The plan for a British hospital ship gains political support

Back in 2014, we published an article suggesting that a small portion of the generous overseas aid budget be used to construct and operate a British hospital ship. The idea received a very positive response and after some work behind the scenes, now has the support of Penny Mordaunt, the Secretary of State for International Development. Here we take a more nuanced and updated look at some of the options and benefits of the proposal.

Background

Making it law that 0.7% of GDP must be spent on overseas aid was a manifesto promise of all three main political parties in 2010. The act was passed in 2015 and means that the DFID budget amounted to £14 billion last year. Taxpayers money given away in foreign aid has always been a source of controversy, especially in an age of austerity and cuts, many would like to see it axed altogether and entirely re-redirected to spending on their area of interest such as health, education or the armed forces.

The principle that rich nations should be helping the poorest and the most vulnerable in the world is sound. Apart from common humanity, It is also in our own self-interest to reduce poverty, suffering and eradicate disease which often leads to more conflict and migration which impact us directly. Overseas development is a good thing but there is no doubt that there have been some cases of corruption and badly executed projects that give the impression of precious taxpayers money being wasted. The plan for a hospital ship is a constructive example of how a small part of the DFID budget could be used to achieve aid and development goals in a way that benefits everyone.

With climate change bringing more extreme weather, regular earthquakes and tsunamis, it is sad to say that disaster relief services will be needed many times in the coming decades. 95 of the 100 largest cities in the world are port cities and the 90% of the world’s population live within 200 miles of the sea, aid and assistance from ships will often be the most appropriate way to deliver large-scale relief.

Former Royal Marine and defence advocate, James Glancy presented the hospital ship idea to a government Minister at DSEI in September 2017. The response from several senior government figures at the time was positive and the Daily Mail reported on Monday that there is now Ministerial support for taking this further. Penny Mordaunt is a former Naval Reservist (she was named after HMS Penelope) and the idea is in line with her goals to spend international aid more effectively and reduce the pressure on the Royal Navy. At least two well-known UK shipbuilding companies have also expressed an interest in developing concepts for the project and work is ongoing behind the scenes to gather political momentum and make the idea a reality.

Hospital ships of the world

The images below are a survey of existing hospital ships. There are a lot of valuable lessons to be learned from these vessels and their operations but it is unlikely any of these quite meet the diverse UK requirements.

  • The Africa Mercy is operated by the Christian charity, Mercy Ships and provides free medical care to poor countries. The ship spends several months berthed in a port and the local population is invited to visit the ship to be assessed for medical care which can range from the prescription of medicines through to major surgical procedures. Volunteers from the ship also work in host nations to improve the way healthcare is delivered across the country.

  • Atlantic Mercy

    Mercy Ships is about to commission the Atlantic Mercy, a purpose-built $100million, 37,000-tonne, vessel being built in China which will be the largest NGO vessel in the world. Since being founded in 1978, Mercy ships have performed around 89,000 life-changing surgeries and 423,000 dental procedures in the poorest nations.

  • The Chinese hospital ship Daishan Dao or “Peace Ark” was commissioned in 2007 and has a 300-beds for patients, seen here on a visit to Pearl Harbour in 2016. (US Navy photo)

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    US Hospital ship - USNS Mercy

    USNS Mercy, one of two 70,000-tonne US hospital ships converted from oil tankers in the mid-1980s and have 1000 patient beds. These are the largest hospital ships in the world and have a core crew of 70 but her embarked personnel can rise to 1,300 including medical personnel when on operations. Besides responding to natural disasters, they deployed to poor counties to provide free medical care in a similar way to Mercy Ships. RN personnel have served on board her recently, during Pacific Partnership 2018 tour in South East Asia.

  • The Black Sea Fleet Hospital Ship ‘Yenisey’ seen in Sevastapol, one of four 11,300-tonne ships built in Poland in 1980 for Russia. Three of the ships survive and the ‘Irtysh’ of the Pacific fleet was recently modernised. They have 100-bed hospital and have also been used for personnel accommodation and troop transport. They have civilian crews but carry naval medical personnel.

  • The Esperanza del Mar is a 5,000-tone purpose-built hospital ship constructed for the Spanish government and part-funded by the EU in 2001. Her main role is to provide support to Spanish fishermen working in the seas off West Africa. (Photo: Jose Miralles)

  • The People’s Republic of Vietnam Navy operates a 2,070-tonne hospital ship built in 2013, the Khanh Hoa 01 which has a full suite of medical facilities, 15 beds and a decompression chamber. It is usually deployed in the South China Sea to assist fisherman, divers and construction workers in the Spratly Islands.

  • Originally built in South Korea for $35M in 2003 as an amphibious assault ship (LPD), the Indonesian Navy has converted the 16,000-tonne KRI Dr Soeharso into a hospital ship. She is equipped with a full suite of medical facilities and has two 20-bed wards. She is unique as the only hospital ship in the world with a well dock and is ideally suited to disaster relief in work in the Indonesia Islands.

There are plenty of opinions about what a UK hospital ship might look like. We will not attempt to define the exact specifications but will suggest a few principles.

Commonality with existing equipment and infrastructure will reduce costs and increase flexibility. Ships should be manned and operated by the Royal Fleet Auxiliary utilising the existing training pipeline, expertise and procedures. The ships equipment fit should reflect standard RFA practice as far as possible to simplify logistic support and training. Flight deck, hangars and aircraft support arrangements should follow standard RN/RFA practice.

Flexibility – The ship needs to be able to operate independently for a sustained period and be reconfigured for different types of operations in different environments. The ship needs to be able to anchor offshore if port facilities are unavailable or provide aid efficiently using normal port facilities.

Simplicity – ideally the ship could be based on an existing platform, modified for the role. This reduces cost, risk, development time and can utilise existing logistics. Maintenance should be made as easy as possible and so can be performed by non-specialist contractors in overseas locations if needed. Avoid exquisite bespoke solutions as much as possible.

The Argus conundrum
RFA Argus is the nearest the UK has to a hospital ship. Designated a “Primary Casualty Receiving Ship” (PCRS), she is equipped with a 100-bed hospital. However, she is painted grey and does not conform to the strict requirements of the Geneva Convention on white-painted hospital ships which state that not only can no weapons or military personnel be carried, but the communications fit must be limited and authorities notified of the ships operating areas. Argus is also the Navy’s helicopter training vessel, and in wartime, she would be a very useful extra helicopter carrier. Originally converted from a container ship for the Falklands War and then significantly rebuilt, few vessels have provided the taxpayer with better value for money. Argus has just completed a major refit but is due for retirement in 2024 with no current plan or funding to replace her. With the loss of HMS Ocean, the RN is short of big decks and using the QEC aircraft carriers to train its baby helicopter pilots would be an expensive use of a major asset. Should the plan for a hospital ship be adopted, then Argus could be replaced by a cheaper, simpler ship, perhaps a merchant conversion provided by Serco which already operates naval support vessels, SD Victoria and SD Northern River.RFA Argus

Hospital ship or Aid ship?

There are two main types of capability that should be considered. The first is the ‘traditional’ hospital ship similar to the Mercy ships or the American USNS Mercy and Comfort. They are effectively floating hospitals and spend most of their time visiting poor nations offering free medical and dental care, usually tied up alongside in a large port for many weeks. Alternatively a dedicated hospital ship can be employed to receive mass casualties in the wake of natural disasters or battle casualties during a conflict.

The second type of vessel is the “aid ship” which has a medical facility but is primarily an amphibious logistics vessel, capable of independently delivering supplies to support the relief work. This would suggest aviation facilities, large access doors and ramps to for vehicle access and possibly an internal dock for landing craft. The ship needs to have accessible storage for standard TEU containers, food, relief and medical supplies and heavy equipment with the ability to make fresh water on board. The ship needs plenty of additional accommodation for medical and aid workers and attached military personnel. In some cases, it may be a better solution to deliver a tented field hospital ashore which is more easily accessible and does not have the space constraints of a ship.

Recent UK sea-based disaster relief work has been much more about logistic support to operations ashore rather than embarking large numbers of casualties to the ships. Looking at some recent examples is instructive. In the wake of the Haiti earthquake in 2010 RFA Largs Bay delivered 5,700 sheets of corrugated iron to build shelters, 40 vehicles and 15 containers of general stores. The port facilities were damaged and she used her amphibious capability to deliver stores over the beaches. During operation PATWIN in the wake of the Typhoon Haiyan that struck Indonesia in 2013, HMS Illustrious and HMS Daring helped 22,000 people, providing 16,000 litres of drinking water, distributed nearly 70 tonnes of food and distributing 400 shelter packs. This relief work was done amongst small island communities, often the most vulnerable to natural disasters and lacking the ports, airfields and infrastructure needed to receive supplies quickly. RFA Argus spent 6 months on operation GRITROCK, in 2015 the UK response to the Ebola outbreak in West Africa. She was instrumental in providing support to the personnel on the ground using boats and Merlin helicopters to transport personnel and materials to all areas of Sierra Leone. She effectively acted as a logistics hub to support the work ashore and did not embark any ebola patients to her 100-bed medical facility.

It is plain to see that ships designed with a range of logistic capabilities would suit UK aid and disaster relief requirements better than a just a floating hospital.

Ms Mordaunt is quoted as saying the ships could also be used to “build on our efforts to promote UK businesses overseas”. As a platform for trade and diplomacy, these ships could potentially be employed as floating ambassadors, hosting receptions and trade delegations. This may also help to harness existing public and political support from those advocating a new Royal Yacht, primarily for this role. It should be noted that the RN is already expert in hosting these type of events on its warships, HMS Queen Elizabeth’s recent visit to New York was an early indicator of the aircraft carriers huge potential to serve in this way.

  • MV Hartland Point is one of four vessels on charter to the MoD for transport of miliary equipment. Adapting this design as a ‘bare bones’ aid ship with the addition of a flight deck, a medical facility and fully containerised logistics would be an option.

  • RFA Mounts Bay delivers aid to the Virgin Islands after Hurrican Irma in 2017. The Bay class offer a blueprint for a logistical support/aid ship with plentiful accommodation, small medical facility, flight deck and well deck that allows landing craft and mexeflotes to deliver heavy loads directly to the beach.

  • The 27,800-tonne Dutch Joint Logistic Support ship (JLSS) HNLMS Karel Doorman might be a good basis for the design of a larger aid ship (although her replenishment at sea capability would not be needed). She has 2,000 lane-metres for vehicles or containers, a well deck, large flight deck and hangar with space for up to 6 Merlin size helicopters. She has a 20-bed hospital and can comfortably accommodate up to 300 people.

  • Fleet Solid Support Ship

    This is the latest rendering of a possible design for the Fleet Solid Support ships (FSS) that will be constructed for the RFA in the early 2020s. One solution to building an aid ships could be to build additional FSS with a large medical facility and configured for aid operations instead of replenishment at sea.

  • A plan of the recently completed 28,000-tonne HMNoS Maud. Designed in the by BMT in the UK and built at DSME in South Korea, the Maud is a smaller cousin of the Tide class RFAs. She is an interesting hybrid – an auxiliary supply ship that doubles as a hospital ship for the Norwegian navy.

  • The US Navy’s civilian support arm operates several unconventional logistic vessels that could potentially be the basis for an aid ship. The 78,000 tonne USNS Lewis B. Puller, on the large side for UK requirements, is designated as an Expeditionary Mobile Base. She is a converted oil tanker that can semi-submerge to offload boats and has extensive aviation facilities and storage.

An ‘everybody wins’ scenario?

  • The hospital or aid ship will cost the Treasury and taxpayer nothing extra, it simply redirects a small part of the £14Bn we are spending on foreign aid.
  • The ship can directly help those suffering the impacts of natural disasters in coastal areas across the globe and potentially provide medical care to people in some of the poorest parts of the world. The International Aid budget is spent in a tangible way with impacts that are measurable. Expenditure on an aid ship reduces the potential for corruption or middle-men profiting from aid funds.
  • The UK gets a highly visible ambassador which is a force for good in the world. The ship would help underline Britain’s post-Brexit engagement with the international community.
  • Pressure is reduced on the Naval Service at no extra cost to the MoD. This could relieve the Bay class or Wave class RFA vessel stationed almost permanently in the Caribbean region for the last few years, ready to provide disaster relief in the even of hurricanes impacting the region.
  • In the case of a major conflict, the new ships also add to the number of government-controlled vessels available and can either be declared as Geneva convention-compliant hospital ships to receive battle casualties or used as additional logistics support for operations.
  • UK industry and the economy would benefit from building the ships and equipping them. Perhaps the dogma applied by the MoD to the Fleet Solid Support ships that “the construction of non-warlike vessels must be open to foreign competition” might evaporate if DFID are footing the bill for these vessels onshore construction would help build political support for the project?
  • Both military and civilian medical personnel get the opportunity to broaden experience and work in a variety of locations across the world backed by on a well-equipped vessel. A DFID ‘Peace Corps’ of personnel specifically trained and ready to deploy on the aid ship (or be transported by air) to help in the wake of natural disasters or outbreaks of disease is another possibility to consider.

Potential stumbling blocks

The Organisation for Economic Co-operation and Development (OECD) writes the rulebook on what constitutes aid spending. How funding aid ships would fit into this framework will be one for the lawyers to pick over. The UK has already won some sensible concessions from the OECD, loosening the rules on the use of military to support aid objectives. As the fourth largest overseas aid donor in the world, the UK should argue against any bureaucratic impediment against a sensible plan which will benefit everyone.

Money donated overseas is a never-ending source of complaint for some and an aid ship project would doubtless generate sentiments along the lines of “We can afford to build ships to give medical support to foreigners but can’t properly fund my local NHS hospital /doctors surgery / social service etc”. Not only is this an entirely different budget but to put this in context the government has just raised NHS funding by a further £20 Billion next year, on top of the £124Bn spent in 2017-18.

There are lots of variables that will determine the size of the core crew requirement for the two vessels but it is important that the ships do not create a large new personnel problem for the RFA. Around 80 people are needed to man the modern, automated diesel-electric Bay and Wave class ship. Not replacing RFA Argus would release around 80 so the small extra manpower requirement is attainable. As a guiding principle for the project, DFID, other government departments or the private sector should bear the vast majority of the cost of building and maintaining the ship as well as mounting relief operations, avoiding any additional pressure on the MoD’s parlous finances. There would undoubtedly be some complex inter-departmental discussions required around the funding and prioritisation of supporting assets such as helicopters, landing craft, military medical staff and specialist personnel.

Final thoughts

Financing the project will be a critical factor in deciding if this ever goes beyond an idea on a website and some interesting discussions. There are too many variables at this stage to even define an approximate budget, but as a starting point the UK-built Bay class ships cost around £130 million each in 2007 and are a bargain at about £10m per year to operate. It is not the top priority, but perhaps the naval architects should be briefed to pay attention to aesthetics. We are not building a Royal Yacht but a ship that will represent Britain, so why not make it easy on the eye? Everyone will have ideas for names. There is no shortage of great reformers and humanitarians in British history for inspiration, RFA Wilberforce and RFA Nightingale perhaps?