AFC0045

Written evidence submitted by David McLoughlin.

I note that the Secretary of State has granted special dispensation for Service Personnel (SP) to provide evidence to the Committee's inquiry into the Armed Forces Covenant. I, therefore, offer the following written submission in support of the Defence Committee’s inquiry. This submission is based on my own personal experiences of the Armed Forces Covenant. I make some general observations before trying to address the specific questions set by the Defence Committee.

Context for Submission

I am currently serving as the 2* Director of Defence Healthcare. In this role I am responsible for the provision of healthcare to SP and entitled civilians across the 4 nations of the UK and overseas bases. Defence Healthcare delivers primary care, dental care, rehabilitation, mental health services and occupational medicine. The NHS is, in general, responsible for the provision of secondary care for SPs and their families. In my current role I regularly engage with the DHSC through established Partnership Boards and through regular meetings with healthcare leaders in England and the devolved administrations. Engagements include meetings with Perm Secs, CEOs, Chief Medical Officers, Chief Dental Officers and Chief Nursing Officers. The application of the Armed Forces Covenant is a regular topic in these meetings as I try to ensure that SP and their families are not disadvantaged in the provision of health and dental care.

Importance of Healthcare Provision

Healthcare provision is non-discretionary and a top issue for the electorate in the UK. SPs and their families also care deeply about the provision of healthcare. In the annual Armed Forces Continuous Attitude Survey, the provision of healthcare and dental care has been consistently in the top 3 reasons for why SPs stay in Defence. In AFCAS 2024 dental care was the number 2 retention factor and healthcare were the number 3 retention factor. This is important given the current recruitment and retention crisis across all 3 services.

In what areas is the Armed Forces Covenant working well?

The Armed Forces Covenant and the legal duty in the Armed Forces Act 2021 are significant achievements. The legal duty provides a clear and visible reference that I use on a regular basis to attempt to leverage actions from the NHS to ensure SPs and their families are not disadvantaged. Recent positive examples include SP access to specialist NHS services and cancer screening programmes no matter where they are based. Maintenance of places on NHS waiting lists for secondary care despite postings to different regions and countries. The encouragement of NHS Dental practices to register service families particularly in Scotland. Furthermore, the Prime Minister has stated that the NHS is one of his top 5 priorities and we have been able to insert SPs into some of the national NHS waiting list initiatives. Currently 2 of the Chief Medical Officers have honorary appointments in the military medical reserves which have deepened links and understanding of the Armed Forces Covenant in the respective government departments.

Other examples of where the Armed Forces Covenant is working well in healthcare have been listed in the Armed Force Covenant report 2024. Many of the healthcare initiatives relate to veterans. I believe the Office for Veterans and ministerial focus have benefitted veterans. Of note I am the current SRO for one of the listed healthcare initiatives in the 2024 annual Armed Forces Covenant report.

Where is the Armed Forces Covenant failing the Armed Forces Community?

Arguably the covenant has not been as successful for current serving personnel and their families. Furthermore, the application of the Armed Forces Covenant is neither automatic nor universal across the NHS despite the clear legal duty on the NHS in all 4 nations. Indeed, the application of the covenant in the NHS appears to depend on knowledge of the covenant, appropriate application of the covenant, significant time to implement, political willingness and how the covenant fits with other health priorities. For example, the Armed Forces covenant is important to the MOD and SP, but it is not a priority for the DHSC. In simple terms how often does a health minister talk about the Armed Forces Covenant during a winter crisis in the NHS?

The Armed Forces community also struggles in some specific areas. Access to NHS dentistry is a known problem for the general population with variable provision based on geography. With frequent postings SPs and their families can go from dental provision in some areas to being at the back of the queue for NHS dentistry in new locations. In the worse case scenario of frequent family moves children of SPs may receive little to no preventive dental care over many years. SP and families can also lose places on NHS waiting lists with new postings. This is a particular problem for those referred to specialist services or when the new posting involves cross border moves within the UK and overseas. In addition, NHS waiting times in Scotland and NI are significantly longer than in NHS England. Therefore, SPs and families posted to these nations may not come to the top of waiting lists during their entire tour length and before another posting to a different region whereupon they are then move to the back of the queue yest again. Finally new initiatives for SPs can take an extended period to implement in the NHS despite the covenant. In addition, the NHS frequently requires the MOD to pay the full costs of these initiatives despite SP being entitled to NHS care. Arguably the Armed Forces covenant suggests that there should be no additional costs. A recent example is SP access to NHS prescriptions where the NHS Business Supply Authority expects MOD to pay for the processing of prescriptions for SPs throughout England.

What are the main causes for these failings?

I believe there are several causes for these failings including the following:

Lack of Knowledge of the Covenant. The NHS is one of the largest organisations in the world with approximately 1.4 million workers. Many of the healthcare workers in the NHS will have little or no contact with the Armed Forces and no knowledge of the Armed Forces Covenant. Within the NHS it is generally accepted that there are numerous stove piped organisations, arm’s length bodies and different regions that exacerbate the difficulties of communicating the Armed Forces Covenant legal duty. Where living accommodation for SP is spread across NHS regional boundaries this can lead to healthcare inequalities for SP and their families working at the same base. I can give multiple examples if required.

Lack of Understanding of the Covenant. The covenant and legal duty seek to prevent SPs and their families being disadvantaged by service life. Some misunderstand the covenant or inappropriately believe we are trying to seek advantage for SPs.

Conflicting Priorities in Healthcare. In the NHS waiting times and the level of care is based on the long-standing principal of clinical need. In general, very sick patients will get priority and they are likely to receive a higher standard of care earlier than a patient with lower clinical needs. The NHS does not prioritise care based on occupation even for their own NHS staff. Therefore, conversations with the NHS to ensure SPs and their families are not disadvantaged can be tough.

Weak legal duty that is open to interpretation. The current legal duty hinges around the ‘due regard’ piece. In practice this is a weak phrase that is open to wide interpretation. At the most flippant end I have been told that ‘due regard’ means they have given the issue a short period of thought and the answer is no to a request from me or a member of my Defence Healthcare team.

Conflicting legal interpretations in Northern Ireland. In Northern Ireland implementation of the Armed Forces Covenant is hampered by the conflicting legal interpretations of the ‘Good Friday’ agreement and the Armed Forces Act 2021. While the Armed Forces Act does apply in NI legal advice given to the NI Office is that the Good Friday agreement takes precedence. In addition, the legacy of the troubles and the continuing security risks for SPs also hamper implementation of the Armed Forces Covenant in NI.

Are there areas which the Armed Forces Covenant ought to be extended to and why?

I am not an expert in areas beyond healthcare. However, the premise of the Armed Forces Covenant is that SPs and their families, who may have to make the ultimate sacrifice in defence of their country, should not be disadvantaged. Therefore, in theory, the covenant should apply to all parts of government and the devolved administrations.

If so, which are the priority areas?

Frequent townhalls suggest that the main concerns of SPs and their families include pay/cost of living, health and dental care, education provision, standard of accommodation, poor transport links and inadequate welfare support.

What legislative changes should be made and why?

A clearer and tighter legal duty would be most welcome. Any new covenant should be clearly articulated across all relevant parts of government with the implementation automated where possible to ensure SPs are not disadvantaged and that they do not have to fight their specific case on an individual basis.

What impact would the extension of the Armed Forces Covenant legal duty to central government and devolved administrations have?

In healthcare there is already a legal duty on central government and the devolved administrations. However, knowledge and application of the covenant is variable.

Conclusion

I am grateful for the opportunity to submit written evidence to the Defence Committee and I hope it is of some value to the inquiry into the Armed Forces Covenant. I believe this inquiry is very timely given the government’s planned review of the Covenant and the current SDR, Defence Reform and Recruitment and Retention initiatives.

24th January 2025