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The RUSI Journal

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Innovation Strategies for Defence

Matthew Ford, Timothy Hodgetts & David Williams

To cite this article: Matthew Ford, Timothy Hodgetts & David Williams (2017) Innovation
Strategies for Defence, The RUSI Journal, 162:2, 52-58, DOI: 10.1080/03071847.2017.1301216

To link to this article: https://doi.org/10.1080/03071847.2017.1301216

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Published online: 05 Jun 2017.

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Over the past 20 years, the Defence Medical Services (DMS, the umbrella organisation for
medical provision within the British armed forces) has been innovating consistently and at
pace within the Ministry of Defence. The result of this sustained effort has led to progressive
improvement in the outcomes of the critically injured. Separately, it has also led to global
transformational innovation in support of the response to the Ebola epidemic in Sierra
Leone. Through planned and orchestrated interventions across the entire organisation, from
leadership to technology, medical practices to training and organisational design, the DMS
can legitimately claim to have achieved a ‘Revolution in Military Medical Affairs’. Matthew
Ford, Timothy Hodgetts and David Williams examine the innovation lifecycle within the DMS
as it defines its response to the challenges of the changing character of conflict and consider
the way defence medicine is an example to the wider military.

n September 2015, General Nicholas and services, the SDSR observed, is the public sector. In 2014, for instance, the
Houghton, then Chief of the Defence vital for maintaining an advantage over top 20 global companies had a combined
Staff, made a number of observations adversaries. However, more than this, research and development budget of more
about the future of global security. innovation helps to influence industrial than £100 billion.5 With the private sector
Prominent in his list of seven themes and strategic partners and, at the same shouldering the burden of the global
were the constant challenge produced time, promote national prosperity. research effort, the Ministry of Defence
out of uncertainty and the growing rise In many respects, the government’s (MoD) needs to find ways to redirect
of instability and threat diversification. pronouncements on innovation mirror and leverage these investments through
As far as he was concerned, the question those of the US Department of Defense’s partnering with industry. Thus the SDSR
was clear: how could the UK match third offset strategy.3 Like the US strategy, focuses on Defence Growth Partnerships
its limited capabilities to the multiple the SDSR seeks to re-fashion and apply and Security and Resilience Growth
demands produced by a changing commercial practices and off-the-shelf Partnerships with the intention of bringing
security environment?1 technologies for military technical together the UK’s universities, small and
The government’s response came advantage, not just for today but in medium-sized enterprises and start-ups
in November 2015 with the publication preparation for future threats. For the to develop collaborative and commercially
of the National Security Strategy and UK, just like its transatlantic counterparts, aware approaches to risk, investment
Strategic Defence and Security Review this recognises that the ‘private sector, planning and project management.
2015 (SDSR).2 Taking a different line not governments’ now drives the pace When it comes to delivering on the
to previous reviews, this SDSR made of technological change.4 This not only ambitions set out in the SDSR, however,
innovation a key focal point in the reflects fiscal realities, but also the fact there is still a great deal that needs to be
effort to manage contemporary security that the private sector is now investing defined. This includes: how to transform
concerns. Developing innovative products more in research and development than military organisations; how to embed

RUSI JOURNAL APRIL/MAY 2017 VOL. 162 NO. 2 pp. 52–58 DOI: 10.1080/03071847.2017.1301216
Naval Nurse Sarah Butler and Medical Assistant Georgina Francis treat an injured soldier at Camp Bastion’s field hospital in Helmand province, Afghanistan, February
2009. Courtesy of PA Images/Katie Dawson

and sustain public sector transformation the government’s commitment to the demands produced by rapid deployment
through harnessing private sector Armed Forces Covenant.7 Despite the and the requirement to adapt to the
investments; and how to deliver solutions increasing severity of wounds over changing operating environment.
that produce more than short-term and the course of the Helmand campaign, No greater example has been the
costly technology adaptations. The task the unexpected survival rate significantly innovations in organisation, technology,
of this article is, therefore, to sketch out surpassed that of the National Health training and clinical practice to support
how an innovation strategy might be Service (NHS). As a result, soldiers and the transformation of a field hospital to
operationalised so that the MoD might their commanders understood that if they manage Ebola patients in Sierra Leone.10
optimise its investment decisions. In this ‘got into trouble’ everything that could In terms of battlefield success, the
respect, the article considers the experience be done to guarantee their survival and foundation for the DMS’s Operational
of the Defence Medical Services (DMS) future welfare was being done.8 Patient Care Pathway is based on three
and attempts to show how successful However, achieving these successes mutually supporting pillars.11 In the first
innovation might be more widely exploited has been hard won. Only through 20 years instance, there has been a conceptual
in a British military context. of continual performance improvement revolution in patient care. Central to this
at all levels of the organisation, spanning was the recognition that catastrophic
Defence Medical Services: Long- technology to governance, has the DMS haemorrhage from limbs has been a
Term Innovation Enables Short- put itself at the forefront of clinical results major cause of avoidable death on the
Term Adaptation both in terms of military and civilian battlefield.12 Establishing the evidential
The DMS has achieved outstanding medical practice. Indeed, it was stated base in support of this conclusion has
clinical results which some have described by the Healthcare Commission, one of taken time and scrutiny of historical
as constituting a ‘Revolution in Medical the three organisations that make up the conflicts. The new concept meant breaking
Military Affairs’.6 Not only have these Care Quality Commission, that there is away from established civilian practice
successes sustained the moral component, much the NHS can learn from the DMS.9 of trauma care that emphasised ‘airway,
further enabling momentum on the Key to this has been the balancing of breathing and circulation’. Making this
battlefield, they have also underlined long-term innovation cycles against the change was disruptive and was met with

Innovation Strategies for Defence

internal resistance.13 Having made the British military operations in the 1991 Gulf In terms of clinical governance, the
conceptual break, a number of doctrinal, War – and during mass casualty situations need to use the RCDM to institutionalise
organisational and training challenges in the Balkan conflicts.17 BATLS provided change was brought to a head in 2003.
needed to be overcome. Advances in a framework for thinking about trauma During a class action brought by nearly
pre-hospital emergency care capability care from battlefield to field hospital, 2,000 former British military personnel
were needed to ensure that the casualty retaining its use even as various aspects suffering from post-traumatic stress
made it from the battlefield to the field evolved due to a changing approach to disorder, the High Court judge, Justice
hospital alive. In Afghanistan, the most haemorrhage.18 Owen, questioned whether the DMS
tangible signs of these changes were If BATLS provided a common had been negligent in keeping abreast
the first aid equipment carried by every language for thinking through the military of the developing state of knowledge in
soldier, the introduction of the army team response to trauma, then it took the final psychiatric care.22 Although the case was
medic and enhancements to the airborne pillar of the Operational Patient Care eventually dismissed, the censure led
Medical Emergency Response Team Pathway to provide the means through to the implementation of new national
(MERT) to secure and stabilise the casualty which transformative change was made clinical guidelines underpinned by
as they made their way to Camp Bastion. possible. Here, the challenges were technologies that enabled the effective
MERTs and battlefield medics by concerned with organisation, medical collection and analysis of medical data
themselves do not represent particularly governance and technology. As discussed through the much expanded Military
revolutionary practices. The concept below, some of these changes were Trauma Registry. The goal was to
of bringing emergency medicine to the imposed from outside the DMS, some implement a clinical governance model
front line had precedents in the Incident were a response to budgetary pressures that emphasised quality assurance.23 This
Response Teams of the 1990s.14 Battlefield and others came from an effort to in turn was supported by the greater use
medics had antecedents in the ‘buddy optimise performance. of a peer-review framework established
system’ developed by US Special Forces In the first instance, the Strategic at the RCDM designed to evaluate the
in Vietnam.15 When reimagined through Defence Review 1998 reorganised the number and reasons for unexpected
the lens of catastrophic haemorrhage, DMS, further centralising and integrating survival and to analyse every operational
however, prevention of blood loss became the single service medical components trauma death. In the process, the RCDM
the driving concern for those involved under the surgeon general.19 At the end became the fulcrum around which a
in pre-hospital care. New technologies of the Cold War there were fourteen shared DMS culture could establish itself.
that prevented blood loss could be put British military hospitals dispersed across This culture was tolerant of and founded
into service. Old technologies, some of the country and each of the services had on a systematic and constructive process
which had previously been dismissed as separate centres of academia and clinical of rigorous self-criticism and analysis.
counterproductive, could be reconsidered. excellence. The peace dividend cuts These long-term innovations ensured
Thus, even as battlefield medics and MERT of 1994 forced a rethink and led to the that the DMS was ready to field medical
personnel made greater use of pelvic closure of all but one military hospital and personnel to Afghanistan and Iraq. More
binders and compression and haemostatic the dispersal of military clinicians to five than this, however, these changes produced
dressings, older, more soldier-proof NHS hospitals. By 1997, the Defence Select a degree of organisational resilience that
technologies such as tourniquets, could Committee was questioning whether made it possible for the DMS to rapidly
be used in the knowledge that this would the DMS could continue to exist.20 In respond, test and disseminate change and
increase survival. response, the DMS decided to more adapt to the necessities produced out of
Enabling the conceptual revolutions actively partner with the NHS and open a battle. Thus by 2007, Joint Theatre Clinical
nevertheless depended on clinical doctrine, centre of academic and military medicine Case Conferences oversaw a revised and
the second pillar of the Operational at what would become the Royal Centre expanded Joint Theatre Trauma Registry,
Patient Care Pathway. In this respect, a for Defence Medicine (RCDM) at the which made it possible for rear-echelon
key enabler for change – one based on a Queen Elizabeth Hospital Birmingham. and in-theatre medical practitioners to
much longer innovation trajectory – was Originally, the RCDM was at Selly Oak NHS coordinate their treatment plans, ensuring
the work of then Colonel Ian Haywood, Trust Hospital, where it officially opened that clinician decision-making and casualty
who in the late 1980s developed a in 2001. Although there were initial information were in lockstep as wounded
military equivalent to civilian Advanced problems managing military personnel soldiers were taken from the battlefield
Trauma Life Support practices.16 It was within an NHS context, these challenges to treatment in Birmingham.24 When
initially known as British Army Advanced were overcome. The net effect of these supported by peer review and analysis
Trauma Life Support but then became reforms did not produce what some undertaken at the RCDM, decisions taken
known as Battlefield Advanced Trauma theorists of military-technical change in field hospitals could be assessed and
Life Support (BATLS) when medicine sometimes characterise as either top- further optimisations and interventions
became a concern for all branches of down or bottom-up innovation. Instead, made. By 2009, it became clear that
the armed forces. BATLS codified trauma they resulted in the RCDM generating the managerial burden produced by the
care, repeatedly demonstrating its value the expertise to drive change in military changes to medical doctrine concerning
in Operation Granby – the name given to medicine from the middle out.21 damage control resuscitation,25 rapid


Ford, Hodgetts and Williams

Figure 1: Major Developments in Trauma Care Standards in the DMS and NHS since 1995

Source: Authors’ own work.

evacuation, aeromedical transportation context was too great. Consequently, and maintaining quality assurance.26
home (C17A Globemasters equipped as the DMS deployed a medical director to Further institutionalised through military
flying hospitals) and working within an Camp Bastion so that the clinical director operational support training and hospital
inter-disciplinary and international military could remain focused on patient care macro-simulation exercises, it is only

Innovation Strategies for Defence

through a combination of multiple long- such that the organisation can continue its demands of defence thus lend themselves
term and short-term interventions that transformation trajectory. In this respect, to working closely with industrial partners
truly transformational results have been the authors assert that the ability of the in new medical technologies, but only
made possible. DMS to prepare for future conflicts and on the basis that the DMS can define its
emergencies will come through harnessing business requirements clearly. Generating
Understanding the Need: the opportunities that the state can provide that clarity will demand proper horizon
From Adapting to Change to to the private sector to test and embed scanning, mapping research interventions
Disrupting the Organisation disruptive innovation. This approach has against potential payoffs for industry
The DMS has innovated itself by continually more in common with the findings of and the NHS, and aligning innovation
investing in practices, infrastructure and Mariana Mazzucato, who observed that with the regulatory regime and ethical
technologies that have the potential to the public sector has regularly invested in considerations that frame research.
bring long-term benefit in patient care. fledgling innovations and in the process Some of the infrastructure to deliver on
However, not all of these changes have incubated entirely new markets.28 this agenda is already in place with the
necessarily fallen into preplanned patterns Thus, the question facing the DMS – aggregation of UK defence medicine
following centralised directives. In some indeed the question facing the whole MoD assets in the Midlands. These assets will be
instances – notably those associated with – is how to plan for and manage disruptive further enhanced following the opening
organisation, clinical governance and changes even as the organisation of the Defence National Rehabilitation
technology – budgetary pressures and optimises its capacity to make adaptations Centre, on the Stanford Hall estate in
grand strategic decision-making disrupted in war. All future operating contexts and Stanford-on-Soar near Loughborough,
existing DMS business. At the same demands placed on the DMS cannot be in 2018. The DMS now needs to move
time, battlefield experience has offered known, but plans can be devised for the quickly to capitalise on this alignment,
continual opportunities to test, refine, kinds of long-term investment that can thereby turning the transformations of
improve and reject methods, techniques ensure the entrepreneurial state helps the past 20 years into enduring change
and technologies depending on how to sustain adaptation. Given industry’s that will benefit defence over the next
they affect patient care outcomes. In the increasingly large R&D budgets, it is clear two decades. In particular, the DMS now
case of long-term investment, external, that rapid experimentation will be enabled needs to take the lead and help create a
unplanned and otherwise disruptive through collaboration with it. Putting med-tech incubator to solve contemporary
change has enhanced the capability of the in place principles of engagement that defence medical challenges and at the
DMS through the creation of the RCDM and manage the structure of risk and reward same time lead the way on med-tech for
focusing on quality. In terms of battlefield while resolving procurement and supply industry and the NHS.
necessities, the prior preparations put chain challenges will enhance the DMS’s
in place by the DMS ensured that the ability to adapt rapidly. Finding ways to Payoffs and Challenges
organisation could rapidly adapt to the align DMS requirements with industry’s Sustaining the transformation in the
immediate and challenging circumstances ambitions to develop broad markets DMS thus depends on multiple value
generated by war. may involve procurement-linked projects propositions for various constituencies
However, it would be inaccurate under the Small Business Research and careful capture and communication
to describe this disruptive change as Initiative to help jumpstart opportunities. of defence medicine requirements.
institutionalised within the DMS in a Urgent Operational Requirements Industrial partners need to know that
similar manner to that advocated for (UOR) represent an established route their investment will lead to commercially
commercial organisations by Clayton M for resolving battlefield imperatives. viable innovations. Commanders will
Christensen in his work The Innovator’s What this article proposes, however, rightfully want to know that their soldiers
Dilemma.27 Disrupting the DMS has not are processes and mechanisms that will are being properly looked after. Soldiers
been a market-led activity. Rather, the accelerate the development of solutions will want to know that they are not
kinds of innovation this article describes that cannot yet be accommodated by just guinea pigs for industry but rather
have been based on changes that have the UOR system and cannot be provided the focal point for delivering quality
been prescribed by and implemented through the public sector. healthcare. The country will want to see
through the public sector. Indeed, much To do this effectively, the DMS will high standards being maintained and
of the innovation that has emerged from need to clarify the relationships it has taxpayers will want to see returns on any
the DMS has depended on enablers that with the NHS to ensure that innovation in investment they make. Putting in place a
have their basis in academic clinicians defence produces longer-term benefits for carefully managed innovation incubator
whose defence medical professorships the public. At the same time, the UK needs that delivers on these opportunities
are rooted in their NHS practices. to accept that the NHS is not geared up will require care, business acumen and
The kinds of disruptive change to innovate as quickly as the DMS, given a great deal of effective leadership.
this article discusses, therefore, need the complex military and emergency relief However, the potential benefits that
some further explanation if a case is challenges the military faces and the the DMS can generate by working with
to be made for finding ways to embed acknowledged role of defence medicine industry warrant the investment of time
processes of innovation within the DMS as a first mover in innovation. The clinical and energy.


Ford, Hodgetts and Williams

Challenges to fulfilling the potential of world-leading trauma-care specialists. History. Previously, he worked in
payoffs will nevertheless remain. There The DMS is well placed, therefore, to offer management consulting for a top four
needs to be a certain degree of realism the benefits of its innovation know-how to global professional services firm and as
in the way that meaningful innovation the rest of the MoD. a strategic analyst with Dstl. His first
challenges are formulated. Technology Nonetheless, the DMS recognises book, Weapon of Choice: Small Arms
bottlenecks need to be accounted for that if it is to further embed, sustain and the Culture of Military Innovation, is
and the interfaces between multiple and take advantage of the propitious published by Hurst in 2017.
disciplines and stakeholders will be circumstances it has created for itself, it
challenging. Technical issues will demand must continue to embrace the innovation Timothy Hodgetts is a brigadier who
careful testing and validation to guarantee agenda that the government set out. The trained as a general physician and
sponsor engagement. Commercial, clinical DMS is confident of its ability to embrace then progressed to higher training in
and military cultures are different and innovation as a core consideration in emergency medicine. He has a PhD
will consider questions of risk, certainty its change agenda and in this respect it in Public Health, master’s degrees
and resilience differently. Moreover, has already started to define and put in in Medical Education and Business
the private sector, the MoD and the place effective networks and structures Administration and is a chartered
armed forces themselves have different to facilitate the creation of an innovation manager. He graduated from the
hierarchical structures and attitudes incubator. This organisational device will Joint Command and Staff College in
towards bureaucracy. The Defence Science allow the public and private sectors to 2011. He has served on operations as
and Technology Laboratory (Dstl) provides share risks and rewards in ways that will a practising emergency physician in
a mechanism for reconciling some of the benefit everyone. hospitals in Northern Ireland, Kosovo,
challenges a DMS med-tech incubator The DMS has already demonstrated Oman, Afghanistan (three tours),
might produce. However, this will be a degree of entrepreneurialism. Central Kuwait and Iraq (four tours). On six
possible only if all stakeholders recognise directives and disruptive challenges have in of these tours, he was appointed the
the strategic benefits that can be realised part set the framework for organisational hospital’s medical director, including
from everyone working together. change. However, the energy for steering the multinational Danish–UK–US
innovation has been dependent on the hospital in Afghanistan in 2009. From
Conclusion RCDM and the evidential base supplied 2011–13, he was the medical director
Nicholas Houghton was clear in his by academic clinicians, who have driven within NATO’s Allied Rapid Reaction
assessment of the future security transformation from the middle of the Corps, and from 2014 has been the
environment. Threat diversification and organisation. In the future, if the DMS is medical director for the UK Defence
instability are becoming major challenges to be ready for everything from Ebola to Medical Services.
for the UK and its NATO partners. In terror attacks, and disaster relief to war,
recognising this broadening of the security then it must further exploit its unique David Williams is Professor of Healthcare
agenda, the government’s response has capabilities through investment in new Engineering at Loughborough University.
developed along several axes. For the first and existing partnerships. The potential He has held senior leadership positions
time, however, the SDSR has explicitly to deliver significant benefits for industry, in academia and industry, working for
described innovation as a central plank in the public good and for soldiers is too much of his career at their interface
the government’s set of policy responses. great an opportunity and ought not to and in healthcare since 1999. Current
This article has shown that be missed.  research addresses manufacturing and
transformative innovation within defence regulatory science of clinician-pulled,
medicine has been ongoing for some time Matthew Ford is a senior lecturer in cell-based therapies and opportunities
and with remarkable success. Consequently, International Relations at the University for engineers within defence medicine.
government policy in relation to UK defence of Sussex. He has a PhD in War Studies David serves on a number of key UK
has some foundation in the successful from King’s College London and is and European funding committees for
experience of the DMS. Soldier survival an Honorary Historical Consultant to the translation of medical technologies.
and unexpected survival rates have been the Royal Armouries, a former West He was made a Fellow of the Royal
well in advance of the NHS to the extent Point fellow and a founding editor-in- Academy of Engineering (FREng) in 2002
that DMS is now recognised to be a centre chief of the British Journal for Military and an OBE in 2014.


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Innovation Strategies for Defence

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