The RAMC forward units, as with most formations, found their arrangements in disarray during the early days of the war. During the retreat phase of 1914 the general principle of rear units evacuating those forward was dislocated, resulting in a breakdown in the evacuation chain. The development of static, siege warfare allowed this chain to reform but also lead to a major change in structure due to the rise of the Casualty Clearing Station [CCS]. Constant attritional flow of wounded, coupled with the development of the transport infrastructure, allowed a greater emphasis on definitive care within the CCS. Its static location allowed for a larger scaling of equipment and staff, and the resulting ability to hold patients for longer recovery periods made the CCS the venue of choice for surgery. The field ambulance role reverted to that of bridging the gap between wounding and surgery.
The significance of the Somme
Despite the horrendous conditions of 1 July 1916, the forward elements of the RAMC coped relatively well. As circumstances allowed casualties were moved down via, RAP, dressing station and onwards.The sheer numbers of wounded in many areas caused congestion in the evacuation of casualties and impeded the advance of reinforcements. The main criticism later aimed at the chain of evacuation was the lack of ambulance trains to remove casualties from the various CCS. This combined with the relatively rapid transit of casualties from the forward units and the large numbers involved lead to the overwhelming of some CCSs.
Whilst the infantry, and to some degree artillery, tactics varied between divisions, the medical arrangements were fairly constant. The 56th Division had been formed earlier in 1916 and took part in the diversionary attack at Gommecourt. During June 1916 the division prepared for its role in the forthcoming offensive, the ADMS issuing his orders for the division’s medical arrangements. With four RAPs in the line, an ADS was established in Hebuterne, staffed by 4 officers and 110 men of the 2/1 London Field Ambulance. Another field ambulance was stationed nearby, packed ready to advance with the third [less a detachment running the Divisional Rest Station] in reserve.At the ADS position [a cellar bolstered with elephant shelters] accommodation for 20 lying or 40 sitting casualties had been prepared. The plan for evacuation still reflected RAMC 1911, bearers evacuating the RAP to the ADS with evacuation being carried out at night. A separate post for the walking wounded was established, sharing a common route of evacuation to the area of the ADS. The only signs of alteration to pre-war plans is seen in the pooling of all the division’s ambulance cars under the command of the OC 2/1 London Field Ambulance.
This structure struggled but held on 1 July 1916, unable to await nightfall the hard work of the bearers continued day and night, reinforcements being sent forward by the field ambulances being held in reserve. By the time the ADMS completed his war diary on 2 July 1916 his ADS had treated 1911 casualties.With ambulance cars not able to move forward of the ADS the work of the bearer divisions became essential. The physical toll on the bearers seems little appreciated, initially plans were made to relieve them after 48 hours.The bearers had to fight their instincts following specific instruction not to run or jog with a stretcher:
“in case a man’s life depended on a tourniquet or the dislodgement of a blood clot.”
As the summer of 1916 became autumn the methods of the BEF were changing. In this culture of change the deployment of the RAMC field ambulances was amended, unfortunately following an incorrect conclusion. Conscious of the need to remove the wounded rapidly, but ignoring the recent ad-hoc nature of reinforcement and reliefs, the bearer sections of field ambulances were attached forward to specific Brigades. Aiming to increase co-operation with the regimental medical presence, it merely placed the field ambulance assets in small pockets. Whilst sufficient for removing the constant, but low, numbers of casualties incurred during periods of holding the line, the bearers struggled with the large numbers faced during active operations. Assuming the casualty could be reached, the ground conditions and the scattered medical resources made an evacuation time from RAP to ADS of four hours commonplace. Despite the best efforts of the individual bearers men died during this prolonged journey. Many of the medical facilities found themselves having to dispose of those who had died in transit. After a five-hour journey with his casualty a bearer arriving at an ADS near Longuevel found:
“a pile of blanketed bodies, like Egyptian mummies. A crudely painted notice announced, “Deceased awaiting burial.”
After the 56th ( London
“In a typical instance each of the eight ambulance men was carrying, besides his own equipment, some fifty sandbags and a shovel or pick, while between them they also bore four stretchers, four blankets, bags of dressings and the usual sandbag of rations.”
The sheer physical effort of movement through the ground conditions and the distances involved forced the inclusion of more posts in the chain of evacuation. Whilst against the principles of RAMC 1911 this was a necessary evil, with Collecting Posts [CP] and Bearer Relay Posts [BRP] appearing between the RAP and ADS.These first appear to be purely a resting point and navigation landmark for the bearers, including some basic form of cover:
“Collecting Post. Near FORT SOUTHDOWN
The need for control of the bearers and possible re-assessment of the casualty lead to these posts becoming a dedicated stage in the evacuation chain. By October 1916 the same ADMS quoted above allocated 1 Officer, 1 Sergeant and 36 men to staff a Collecting Post forward of his ADS at Colincamps. These men could also be called upon to reinforce, or re-supply the bearers to their front in keeping with general principles of the chain of evacuation. In an operation order dated 23 October 1916 the ADMS of the 51st Division is still placing bearers from the field ambulance forward, attached to the battalions, but by November these men, whilst often located in the RAP are back under the control of the field ambulance. In a “Report on operations 13th-15th November. MEDICAL SERVICES”, covering the 51st Division’s attack on Beaumont Hamel the reasoning behind theses moves is laid out:
“In general it may be stated that delay in evacuation arises from loss of touch between Regimental Medical Officers and Field Ambulance Bearer Officers. During the operations under review touch was not at any time lost and no hitch occurred in evacuation from Regimental Aid Posts.”
The movement forward of the bearer officer and delegation to him of the responsibility for keeping touch with the RAP, allowed the field ambulance to return to its most effective structure based on its position as an asset of the division. Able to concentrate its resources on the point[s] of most need, the field ambulance, via it's bearer section, was able to keep pace with the battle. Wherever the RMO positioned his RAP the field ambulance personnel would find and clear the casualties. The movement down the chain of evacuation once in the care of the field ambulance had become more structured with the appearance of CPs and BRPs. With a growing freedom to deploy itself the field ambulance had evolved slightly during the rigours of 1916.
The 51st Division’s attack on Beaumont Hamel effectively signalled the end of the Somme Arras
 The Casualty Clearing Station had replaced the Clearing Hospital
See appendix 2 for a sample chain of evacuation of the 1 July 1916
Famously during the 1 July 1916 attack on Beaumont Hamel, the 1 Essex and Newfoundland Regiment couldn’t advance through trenches due to congestion. The New Zealand Medical Services experienced similar difficulties during operations near Flers in September 1916, see Carbery, Lt Col
Niall Cherry, ‘The RAMC on the Somme
TNA: WO 95/2938 June 1916, order dated 16 June 1916.
2/2 London Field Ambulance and 2/3 London Field Ambulance respectively.
TNA: WO 95/2938, 1 July 1916 1 officer and 1 other rank sick, 48 other ranks wounded; 2 July 3 officers and 3 men sick, 63 officers and 1802 men wounded.
In contrast the ADMS 51st Division felt 24 hours was the maximum with a minimum period of 12 hours rest required before redeployment. See TNA: WO 95/2851 ADMS 51st Division
 Imperial War Museum
See 56th ( London
 Carbery , New Zealand
, New Zealand
IWM 8603 01/36/1 J Brady p 93-94 talking of ADS of the 14th Division at Flers.
TNA:WO 95/2938 ADMS 56th Division operation order dated 12 September 1916
Anon The “Second-Seconds” in France
RAMC 1911 states the numbers of positions through which the man must past are to be kept to a minimum.
TNA: WO 95/2851 ADMS 51st Division. Operation orders of the first mention a collecting post in late September 1916, with four bearers being stationed at this post. By October 1916 the collecting post is a feature of the chain of evacuation. Mention of bearer relay posts can be found in TNA: WO 95/2938 ADMS 56 Division supplementary order dated 6 October 1916.
TNA: WO 95/2851 September 1916 Appendix B
TNA: WO 95/2851 November 1916 Appendix A dated 29th November 1916
TNA: WO 95/2851 November 1916 Appendix A dated 29th November 1916 Para II