Introduction
The NHS in England is generally expected to manage emergency response within its own capabilities. However, in some instances, where it does not have the capacity or specific capability to respond and support from the private/commercial sector cannot be sourced, it may need to call on the military.
Military support in an emergency on an assistance basis is known as military aid to the civil authorities (MACA). MACA is not guaranteed and there may be a charge, unless it is requested for response to an immediate threat to life.
Routinely such requests require both Department of Health and Social Care (DHSC) and Ministry of Defence (MoD) ministerial authorisation. However, in very exceptional circumstances – for example, grave and sudden emergencies where there is an urgent need to protect life – a local (military) commander can deploy assets to manage the situation without ministerial authority.
The Defence contribution to resilience in the UK is usually provided by spare capacity and depends on available resources. Full details of this contribution are given in the Joint doctrine publication 02 UK operations: the defence contribution to resilience.
1. Purpose
This guidance outlines the requirements and process for the NHS in England to request MACA.
In the event that an incident is widespread and involves multi-agency partners, health-related MACA requests should be coordinated with the Strategic Coordinating Group (SCG). Requests from NHS providers or integrated care boards must be submitted via the relevant regional NHS England Emergency preparedness, resilience and response (EPRR) team. These are then considered by the NHS England Resilience team (national) and then submitted to DHSC for authorisation by a health minister before being submitted to MoD.
Local resilience forums should make MACA requests through the Ministry of Housing, Communities and Local Government (MHCLG).
2. Principles
Military assistance is governed by 4 principles that identify the only circumstances in which it should be provided:
- when there is a definite need to act, and the tasks the Armed Forces are being asked to perform are clear
- when other options, including mutual aid, commercial alternatives and assistance from the voluntary sector, have been discounted and either:
- the civil authority lacks the necessary capability to fulfil the task and it is unreasonable or prohibitively expensive to expect it to develop this, or
- the civil authority has the capability or capacity or some of it, but this may not be available immediately or of the required scale, and the urgency of the task requires rapid external support from MoD
NHS England will co-ordinate all MACA requests on behalf of the NHS in England, supported by the NHS England military liaison officer.
It is important to remember that, unless there is an immediate threat to life, the financial implications of a request must be considered. The requesting organisation must reach agreement on which organisation(s) will fund the MACA support before making a MACA request.
To maintain their clinical competency, many Defence Medical Services (DMS) personnel work in the NHS. Any MACA request for DMS support may see these staff recalled from the NHS to support delivery of the MACA. However, as this could significantly impact on NHS service provision, MACA requests for DMS healthcare professionals are likely only to be supported in exceptional circumstances.
3. Blast and high velocity injuries
DMS personnel are experienced in the clinical management of blast and high velocity injuries. They can provide expert advice and guidance on the treatment of these types of wounds, including in the fields of anaesthetics, emergency medicine, plastic and reconstructive surgery, general surgery, trauma and orthopaedic surgery, and radiology. If the required advice and guidance is over and above agreed assistance, it can be requested through the MACA request process – see section 5.
4. Submitting a request for military support
A military joint regional liaison officer (JRLO) is a senior military officer who is assigned full time to liaison duties for a specific region. They work alongside civilian responders in a role similar to EPRR and are on call 24/7 to respond to incidents. The JRLO is often represented routinely on local resilience forums (LRFs) and when a crisis occurs may represent the military at the Strategic Coordinating Group.
As the local MACA expert, they will guide and advise requesting organisations on every aspect of MACA throughout the process.
The requesting organisation should engage the relevant JRLO at the earliest opportunity to seek advice and support at a local level on its MACA request. The organisation should also involve the NHS England regional EPRR team before submitting the request to them, especially for pre-planned events including industrial action.
The process for requesting MACA support to the NHS in England is shown in annex A.
A generic request form for the NHS is provided in annex B.
Any request must identify:
- General background – brief description of the situation.
- Assistance required – the effect the requesting organisation believes the support it is requesting will have.
- Timings – when and where support is required and for how long.
- Evidence of the capability gap – confirmation that reasonable efforts have been made to address the requirement through mutual aid, other organisations and the private sector.
Multiple MACA requests for the same incident must still be written and submitted by the appropriate NHS provider or integrated care board but they will then be collated and co-ordinated nationally.
Where multiple MACA requests are submitted, the NHS England Resilience team (national) MACA panel will manage them. This panel comprises senior representatives from NHS departments such as finance, workforce and legal as well as representation from MoD, and provides a governance and assurance function, ensuring that requests for military resources are appropriately triaged. Requesting organisations are not required to attend.
5. What happens once a request is submitted
The NHS England Resilience team (national) will review the request with input from the relevant NHS England regional EPRR team, before submitting it to an NHS England MACA panel.
Requests endorsed by the panel will then be submitted to MoD, where a variety of personnel within Standing Joint Command (UK), including policy, legal and financial advisers, will review it. This will include generating rough order of magnitude (ROM) costings for the requested support.
Military Strategy, Operations and Commitments (MSOC) based in Ministry of Defence (MoD) will also review the request.
Once these reviews have been completed, the Security, Policy and Operations (SPO) team will prepare a ministerial submission for defence ministers. This will include any recommendations for a ministerial decision.
At the same time, DHSC will prepare a ministerial submission for health ministers.
Whilst there is a clear process that needs to be undertaken, it can be delivered at speed where necessary.
6. Finance and indemnity
The requesting NHS provider or integrated care board must meet all costs associated with a MACA and requests must be signed off by its finance director or an executive director with financial authority, before they are formally submitted and before receiving DHSC’s own ministerial endorsement.
However, in the event of multiple MACA requests (such as during the COVID-19 response), the NHS England Resilience Team (national) may centrally co-ordinate the costs.
DHSC must accept the financial costs as calculated by MoD and, if required, indemnify MoD. There are 3 charging levels for MACA:
- full costs: the requesting organisation covers all costs associated with the MACA request
- marginal costs: the requesting organisation covers only the accommodation and subsistence for the military personnel supporting the MACA
- cost waiver: all costs are waived; they are centrally funded by government via DHSC
The charging policy may change during a MACA operation. Marginal costs are likely to be applied in the early, dynamic stages of a response to a disruptive challenge, increasing to full costs levied during the recovery phase due to protracted defence involvement and the resulting impact on MoD primary output. When response is in the national interest, defence ministers may agree to reduce or waive costs.
7. Communications
Any request for MACA will be of interest to the public and patients and the public will need to be reassured around the safe provision of services.
While any announcement of deployment of military personnel sits with MoD, it is important for NHS England, DHSC and MoD to work together to ensure there is appropriate communication around the safety of patients, informing NHS staff of the military support being provided, safe provision of services and level of support being provided to the NHS.
Where possible, both the announcement and the reassurance for patients and the public should be covered in joint press releases. The NHS England Communications Response team will work with DHSC and MoD colleagues and, where required, also with media, regional communication and stakeholder teams.
Annex A: the MACA process
Annex A: the MACA process: accessible text:
This object shows the process for requesting and submitting a MACA request for approval. For top down MACA requests:
- goes to Ministry of Defence (MoD) liaison officer (LO)/ joint regional liaison officer (JRLO) advice and input
- then to National NHS Resilience Endorsement
- then MACA request form submitted
- then MACA panel (if required)
- then submitted to MoD with a copy to Security, Policy and Operations (SPO) and the Department of Health and Social Care (DHSC) (for information)
- it is then allocated to a desk officer
- it is then subject to MoD review and costings – endorsed by NHS Finance
- at this point there is SPO input and policy opinion and Chief of Staff of the Standing Joint Command (COS SJC) endorsement
- Following this it is submitted to Secretary of State (SoS) Health ministerial submission and endorsement
- then there is Minister for Armed Forces (Min AF) ministerial submission and endorsement
- finally the MACA is authorised
For bottom up MACA requests:
- goes to MoD LO/JRLO advice and input
- it is then submitted to regional EPRR/Resilience
- then MACA request form submitted
- then MACA panel (if required)
- then submitted to MoD with a copy to SPO and DHSC (for information)
- it is then allocated to a desk officer
- it is then subject to MoD review and costings – endorsed by NHS Finance
- at this point there is SPO input and policy opinion and COS SJC endorsement
- following this it is submitted to SoS Health ministerial submission and endorsement
- then there are Min AF ministerial submission and endorsement
- finally the MACA is authorised
Annex B: MACA request form
Download the MACA request form.
Publication reference: PRN01799