Flo Module.

    The reason is that however excellent Argus is she is difficult to justify the rest of the time. Aviation Training Ship was one justification – less applicable now. The other was a poor-mans LPH – which she wasn’t much good at. I can’t see a dedicated facility being anything other than HMC Ocean painted white. The trouble with this is we know full well how important an LCU in the back would be for disaster relief and/or moving medical equipment and people to/from shore.

    The nice thing about the Flo-Flo with Hospital Module is that the ship can be leased to civillian operations and also used for amphibious support. If it can also provide Forward Repair and replace the capability lost with Dilligence then even better.

    For the time being however simply taking one of the Bay Class and fitting it out with the necessary facilities makes the most sense. There are numerous reasons for this. One being that given we’ve only really got two Commandos we barely need the third LSD. Another being a difficulty in crewing the ships and using it as a dedicated humanitarian ship will change the recruitment profile. The last is that it has a well deck and can take an LCU (again, painted white). I’d also attempt to make the hospital fitout modular. If only to exercise the brains of the designers and get used to this kind of thing for future projects. The “modules” do not have to be easy to fit, do not have to be containers, do not have to be wheeled. They also don’t really have to ever be removed. The ability to do it should push come to shove is all that is needed.

    PS: I’d have kept Largs and done this with two of the Bays a long time ago.
    PPS: Alternatively, sell another Bay to Australia (if they need two) and use the proceeds to buy the Flo-Flo option.

  6. S O

    I remember that the U.S. didn’t deploy either of its two hospital ships to the Sierra Leone Ebola crisis. They did instead create a ridiculously inefficient (100+ troops per medical bed) field hospital.
    There was a suspicion that the ships might have been unsuitable for such outbreaks because of insufficient quarantining capabilities.

    A new-built hospiral ship yould have proper disinfection (including the climate control piping and filters) to deal with all kinds of infectious diseases outbreaks.

    The ship itself would cost € 100 million or less. The expensive part would be the medical modules. I do thus doubt that a containerised (40 ft ISO) solution would save much cost. It might keep the whole hospital deployable to inland locations, though.

  7. S O

    I should have added:
    Plenty drinking water generation for disaster relief is a must (for a couple ten thousand people), including storage of huge quantities of empty plastic water bladders with easily used screw-on plastic cap and pallets good for transport on pickups.
    Also, huge pharmacy stocks.

  8. Frank Morelli

    For my ha’pennysworth, the functionality of a Flo-Flo ship is the dock space it offers, at least in the commercial world, whether this is in use as a dock, or for containers, or for modules or whatever. Whether in use as a hospital ship or in other (military) roles, a simple adaptation of an existing commercial design would be missing a lot, not least a lot of accommodation. If the FloFlo space is used for housing that restricts the utility of the vessel as either a hospital ship or for other transport/amphibious roles. That said there are many attractions in having a great big dock available; the ability (in a military context) of carrying large numbers of landing craft, or other kit; high capability hospital modules plus the helodecks and (ideally) at least small dock to get best use of the hospital. All as per this post and one or two previous TD posts…
    We ought also to consider the need to replace Bulwark and Albion in the future. Perhaps even we could think about preserving what’s left of the UK shipbuilding industry…
    It is possible to imagine a three-ship buy phased over a number of years of vessels of the same design but capable of fulfilling different roles due to their inherent flexibility. To be a Geneva-convention hospital ship we would have to ensure that any weapons fitted were easily removable (e.g. containerised) but apart from that the legal differences are mostly paint. If we consider that DFID pays for purchase and running costs of one ship to be permanently fitted with hospital modules at least in peacetime and MoD purchases two more to replace thz LPDs, and we order all from the same shipyard consortium in UK with the build spread out over a decade …. it should be possible to get a good deal, especially if the military requirements are kept in bounds. Albion and Bulwark when purchased were not so expensive…
    To be an LPD as well as a hospital ship a FloFlo would need lots of accommodation for either soldiers or medical staff. It would need space to store munitions (or pharmaceuticals) and space for water purification plant (?containerised in a hold should be possible) or stores and vehicles. And it would need a bloody great dock. If we contemplate a length of 130M and width about 16M that allows potentially 8 LCUs (and I know UK only currently has 10); if we have a dock depth of 13M plus that allows potentially LCUs below in a floodable part and a tweendeck above carrying further equipment; if the tweendeck is moveable while loaded then it could be used for still more amphibious craft of smaller dimensions than an LCU. That would be a very efficient use of ship volume in an amphibious role, while being completely compatible with the need to get big hospital (or other) modules in and out for other functions. The US LSD41 Whidbey Island class is currently in service with this length of dock although not this useable depth nor with a tweendeck.
    Assuming the dock is roofed over with removeable [to allow module installation] decking which can support heavylift helicopters it also gives a 130M long flight deck about the size of RFA Argus’ and big enough for three Chinooks to be spotted. We could then envisage the front end of a Bulwark/Albion type vessel for the crew and on board personnel space and storage space flexible enough to meet the needs of the various roles, up to and including the C3 installations for an amphibious landing. This would be a big ship, at least as big as Argus and probably significantly bigger, but as it would mostly contain empty space in the dock it need not be excruciatingly expensive. For the hospital role about 65-75% of the dock would be used for modules leaving a useful space remaining for a helodeck above and landing craft below. As far as manning goes I would propose that all three vessels should be RFA manned permanently. I know the LPDs are not but the Bay class which perform similar roles in similar areas of conflict are, as are all the RN’s Fleet Support Ships; all these carry weapons and have to go in harm’s way. For a civilian role as a hospital ship for DFID the RFA as civilians would be potentially an advantage. Generally speaking, one ship would be hospital roled permanently, but when it is refitting or otherwise unavailable one of the others could be reroled fairly simply… and of course vice versa if the need arose. Of course it would be best to have a fourth ship to cover refits etc. but that is probably too optimistic. For the manning of the hospital element the ideal way to do this would be with military medical service reservists who would gain valuable medical and on-board experience in peacetime for DFID which would then stand them in good stead on callup for ops as soldiers/sailors etc.
    And finally all the above only extends somewhat the ideas already put forward in TD in a number of posts which I think are extremely sound.

  9. BSmitty

    How about a jack up hospital barge? When the FLO/FLO moves it in-theater, it can be floated off, moved near shore, and jacked up to provide stability. The FLO/FLO can then be freed for other tasks. It could include a an extendable ramp to allow vehicles access.

  10. Rocket Banana

    Just been doing some sizing and if TD’s 120m x 60m Role 3 is anything to go by then that should fit perfectly into Bay’s 120m x 20m x 3 story vehicle deck.

  11. Captain Nemo

    “We can’t help them and kill them at the same time, it just ain’t humanly possible”
    General Glenn McMahon – War Machine

    I’m not a fan of the foreign aid situation, you could halve it to fix defence and still be near the top of the list, with an enviable hard and soft power mix. But, this all looks a bit naughty, however it’s presented some will interpret it as a navy raid on the foreign aid budget and you could conceive of a situation in which a hospital ship that had been floating off some distant shore could be going back six months later with the marines and prove them right.
    That said, a great article as always and weighty enough to deliver aid by itself, the FLOFLO idea is inspired, from a psychological perspective I like the message that physically dropping a hospital on their doorstep would send to people in their time of need, well there’s that and that for the module cost the navy could leverage its own hospital, repair ship and an expeditionary transfer dock from the deal. The SBS could also finally steal an entire ship and its crew, which I think they’ve been wanting to do for years.
    I think you’d sidestep the moral grey area by putting the modules in different budgets and having the RFA simply provide delivery, to that end the foreign aid budget could pay into the RFA budget for developing the capability and for guaranteed availability in the same manner that the MOD pays on its PFI for the Point Class.


  12. White Hackle

    Great article TD. I am very in favour of a flexible ship conducting joint-funded missions and hope we can resource it in coming years.

    What about a British version of the Dutch Karel Doorman Joint Support Ship? Looks to me to be an ideal Argus replacement: capable of being the offshore sustainment platform in war and HADR operations, aviation training role, C4I hub and even undertake RAS tasks.

  13. Jonathan

    I think the idea of a giant module is neat, however the sheer size requires very large lifting gear available where ever it is removed/ stored. FLOFLO is another neat idea, however I would suggest a 4th alternative: a Tug/ Barge combination.
    These are designed to work as a unit at seas yet are easily separated. Sometimes they are used as rule beaters depending on local maritime law; other times they are used when loading and unloading takes a long time – in that use case, one tug can operate multiple barges.
    The single “tug”, which in this case would be rather large, could do some transport/ response/ patrol duties on its own or it could mate with multiple barge options depending on the mission – dedicated hospital, disaster response, equipment transport, etc.
    In the case of a national asset, I could see having a number of barge options, some of them prepositioned and used as floating facilities, and then 2 or 3 tug units to move the barges as needed.
    A hospital barge could be used pierside in a big city during normal times, then moved as needed elsewhere; an equipment barge could be a warehouse for a military or civilian unit and then be moved as needed also.

    While these roles could be covered by a large module or a FLOFLO barge, those both require more significant assets to enable movement than a tug (very large shore cranes, or a heavy lift ship). In special circumstances, the barge part of a tug/ barge combo could be towed by any available vessel, such as commercial tugs (even a destroyer or tanker depending on relative sizes). However, the history of large traditional oceangoing barges isn’t the best, so as firmly mated tug/barge combination is better in terms of speed and handling bad weather.

    Just a few thoughts…

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