Baroness Merron

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That the Bill be now read a second time.

Northern Ireland, Scottish and Welsh legislative consent sought.

The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)

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My Lords, it is essential that the changes we hope to make in this Bill resolve some of the existing workforce issues within our NHS. I say at the outset that the Bill will not be a silver bullet, and I do not wish to present it as such, but the changes it introduces for foundation and specialty training will lead to a more sustainable medical workforce that can better meet the health needs of our population.

I am most grateful to all those who have engaged with us, including the devolved Governments, to recognise the shared challenges that we face across the United Kingdom. My thanks are also due to noble Lords from across the House for their constructive contributions, time and interest in meeting me and officials. I am also most grateful for the cross-party support that has been demonstrated, both in the other place and in my discussions with the Front Benches in this House. A number of organisations have also expressed their support, including: the BMA, the Academy of Medical Royal Colleges, the Royal College of Physicians, and the Royal College of Surgeons of Edinburgh.

The NHS is beginning to show signs of recovery, following a period of unprecedented strain. Nothing in the NHS functions without its workforce and I am grateful for the dedication and professionalism of our workforce. Supporting, valuing and planning for that workforce is fundamental and, I know, something that your Lordships’ House takes a great interest in—and rightly so. Because the NHS depends on its workforce, we are developing a long-term approach to workforce planning, aligned with the ambitions set out in the 10-year health plan published in July, which set out the intent of this Bill.

That work will culminate in the publication of a 10-year workforce plan in the spring, setting out how we intend to ensure that the NHS has the right people in the right places with the right skills. Staff have been clear for some time that they want change, not only in absolute numbers but in how they are trained, supported and treated at work. We have heard from many who have been exceptionally frustrated by the current application process. There are challenges within medical training that cannot be addressed without legislative change, and that is why we are taking action with this Bill. I am absolutely delighted that my noble friends Lord Duvall and Lord Roe have chosen to make their maiden speeches in this important debate. I, like all noble Lords, very much look forward to hearing from them.

One of the most pressing of those challenges is the severe bottleneck in postgraduate medical training. For several years now, the number of applicants for foundation and specialty training places has grown far more rapidly than the number of available posts. In 2019, there were around 12,000 applicants for 9,000 specialty training places. In 2020, visa restrictions were lifted, and we find this year that this has soared to nearly 40,000 applicants for 10,000 places, with significantly more overseas-trained applicants than UK-trained ones.

This has created intense competition, uncertainty and frustration for many at the start of their careers. At the same time our NHS has become increasingly reliant on international recruitment. This Government deeply value the contribution made by doctors from all around the world, many of whom have played and continue to play a vital role in patient care, and nothing in in this Bill diminishes that contribution. However, it is neither sustainable nor ethically comfortable for the UK to depend so heavily on recruiting doctors from countries that themselves face serious workforce challenges while a growing number of UK-trained doctors struggle to access training posts. Competition for medical staff has never been fiercer. The World Health Organization estimates a shortfall of 11 million health workers by 2030. Shoring up our own workforce will limit our exposure to such global pressures without depriving other countries of their homegrown talent, and this Bill seeks to address that imbalance.

Let me turn to the Bill itself. The Medical Training (Prioritisation) Bill gives effect to the Government’s commitment to place UK-trained doctors and other defined priority groups at the front of the queue for medical training posts. It does so while continuing to allow internationally trained doctors to apply for and contribute to the NHS. Let me emphasise that the Bill is about prioritisation. It is not about excluding people, but it is unashamedly about prioritisation. For the UK foundation programme, the Bill requires that places are allocated to UK medical graduates and those in priority groups before being offered to other eligible applicants. For specialty training, it introduces prioritisation initially at the offer stage for 2026 and from 2027 at both the short-listing and offer stages. That will significantly reduce the level of competition being faced by UK-trained applicants, and it will provide greater certainty at a critical point in their career.

Internationally trained doctors with significant NHS experience will continue to be prioritised for specialty training, recognising the service that they have given. This year, immigration status will be used as a practical proxy for NHS experience in order to allow prioritisation to begin swiftly. For following years, we have taken powers in regulations to enable us to refine this approach in consultation with key partners. I have been asked by noble Lords what this means for those with refugee status. This status is not a stand-alone priority group, although refugees will be prioritised for specialty training in 2026 if they fall within another priority category, such as holding indefinite leave to remain or having completed the foundation programme. Refugees who do not fall within a prioritised group may still apply for specialty training posts and the Bill will not change their eligibility to apply for locally employed doctors’ roles.

I am seeking to address up front some of the concerns that will quite rightly be raised in the course of the debate. One of those is a concern I have heard about why British citizens who have graduated from medical schools outside the UK will not be in the priority group, including some doctors who would be eligible only for provisional GMC registration. I understand the reasons why this is being raised, and I have heard how some would prefer all British citizens, in a blanket sense, to be prioritised. The problem with that is that it would undermine the very intent of the legislation, which is to enable effective workforce planning and the development of our future medical workforce.

The principle is to create a sustainable domestic workforce. It is not about where a student is born; it is about where they are trained, and the fact is that UK-trained doctors are more likely to work in the NHS for longer. In addition, the Government set UK medical school places based on future health system needs. Student intakes and graduate outputs of overseas medical schools are not included in our domestic workforce planning. If we prioritised British citizens in a blanket sense for foundation training places regardless of where they studied, that would undermine our key aim to build UK-trained capacity while ensuring that we do not provide more foundation programme places than we need. I reiterate that this Bill is about prioritisation and not exclusion. All eligible applicants will still be able to apply and will be offered places if vacancies remain after prioritised applicants have received offers, which we expect to be the case on the basis of our long experience.

I have also listened to colleagues expressing concerns around the treatment of applicants graduating in Malta. The UK’s long-standing partnership with Malta on healthcare is valued and will continue. Doctors training in Malta will still be able to come to the UK to gain NHS experience to support their training, for example through fellowship schemes. These arrangements are not affected by the Bill. However, as I stated earlier, for recruitment to specialty training places in the UK, the Government assess that it is important to prioritise to ensure a sustainable workforce that meets health needs.

I turn to the matter of public health specialists, who are particularly identified in the Bill. Public health is a unique medical specialty that draws applicants from medicine and other professional backgrounds who all undergo the same rigorous training. All public health specialists, regardless of professional background, complete the same rigorous medical specialty training programme and are subject to the same high professional standards. The Bill excludes from prioritisation any specialty programmes wholly in the field of public health, as it would undermine the multidisciplinary public health specialist workforce. The Government will monitor the impact on the public health specialist training programme, which currently accepts very small numbers of international medical graduates.

I am aware that there are concerns relating to terms and conditions and mobility for some specialists. We have set out the actions we will take to make the NHS a better and great employer. However, a focus on the NHS alone will not support the whole health workforce, as many public health specialists work outside the NHS with differing employment arrangements. But we are committed to working with the BMA, employers and professional bodies to make public health careers more attractive.

On timing, the Bill includes provisions to allow prioritisation to apply to the current application cycle, with posts commencing this August. That requires Royal Assent by 5 March. It is therefore important to seek timely passage for this Bill to avoid disruption for trainees who need sufficient time to find somewhere to live, sort out childcare and arrange any other aspects of their lives before their posts start, and for NHS trusts that are planning the front-line services. I hear the concerns of some noble Lords about the impact on those applying in the current application cycle, particularly where applicants report that they did not know how prioritisation might affect them. As I said earlier, these concerns are understandable, and they have been carefully considered. However, delaying action would only prolong the current problem by further entrenching the existing imbalance in training competition and it would weaken our ability to plan a sustainable workforce.

The commencement provisions provide necessary flexibility, ensuring that implementation can be carried out in an orderly and workable way, taking account of operational realities. On that point, there is a material consideration, which I am sure will be raised and understandably so, about whether it is possible to proceed if strike action is ongoing. The disruption strikes cause, and the pressure they put on resources, would undoubtedly make it a lot harder operationally to deliver the important measures in this Bill. It is our intention to commence as soon as we can, subject to the Bill’s passage through Parliament, but it is vital to have a safeguard to ensure that the systems planning and operational capacity required for successful implementation are firmly in place.

I conclude by saying that the Bill will not solve every workforce challenge, but it is a very important step towards a more coherent, ethical and sustainable approach to medical training and workforce planning: something that has been called for for many years.

It is estimated that four resident doctors will be competing for every specialty training post in 2026. With the delivery of this Bill, this number can reduce to two resident doctors per place. British taxpayers spend £4 billion training medics every single year. It will be by better aligning public investment, training capacity and long-term service needs that the Bill will give UK-trained doctors a fair chance to serve in the health service they train to support, and to do so in a way that benefits us, the public, across the country. I beg to move.

Earl Howe (Con)

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My Lords, I begin by declaring my interest as an honorary fellow of the Royal College of Physicians. It is a pleasure to open the first of our discussions on the Bill, and I should like to express my thanks to the Minister for her clear explanation of its provisions and its policy background.

I also thank her for the informative letter that she circulated earlier this week, and for the helpful private discussions she has facilitated. Like the noble Baroness, I look forward to the two maiden speeches we are to hear later from the noble Lords, Lord Roe and Lord Duvall, whom I welcome very warmly to the House.

This Bill may be small in length, but it is far from insignificant, not least because it is being introduced to Parliament on an emergency timetable. More pertinently perhaps, its significance can be measured in its potential effect on the lives and careers of many thousands of doctors. That fact alone makes this a measure deserving of the closest scrutiny, and I am therefore appreciative of the fact that the Government and the usual channels have enabled a greater interval between each stage of the Bill’s passage through the House than was the case last week in the other place.

I should say to the noble Baroness at the outset that His Majesty’s Opposition have no quarrel with the principle underpinning the Bill. However, as she would expect, we have identified and been made aware of very considerable concerns over a number of its key provisions, and I know she will understand that we need to explore these thoroughly during the course of our proceedings.

Doctors trained in this country and funded by the taxpayer should have a fair, clear and consistent pathway to progression within our NHS. Britain trains some of the finest doctors in the world, yet too many are being lost because they cannot access the training places they require. That represents a waste of talent, it undermines morale and it ultimately has consequences for patient care. It also represents a loss of taxpayer investment made through the public support of medical education and training when doctors are forced to take their skills abroad because they cannot progress within the system at home. It is, therefore, a problem that we on these Benches agree must be addressed.

However, the manner in which these challenges are addressed matters greatly. There has to be a test of reasonableness and fairness if the Government’s response can be judged acceptable not only in the eyes of UK-based doctors but to doctors who have studied overseas. The solution to the problem must also offer sustainable, long-term change and not just a short-term sticking plaster. I say that because, as we all know, the danger inherent in emergency legislation of any kind is that it can result in unintended and unwanted effects.

To my eyes, one of the first ways in which the Bill falls short, along with the Government’s narrative, is its failure to address the wider question of how its provisions dovetail with any changes in the availability of training places. To solve the problem of recruitment bottlenecks, the Government are using the Bill to refashion the order in which eligible applicants are considered. However, the other way of approaching the issue is to expand the number of training places. Elsewhere, the Government have promised to deliver 4,000 new specialist training places, including 1,000 places that are needed in reasonably short order.

Where do these plans now sit and how are they likely to affect the career prospects of the doctors of the future and those already in the system, particularly those doctors trained overseas? How quickly can capacity be expanded? These were questions that the previous Government tried to address head-on in the NHS Long Term Workforce Plan, published in 2023, which was well received across the medical community.

I mentioned just now the risks and dangers inherent in introducing emergency legislation on a curtailed timetable and, in that vein, another area of concern is the seeming contradiction in the Government’s characterisation of this legislation as an emergency measure. As we understand it, the Government are proposing that the Bill should come into force not on Royal Assent but at a time of the Secretary of State’s choosing. Why is that? If the Bill before us were genuinely urgent, addressing, as it purports to, the 2026 recruitment round, it is difficult to understand why it would not be commenced immediately following its approval by Parliament and the sovereign.

The disconnect between the Government’s rhetoric and reality is troubling, not least because it serves to highlight a number of provisions in the Bill that pose real worries. One such worry concerns the Bill’s impact on doctors who are trained overseas through established UK higher education institutions. These are doctors who are undertaking identical GMC-approved MBBS courses, sitting the same assessments and receiving the same GMC-approved degrees as their counterparts trained in the United Kingdom.

Under the Bill, these doctors will find themselves suddenly classified in the non-priority category of applicants, both for foundation programmes and for specialty training. We are aware that at least one of these programmes operates under a long-standing international arrangement, with wider diplomatic and institutional implications. The noble Baroness, Lady Gerada, will be addressing the issue in greater detail. At this stage, however, I wish to highlight one programme run by Queen Mary University of London in Malta, which is sustained by a long-standing UK-Malta agreement, first established in 2009 and reviewed as recently as 2024. That agreement sits within a broader context of deep and enduring ties between the two countries’ health systems and approaches to medical education.

Undermining it risks significant and long-lasting repercussions for the UK-Malta relationship. I understand that the Government of Malta have written to the Secretary of State to raise these concerns—so far, I understand, without a response. The Minister very helpfully referred to the Maltese concern in her recent round robin letter, as she did today. But I believe it is an issue we shall want to pursue in Committee in greater depth. The concern is multifaceted because, in the scheme of things, what the Bill does to Maltese doctors looks completely unnecessary. The numbers involved are tiny. The Maltese example demonstrates that the Bill as drafted risks causing disproportionate harm to well-established international partnerships, seemingly not as a matter of policy intent but as a consequence of legislation being rushed through Parliament.

There is a further issue that has been brought repeatedly to our attention by doctors and medical academics in this country and abroad: the position of applicants who are already part way through the current foundation programme recruitment round. The noble Baroness mentioned this in her speech. We have heard compelling evidence of a real risk of creating what has been described as a “stranded cohort”: that is, the cohort of doctors who entered a live national recruitment process in good faith, under published rules and fixed deadlines, only to face the risk of materially different outcomes because prioritisation is applied mid-cycle in a radically different way from before.

We need to be clear on the point that applicants at this stage have already committed significant time and cost to the process and are making concrete plans around registration, visas, relocation and employment. For foundation programme applicants in particular, there is often no straightforward alternative NHS route if an outcome is delayed or left indeterminate, given the constraints around provisional registration.

From a system perspective, uncertainty of this kind also risks avoidable disruption to workforce planning, late withdrawals and rota instability. None of these comments are intended to challenge the core principles of the Bill, but they surely call into question the justification for the process and whether it is fair and reasonable for Parliament to permit what amounts to retrospective disruption to an already defined recruitment cohort. Are the Government willing to make use of the commencement and transitional powers in the Bill to ensure that the changes introduced operate only prospectively, so as to give clarity and fairness for those already in the pipeline?

Beyond the issues I have already referred to, there are a number of further concerns about the way the Bill is framed and how it will operate in practice. As drafted, the prioritisation process that the Bill envisages rests chiefly on one decisive qualifying factor—where a doctor was trained. While that may work as an idea in general terms, we are concerned that it risks excluding from the priority group individuals who are British citizens but who have undertaken part of their training overseas, which can arise for entirely normal and legitimate reasons. Again, I listened to what the noble Baroness had to say on this subject, but one clear example is doctors who have completed elements of their medical training while serving with the UK’s Armed Forces abroad. Those individuals have trained within UK systems, often in demanding circumstances and in the service of this country. It would be perverse if their contribution were overlooked simply because aspects of their training took place outside the British Isles. Any credible definition of a UK medical graduate ought to be capable of recognising that reality.

We must also consider the wider implications of this legislation for medical schools. Changes to prioritisation will inevitably influence the number of international students choosing to study medicine in the UK, with potential adverse financial consequences for institutions that are already under significant pressure. Parliament should not be asked to legislate in the dark on such effects, which is why we believe that there is a strong case for the Government reporting regularly on the impact of these provisions on student numbers and on the financial sustainability of medical schools—centres of excellence that sustain a world-class teaching environment that is a genuine credit to this country.

The Bill was prompted by a problem that we all recognise—too many talented British doctors are finding their progression blocked, and the NHS and, ultimately, patients are paying the price. We support the principle that UK training, public investment and commitment to the NHS should be properly recognised, but principle alone is never enough. If this legislation is to succeed, and succeed fairly, it must be both precise and proportionate. Of course, it must address the core of the problem in a sufficiently far-reaching way. However, it must also recognise the realities of life for aspiring doctors who have submitted applications to enter UK training programmes, relied in good faith on explicit written assurances from the relevant authorities and committed what are often large sums of their own money on the back of those assurances, and who now find the rug pulled from under them.

Legislation designed to remedy the current problem must also take full account of those elements of UK and foreign-based training systems that are in practical terms identical. It must be robust enough to protect UK training pathways stemming from long-standing international partnerships that are already established firmly in our medical education system. Our relations with allies and Commonwealth members such as Malta really matter.

We approach the next stages of the Bill in a constructive spirit. Our aim is not to frustrate its passage but to improve its drafting to ensure that it does what it is intended to do without unintended consequences. We want it to command confidence across the House as well as outside it so that the future of medical training, and indeed the future of the NHS, is genuinely safeguarded and strengthened.

Lord Clement-Jones (LD)

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My Lords, I too thank the Minister for her introduction. I look forward to hearing from our two maiden speakers and add to the noble Earl’s welcome to the House to them. It is a pleasure to follow the noble Earl, and I agree with a great deal of what he said.

Let me say from the outset that we on these Benches support the underlying principles of the Bill. The Government’s impact statement makes the case that UK graduates are significantly more likely to remain in the NHS long term than their international counterparts. It is entirely reasonable that where the British taxpayer invests some £4 billion annually in medical education, there should be a secure pipeline for those graduates into our health service.

However, while the intent is sound, the execution is marred by serious flaws. Fairness requires that those who have relied on a long-standing government position are not disadvantaged by abrupt alterations. Six months’ notice is wholly inadequate for a decision with such a long lead-in time, and few could reasonably have expected such a significant change to be implemented with so little warning.

I want to highlight two specific areas where the Bill creates profound inequity—the treatment of UK university campuses overseas, specifically Queen Mary University of London in Malta, and the flawed criteria used to assess significant NHS experience for our international colleagues.

First, on the anomaly regarding Queen Mary University of London and its campus in Malta, until mid-last year, I was chair of Queen Mary University of London’s governing council. It is vital to understand that Queen Mary University in Malta is not a foreign institution or a private commercial venture; it is an integrated campus of a UK public university. Its students study a curriculum identical to that of their peers in London. They sit the same assessments, including the UK medical licensing assessment, and they are awarded the exact same GMC-approved primary medical qualification.

In her letter to noble Lords this week, and I welcome her correspondence, the Minister argued that these graduates should not be prioritised because they may lack familiarity with local epidemiology and NHS systems. With respect, that does not hold water. These students follow the exact same NHS-aligned curriculum as Queen Mary students in Whitechapel.

Contrast that with Clause 4, in which the Government rightly prioritise graduates from Ireland, but also prioritise graduates from Switzerland, Norway, Iceland and Liechtenstein. A graduate from Liechtenstein has no UK medical degree, has not sat the UK medical licensing assessment and has no training in UK epidemiology. Yet, under the Bill, they will be prioritised over a Queen Mary in Malta student who holds a UK degree and has been specifically prepared for the NHS. This is a manifest absurdity.

The Minister’s letter also suggests that including those students would undermine workforce planning because numbers are uncontrolled. That is incorrect. Queen Mary in Malta’s student numbers are capped by the Maltese Government at just 50 to 70 graduates a year—statistically negligible in a system of 11,000 places. To penalise them on such grounds is neither proportionate nor fair.

Furthermore, the Government’s own impact assessment justifies the Bill on the need to protect taxpayer investment, yet Queen Mary in Malta students are self-funded. This is not merely a matter of academic equivalence; these graduates provide the NHS with doctors trained to UK standards at no cost to the British taxpayer, representing a rare example of value without expenditure —precisely the kind of pipeline a fair system ought to support rather than disadvantage. By excluding them, the Government are working against their own value-for-money logic.

We also risk breaking a solemn international commitment. The Minister’s letter implies that our agreement with Malta is limited to ad hoc training. That downplays the reality. Since 2009, the UK and Malta have operated under a unique mutual recognition agreement regarding the foundation programme itself, explicitly renewed by the Department of Health and Social Care as recently as 2024. Malta is the only country in the world with this status. By unilaterally demoting these graduates, we are, in effect, tearing up a long-standing agreement with a Commonwealth partner—one that Malta’s own Minister for Health describes as having served both countries for over two centuries. Other universities, such as Newcastle University, which operates a similar campus in Malaysia, face similar predicaments. Its vice-chancellor has noted that its graduates too receive identical accreditation and transition seamlessly into the UK workforce.

Then there is the second critical flaw in the Bill: how it attempts to identify significant NHS experience for the upcoming 2026 recruitment round. Under Clause 2, the Government propose using immigration status, specifically indefinite leave to remain—ILR—as a crude proxy for NHS experience. This reveals a fundamental misunderstanding of medical training timelines. ILR typically, at the moment, requires five years of residence, yet UK graduates enter specialty training after just two years of the foundation programme. That creates a perverse experience gap. International doctors who have served on our front lines for three or four years, passed royal college exams, built a career portfolio and worked the same rotas as their UK colleagues will be treated as if they have no experience at all, simply because they have not yet clocked up the five years required for ILR. This, effectively, tells dedicated doctors that their three years of service counts for nothing.

In her earlier letter, the Minister defends this blunt proxy, as she did today, by claiming it was not operationally feasible to assess all applications for actual NHS experience in time for the 2026 cycle. We have received compelling evidence to the contrary. Doctors currently using the recruitment platform Oriel inform us that the system already captures data on months of NHS experience. The data exists, the mechanism to do this fairly exists, and to persist with the ILR requirement is to prioritise administrative convenience over the reality of clinical contribution. We should define significant experience not by visa status but by time served. A benchmark of two years of NHS experience would be equitable, and mirror the two years of core training required of UK graduates.

Furthermore, we have all received distressing correspondence regarding doctors on spousal visas. These are permanent residents, married to British citizens, with an unrestricted right to work, yet under the Bill they are placed in the lowest priority tier. We risk driving away not just those doctors but their British spouses who work in our public sector as families are forced to emigrate to find work.

There is a deep anxiety, in particular, regarding the mid-cycle implementation of these rules. We have received correspondence from doctors who have spent years building career portfolios and investing substantial resources based on published criteria, only to find the rules changing while the recruitment process is active. This creates procedural unfairness and huge instability for their families. If our guiding principle is, as it must be, fairness, then it cannot be right to introduce such consequential changes mid-cycle when candidates have already ordered their lives and careers around criteria that have stood in place for many years.

To cap it all, there is a glaring incoherence at the heart of the Government’s approach. Just days ago, the Education Secretary, Bridget Phillipson, announced a new strategy to grow our education exports to £40 billion a year by 2030. She explicitly encouraged our universities to expand transnational education and open campuses overseas. Yet in the Bill, the Department of Health and Social Care is actively undermining that very strategy. We cannot have the Department for Education urging universities to go global to boost the economy while the Department of Health and Social Care simultaneously pulls up the drawbridge against the very students who enrol. That is a fundamental contradiction.

For Queen Mary in Malta, the solution is simple: a minor amendment to Clause 4 to recognise its UK degree, or the inclusion of Malta in the priority list, honouring our 2009 agreement. For the broader issues affecting international medical graduates, we must abandon the blunt instrument of ILR and use the data we already have to recognise two years of service as the true mark of commitment. Let us not mar a necessary piece of legislation by failing to correct these obvious injustices.

Baroness Finlay of Llandaff (CB)

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My Lords, I declare my recent observer role with the Medical Schools Council, and as a pro-chancellor at Cardiff University, which, of course, has a medical school. The Bill aims to address a problem that has been brewing for years—but some medical graduates will unintentionally suffer, and we must consider them.

Specific groups have already been mentioned by the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, but they warrant reiterating. First, there are medical graduates from established overseas branch campuses of UK universities. That is not only Malta; Newcastle has already been spoken of, and there are others. There are also UK citizens studying medicine in the EU in good faith, always intending to work in the NHS, and international graduates unable to receive specialist training in their own country, who come here before returning to develop key specialist services in their home country. There are also those who relied on the published recruitment framework in good faith for years, and made irreversible decisions—relocating families, investing time and money, filling rota gaps and sustaining NHS services through Covid—never expecting specialty training to be rewritten while applications were already in progress. Would a separate tier, after the current priorities but ahead of those with no UK connection, provide a solution?

As has been said, a few UK medical schools deliver their degrees from established branch campuses abroad, by fully accredited programmes regulated by the General Medical Council. They follow the UK curriculum, and are taught and assessed in English to identical academic and clinical standards. These students graduate with a UK medical degree and will have passed the UK medical licensing assessment. They often apply to work in the NHS and transition smoothly into clinical practice, benefiting the NHS. These graduates have applied for UK training posts under one set of rules, but face different rules with limited options. Should these UK medical graduates not be prioritised over graduates from non-UK universities across the world?

There is a wider significance, as has already been alluded to. The Government’s international education strategy states the importance of universities seeking global opportunities, such as developing branch campuses. To avoid opening the floodgates, do the Government envisage capping UK healthcare degrees delivered offshore? This year, there were over 25,500 UK applicants for just over 10,000 UK medical school places. Selection at 18 years old is difficult. Each year, having invested in years of their schooling, we reject highly capable home applicants who would be excellent doctors. Many of them choose to study abroad, determined to return to work in the NHS. Should they be required to pass the UK medical licensing assessment, so that UK citizens studying in the EU after school are not left stranded?

For postgraduate trainees who applied through the previous recruitment framework and are currently working in the NHS, with several years’ experience, would recognising service from Covid onwards be considered in the eligibility in the current round? Where is the expansion of specialty training posts and academic posts for some of these graduates?

Lastly, all UK health expertise benefits international development. Many countries lack their own training expertise, and historically the UK has trained specialists to go back to develop services in their home countries. This altruism improves global health and creates opportunities for the NHS, universities and pharmaceutical and tech companies to gain international contracts. Without routes for overseas doctors to train here, our international partners will look elsewhere.

The Bill apparently aims to secure a reliable supply of doctors for the future, ensuring that those with a UK medical link are more likely to progress to current consultant roles and continue their careers in the NHS. Will international medical student places here be further limited? Otherwise, the Bill could mean that UK students forced to train overseas through limited home student places will not be prioritised, whereas international medical students at UK medical schools will. In passing the Bill with speed, we must avoid penalising our own graduates, jeopardising international partnerships, or appearing hostile to international excellence or unreliable by suddenly changing the rules. Will the Minister consider widening the priority group or adding other tiers to recognise the importance of medical graduates?

Lord Roe of West Wickham (Lab) (Maiden Speech)

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My Lords, it is the greatest honour to speak in your Lordships’ House for the first time. I thank my fellow noble Lords from right across the House for the warmth of their welcome, extended not just to me but to my family on my introduction. Equally, I thank all the staff, from Black Rod and the Clerk of the Parliaments to the doorkeepers, police and security staff—and, perhaps most importantly, as I have spent the past two weeks eating, to the caterers. I can say with some certainty that your Lordships’ House has some of the best work canteens I have ever encountered, and I have been in some over the years. Without wanting to labour this—pardon the pun—the ham, egg and chips in the Millbank basement is of particular note to a connoisseur of such matters. The professionalism and patient good humour of every single noble Lord towards a new Member of this House is a credit to the extraordinary place that they both protect and sustain.

I thank my sponsors, my noble friends Lord Kennedy of Southwark and Lady Twycross, who, alongside my noble friend Lady Smith of Basildon, have offered encouragement and support as they have guided me in the process of joining your Lordships’ House. In particular —and I am looking at her now—I need to thank my noble friend Lady Twycross, who was my deputy mayor when I was first appointed as London Fire Commissioner. She deserves particular thanks, as my noble friend is probably asking herself once again why she is having to keep me on the straight and narrow in a new job. It is also a particular pleasure to see in his place my old friend, my noble friend Lord Duvall, who also served London for so many years and was such a great supporter of the London Fire Brigade—my chosen profession—and to speak on the same evening as him. That gives me great pleasure.

I am very much a son of south London, and my journey here has been shaped by that, along with a lifetime in uniformed service, first in the British Army, coming from a long line of soldiers on my father’s side, and then in the London Fire Brigade, where I served at every rank from firefighter to commissioner.

I believe that I am the first firefighter in history ever to sit in your Lordships’ House. Serving for half my life in, and eventually commanding, the brigade, one of the world’s largest and busiest emergency services, and one of this country’s last great remaining working-class institutions, was the most enormous privilege. It gave me an education in life and membership of a club that you cannot pay to be part of. I hope that I can therefore give firefighters and their families some voice in my contributions here.

I would also like to speak to the role boxing has had in my life, first as a competitive fighter for many years, then as a coach, still now as a club chair and—unbelievably to me, as that young kid walking into a boxing club in south London all those years ago—sitting on the national board that supports our great British Olympic team. The support and the safe space that boxing clubs provide young people, particularly in some of the poorest places in this country, must not be underestimated. Boxing gave me confidence, fitness, discipline, purpose and a structure.

At a time when the politics of division seem to be painting a picture of Britain, characterising Englishness in particular in a way that, as a proud Englishman, I simply do not recognise, boxing clubs are still very much beacons of openness, tolerance and unity. I have fought and trained in clubs and halls the length and breadth of these islands, and I can say that without exception my experience is that in boxing your faith, race, background and nationality are irrelevant, as what is shared in a boxing club is a common respect for anyone who has had the courage to take that first step into the squared circle and face their own fears. In that sense, the sport and its spaces both epitomise and set the standard for true British values.

In respect of today’s debate, addressing the quality and accessibility of the training we give our doctors, I believe that my experiences bear some relevance. Having responded alongside so many medical colleagues over the years, I know that, like being a firefighter or a soldier, a career in medicine is profoundly rewarding and has the greatest benefit to both the individual and their community. It seems clear to me that, by ensuring that our graduates are given priority access to the best available training, we will help to sustain and protect our health service while also providing important opportunities to young British people of all backgrounds to make a difference.

Lastly, and perhaps most personally to me, in my working life, both as a soldier and as a firefighter, I have been repeatedly and directly involved in the tragedies that befall ordinary people when politics, institutions and systems simply fail to protect them, often with catastrophic loss of life. I have been a witness in those moments, standing on streets from Portadown to inner London—witness to the unbelievable heroism of my fellow soldiers and firefighters in their actions in responding to those failures. Some of them made the ultimate sacrifice, whether then or in later years. They are never very far from my mind, and I must pay tribute to them today.

Equally, I recognise the resilience, courage and decency of survivors and families, particularly those I saw suffer so much following the Grenfell Tower fire. In their continued drive for justice and a safer built environment for everyone, they provide me with a lesson in dignity, resolve and clear purpose every time I meet them. I hope I might give them a voice in your Lordships’ House too.

It is in that context that I understand my privilege and responsibility in the House, as what gets said and done here and in the other place can, for better or worse, have the most profound consequences for our fellow citizens. With that in mind, I hope I can contribute with some value, give voice to those I met on the way and avoid adding, in the powerful words of Bishop James Jones following the horror of the Hillsborough disaster, to

“‘the patronising disposition of unaccountable power”.

I thank noble Lords again so much for their warm welcome and this incredible opportunity.

Lord Stevenson of Balmacara (Lab)

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My Lords, it is a real pleasure to follow my noble friend Lord Roe of West Wickham, and to congratulate him not only on his excellent maiden speech but on the wealth of experience and expertise that he brings to our House. I look forward to a lot more—but I will not be meeting him in a boxing ring.

If you read a quick resumé of my noble friend Lord Roe’s career—university. Sandhurst, distinguished military service, Commissioner of the London Fire Brigade—you might be astonished, as I was, to realise how much he has achieved in so little time; he is really quite young. Although he is too modest to have gone into the detail, we can all guess what two tours in Northern Ireland, where he was wounded, must have involved. We should also note, as he said, that he rose through all the ranks in the London Fire Brigade, including being incident commander for the Grenfell Tower fire, before being appointed London Fire Commissioner.

I am sure I speak for the whole House in joining my noble friend Lord Roe in paying tribute to the heroism of his fellow soldiers and firefighters. I welcome his determination to give voice to those he met during his uniformed service. We are delighted to welcome our first ex-firefighter to the Lords; I am sure I also speak for all in saying that we look forward to hearing his future contributions, and indeed those of my noble friend Lord Duvall, when he comes to speak.

Turning to the Bill before us, it is good to have confirmed that its aim is to address issues created by the current approach to allocating places on the foundation programme and medical specialty training in the UK. However, while the Bill deals with process, it does not deal with the content of courses. While I get the importance of having medical staff trained within the NHS, should the 10-year health plan of which it is part not also have an engagement with the curriculum content?

To give an example of what I mean, I ask my noble friend Lady Merron: how do His Majesty’s Government intend to implement the Council of Europe Committee of Ministers’ recent recommendation on equal rights for intersex persons? I declare an interest as a person born with hypospadias, which is an intersex condition. Implementing this recommendation could require significant changes in the academic training of our doctors and surgeons, which surely need to be monitored. For example, it includes: prohibiting non-consensual medical interventions on intersex children, ensuring such procedures are postponed until the individual can provide informed consent; strengthening anti-discrimination measures and ensuring access to justice, including protection from hate speech and crime; addressing inequalities in healthcare, education, employment and sports, including the need for inclusive policies and safe environments for children; ensuring that family laws, including those relating to legal recognition and parentage, are accessible to intersex people without discrimination; and calling on member states to take concrete legal and non-legal measures to uphold the dignity and rights of intersex people.

Some of these recommendations have already been legislated for in the UK, most notably the law against female genital mutilation. But the recommendation is seen by many people as a landmark, as it shifts the focus from medicalising what are often seen as disorders towards protecting fundamental human rights and ensuring equal participation of intersex people in society. It seems important that these things are fed into the medical curriculum, and I look forward to hearing the Minister’s response to that.

I appreciate that this is a complex issue and that this Bill may not be the most appropriate place to introduce such changes but, when she comes to respond, I hope my noble friend will recognise that my underlying point is about how the content of the courses provided within the foundation programme and medical specialty training in the UK can take account of policy initiatives of this type. I would of course be happy to meet with her to discuss how best to take the issue forward.

Lord Patel (CB)

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My Lords, when there is such a short Bill, there is a temptation to repeat what has already been said in great detail, because it has not been said by me. I will not succumb to that temptation but will briefly point out the areas where I agree with what has been said, particularly by the noble Earl, Lord Howe, the noble Lord, Lord Clement-Jones, and the noble Baroness, Lady Finlay.

In the many letters and emails—hundreds of them—that I have received, two things stood out. One was the grievance felt by people who were already in the process of applying for the jobs; they now feel as if they have been thrown to the wolves. The other lot were the people who are British citizens who trained overseas and cannot now access training in our programmes. There is one other minority group: those who felt that they have had some experience in the NHS, but it is not as yet defined how much of their experience, starting in 2027, will be counted. The noble Lord, Lord Clement-Jones, referred to the immigration requirements which may or may not be counted, but that produces another. These are the groups that feel disadvantaged. What I felt on receiving these letters was that we are making people who have serviced our NHS for decades feel they are no longer required and are to be abandoned. I hope we do not give that impression.

Having said that, I recognise that, in principle, the idea that UK medical graduates should be prioritised for jobs in our NHS is correct, because it is not right that they cannot get the jobs they apply for, particularly in foundation and specialist training. On the foundation programme in Clause 1, I am concerned that British citizens who may have trained in GMC-approved institutions with the same kind of curriculum described by the noble Lord, Lord Clement-Jones, cannot be considered for that. I have already made the point about specialist training programmes and those who have gone through the process of applying in good faith. We do not as yet know what experience will be counted from 2027 onwards, so I hope the Minister can comment on that.

Clause 4 refers to a “UK medical graduate”, and says:

“‘UK medical graduate’ means a person who holds a primary United Kingdom qualification”.


It does not say a “UK citizen” who is qualified. Does that mean that an overseas student attending medical courses in our universities, who is therefore a graduate of our universities, qualifies or not? I might be wrong in my interpretation. The clause continues:

“but does not include a person”

with

“a majority of their … training for that qualification outside the British Islands”.

Some of our universities run joint courses. I am a professor emeritus of the University of Dundee, which, for instance, runs one course for Malaysian students. They do part of their training in Malaysia and finish their clinical training in the UK, at Dundee. The Bill refers to a majority of their training but, in a five-year course, if the overseas student does three years in a UK university, does that count as a majority of their training in the United Kingdom?

I am glad that the Minister alluded to refugee status and was pleased to hear what she said. That was to be one of my points, because I have had representation from Ukrainian refugees who are already working in the NHS, and whose status would otherwise have been removed.

Clause 4(5) says:

“‘primary medical qualification’ means a qualification that is treated by the General Medical Council as equivalent to a primary United Kingdom qualification within the meaning of the Medical Act”.

There are lots of institutions which the GMC recognises as equivalent, but we do not regard their graduates as UK graduates, although they do the same curriculum. Universities such as Newcastle have already been mentioned several times. They have been encouraged by the education department to open campuses, as other universities have been, and to provide the same curriculum. There are then graduates of Queen Mary University, Newcastle University or Dundee University. Their status is not quite clear.

I am concerned about these issues and hope that we will be able to have greater clarification. But I accept that, in principle, prioritising postgraduate medical training for UK graduates is correct.

Lord Stevens of Birmingham (CB)

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My Lords, I declare an interest as an honorary fellow of the Royal College of Physicians and the Royal College of General Practitioners, and as chair of the council of King’s College London, which is Europe’s largest educator of health professionals. I too congratulate the noble Lord, Lord Roe, on his excellent maiden speech. Given the deteriorating physical fabric of the Palace of Westminster, it is reassuring to know that we have a firefighter in our midst.

I start by endorsing the thrust of the policy set out in the Bill. It clearly makes sense for the NHS and for British taxpayers to properly connect undergraduate medical education with access to specialist training, and then the flow-through of doctors able to contribute over the balance of their careers to the work of the NHS. All that makes total sense. Nevertheless, I echo three of the concerns we have heard already in the brilliant contributions to this debate.

The first is about the difficulties and concerns around the transition year, 2026, that the Bill proposes. For 2027 and beyond, rightly, there is the suggestion in the Bill that applications will be prioritised from doctors with NHS experience, who have made a contribution to the NHS. But because of not being able to get the computer system right, that is excluded for the 2026 transitional period.

As we heard from, I think, the noble Lord, Lord Clement-Jones, there is a range of views that suggest that that is not a correct assessment. I think the impact assessment says it is £100,000 to sort out the Oriel computer system—against a £4.3 billion taxpayer expenditure in this area. This is an area where the Minister and the Minister in the Commons, Karin Smyth, might want to give officialdom a little tap and just double-check that what they are being told is right, not least because there is a degree of oddity about this in that the Government declared their intention to introduce this new prioritisation for UK graduates seven months ago. It was in the 10-year NHS plan published on 3 July. It is not completely clear why there has been a seven-month lapse before we get this emergency Bill that has to be passed within four weeks.

There is the transitional 2026 concern and then, relatedly, there is the question of whether, by just changing the prioritisation, the Government actually have a game plan to deal with the more fundamental, underlying problem of the bottlenecks. This piece of legislation by itself does not widen the bottlenecks, it just changes who will occupy them. As the noble Earl, Lord Howe, I think, asked, it would be very useful to know, of the 1,000 additional specialty training places over three years promised in the 10-year plan, or the 4,000 put on the table in December as part of the Government’s negotiation with the BMA—of which 1,000 extra were to be in place for the coming year—what is their current assumption about the expansion in specialty training that will go alongside this reprioritisation for 2026 and 2027?

Today, we have seen the publication of the cancer plan, which, quite rightly, says that the Government

“will work with the Royal Colleges to encourage resident doctors and internal medicine trainees to specialise in clinical and medical oncology”—

where there are significant shortages—and will prioritise

“training places in trusts … where vacancy rates are higher and performance is lower”.

Can the Minister tell us whether the Government will give effect to that commitment in the cancer plan with the 2026 and 2027 increases in specialty training places, which are clearly required?

To circle back to a point that the Minister made—and, indeed, the Health and Social Care Secretary made at Second Reading in the Commons on 27 January—the Government’s estimate appears to be that even with this tighter, or reshaped, prioritisation, there will still be a ratio of two applicants to every place for specialty training. Just stand back a moment—that means we will be turning away half the doctors who would be able to fill those places. Are the Government sure that they are going pedal to the metal on the expansion in specialty training to reduce that oversubscription rate?

How does that connect with the upcoming rebadged, or refreshed, long-term workforce plan, given that the undergraduate doctors who start their training this year will be, in practice, coming out to deliver clinical care as consultants from 2040 and training their successors up to 2070? We really do need a long-term plan here, rather than the constant chopping and changing that, sadly, we have seen.

Finally, I completely endorse the comments about Malta. Three collective institutions have been awarded the George Cross—Malta and the NHS are two of them. We should sustain those relationships. The idea that we have less in common with the Maltese than with the good people of Liechtenstein—I have just had a quick look and Liechtenstein has one 35-bed hospital and a per capita GDP more than three times that of the UK—misses the point. We have to see the wood for the trees; the Department of Health and Social Care needs to raise its gaze and value these historic relationships that are so important for us.

Baroness Coffey (Con)

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My Lords, I start by welcoming the noble Lord, Lord Roe, to the House. I am sure that his experience will be informative in many ways, including now as chair of the building safety regulator. I am sure his insight will be very valuable to the R&R committee in a variety of ways. At some point I would love to have a conversation with him about his experience, including not having retained firefighters in London and what more we could do to try to get every firefighter across this country to potentially become a first responder; again, making sure that the blue-light services work together.

Turning to the Bill, I think there are a number of issues in it. By and large, I support the principle, but in terms of prioritisation, my sense is that it does not really prioritise, certainly not by making sure that UK students get priority ahead of other people in the different priority groups. Discussion has been had about Switzerland, Liechtenstein and Iceland; I assume there is some historic international treaty. It is clear in the way that the Government have brought this legislation forward that there is no such agreement or treaty when it comes to Malta, but I am more sympathetic to the Government on this issue than perhaps some other people on these Benches are.

This may seem unimportant, but this was rushed through in a day in the Commons by the right honourable Wes Streeting. Normally this sort of legislation is genuinely for emergencies, very specific situations, so it beggars belief that the Government seem to be using this as leverage with the BMA on strikes. Indeed, the Secretary of State mentioned this. When he was asked whether this was so urgent—and it will please students who are members of the BMA—he stated:

“It is important that the Bill is workable. A number of factors may well interrupt our ability … One of those factors is the ongoing risk of industrial action”.—[Official Report, Commons, 27/1/26; col. 805.]


I am not sure that that is a valid reason for the Bill not to be commenced immediately, and it would certainly reduce the uncertainty for some of the other situations, including the 2026 application.

I just wanted to check my understanding on something. I am not suggesting that the department is cooking the books in any way, but the impact statement provides analysis that does not help us to get into the core detail. I would be grateful if the Minister would consider releasing more raw data. I ask that because we lump all our international medical graduates into one category in this analysis, and the Bill is asking us to have more categories of IMGs.

The noble Lord, Lord Patel, was accurate in his understanding. I think there has been quite a lot of debate in the Commons, given that the UK Government have paid a lot of money—I think we heard it was about £4 billion a year on the clinical elements. I assume that is a combination of the NHS tuition fee bursary and other elements provided to medical schools. International students do not get that bursary. At the moment, it seems that by paying the £40,000 to £50,000 a year for being trained in a UK degree at a UK medical school, international students could well get priority. Within UK medical graduates, or indeed persons in the priority group which we just referred to, there is no actual prioritisation for UK students—by that, I mean UK nationals.

I think it is fair about the relationship with the Republic of Ireland; that is a historic relationship, and I do not object to that. But in the specialty training programmes, Clause 2(2)(e) covers, basically, people from the European Union and I am trying to understand why that is necessary. We just keep coming back to the fact that none of this is really prioritising UK students in UK medical schools. I would be grateful if the Minister could set out how the Government intend to prioritise all the different categories. Is it the intention that the prioritisation will start with (a), then (b), then (c) and then (d)? It would be useful to understand that.

At the moment, the Bill would allow people under paragraph (d)—to be set out in regulations—to get priority ahead of UK medical graduates. It is unclear, therefore, how this might work.

I appreciate that what happened with visas has been cited as part of the problem. There is another way, however, in that the Government could adjust the skilled worker visa to address some of these issues. Have they considered that? I would be grateful if the Minister would write to me and the House. Generally speaking, though, I intend to support this Bill.

Baroness Hollins (CB)

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I add my congratulations to the noble Lord, Lord Roe, on an excellent maiden speech.

I welcome the Minister’s explanation of the Bill’s priorities, which I broadly support, but I have some concerns about the possible unintended impact on the UK’s medical training reputation, especially given recent investments in international recruitment. While some predict that artificial intelligence may reduce demand for doctors, I believe that medicine remains fundamentally human, and current shortages make such predictions rather unconvincing. The NHS continues to face consultant-level vacancies and low morale among doctors. I agree with the noble Earl, Lord Howe, about the need for a significant increase in training placements.

Competition for medical jobs is long-standing. Certainly when I qualified—a long time ago now—there was no guarantee of specialty training at all. There was an assumption that the majority of graduates would proceed into general practice. But a shortage of specialty training placements now prevents both domestic and international graduates from progressing. This situation is made worse by poor workforce planning over many years, despite well-forecast numbers of medical students. It is this systemic issue that needs urgent attention. There are some key questions, such as whether this Bill is the best solution, whose investment in training is at risk, and how affected students and doctors will be notified and understand the impact for themselves. Many correspondents have shared their anxiety about the Bill’s career impact for them.

I will not repeat the arguments made by the noble Lord, Lord Clement-Jones, regarding the Queen Mary’s students in Malta. Similar arguments apply to students at City St George’s Cyprus campus, who follow the UK curriculum, meet GMC standards and are awarded UK-recognised qualifications yet will be deprioritised simply for studying overseas. They have taken identical exams and have committed significant time and money based on assurances that they could compete for UK foundation programme posts. Changing eligibility rules just as they graduate is unfair; it undermines confidence in our system and risks leaving qualified graduates without posts, damaging both the NHS and, of course, the reputation of City St George’s.

As an emeritus professor at City St George’s, University of London, I asked the dean for more information about the contracts that City St George’s has with students in Cyprus. Paragraph 3.4 of its contract says:

“On successful completion of the Programme, SGUL shall grant to the Student an award certificate to which he or she is entitled under the provisions of SGUL Policies and Regulations and will provide the Student’s name to the GMC in accordance with GMC requirements to enable students to be registered with the GMC as having a Primary Medical Qualification”.


This means that graduates were able to apply for the foundation programme and be considered equally alongside students who had studied in the UK. The issue of any visas required by graduates, of course, is outside the contract, as work permits for the UK sit under UK Immigration Rules. The question is whether there will be any legal risks. If a legal challenge was successful, presumably it would be financial, and presumably it would be the Government who would be accountable. I am not sure that the university could be held accountable for a breach of contract if the breach is the result of a change in law.

I also urge that consideration be given to whether those studying in overseas campuses might be included in the priority group, or at least to phasing in the changes prospectively for the sake of those already in training. Excluding such students devalues these important collaborations. I would be interested in the Minister’s response on whether there could be some valid legal challenges.

Fair workforce planning seems to be essential. Without adjustments, the Bill threatens morale and may drive talented doctors away. I have been thinking about proposing an amendment to ensure that graduates with UK medical degrees are prioritised for foundation programme entry, regardless of study location, which would seem to be fairer. One final point is that, for these overseas campuses, the numbers are actually quite small.

Lord Duvall (Lab) (Maiden Speech)

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My Lords, like my noble friend Lord Roe, it is an honour and a privilege to make my maiden speech today. Just over three weeks have passed since my introduction to this House. I have a sense of awe and pride at the history of this House but also the knowledge of how I have encountered Members from all sides of the House.

I would like to extend my thanks to the doorkeepers, the housekeepers and the catering staff, along with Garter, Black Rod and the Clerk of the Parliaments. I would like also to thank my introducers, my noble friend Lord Harris and my noble and learned friend Lord Falconer, who are former colleagues and valued friends with whom I have worked over many years. My thanks go to the Leader of the House, of course, and to the Chief Whip for the support and wise advice that they have given me.

I am also thankful for the way that I have been welcomed and received by noble Lords, again from all sides of the House. I have worked with many noble Lords in my time in local and regional politics, and it is a pleasure to be working with so many of you again for the benefit not just of London but of the country.

I want to take a moment to thank my partner, Jackie Smith. I am not referring to Jacqui Smith, my noble friend Lady Smith—I do not want to set any hares running. My Jackie Smith hails from Bermondsey, south London; perhaps I should not have mentioned, but a number of us have south London connections. I owe a lot to my Jackie. She has her own political career and her own achievements. She has been a councillor in her own right, and she has achieved many great things locally for the council and for the people that she serves. She supported me unfailingly over many years, and when I underwent a double bypass, she and the NHS carried me through it. There were difficulties, and, quite honestly, I would not be here today without her. In every sense, I am a better man because of her.

My journey—and it is a journey that I have been on before coming to this House—would not have been possible without the opportunities created for me by others: in education; in employment; and in the Labour Party and my trade union NUPE, now Unison. It also rests on the enduring influence of my mum and dad, who are not here to share this moment today.

I was made in Woolwich. The place has always been my home. Woolwich is full of history at every level, from its deep military traditions to its social legacy of the Royal Arsenal Co-operative Society and the polytechnics that opened the way for part-time learning and women returners into education. I am proud of my Anglo-Indian roots, proud of my mixed heritage and proud to be part of our nation of countries and nations. I am in Woolwich partly because of the Royal Artillery; I share that with my noble friend Lord Roe. My dad and both my grandfathers were gunners, and their service greatly impacted on my life. I am, by choice, the Mayor of London’s Armed Forces champion, and I will continue to advocate for our service men and women, veterans and their families in this Chamber if I can.

What most people do not know about my life is that I had ill health as a child. I spent 10 years in a special school. I left school at 16 and went straight into the world of work. My first role was working in a youth centre with young people. I was young myself; it takes me a while to think about that. I then became a trainee, what we would call an apprenticeship trainee, in local government, which gave me a solid grounding in public services.

I was also active in the trade union movement, representing and advocating for colleagues. I served as a shop steward and later I became a branch secretary. More importantly, I took advantage of the training opportunities that the trade union movement, and my employer, offered me. I remain grateful for that to this day.

I am also proud that I have had some opportunities to do international work. I have been involved, through the Commonwealth Local Government Forum and with colleagues in the Council of Europe, in promoting best practice within local government in regional chambers.

Closer to home, I am proud that I led Greenwich council and that I have spent the past 25 years at the London Assembly, taking on both scrutiny and many executive responsibilities. It is a real privilege to be in public life and serve people, and it is a privilege I never take lightly. I have spent my political life responding to and promoting change. You have to pre-empt, prepare and shape change, not be carried by it. It is interesting in the context of the debate that we are having tonight. Our country faces that change now, and the work which this Government are undertaking, the policies we scrutinise in this House and the way we do it define how the country embraces that change.

The Bill before us is about changing how medical training posts are allocated in the UK, ensuring that those trained here are first in line for NHS training programmes. It says something about the economic challenges our young people face today that those graduating from medical schools after five years of university study are often struggling and waiting to secure their first roles in medical training posts.

The Bill will help us develop the next generation of healthcare professionals. Internationally trained doctors will continue to make a huge contribution to our NHS. Nobody will be excluded from applying. There are some issues around the detail, which the Minister will want to respond to, but it will help us ensure that young people who have spent their early lives working incredibly hard in our schools and universities can fulfil their dreams. It will give them certainty as to where their hospital posting will be, and it will help maintain an NHS workforce that can continue to provide world-leading, life-saving care. I see this as giving an opportunity, in the same way that others have created opportunities for me throughout my life. Thank you.

Baroness Thornton (Lab)

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My Lords, it is wonderful to follow the great maiden speech of my noble friend Lord Duvall—Len, to the rest of us—and I am proud to welcome another Labour and Co-op member to your Lordships’ House.

Len and I were trying to remember how long we had known each other. It is certainly since the mid-1980s, when I was the political secretary of that venerable institution, the Royal Arsenal Co-operative Society, based in Woolwich, and young Len, as he said, was born and grew up in Woolwich with close connections to the Royal Arsenal; his father and grandfather served as gunners in the Royal Artillery, and he was a local member.

It was clear to me that this young activist was clearly going places, and indeed he did. He was elected to Greenwich council in 1990 and became its leader in 1992, standing down when he became a London Assembly member. Remarkably, my noble friend—although he did not say this—has held his seat of Greenwich and Lewisham for the last seven GLA elections and is the only member of the GLA to serve since it was founded in 2000. During that time, he has held many positions, including chair of the Metropolitan Police Authority.

But the measure of a person is not just the positions they hold; it is what they do and achieve. I think we can safely say that my noble friend has served his Greenwich community and London magnificently over the years, with the regeneration of the Thames Gateway, the Greenwich waterfront, campaigning and getting investment in local communities, and much more. I understand that my noble friend has been and will continue to be chair of the Labour group in the GLA and, close to my heart, he also has an unmatched record of support for equality and human rights.

Finally, I think it is likely that my noble friend and I are the only Members of your Lordships’ House who have both been chairs of the Greater London Labour Party. I became chair in 1986 and served for several years, and my noble friend became chair in 2002. I think it is safe to say that we both bear the honour and the scars of that position. I welcome my noble friend to our Benches and I know we have much to look forward to in his contributions.

I thank the Minister for her introduction to the Bill, and the noble Lord, Lord Roe, for his wonderful maiden speech. In the debate, I had a sense of déjà vu because, as I look around the Chamber, I see that many of us have been here before. I was in a different position at that time, but it gave me a great deal of pleasure to look round and listen, even to the noble Earl, Lord Howe, opposite whom I have been for about 20 years in various forms, discussing health.

It does not seem so long ago that, during the course of what became the Health and Care Act 2022 which established ICBs, many of us across the House were begging the then Secretary of State to include a commitment in the Act to have a workforce strategy, to no avail. However, as the noble Earl said, the work- force strategy then appeared in 2023.

It seems to me that a key moment in 2026 will be the publication of the new long-term workforce plan for the NHS. The plan, due this spring, will be the first for our Labour Government and is expected to set out how the workforce will be developed to underpin the 10-year health plan. It has of course been built on earlier workforce strategy work and will set out how staffing needs can be matched to the future model of care.

As the Minister said in her opening remarks, delivering that plan depends on our staffing. Therefore, improving NHS staff recruitment and retention will be central to delivering this plan. This small and important Bill should be seen in that wider context. It addresses an immediate problem and offers an immediate solution with its main functions, which have been outlined to us: for medical foundation training, the prioritisation of graduates of UK medical schools; for medical specialty training posts starting in 2026, prioritisation at offer stage of graduates of UK and Republic of Ireland medical schools; and for medical specialty training posts starting in 2027 onwards, prioritisation at interview and offer stage of graduates of UK medical schools.

I am aware that many of us have received letters about this from students who feel sometimes aggrieved and, certainly, concerned—particularly students from Malta, and I know the noble Baroness, Lady Gerada, will be addressing this, as others have. There are three things that have been identified, as outlined by the noble Lord, Lord Patel, and other noble Lords.

We will need to address, and solve, in the Bill whether or not we are ensuring fairness as the Bill progresses. I have two nephews who have qualified in recent years—one in Liverpool, one in London—and I recall from both of them the uncertainty they faced about where they might end up. It seems to me that, if we are increasing the number of places available, we must ensure that it is done in a way that addresses regional issues and regional needs. I ask the Minister to confirm that that is one of the things that will be taken account of as this progresses.

This Bill is welcome, and I welcome the rapidity with which we have responded to this issue. We can be sure that the House will resolve the issues facing us—fairness, our overseas graduates and all the others that have been outlined—because there is good will to take the Bill through the House. I think that means that it will fare well.

Baroness Gerada (CB)

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My Lords, I also congratulate the noble Lords, Lord Roe and Lord Duvall, on entering this House. As a newbie myself—I have been here only about six weeks—I know that it is an enormous privilege, as well as incredibly hard work.

The principle at the heart of this Bill is the right one: UK-trained medical graduates should be properly prioritised for the foundation programme and subsequent specialist training. No one can dispute that it is wrong that UK graduates, educated at a cost of billions to the taxpayer, are forced to compete with overseas students, pushing many doctors abroad and depleting the talent pool that should be powering the NHS. I am grateful to the Minister for engaging with me over the last few days both personally and in meetings.

However, I have some serious concerns. The first, as has been alluded to, relates to Malta. As the only Member of this House to have Maltese heritage— I thank the noble Lord, Lord Stevens, for reminding me that I have two George Crosses, one from having Maltese nationality and the other from working in the NHS—this is especially important to me. Like many noble Lords, I have received letters and concerns, but I have also received representation from all quarters in the UK and in Malta about the impact of the Bill on Malta, including from its Minister for Health and Active Ageing. He wrote a letter to our government health team where he said:

“Whilst acknowledging the supreme interest of ‘home-grown’ graduates, this development raises serious concerns for this Ministry and the people of Malta. Aside from risking to undermine two centuries of proud tradition and the dissolution of a strong bilateral relationship in healthcare, this strategy puts the training and specialisation of Maltese graduates in jeopardy”.


This matters because Malta has a long, deep and historic relationship with the United Kingdom, and not just in medicine, although I will stick to that. For nearly 200 years, since the first Maltese doctor received their licence to practise from the Royal College of Surgeons, British and Maltese medicine have grown side by side: the same language, the same exams and, for many years, the same training programme. This is why it has been possible for doctors such as my father, who came to this country in 1963, to dedicate their professional lives to the service of the NHS. This is a small group of doctors but they have had an enormous impact—tonight I should have been at a conference celebrating the power and impact that Maltese doctors have had—from revolutionary surgery treatment for Parkinson’s to revolutionary, innovative treatments for cancer.

Nowadays, each year around 50 doctors complete their specialty training in the NHS, under a special arrangement in which the Maltese Government cover 70% of their salary, with a contractual agreement that these doctors return to Malta. It is a so-called finishing school; they come here to do parts of the training that they cannot get in Malta, such as for sickle cell in haematology. It is a win-win. The NHS gets talented, skilled doctors, often working in hard-to-fill non-training grade posts, at very little cost to it.

This Maltese-UK relationship has been strengthened in recent years, as we have heard, with the establishment in Malta of a UK-based medical school, Queen Mary University of London. This is a multi-million pound initiative of QMUL and the Maltese Government. Since 2009, QMUL has delivered an integrated training programme, awarding an MBBS degree that is academically and regulatorily identical to the UK London programme. These are not rich kids buying a medical degree; they are hard-working students, among the top performers across the MBBS exam. The diversity of the campus in Malta mirrors that of the UK: 80% are from Black and minority-ethnic groups, 20% are disabled and 65% are women. Their training is aligned to NHS principles and practice. Nearly 80% of them do part of their training in a UK NHS hospital. Of course they understand the NHS—nearly 70% of these students are British nationals or have indefinite leave to remain in the UK. Deprioritising these doctors risks abandoning a small, committed cohort without a fallback, simply because they choose to fund their own training. This seems unfair.

I will briefly move to another area where I have serious concerns. This legislation will disadvantage many international graduates already in training who have spent thousands of pounds in good faith and were encouraged to come to this country to train. I have received representation from the British Association of Physicians of Indian Origin, which is seriously concerned about this. These international medical graduates have been disadvantaged since the start of the NHS; they have been subject to racism, bullying, disproportionate complaints and punishment, and failure to progress in their career. They now risk losing employment, their visa status and everything they have worked for. This seems unfair, especially given the assurance by the UK Foundation Programme that the same preference informed allocation method used in 2024 and 2025 would be used for 2026. Should there not be transitional arrangements for these doctors, who have relied on public assurances?

As is often said, if one intervenes in a complex system, there is no guarantee that outcomes will be achieved but there is a guarantee of unintended consequences. I look forward to engaging with the Minister further and hope we can redress some of these issues.

Lord Mohammed of Tinsley (LD)

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My Lords, I thank noble Lords across the Chamber for their contributions, and in particular the noble Lords, Lord Roe and Lord Duvall, for their fantastic maiden speeches. I look forward to working alongside both noble Lords in taking forward this and other Bills. I was particularly interested to hear about the journey that the noble Lord, Lord Duvall, took here; I also worked with young people in a youth centre, and I have military history on both my mum’s side and my dad’s side of the family, spanning the First World War and the Second World War—although I confess that my mum’s uncle was not really sure where he was when he came to Europe to fight in the First World War.

I start by acknowledging, as my noble friend Lord Clement-Jones did, that I support the broad objectives of this legislation. As we have heard from other noble Lords, it is entirely reasonable for the United Kingdom to seek to ensure that our investment in medical education strengthens the NHS workforce and benefits patients here at home. Prioritising those who have trained and worked within our NHS is a legitimate aim. However, the way that principle is delivered matters greatly.

My first concern relates to the breadth of ministerial discretion in the Bill. It has not been covered by others, but it is really important. As drafted, the Bill will allow future changes on prioritisation to be made with limited parliamentary oversight. Decisions about who is prioritised for medical training places are not just technical adjustments; they shape careers, determine workforce supply and directly affect patients. Such decisions should therefore be subject to proper scrutiny and democratic accountability. This House has a principal responsibility to ensure that powers of this significance are exercised transparently and proportionately.

Many noble Lords have raised concerns about the timing of the Bill. As it makes its way through the legislative process, final-year students have seen their foundation training allocations paused. Thousands of graduates now face waiting until the last minute to discover where they will be working later this summer, potentially having to move across the country, as we have heard, with little notice. That uncertainty is deeply unsettling for graduates at the very start of their careers.

As we have heard from many noble Lords, including the noble Earl, Lord Howe, and the noble Lord, Lord Patel, the intention to introduce new prioritisation rules part way through the 2026 specialty training cycle also risks causing real harm. More broadly, we must be clear-eyed about the workforce challenges and what this Bill can and cannot deliver. On its own, it will not resolve the problem, which is the critical shortage of training places, as we heard earlier. The noble Lord, Lord Stevens of Birmingham, talked about it as the bottleneck. Without a significant expansion in this, there is a real risk of this being only a partial fix. Indeed, in many respects, this feels like closing the stable door after the horse has bolted.

In recent years, the number of domestic undergraduate medical school places has expanded, while at the same time the GMC has registered a large number of overseas graduates. Staff-grade jobs that were difficult to fill even five years ago are now inundated with applications, and the appetite among NHS employers to actively recruit candidates overseas has already disappeared. All of this sits against the background of a highly restrictive government cap on the number of medical and dental students that UK universities are permitted to train—caps to which international partners are not subject. Because of these constraints, medical schools have developed partnerships with overseas institutions and Governments to help cover the increasing cost of teaching UK students. Therefore, I ask the Government to reflect carefully on any unintended reputational damage the Bill may cause to UK’s medical education sector and to those international relationships, as we heard from the noble Baroness, Lady Hollins, and others.

Malta has been mentioned, but I will not mention it further. My noble friend Lord Clement-Jones and the noble Baroness, Lady Gerada, both made that point forcefully.

I want to mention the emails that we have had from Newcastle, but there are also other universities out there that have partnership arrangements with Malaysia in particular, and I just want to talk about Nottingham and Southampton. I know that, in the past, the university that I attended, the University of Sheffield, also had that working relationship where the first two years of the medical degree were done in Malaysia and then the students came across here.

I am also concerned about the wider workforce consequences and shortages not confined to one area of medicine. Radiology has been mentioned, but mental health services and other specialties are already under intense strain, with evidence that professional bodies are linking workforce gaps directly to potential patient safety concerns, particularly in the cancer care area. Any reforms of training prioritisation must therefore be accompanied by a clear and ongoing assessment of their impact across specialties.

At the same time, the Government are hastily implementing the Leng review without adequate consultation, which risks placing additional long-term pressures on resident doctors during their postgraduate training through an unanticipated reduction in the number of medical associate professionals supporting doctors in their clinical workloads.

Finally, I wish to raise a fundamental question about the Government’s chosen mechanism for prioritisation. The Bill places significant weight on immigration status, as we have heard from other noble Lords, particularly indefinite leave to remain. I struggle to understand why this is the most appropriate or effective measure. The NHS, as we have heard, already has a robust system in place through the Oriel recruitment platform, which records where doctors have trained, how long they have worked in the NHS and their progression through the system. That data speaks directly to commitment, experience and contribution to our health service.

Prioritising doctors on the basis of time worked in the NHS, clinical excellence and demonstrable service to patients would seem far more closely aligned to the Bill’s stated purpose than relying on immigration status, which, as we heard, with the recent changes potentially coming through as well, is shaped by factors beyond an individual’s control. Therefore, I urge the Government to explain why they have chosen this route and whether they have fully considered the unintended consequences for recruitment, retention and morale within the medical workforce.

The Bill seeks to address real challenges and its objectives are worthy. I just want to pick up on the point that the noble Baroness, Lady Coffey, raised about the grouping of applicants from around the world in just one group. It is only right and proper that, if we are scrutinising the Bill, we see data that I am sure the NHS holds about the origin of some of those students. To succeed, the Bill has to be fair and transparent and firmly rooted in the realities of the NHS workforce. Above all, it must sit alongside a serious commitment to expand training and capacity. I hope that the Government will reflect carefully on the issues that we have raised in your Lordships’ Chamber tonight as the Bill progresses through the House.

The Earl of Effingham (Con)

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My Lords, I thank all noble Lords who have made such valuable contributions to this debate. I greatly enjoyed hearing the maiden speech of the noble Lord, Lord Roe of West Wickham. He mentioned ham, egg and chips, and I can assure him that he will enjoy himself very much in your Lordships’ House, but it is the staff in this House who are amazing. I know they are going to look after him as well. They do an incredible job, and they are part of the package; they will do everything they can to make his experience an enjoyable one. He mentioned that he had served over half his life in the fire brigade, which is an incredible achievement, as well as his Army service. I think when he referenced boxing, it was incredibly appropriate, because fitness, discipline and mutual respect will greatly assist him in making a real difference in your Lordships’ House, and we are really looking forward to hearing his future contributions.

I must say the same for the noble Lord, Lord Duvall. It was most interesting to hear his background. The noble Lord is obviously an expert in local and regional politics. He was made in Woolwich. He then went on to lead Greenwich council, and I think the noble Baroness, Lady Thornton, was entirely correct when she said, back in the 1980s, that Len was going places. I think it is a huge testament to the NHS that the noble Lord, Lord Duvall, has had a double bypass and he is standing before us, fighting fit. He is going to enjoy constructively challenging His Majesty’s Government —and, I am sure, His Majesty’s loyal Opposition—and we are very much looking forward to hearing his contributions as well.

As many noble Lords have put it so well, there is a great deal to think about in this Bill, and there are a number of areas where His Majesty’s loyal Opposition and other noble Lords will wish to press the Government further. The Bill is intended to address a situation that is universally recognised as both serious and unsustainable, and precisely because there is such broad agreement on the problem, it is all the more important that your Lordships’ House scrutinises the Bill with a laser focus to ensure that the final proposals will be hallmarked as best market practice.

The interventions thus far have already highlighted the value of that scrutiny, with noble Lords identifying a number of areas that would benefit from further consideration. The noble Baroness, Lady Finlay—who is, of course, widely respected in this area of legislation—the noble Baroness, Lady Gerada, and the noble Lord, Lord Mohammed of Tinsley, all spoke about unintended consequences. In attempting to solve the problem, there may always be unintended consequences. Our desire is to stress-test the potential outcomes to resolve that the end result is indeed beneficial for those who need the help and does not formulate a situation where more harm is done than good.

The noble Baroness, Lady Coffey, referenced the fact that this is a pressing issue and time sensitive, but that is no excuse for poorly drafted legislation, which may have serious ramifications for both questions of fairness and trusted relationships with our international allies.

His Majesty’s loyal Opposition support the core principle and intended purpose of the Bill but are clear that there are areas that would benefit from constructive challenge and a moulded consensus as we progress. We have had the opportunity today to discuss some of the practical effects that the Bill will create. Certain groups will, for a variety of reasons, fall outside the mainstream. The noble Lord, Lord Clement-Jones, said that the situation Malta was a “manifest absurdity”. The noble Baroness, Lady Finlay, rightly recognised that routes for overseas doctors to train here have multiple ancillary benefits. The noble Lord, Lord Patel, likened this situation to being “thrown to the wolves”. So those studying on accredited programmes as part of agreements with third countries, and British citizens who have done the majority of their training abroad for legitimate reasons such as military service, are two examples where we need further scrutiny.

In light of the potential unintended consequences of the Bill, where Parliament has had a limited opportunity for detailed analysis both in your Lordships’ House and particularly in the other place, it is vital that it contains robust mechanisms for review and accountability. Clear duties to review and report on the operational and “lived experiences” impact of this legislation will provide a pivotal safeguard, ensuring that Parliament retains a meaningful and proactive role in holding the Government to account as this framework is implemented. This would seem an entirely proportionate and sensible approach, allowing the Bill to work effectively while minimising potential unforced errors. We are confident that noble Lords will be keen to embed such provisions in the Bill.

Workplace confidence and consistency were mentioned. The noble Lord, Lord Clement-Jones, said that the execution is “flawed”, and the noble Baroness, Lady Hollins, said that there is a great risk of undermining confidence. So we must address the question of confidence among individuals for whom this legislation contains far-reaching consequences and whom it directly affects. Doctors make long-term, often irreversible, decisions about their training, specialisation and careers. Those decisions are shaped not only by pay or conditions but by their confidence that the system is fair, predictable and stable. They need to know what the rules of engagement are and that their career paths will be, within reason, clear, coherent and consistently applied.

No one likes uncertainty and, whether for government, business or relationships, everyone needs stability. Doctors are no different. Knowing that the goalposts will not shift unexpectedly part way through training is a must-have. Where legislation is rushed or where its effects are uncertain, that very confidence can be undermined. Even reforms that are well intentioned can have negative knock-on consequences if doctors feel that eligibility criteria are opaque, that established pathways may suddenly be reclassified or that decisions affecting their future are taken without sufficient forethought or scrutiny.

That matters because confidence and morale are central to retention in every aspect of life. If talented doctors harbour doubts that the system they are held to may not treat them fairly, or doubts about whether their own significant investment in training, as mentioned by many noble Lords, will be recognised, they may choose to take their skill set elsewhere—not because they lack commitment to our National Health Service but because they lack confidence in the framework governing their progression. A lack of confidence in any system will lead to pitfalls.

This is precisely why the detail of the Bill matters so much. Getting it right is not simply a technical or procedural exercise; it goes right to the heart of whether doctors feel valued, supported and willing to commit their careers to the National Health Service. An open and transparent workflow of prioritisation will only strengthen confidence. A rushed or overly rigid one risks doing the opposite.

Many former Members of the other place would suggest that helping health and social care in some small way is critical because it provides a unique opportunity to do the right thing through debate and constructive challenge, which should result and positive outcomes for everyone living in the United Kingdom. Our National Health Service, while not perfect—indeed, nothing is—remains based on the founding principle of providing universal care that is free at the point of use, and our doctors are at the heart of that premise.

This Bill aims to make provision about the prioritisation of graduates from medical schools in the United Kingdom, and His Majesty’s loyal Opposition look forward to working constructively with the Government and all noble Lords in facilitating that desired outcome.

Baroness Merron (Lab)

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My Lords, I am most grateful to all noble Lords who contributed to this debate for the support given, including just now by the noble Earl, Lord Effingham, to working with us, because I think there is general recognition that we have a problem that needs to be dealt with. I am very glad, as I said at the outset, to have been the Minister at the Dispatch Box when my noble friends Lord Duvall and Lord Roe made their moving maiden speeches. They both have many years of distinction in public service, and I know that that will continue as they bring their own unique experiences and views on the world to your Lordships’ House, which will be much enriched by their presence.

A strong and consistent theme has come through today’s debate: a shared concern for the well-being of NHS staff, recognition of the importance of workforce planning and the need for a sustainable health service. I am grateful for the thoughtful questions, and I will endeavour to answer as many as possible—I have already referred to some in my opening remarks. I will of course review the debate, as always, and I will be pleased to write to noble Lords on those matters I was not able to get to.

This legislation is about giving future generations of doctors trained in the UK a clearer and more secure pathway into NHS careers. It is about sustainable workforce planning and, as the noble Earl, Lord Howe, referred to, about fairness—to those who train here, to taxpayers who fund that training and to patients. As many noble Lords acknowledged, significant public investment goes into medical education every year, so it is right that we ask ourselves how that investment can be best aligned to what we need.

I have listened closely to the concerns raised today, particularly about the Bill’s impact on those who will not be prioritised. To reiterate, the way I look at this is that the Bill is about prioritisation, not exclusion. I assure your Lordships’ House that all eligible applicants will still be able to apply, and they will be offered places if vacancies remain after prioritised applicants have received theirs. We absolutely expect that to be the case; that is our experience. To be more specific, there are likely to be opportunities in specialties such as general practice, core psychiatry and internal medicine, which historically attract fewer applicants than the groups we are prioritising for 2026. We still need those people.

The noble Baroness, Lady Hollins, asked about possible unintended consequences for the UK’s international reputation. I believe our proud history of welcoming colleagues from across the world will continue and, as I have just said, international colleagues can, of course, continue to apply after prioritisation has taken place and there are vacancies.

On new specialty training posts, we have committed to creating 1,000 of these new posts over the next three years, focusing on specialties where there is greatest need. This is on top of creating 250 additional GP training places each year. The noble Earl, Lord Howe, raised questions about the availability of training places. Expansion will be matched with training capacity. We have not yet confirmed which specialties will receive the new posts, but we will ensure that expansion is targeted where patient demand and workforce pressures are the most acute.

I am glad that the noble Lord, Lord Stevens, made reference to the cancer plan. It was a bright spot in today’s news—I am sure all noble Lords will understand —and has not had the airtime it ought to have had, so I am most grateful to him. What I can tell the noble Lord about the creation of new specialty training posts is that there will be a focus on those with greatest need. We will set out steps in due course and I look forward to keeping the noble Lord informed. Non-prioritised graduates will also continue to have routes into NHS careers through locally employed doctor roles, gaining experience that can support future progression and prioritisation.

Let me turn to some of the specific points that were raised by noble Lords. The noble Lord, Lord Patel, asked about British citizens who have graduated from medical schools outside the UK and will not be in the priority group. I understand why these concerns are being raised but, going back to the core of the Bill, to prioritise them would undermine our aim to build UK-trained capacity while ensuring we do not provide any more foundation programme places than we need. To reiterate, UK-trained doctors are more likely to work in the NHS for longer, and retention is an issue that is much discussed in your Lordships’ House. They will be better equipped to deliver tailored healthcare that suits the UK’s population because of what they understand. Reference was made to the provision extending also to the Republic of Ireland graduates. Their inclusion ensures consistency in workforce planning across both jurisdictions, which reflects the long-standing protocol rights for movement and employment. That was something in which the noble Lord, Lord Clement-Jones, was particularly interested.

On specialty training places starting in 2026, British citizens will be prioritised, because that is one of the prioritised immigration statuses being used as a proxy to indicate someone who is likely to have significant experience of the NHS. Why? Because applications for posts starting in 2026 have already been made. Prioritisation is only at offer stage because shortlisting is under way, so it is a timing matter about implementation. From 2027, immigration status will no longer automatically determine priority, but we have the ability to set out in regulations the persons who will be prioritised based on criteria which indicate they are likely to have significant NHS experience, or based on their immigration status. As I said earlier, we will be engaging with our partners to work out how best to define that.

On the point made by a number of noble Lords, including the noble Earl, Lord Howe, and the noble Lords, Lord Clement-Jones and Lord Stevens, about graduates of overseas campuses, including Malta, which I will turn to presently, having heard the noble Baroness, Lady Gerada, the UK foundation programme applications for 2026 show that there are almost 300 applicants from these overseas campuses, of whom 152 are UK nationals. This is a substantial number and, if we were to do what is being asked—to prioritise graduates of UK overseas campuses—our estimation is that this could encourage universities to establish further international partnerships which would simply increase pressure still further. It also risks creating a loophole that would encourage new overseas partnerships to seek preferential access to the foundation programme across the UK. The noble Lord, Lord Clement-Jones, picked out Liechtenstein in particular, but, as the noble Baroness, Lady Coffey, referred to, we are talking about the EFTA countries, which include Liechtenstein, and they are prioritised simply because of existing international agreements that we are obliged to honour. However, in practice, not all these countries are going to have eligible applicants.

Lord Clement-Jones (LD)

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I hope the Minister does not mind. Does the Minister think that the agreement with Malta should be honoured as well?

Baroness Merron (Lab)

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I am coming on to this, but the agreement in respect of Malta that I would refer to is a reciprocal health agreement. It does not apply in this area. It is about the reciprocal provision of healthcare. I will turn to Malta, however, after saying a brief word about overseas campuses generally.

Just to re-emphasise, overseas campus students are not part of the numbers that the Government are setting. We do not have that control. If we prioritised those graduates as well, that would eat away at the very core of the Bill and the things people actually want us to do.

The noble Baroness, Lady Finlay, and the noble Lord, Lord Clement-Jones, wanted an indication of how this would all align with the international education strategy. The Bill does not conflict with this, because the international education strategy supports universities expanding internationally. It does not prevent UK universities delivering medical degrees overseas. That strategy stays in place.

I turn to Malta for the noble Baroness, Lady Gerada—

Baroness Hollins (CB)

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Can I just a question? The Minister has suggested that these students could come and work in non-training posts. But the problem, as I understand it—do correct me if I am wrong—is that, for example, St George’s students must complete their foundation year in the UK to be eligible to apply for full registration. Therefore, it means that they cannot complete their medical education without being eligible to apply for the foundation training. While a different contract could potentially be negotiated for future students at an overseas campus, the current students who have this contract and expectation in place need to have that honoured. I do not feel that the Minister has responded to the concerns that have been raised eloquently around the House.

Baroness Merron (Lab)

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As I said at the outset, I will endeavour to answer all questions, but where I do not have an answer, particularly where I want to look at them in closer detail, I will be very pleased to write, of course, as always.

Still turning to Malta—which is a pleasure—let me say straight away that we do have a long-standing partnership with Malta on healthcare. It is valued and it will continue. Doctors who are training in Malta will still come to the UK, as they do now, to gain NHS experience to support their training, for example through fellowship schemes. This is not affected by the Bill.

As I discussed with the noble Baroness just yesterday, senior officials in my department have met with the High Commissioner of Malta to the United Kingdom in order to assure him of this. But it is important to prioritise in order to ensure a sustainable workforce that meets its health needs. Again, that is at the core of the Bill. Malta has its own foundation school. This is not part of the UK foundation programme: it is affiliated with the UK foundation programme office which administers the UK programme. That means—this point has been made to me—the Malta Foundation School delivers the same curriculum and offers the same education and training as the UK foundation programme. The Bill will not impact this affiliation or the other ways in which work carries on closely with the Government of Malta when it comes to health.

The noble Earl, Lord Howe, also made the point that he believed small numbers of students were impacted. I have referred to the 300 applicants from overseas campuses. I hope it is understood that that is why there is a significance there.

If there are other matters that I have not addressed to the satisfaction of the noble Baroness, Lady Gerada, I will be very pleased to review this, because I suspect there were some more points to address. I will be very pleased to write to her to give her comfort in this regard.

I move on now to the impact on doctors who were part way through the application process—a point spoken to by noble Lords, Lord Patel, Lord Mohammed, Lord Clement-Jones, and other noble Lords. As I stated earlier, delaying implementation of the Bill until next year, which would be required if we were to respond as requested, would mean another full year where we are not tackling the issue of bottlenecks in medical training. It seemed to me that the feeling in the House was that we did need to do that.

I understand the discomfort of noble Lords around this. It is important that I recognise that, but it is also important to recognise when introducing legislation that sometimes it will not work perfectly for everybody. This is about prioritisation, not about exclusion.

Following that point, the noble Lord, Lord Stevens, the noble Baroness, Lady Coffey, and the noble Earl, Lord Effingham, asked about emergency legislation. They asked: why now? As the Health Secretary set out in the other place, he has listened to resident doctors and their concerns about a system that does not work for them. He agreed to bring forward that emergency legislation as quickly as possible, rather than wait—this is key for a number of the points raised—another year to do so.

The noble Earl, Lord Howe, and the noble Baroness, Lady Coffey, asked about the Bill’s commencement and why it will not commence at Royal Assent—that is a very fair question. We are introducing reforms for a large-scale recruitment process. I know that noble Lords will understand what a major undertaking this is. We do not want to create errors or more uncertainty. To make sure that it is effective in commencement, we must have clear processes for delivery across the health system, and I am sure that all noble Lords appreciate that these elements cannot be switched on overnight. As the Secretary of State said in the other place, there is a material consideration about whether it is even possible to proceed if the strikes are ongoing. He is concerned—I share this concern, as I am sure all noble Lords do—about the disruption that strikes cause and the pressure they put on resources, which would make it so much harder operationally to deliver the measures in the Bill.

Lord Mohammed of Tinsley (LD)

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I will press the point I made earlier about uncertainty. Not having a commencement date creates a lot of uncertainty for the current batch of students, who are really worried about whether they will they gain a place and, more importantly, where. I want to impress this issue on the Minister; it was raised by the Russell group medical school admissions head with me personally.

Baroness Merron (Lab)

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I completely understand the point about uncertainty. Uncertainty exists in the current system, and uncertainty may transfer for different reasons. We are keen to get on with this. I am just indicating some of the circumstances—strike action—that would cause difficulty for us in terms of commencement. I hope we can proceed. I think the noble Lord will understand exactly what I am saying.

The noble Baroness, Lady Coffey, asked about the release of more granular detail. I draw noble Lords’ attention to the fact that NHS England already publishes a wide range of recruitment data, including data on country of qualification and nationality groups. It will publish further granular data when possible and monitor the implementation of the Bill, should it pass—that, for me, is the most important point. If the noble Baroness is referring to other information, she is very welcome to raise that with me.

I am of course very happy to meet with my noble friend Lord Stevenson. In general, the 10-year health plan commits to working with professional regulators and educational institutions over the next three years to overhaul education and training curricula.

To answer the question from the noble Baroness, Lady Coffey, on prioritisation, if I can put it in my language: you either are or are not prioritised. There are no tiers of priorities within priorities; it is as it is written in the Bill.

The noble Lord, Lord Mohammed, asked about the impact of prioritisation on harder-to-fill specialties. This approach will not negatively impact recruitment. In fact, it will ensure that priority groups are considered first, while keeping the door open for when we need people. I think it will help get people into the areas in which we need them, because it will direct people to where we do not have sufficient applicants.

At its heart, the Bill is about the UK-trained medical graduates on whom the NHS heavily relies. We are grateful for their skill, commitment and professionalism. It is our responsibility to ensure they are trained, supported and treated well at work. This is a more sustainable and considered approach to the allocation of medical training places. A number of noble Lords said that this is a problem that has been around for years. We are grasping the proverbial nettle. The Bill is a measured step towards the goals of clarity, fairness and opportunity. It will not, on its own, resolve everything—I am fully aware of that—but it will help us with a pressing problem. With that, I beg to move.

Lord Patel (CB)

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My Lords, my name is also attached to Amendments 3, 6, 7, 8, 12, 13 and 14, which are consequential, so I will not speak to them. This may be the briefest of introductions to any amendment.

My amendment tries to prioritise—which is the main theme of the Bill—UK medical graduates for training in UK programmes. The Bill’s Long Title says it is to:

“Make provision about the prioritisation of graduates from medical schools in the United Kingdom and certain other persons for places on medical training programmes”.


In Clause 1, this therefore also includes

“persons in the priority group”.

In Clause 2, it includes person not only in the priority group but also, in subsection (2), persons who are

“a British citizen … a Commonwealth citizen who has the right of abode in the United Kingdom … an Irish citizen who does not require leave to enter or remain in the United Kingdom … a person with indefinite leave to enter or remain … a person who has leave to enter or remain in the United Kingdom”

and so on. Similarly, Clauses 3 and 4 describe the priority group as including not only UK medical school graduates but many others, including those from countries with which the UK has made a trade deal.

All those priority groups will be able to apply for the same jobs as UK medical graduates. Add to that—several amendments on this are coming later—that the graduates of UK universities that have overseas campuses will also be included in the priority group. They are not all in the amendments today, but if these amendments are accepted, there are other universities not listed which have overseas campuses, such as the two I know—Dundee, for instance—although I did not table an amendment on that.

My amendment is because of the enormous number of emails that we have had, both from UK graduates and overseas graduates who cannot find jobs. I know there are subsequent amendments coming later about those international graduates who are now stuck in a bottleneck for this year, but that is a separate issue. My amendment does not refer to that; it refers to UK medical graduates.

We heard a story on the BBC about Emma, who was one of the 1,000 graduates who cannot get a two-year foundation slot so she cannot progress at all. She cannot find a locum job because they are all full. We heard of people who cannot enter the specialty training programme at years 1 and 2 because the competition for the specialty training programme is four applications for one job. We have 50,000 international medical graduates applying for a job for 2025, for 10,000 slots. If we cannot get UK graduates to find jobs in training programmes, that is scandalous. We could cut the number of medical students—but on the other hand, we are going to increase the number of medical students, and that will compound the issue for future applications for training.

By the way, I am not saying that others in the priority group in these clauses are not to be considered for a job. All I am saying is that UK medical graduates should be prioritised. The definition says “UK medical graduates”, but there are international students who go to our medical schools and therefore they are UK medical school graduates, so we include them. They are about 7% of the total medical graduates of UK universities. My amendment only seeks to prioritise UK medical graduates, who should be considered first—not that the others will not be considered or get jobs in whatever they come to do. This includes the subsequent amendments about overseas campuses and other universities.

I hope that the Opposition Benches will agree that UK medical graduates ought to be the first priority. I doubt that the noble Baroness the Minister will accept my amendment—the Government want this Bill to go through as an emergency Bill and not to be held up because, otherwise, it will run out of time—but I hope that, at the Dispatch Box, while not accepting the amendment, she will recognise that UK medical graduates must have priority above others for training slots. I beg to move.

Baroness Coffey (Con)

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My Lords, I have tabled Amendment 2. The clerks suggested changing the wording to what is now there. It is a probing amendment, and like those of the noble Lord, Lord Patel, it could be applied to other clauses as well. It is about the principle. My strong view is that we have opened up medical schools and made more placements because we want to make sure that we have an ongoing workforce. I am delighted to see the noble Lord, Lord Darzi, in his place. He will have done work not only for Health Secretary Wes Streeting recently but previously in making sure that we have a strong workforce pipeline.

I am conscious that many medical schools, by way of survival, by way of diversity, have opened up a number of places. Admittedly, this is still quite small compared with the number of UK citizens going to medical school. However, as the noble Lord, Lord Patel, said, we have a curious definition in this legislation—that a UK medical graduate is simply somebody who went to a UK medical school. I do not think that is what the public would think that this is about. From a lot of the emails, I do not think that it is what a lot of doctors appreciate either—although I appreciate that it is the position of the BMA, which does not want to differentiate in that regard.

We have young people taking on debt by investing in their own education and several billion pounds being put in by the UK Government, by the UK taxpayer, to have this pipeline. Therefore, it is vital to have what my amendment seeks—a set prioritisation in this legislation and not, as the Minister said the other day, a “just one group and then no more” kind of prioritisation. It is vital that UK citizens are given priority.

It is important to look at some of the analysis. It is not the case that all training posts could be filled by UK citizens who have trained to be doctors—far from it. We would not have GPs coming through. According to the 2024 analysis, only about half of the GPs going on the ST1 or CT1 were from UK medical schools. There is a whole series of issues, and we are seeing this in different elements including psychiatry and paediatrics—very few UK medical students, it seems, want to do paediatrics. I could go on with the series, but the point is clear: this is not about excluding people from the rest of the world coming to work in this country or to fill key roles in the NHS; it is about ensuring that our investment is prioritised on UK citizens.

There is a certain peculiarity, which will come up in other groups, about what then happens with the Republic of Ireland and similar. I am not seeking to get into that debate; perhaps we will a bit later.

I want to get a sense of this from the Minister. One thing that is clear in the statistics, and which the Minister and the Department of Health should be seeking to understand more, is that for quite a wide range of the training courses UK students are turning down the opportunity, once they have been offered placements. Why is that? For general practice, I think that only 57% are accepting. I am conscious that people might get posted around the country, but that needs careful scrutiny as well.

I do not wish to suggest in any way that we are not welcoming people from different parts of the world, but it should go back to trying to make sure that we are addressing particular gaps in our NHS workforce, now and in the future, not squeezing people out, and recognising the work that has been done to increase the potential numbers in home-grown talent.

Those of us who spoke at Second Reading have, in the last week, had a lot of emails coming in. I completely understand that there are different stories. For a brief time, when I was Health Secretary, a by-line suggested that I thought everybody should disappear to Australia—far from it. We cannot stop people leaving this country to go to Australia or elsewhere in the world, but we should be making sure that the reason they are choosing to go elsewhere is not because they cannot get a training place here when they have been deemed appointable. Ideally, they would be offered a role. That is something we can fix with this legislation. I hope the Government will rethink their approach to this during the passage of the Bill.

I apologise to the Committee that I will not be here to deal with my amendment later on, but I know that the Front Bench will do so. The time is pressing to get this right. I had not realised quite how soon a variety of decisions need to be made: I believe they need to be made before, or certainly within a few days of, Easter. It is critical that the Government think again. I am sure that, with encouragement from the Committee and from very distinguished medical practitioners, current and past, they will do so. That is why I commend my amendment to the Committee.

Lord Jackson of Peterborough (Con)

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My Lords, I am delighted to have the opportunity to support my noble friend in her excellent amendment. Broadly speaking, this is a very welcome Bill. I congratulate the Government on bringing it forward to address what is becoming an acute issue, but it could be better. My remarks fall into two separate parts: there is the philosophical issue and there are the practical, evidence-based matters, which I will elucidate in the course of my remarks.

First, it has to be said that British taxpayers fund medical education through universities and the NHS, and we should be thinking much more about the value for money that those taxpayers receive. Prioritising British citizens would ensure that the investment benefits the domestic healthcare system and would, I think, reduce the risk of brain drain, where trained doctors emigrate after completing training. Training costs are substantial—estimated at £200,000 to £500,000 per doctor—and British citizens would be more likely to remain and practise in the UK long term. There is a case that they perhaps provide better value for public investment in medical education.

The wider philosophical issue, as alluded to by the Nuffield Trust, is around the fact that, in recruiting international medical graduates, the NHS has a negative impact on the domestic healthcare sector and staffing shortages in many countries abroad, particularly in Africa and Asia and poorer countries generally. That point has been made over many years. There were issues too about cultural familiarity, language proficiency, better understanding of local healthcare practices and patient expectations, and easier integration into multidisciplinary medical teams.

Specialty training, competition ratios and bottlenecks have reached breaking point. Preliminary information for the 2025 specialty training application cycle is concerning. This year, there are over 33,000 applicants for just under 13,000 training posts. This means that up to 20,000 doctors will be left out of specialty training this August. Even if you are not directly affected, that is a public health and public policy issue.

Lord Mohammed of Tinsley (LD)

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My Lords, I want to speak briefly to the amendments proposed by the noble Lord, Lord Patel, and the noble Baroness, Lady Coffey. The noble Lord, Lord Patel, mentioned that 7% of undergraduates who take medical degrees in the UK are from overseas. I briefly mentioned last week my conversations with the head of admissions at a Russell group medical school. An important point that I did not have time to raise then, but is appropriate to raise now, is the significant amount of money that that 7% contribute not only to that medical school but in additional payments to the local trust.

I wanted to make your Lordships’ House aware of that, but I also want the Minister to talk about the consequences if we accepted the amendment of the noble Baroness, Lady Coffey, and just had British citizens as opposed to the British graduates the noble Lord Patel talked about. What impact would there be? We have held our tuition fees static for a while in this country, while those overseas students have been paying a phenomenal amount. I am just worried that we might throw the baby out with the bath water. The unintended consequence of making some of those courses unviable is a serious concern, and I think it appropriate to raise it at this point.

Lord Winston (Lab)

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My Lords, I too am a little bit concerned about unintended consequences. It is a real pleasure to see my noble friend Lord Darzi in his place, because I hope he will have comments on this issue.

I trained as a clinical academic. Indeed, we know that clinical academics have had a unique value to the health service. They work part-time in the health service with a reduced salary and do research at the same time. I am very concerned that many of the clinical academics we have had at Imperial College, for example, have been from overseas. They were medically qualified elsewhere but had not yet been in Britain and were still junior doctors, in a sense. I am really concerned that there are many such people who come to Britain, do a postdoctoral degree such as a PhD and, in the meantime, keep their medical skills flowing, as I did myself. I was seven years in this situation with the Wellcome Trust. I remember it very well. I was overseas but at least knew that I could come back to Britain. But I was a British subject—that was easy.

There are so many of these people. To give just one example, Professor Jan Brosens at Warwick University is undoubtedly one of the key people who have contributed massively to female health, particularly on implantation of the ovum and in his magnificent work on endometriosis. He came as a junior doctor from Belgium, from Leuven University, to what was then Hammersmith Hospital, which is now, of course, Imperial College. Now, he is a very distinguished professor at Warwick University with a very large team. His recruitment made a very big difference to the whole field. His is not an isolated example; there are many such people I can think of. I hope the noble Baroness can suggest some way of dealing with this problem of unusually good graduates from elsewhere, who may not be British citizens, perhaps, in the current priorities, but who would really be deserving of serious consideration for certain specialty jobs. Not to do that would be a great loss to the health service.

Lord Darzi of Denham (Non-Afl)

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My Lords, many of you will know that I did my medical training in Ireland. In fact, I exercised some of my skills in this Chamber back in 2007. Irish medical education is excellent, and many of its graduates have gone on to distinguished careers in the NHS. I speak today to ensure we strike the right balance in this Bill, specifically by securing fair treatment for doctors who hold degrees approved by the Irish Medical Council.

As drafted, the Bill would exclude graduates of the Royal College of Surgeons in Ireland at its medical campus in Bahrain, for example—a campus that was established more than 20 years ago. Let me be clear about what that institution delivers: it has the same curriculum, the same examinations and the same quality assurance as Dublin, leading to a single national University of Ireland degree. Its programme and clinical training sites are also accredited under Irish regulatory oversight by the Irish Medical Council. I urge that, on Report, wording be introduced to bring graduates of this institution within the priority group. Such a clarification would sit squarely alongside the amendments from the noble Baroness, Lady Gerada, and the noble Lords, Lord Clement-Jones and Lord Mendelsohn. These seek to ensure that medical graduates of a UK university holding a GMC-approved degree and following the same curriculum and assessment, but studying outside the British Isles, are included in the priority group. It would also be consistent with the similar amendment tabled by the noble Lords, Lord Forbes and Lord Shipley, and the noble Baronesses, Lady Finlay and Lady Hollins.

I draw a further anomaly to your Lordships’ attention. The unamended Bill would place graduates of the Royal College of Surgeons in Ireland’s campus in Penang, Malaysia—a joint programme with University College Dublin—within this priority group. These students study an Irish Medical Council-accredited, GMC-recognised degree, completing half their education in Ireland and half in Malaysia. Yet the well-intentioned clarifying amendment of the noble Baroness, Lady Finlay, requiring at least 60% of the time to be spent in Ireland, would inadvertently exclude them.

Lord Clement-Jones (LD)

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My Lords, it has been many years since I last spoke in a health debate. There is a sense of déjà vu in seeing the noble Earl, Lord Howe, on the Opposition Front Bench. It is also an absolute pleasure to hear from the noble Lord, Lord Darzi, and to hear the arguments he has made, which are very consistent with those we will be making later in the group of amendments from the noble Baroness, Lady Gerada.

I rise to speak to the amendments in this group, but particularly to Amendment 2, in the name of the noble Baroness, Lady Coffey, and the amendments tabled by the noble Lord, Lord Patel. On Amendment 2, while I understand the intent of the noble Baroness to protect the domestic workforce, we on these Benches cannot support the introduction of citizenship as a primary filter for medical training priority. To do so would undermine the central logic of this Bill, which is to protect the taxpayers’ investment in training, not to police the passport of the trainee. If a non-UK citizen comes to this country, trains in our medical school for five years, often paying significant international fees—my noble friend made an extremely good point about the value of that to our universities—they cross-subsidise our universities and then commit to the NHS. They are a UK medical graduate in every sense that matters to workforce planning. Their training is identical; their clinical exposure is identical. We on these Benches believe that to deprioritise them, based purely on nationality, would send a disastrous signal to the global talent pool that our NHS has always relied upon. It would also contradict the argument we will make later regarding the amendments from the noble Baroness, Lady Gerada, on the Queen Mary University of London Malta Campus: that it is the content and quality of the qualification that matters, not the geography or the nationality.

Regarding the amendments in the name of the noble Lord, Lord Patel, I sympathise with his desire to ensure that UK graduates are prioritised. That is, after all, the purpose of the Bill, and while we can argue about the definition of a UK graduate, we must be careful not to make the legislation so rigid that it removes any flexibility for the Secretary of State to address shortages in specific specialties, or where international talent is essential. Several noble Lords have mentioned that we have all received correspondence from doctors in hard-to-fill areas who warn that absolute exclusion could leave rotas empty. Prioritisation must not constitute a blockade.

Earl Howe (Con)

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My Lords, the noble Lord, Lord Patel, deserves our thanks for opening our Committee debate in a cogent and powerful way. He is absolutely right: in this country, we train some of the very best doctors in the world—at great expense to them and to the taxpayer—but too many are choosing to leave the training process because in the now expanded competitive scrum they cannot access the training places they require. Each year many remain unemployed. That is a serious policy challenge, and Ministers are right to seek to address it. We need a long-term and fair solution.

The noble Lord, Lord Patel, is seeking to ensure that UK medical graduates are prioritised for training places first before those in the priority group are offered places. There would then be a third tier of prioritisation for any other eligible applicants. This would put UK medical graduates, as defined by Clause 4, ahead in the queue for training places. I do not think we can fault the noble Lord for his logic. If we believe there is currently a massive and disproportionate injustice being meted out to UK medical graduates, we owe them the best chance we can give them to enter further training pathways in this country.

However, I have two questions for the Minister. First, the Explanatory Notes confirm that those who have trained in Ireland, Iceland, Liechtenstein and Norway have been included in the priority group because

“existing agreements require us to recognise their qualifications and offer parity in access to the profession”.

Can the Minister please confirm whether the reordering of prioritisation, as proposed by the noble Lord, Lord Patel, would cut across the existing agreements that the UK Government are bound by?

Secondly, I think many of us agree that emergency legislation should be avoided as far as possible, but where it is necessary, it should be simple and straightforward. On the face of it, the amendments from the noble Lord, Lord Patel, would make the Bill a bit more complicated by adding a further tier of prioritisation. If that is so, I am sure he would argue that the extra complexity is well worth it. It would be helpful if the Minister could tell us whether such an additional tier of prioritisation would make the process more complex to manage.

Amendment 2 in the name of my noble friend Lady Coffey would prioritise UK medical graduates who are British citizens first, then those persons in the priority group and then UK medical graduates who are not British citizens. The category of other eligible applicants is not included. Perhaps it is an inadvertent omission; I do not know. Again, this would create a three-tier prioritisation process, where the Government are currently proposing two tiers, with the added dimension of drawing a distinction between different categories of UK medical graduates. Like the noble Lord, Lord Clement-Jones, I am uncomfortable with that as a matter of policy. On the face of it, the amendment presents a more complex set of arrangements than those proposed by the noble Lord, Lord Patel, so it would be helpful to hear from the Minister how the Government view my noble friend’s suggestions, including their ready workability.

The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)

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My Lords, I am most grateful to all noble Lords for their helpful contributions to this debate. Amendments 1, 3, 6 to 8 and 12 to 14, tabled by the noble Lord, Lord Patel, seek to create tiered categories of prioritisation for the UK foundation programme and specialty programmes. Taken together, they would require places to be allocated to UK medical graduates in the first instance, and then to applicants in the other prioritised categories specified in the Bill. As noble Lords have observed, the Bill sets clear priority groups, but it does not make rankings within these groups, and that is what we are looking at.

I welcome my noble friend Lord Darzi, not least because the review that he undertook for the Government in 2024 recommended that we should prioritise medical training, for all the reasons given by the noble Lords who support it. I will return to this whole area when we debate a later group, but on the point made by the noble Lord, Lord Darzi—this will perhaps also be helpful to the noble Earl, Lord Howe—alongside UK graduates, we are prioritising in the Bill graduates from Ireland and the EFTA countries. This reflects the special nature of our relationship with Ireland—specifically, our reciprocal rights of movement and employment—and our obligations under international trade agreements with the EFTA countries, which the noble Earl, Lord Howe, referred to, that require consistent treatment of these graduates in access to medical training. The amendments that we are looking at would mean that we could not honour these agreements. That, by its nature and definition, would create huge difficulties.

On specialty training, these amendments would also mean that we could not effectively deliver on our policy intention to prioritise applicants with significant NHS experience who understand how the health service works and how to meet the needs of the UK population. It might be helpful if I summarise this by saying that the Bill sets out what I would regard as a binary system where applicants are either prioritised or not. Clearly, once that prioritisation has happened, the normal processes will apply to establish who the appointable applicants are, to fill the posts, and so on.

Amendment 2, tabled by the noble Baroness, Lady Coffey, seeks to create tiered categories of prioritisation for the UK foundation programme and to prioritise UK medical graduates who are British citizens above all other applicants. The Bill as drafted prioritises all UK medical graduates who meet the criteria, regardless of their citizenship status. It might be helpful to the noble Lords, Lord Mohammed and Lord Clement-Jones, to restate that what matters is where a doctor is trained, not where they are born. UK-trained medical graduates have undertaken curricula, clinical placements and assessment standards aligned to the NHS, and are therefore best prepared to move directly into NHS practice.

The Government are committed to prioritising those doctors who have already spent a significant part of their education within the NHS and understand how the health service works and how to meet the needs of the UK population, not least because—this is an issue that we have discussed many times—these doctors are more likely to remain in the NHS for longer, supporting the sustainable medical workforce for the future that we are all looking at.

As I set out in relation to the previous set of amendments tabled by the noble Lord, Lord Patel, this amendment would also mean that we would not be honouring the special nature of our relationship with Ireland and obligations under trade agreements with EFTA countries. I emphasise again in the Chamber today that prioritisation does not mean exclusion. All eligible applicants will still be able to apply and will be offered places if vacancies remain after prioritised applicants have received offers, which we expect to be the case particularly in certain areas.

My noble friend Lord Winston raised a question about the Bill in respect of highly skilled overseas doctors and particularly referenced clinical academics. As I have said, it is not exclusion from applying—it is prioritisation. It may be helpful more broadly for me to emphasise that there are likely to be opportunities in specialties such as general practice, core psychiatry and internal medicine, because historically they attract fewer applicants from the groups that we are prioritising for 2026. I understand the point that my noble friend is making, but we have to focus on the core purpose of the Bill. With that, I hope that noble Lords will feel able not to press their amendments.

Lord Patel (CB)

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Obviously, the Minister is not accepting my amendment, but she makes the point that all the priority groups will be treated in the same way—whatever the definition is of people in the priority group, they will all be grouped together as a priority, and that would include UK medical graduates. What assessment have the Government made of the effect that it will have on UK medical school graduates to include all the others in the priority group? What disadvantage will that put UK medical graduates to? Will it be minimal, medium or a lot?

Baroness Merron (Lab)

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We do not anticipate that that is going to cause a problem. The noble Lord did not specifically refer to the EFTA countries, but I should like to. Some of them will not produce any suitable people who are likely to be included, so in our modelling we do not anticipate that there will be a problem. What matters is patient care and getting people with the right training who understand what the NHS is about, understand the culture of the NHS and provide as best as they can. That is what the whole Bill is directed at doing and prioritising.

Lord Jackson of Peterborough (Con)

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I accept that the Minister is not predisposed to accept the amendment from my noble friend Lady Coffey, and she has made a clear case for that, but is she in a position to reassure the House that the issues raised by my noble friend and others about the relative take-up of specialty training places in less popular disciplines, such as anaesthetics or paediatrics, will be looked at by the department? I did not get the opportunity to make this point, but one point was that prioritising British medical students—not excluding others—would have a positive impact on those particularly hard-to-fill disciplines. Is the department taking that into account generally in its workforce planning?

Baroness Merron (Lab)

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Yes, we are.

Lord Mohammed of Tinsley (LD)

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Can I ask about applications from overseas? I know from the paperwork that has been shared online that everybody has been grouped together as the rest of the world. With the applications that we have had this time and last year, it might be helpful to share the data of the breakdown by each country rather than just lumping it all together as the rest of the world. Then we could see how many applications there are from the nations that we have an international agreement with.

Baroness Merron (Lab)

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I shall be very pleased to do that.

Lord Patel (CB)

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My Lords, I thank all noble Lords who have spoken today, no matter which amendment they spoke to, and I am grateful to the noble Earl, Lord Howe, for his strong support for my amendment. More importantly, he said that UK medical graduates need to be prioritised and should not have to enter into competition with others whose graduation is not from this country. I know that the Minister was not able to say that UK graduates would be seen to be prioritised; I understand that. Of course, these debates help, because the outside world is interested in what is said here. I hope that particularly those who make decisions about interviewing or selecting for interview for training programmes will get the message, take note of this debate and bear in mind what it was all about. I beg leave to withdraw my amendment.

Earl Howe (Con)

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My Lords, I begin by making it clear that this is very much a probing amendment, for reasons which I shall explain. Across all the many representations I have received on the provisions of this Bill—from UK medical graduates; UK citizens studying medicine abroad; non-UK citizens studying abroad; some in the middle of their degree course; some who have finished their degrees, and some who have commenced but not completed a UK foundation programme—there is one issue that rises to the surface. It is an issue that is most easily encapsulated in the phrase “legitimate expectations”.

Quite justifiably, in my view, individuals who have embarked on the long and costly journey that is required of them in order to gain a GMC-approved medical qualification and who have found themselves suddenly deprioritised by one or other provision within this Bill have questioned the fairness of the dividing lines that the Government have chosen to draw in such summary fashion. Medical graduates—many of them British citizens—who have demonstrated both commitment and excellence and who have adhered in good faith to every step of the process laid down under existing rules are now being told that their trust in the system counts for nothing and that, all of a sudden, their legitimate expectations have been overridden.

Noble Lords will note that my amendment relates specifically to the 2026 UK foundation programme. It suggests that a graduate who has already received a written offer of a place on a foundation programme should be able to rely on the validity of that offer. In reality, I understand that, with very few exceptions if any, applicants to the 2026 UK foundation programme have not yet received formal written offers of employment. However, the formal process began last summer. Eligibility applications were completed last July and foundation programme applications in September. Since then, there have been mandatory UKFP-related deadlines, including the national clinical assessment—NCA—in November and PLAB 1 in December. In other words, the process is active, sequential and consequential, notwithstanding as yet the absence of formal written offers.

To take the case of a medical graduate in February 2026 who finds themselves prospectively deprioritised in the way that I have described, in the Government’s view, at what point on that graduate’s journey does the principle of legitimate expectations kick in? How fair is it to say to a talented and high-achieving graduate that, despite their passing through all the existing procedural hoops, they now need to lower their expectations quite dramatically and accept that they are no longer in that part of the queue for a medical qualification which, in good faith, they previously worked to join?

In summary, my amendment is intended to pose a somewhat broader question than its literal wording would suggest. What do the Government have to say to that cohort of soon-to-be deprioritised graduates who have committed time, effort and money to pursuing their goal? Is there any room for movement? I beg to move.

Lord Mohammed of Tinsley (LD)

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My Lords, I speak to the amendments in this group in my name—Amendments 5 and 10—and to Amendments 9, 11, 24 and 25 in the name of the noble Lord, Lord Stevens of Birmingham, which I have also signed.

I follow up the point that the noble Earl, Lord Howe, talked about in terms of the fairness for those people who went into the application process last summer. They started this process with the expectation of getting a confirmation any time now and being able to prepare. That is why my Amendment 5 proposes to postpone the implementation of this speciality training prioritisation for this year’s intake, so that those people who are applying for 2027 know that we are changing the rules, rather than telling those people who applied last summer that we have changed the rules. Let me be clear from the outset: this amendment does not seek to undermine the principle of the objectives of this Bill on medical training; rather, it seeks to ensure that these objectives are implemented fairly, coherently and without unintended harm to the very trainees upon whom our healthcare system depends.

The central issue for us here has always been timing. As the Bill currently stands, these changes would be introduced during an active application cycle. This raises serious concerns about procedural fairness and legitimate expectations. Applicants have made life-altering decisions—academic, financial and personal—based on a set of rules that existed last summer when they applied. To change these rules mid-cycle, in my opinion, is not merely inconvenient but fundamentally unjust. Like many others, I have been contacted by affected medical students who have articulated their concerns around the criteria. They noted that they had complied fully with all the requirements enforced at the time of application, only to find themselves potentially excluded by the change that has now been imposed. Without transitional protections, the Bill would disadvantage applicants who acted in good faith, followed the guidance provided and had every reasonable expectation that the rules would not be rewritten half way through the process. This is not about isolated grievance; it reflects a systematic risk inherent in rushed implementation.

Medicine is a profession that demands long-term planning, with years of study, examination, placement and significant personal sacrifice. When Parliament alters the conditions of progression without adequate notice or transition, it destabilises that planning and erodes trust in the system. My amendment therefore offers a modest but proportionate and sensible solution: a one-year delay that would allow for clarity in communications and proper preparation. It would give institutions time to adjust their process, regulators time to issue clear guidance and applicants time to make informed decisions so that people who will be applying this summer know what the criteria are. Crucially it would also align with the principles of this House, which has long upheld fairness, legal certainty and an avoidance of disadvantage. We should be especially mindful of these principles when legislating in areas that directly affect access to professional training and career progression.

There is also the practical consideration. Disruption of the current application cycle risks creating gaps, appeals and bottlenecks that could ultimately harm workforce planning in the NHS. At a time when staffing pressures are already acute, we should really be wary of reforms that may have unintended consequences and might deter capable candidates. My amendment would not delay the reforms indefinitely, but simply ensure that reforms are done properly. By supporting this amendment, we would send a clear message that, while we are committed to improving medical training pathways, we are equally committed to treating applicants fairly and honouring the rules under which they apply.

We have heard about the immigration status mentioned earlier and the criteria on which that is based. With my Amendment 10, I would like to raise with the Minister the alternative option, given that the Government are also seeking to change the rules around indefinite leave to remain. My understanding is that there is a better option. The NHS has its own recruitment platform, the Oriel system, which is able to demonstrate professional commitment to the NHS. In doing so, it shifts the focus from legal residence status to actual service, contributions and engagement with our health system.

The NHS does not run, as we heard earlier, on immigration categories. It runs on people who turn up to shifts, who trained within its system, who understand its pressures and who have committed themselves to caring for patients day in, day out. The Oriel registration is not just a symbolic tactic; it is a gateway through which NHS recruitment, training and workforce planning operates. It is a clear, objective indicator that an individual is already participating in or seeking to participate in the NHS.

Similarly, the concept of professional commitment to the NHS allows for a broader and fairer assessment of contributions. It recognises work undertaken in the NHS trust, clinical placements, foundation training, research, teaching and other forms of service that directly benefit patients and institutions. This approach reflects reality far more accurately than a single immigration milestone, which may have little bearing on an individual’s clinical engagement or future commitments or intentions.

There is also a serious risk of equality issues at stake. Many doctors who have trained in the UK, worked in NHS hospitals, paid taxes and served our communities for years do not yet hold indefinite leave to remain, due to the structures and lengths of immigration pathways. To divert these such individuals despite their proven service risks sending a deeply damaging message that contribution is secondary to paperwork. At a time when the NHS remains heavily reliant on international medical students, we should be careful not to erect barriers that discourage retention or undermine morale. These clinicians are not temporary stopgaps; they are integral members of our workforce. Many intend to build long-term careers here and many already have.

From a practical standpoint, this amendment also improves administrative clarity. Assessing our registration and documenting NHS experience is straightforward, verifiable and directly relevant to workforce needs. By contrast, tying prioritisation to immigration status risks complexity, inconsistencies and unintended exclusion. If the aim of the Bill is to strengthen medical training and to support the NHS workforce, our criteria must align with that goal. This amendment ensures that prioritisation is based on what truly matters: demonstrated commitment to the NHS and the work that it exists to do. Therefore, I urge noble Lords to support both my amendments.

Lord Stevens of Birmingham (CB)

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My Lords, I repeat my declarations of interest from Second Reading as chair of King’s College London and chair of Cancer Research UK, and as an honorary fellow of the Royal College of Physicians and the Royal College of General Practitioners. I am going to speak to my Amendments 9, 11, 24 and 25. I am most grateful to my co-signatories: the noble Earl, Lord Howe, and the noble Lords, Lord Mohammed of Tinsley and Lord Patel.

The Government, in my opinion rightly, want to prioritise for specialty training doctors who, among other things, have significant prior experience working in the NHS. They propose in the Bill that that would be an explicit criterion to be taken into account from 2027. So the principle is clear. The practice for 2026, however, is said in the impact assessment to be such that they cannot use that criterion for the current cycle. So, instead, a series of proxies are proposed which, in the words of the impact assessment, would

“capture applicants who we believe are most likely to have NHS experience”.

This set of amendments, which should be an easy pill for the Government to swallow, would simply give them the ability to apply in 2026 the same criterion relative to work experience in the NHS that they propose from 2027 onwards. I recognise that there may still be some discussions, as we just heard from the noble Lord, Lord Mohammed of Tinsley, about the executability of that criterion, using the Oriel system or other mechanisms. These amendments would not require the Government to bring forward their 2027 approach but simply permit them to do so if, in the weeks between now and 5 March, for example, if that is the deadline for when Royal Assent is required, it becomes clear to them that the modest enabling work on the computer software, estimated at £100,000, can be put in place if that were needed.

Lord Patel (CB)

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My Lords, I support the amendments in the name of the noble Lord, Lord Stevens of Birmingham, to which I have added my name. I am not going to repeat much of what he said, but I support it because when, in 2026, both the UK and overseas graduates are further down the process of applying—and some have even been asked to come for interview—they will now not be able to continue. That seems morally and ethically wrong, so I support the amendments. I also support the amendment in the name of the noble Earl, Lord Howe. He made his points very strongly.

Baroness Finlay of Llandaff (CB)

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My Lords, I declare my role as a pro-chancellor of Cardiff University, and that I have until recently been an observer on the Medical Schools Council; I am still in touch with it.

This group of amendments seems incredibly important for our international reputation for fairness and consistency in what we commit to, but also in wanting excellence in our NHS. Therefore, there needs to be a sophisticated way of prioritising. One of those important areas is the contribution to the NHS, especially during Covid and major events, when some have gone way above what is normally expected and come back from holiday or maternity leave, or whatever, to deal with a major incident, while others have perhaps not always been quite so flexible.

We certainly have a crisis and must deal with it, so this is not in any way to say that we should not be doing this, but the timing is the worry. I will come on to the other degrees in the next group. Can the Minister explain whether the Oriel system itself is a block to incorporating the flexibility that these amendments ask for? There is a real worry among some that the Oriel system is a rate-limiting step, rather than being flexible enough to be rapidly reprogrammed appropriately to allow the intention of these amendments to be incorporated at great speed, and therefore redress the accusation of unfairness.

Lord Clement-Jones (LD)

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My Lords, I offer our strong support for Amendments 9, 11, 24 and 25 in the name of the noble Lord, Lord Stevens of Birmingham, and Amendments 5 and 10 in the name of my noble friend Lord Mohammed. I thank the noble Earl, Lord Howe, for his Amendment 4, because it, in essence, sets the theme of this group, which is the dashing of legitimate interests for this year, which a number of noble Lords explored.

Before I address the specific mechanics of these amendments, we need to thank the noble Lord, Lord Stevens, and other noble Lords who highlighted at Second Reading the whole question of the protracted failure in long-term workforce planning. For years, we have seen a disconnect between the number of medical school places and the number of specialty training posts. There is a bottleneck of our own making: 12 applications for one post is a disaster. My late wife trained in the 1970s and became a registrar at Barts. I have no recollection of it being anything like on this scale, and we risk dashing the expectations of many of those currently in training.

As the noble Lord, Lord Stevens, noted at Second Reading, the Bill does not widen the bottleneck; it simply reshuffles the queue. Although we on these Benches accept the principle that UK graduates should not face unemployment after taxpayer investment, we must ensure that, in correcting one failure, we do not commit a second failure of fairness against those have served our NHS in good faith.

These amendments address one of the greatest injustices in this Bill: the decision to implement major changes mid-cycle for 2026, using the blunt instrument of indefinite leave to remain as a proxy for experience. The Government claim that assessing actual NHS experience is “not operationally feasible” for the 2026 rounds. Since Second Reading, we have received compelling evidence to the contrary. As my noble friend says, we have heard from doctors currently using the system who confirm that the Oriel recruitment platform already captures data on “months of NHS experience”. The question is there; the data exists. The claim that this cannot be done is a choice, not an administrative necessity.

By refusing to use this data, Clause 2 creates a perverse experience gap. It excludes doctors who have served on our NHS front lines for two or three years but who have not yet reached the five-year threshold for settlement. We have received hundreds of emails detailing the human cost of this decision. We heard from a mother who lived apart from her one year-old child for seven months to study the MSRA exam, only to find the rules changing days after she sat it. We heard from a neurosurgery SHO with two years of NHS service, who notes that this mid-cycle change renders his sunk costs unrecoverable. We have heard from a British citizen whose wife, a doctor on a spousal visa, is deprioritised, despite being a permanent resident.

Amendments 9 and 11 offer the Government a lifeline. They are permissive—my noble friend’s amendments mandate the Government. The bottom line is that the Secretary of State should use the data we know Oriel possesses to prioritise those with significant NHS experience in 2026, just as they intend to do in 2027. To reject this is to choose administrative convenience over natural justice.

I see the amendments at this stage as a probing opportunity. We need the Minister to explain in specific, technical detail why the existing Oriel data fields regarding employment history cannot be used to filter applicants for this cycle. If the Minister cannot provide a satisfactory technical explanation today, and if the Government resist this flexible approach, we will be forced to conclude that this is a choice, not a necessity. In that event, we may well need to return to it on Report.

Baroness Merron (Lab)

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This group of amendments relates to the implementation of prioritisation of posts starting in 2026. I thank all noble Lords for their consideration of this. It is a very important area, as noble Lords have said, and I have listened closely, as ever, to the points made.

Beginning with prioritisation for the UK foundation programme, Amendment 4, tabled by the noble Earl, Lord Howe, seeks to prevent prioritisation applying to offers for the foundation programme that were confirmed before 13 January. To clarify, the Bill will impact only offers for places made after the Bill is passed and becomes law. The Bill will therefore not have any impact on offers to the foundation programme made before it becomes law. In our view, the amendment is therefore not necessary. In any event, no such offers exist, other than for a very small and specific group.

The noble Lord, Lord Stevens, asked about those who have already been allocated. The only individuals who have already been allocated foundation programme places for 2026 are those who deferred last year for statutory reasons, such as maternity leave or sickness absence. These individuals have already been assigned to posts, and this year’s allocation process does not affect them in any way.

On a more general point, as I referred to in the earlier group, and as noble Lords will recall, the 10-year plan, which was published in July 2025, confirmed that it was the intention of the Government to come forward with the Bill we are speaking of today. The noble Lord, Lord Stevens, asked about the time it has taken since that date in July 2025. I can only say to the noble Lord that this is linked to our careful listening, which he will be aware of, to resident doctors and our understanding of the pressures that they are facing. The Bill is about action now. It is about acting decisively and introducing legislation for 2026, because, as noble Lords have kindly acknowledged, we need to start reshaping the workforce pipeline and show our commitment to easing the bottlenecks in training places.

Lord Clement-Jones (LD)

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I would be grateful if the Minister could say what proportion of those who wrote were disappointed with the Bill versus those who wrote supporting it.

Baroness Merron (Lab)

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I cannot give an exact proportion, as the noble Lord is aware, but I have noticed that the proportion has changed as the Bill has progressed. As we have approached Committee, I have certainly seen more email traffic urging a non-amended Bill rather than an amended Bill. I would imagine that that is reflected in other emails. The noble Lord is indicating that it is not. I can see differing responses, but that has certainly been my impression.

The application of prioritisation to the 2026 intake is necessary and justified. If, as I referred to earlier, we waited until 2027, competition ratios are projected to rise even further, meaning that more UK graduates would be unable to progress their careers on time, with a greater risk to the long-term sustainability of the workforce. For these reasons, another year’s delay is not an option, and we cannot accept the noble Lord’s amendment.

Amendment 10, also tabled by the noble Lord, Lord Mohammed, also seeks to change categories of people who would be prioritised for specialty training places, starting in 2026, by virtue of having significant NHS experience or by reference to their immigration status. We cannot accept this amendment on the basis that the effect would be to prioritise every individual who applied for specialty training places in 2026 because all applicants are, by necessity, already registered on Oriel. This amendment would in practice nullify prioritisation for 2026 and render the legislation ineffective. It would not address the severe and growing bottlenecks in specialty training that the Bill aims and is designed to tackle.

The proposal to prioritise those who have demonstrated a professional commitment to the NHS also presents workability problems as there is no clear or objective definition of what such a commitment looks like, nor any reliable way to assess it for tens of thousands of applicants at this stage. Attempting to do so would be unmanageable in a practical sense and would introduce inconsistency, delay and uncertainty for applicants.

Lord Stevens of Birmingham (CB)

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One objective proposition that has been suggested is two years of NHS experience, which, it is said, would be readily trackable on Oriel. Can the Minister confirm whether that would indeed be possible?

Baroness Merron (Lab)

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Although I cannot be specific about what is technically possible, I can say that, as the noble Lord is aware, the arrangements for 2026 in the Bill can change for 2027, and that will be the subject of consultation with a wide range of stakeholders to get the best definitions we can. We know that currently, because of the time pressure, we are going to have to use—I think the noble Lord used the word “proxy”, in my view correctly. So that is where we are.

Lord Clement-Jones (LD)

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The Minister criticised Amendment 10 from my noble friend on the basis that, in a sense, it is technically not doing what it attempts to do. But she has not really addressed the key argument at the core of this, which is that the Oriel system is capable of assessing precisely the kinds of two-year experience that so many of these deprioritised doctors will have. Is the Minister saying that it is absolutely not possible to use the Oriel system for that purpose in this context?

Baroness Merron (Lab)

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My recollection from my discussion with officials about this very point is that, with no criticism of the Oriel system, this is about what we are trying to do now and what we have available to us. It would require—I am looking for the right words—not just using that system but manual attention to thousands of applications. I am very happy to write to the noble Lord with further technical advice on the matter, but that is the situation of which I have been advised. The whole point about the way the Bill is designed is to make it workable. If we change it, we know we cannot deliver in the way the noble Lord might wish.

Lord Clement-Jones (LD)

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I thank the Minister for that. I hope that, despite the recess, there will be time to get all the information we need. There is a real problem here with the credibility of the Government’s position. There are many of us who hope that it will be possible to do something different, particularly since, in a way, the boot is on the other foot. The Government have had since last July, as we keep being told, to get the Oriel system fit for purpose in order to supply the information for 2026.

Baroness Merron (Lab)

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The noble Lord is ambitious on workability, beyond what I can honestly confirm is possible. Noble Lords would not wish me to stand at the Dispatch Box and suggest that, having looked at all we could do, the situation is anything other than that this Bill is a workable option. I can assure him that, as always, all noble Lords will get the information they are promised in a timely fashion. I also hope that the all-Peers letter and the letters I subsequently sent in respect of various areas of concern were helpful to noble Lords. I will of course ensure that anything further is there.

The issue with Amendment 10 is also that there is not that clear objective and definition of what a commitment looks like; it makes reference to it but does not explain it. By contrast, the Bill uses a set of carefully chosen, specified immigration statuses as a practical and proportionate proxy for identifying applicants who are most likely to have an established professional commitment to the NHS, which I believe is what all noble Lords are looking for. After careful consideration, we have concluded that for the 2026 recruitment round, that is the best approach. The amendment would remove any practical effect of prioritisation, which of course is at the heart of the Bill.

Amendments 9, 11, 24 and 25, tabled by the noble Lord, Lord Stevens, seek to create a regulation-making power to define additional persons with significant NHS experience to be prioritised for specialty training in 2026. We cannot accept these amendments. As already stated, the Bill sets out the most suitable criteria for prioritising specialty training places in this year. Under the existing Clause 2(2), for specialty training places starting in 2026, immigration status will be used as a practical proxy for NHS experience to allow prioritisation to begin swiftly. This proxy is being used because applications for posts starting in 2026 have already been made. Therefore, we need to prioritise based on the information already captured, and which can be assessed.

To build on what I was referring to in the exchange with the noble Lord, Lord Clement-Jones—I know this is also of interest to the noble Baroness, Lady Finlay—while NHS experience is captured in the Oriel recruitment system, using it as an assessment criteria for the 2026 allocation round would require a manual review of tens of thousands of applications, “manual review” being the words I was looking for earlier. This is just not operationally feasible. There is no current agreed threshold for what constitutes a meaningful level of NHS experience. Stakeholders offer very different views on this, which is why we have committed to a proper engagement process, subject to the Bill’s passage, to ensure that any future definition is fair, evidence-based and deliverable.

The Bill already gives us flexibility to ensure that we take the best approach to prioritising those with NHS experience for specialty training posts in subsequent years. For posts starting in 2017 onwards, the immigration status category will not apply automatically. Instead, we will be able to make regulations to specify any additional groups who will be prioritised by reference to criteria indicating significant experience as a doctor in the health service, or by reference to immigration status.

For the reasons I have outlined, I ask noble Lords to withdraw or not press their amendments.

Earl Howe (Con)

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My Lords, I am grateful to all noble Lords who have taken part in this debate, especially those from around the Committee who felt able to support my Amendment 4. I think there will be very many people in the medical community who will read the Minister’s reply to my amendment with acute disappointment. I say that not only because of the arguments I tried to articulate about legitimate expectations but also because of the point, well made by the noble Baroness, Lady Finlay, about the damage that the Bill will cause to the UK’s reputation for fairness around the world.

I would also pray in aid the amendment spoken to so ably by the noble Lord, Lord Mohammed of Tinsley, who argued in favour of delaying the implementation of the medical specialty training prioritisation requirements by one year. In doing so, he has very much echoed my thinking in this whole area. My initial reaction to this amendment is that it would have a positive impact on applicant confidence, as well as trust in the system, to pick up again the point by the noble Baroness, Lady Finlay, by allowing an extra year to transition to the new prioritisation process.

I also note that my noble friend Lord Strathclyde, in his role as chairman of the Constitution Committee, has written to the Minister, raising the committee’s concerns about the impact of the new prioritisation regime on applicants for the 2026 cohort who would fall outside the prioritised groups. It seems to me that Ministers really should consider this proposal carefully.

Amendment 10 by the noble Lord, Lord Mohammed, would remove the requirement that those who are prioritised for specialty training programmes must have indefinite leave to remain or leave to enter or remain in the UK, replacing those subsections with the requirement that persons merely need to have been

“registered on the NHS Oriel recruitment platform, or … demonstrated a professional commitment to the National Health Service”.

I thought the noble Lord argued his case very well. Of course, material in this context is the number of applicants who do not currently have leave to enter or remain in the UK who would, under the noble Lord’s amendment, be able to come here. I am, however, quite surprised to hear from the Minister that it would require a manual search of tens of thousands of records to find the answer to that, and that there are not ways of conducting a search automatically or electronically that could reveal the information that is needed. Again, I was disappointed by the Minister’s reply, for the reasons largely cited by the noble Lord, Lord Clement-Jones.

Finally, I comment briefly on the amendments tabled by the noble Lord, Lord Stevens of Birmingham, to which I added my name. These do not seem to me to be onerous on the Government in any way; they merely grant the Secretary of State the power to permit the appropriate authority to make regulations specifying further groups of people who are included. I feel that the Bill is particularly unfair to doctors with significant NHS experience seeking a specialty training post in 2026, and the mechanism proposed in the noble Lord’s amendments could be used to address that unfairness.

It is a pity that the Minister felt compelled to sound a negative note on the proposals by the noble Lord, Lord Stevens. However, having listened to the Minister’s reply and to all the amendments in this group, I think a period of reflection is warranted, hopefully by the Government as well as noble Lords around the Committee. With that, I beg to withdraw Amendment 4.

Baroness Gerada (CB)

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My Lords, I shall speak to Amendments 15, 16 and 19. I want to disclose an interest that I did not have at Second Reading: I am now co-chair of the Malta APPG—and I remain of Maltese heritage.

Amendment 19, in my name and that of the noble Lords, Lord Clement-Jones and Lord Mendelsohn, seeks to add Malta to the list of countries in Clause 4(4). It is precise and proportionate, and it would correct a narrow but serious unintended consequence in the Bill, as I will explain. Of course I acknowledge the need to prioritise UK graduates for training but, as the Minister of Health and Active Ageing of Malta put it in a letter to the Secretary of State for Health and Social Care, the Bill risks

“undermining two centuries of proud tradition and the dissolution of a strong bilateral relationship in healthcare, care, and the training and specialisation of Maltese graduates”.

At Second Reading, I spoke about the unique medical training partnership between the UK and Malta, which dates back two centuries. For example, Maltese surgeons have held licences from our own royal colleges since the 1830s. This is therefore not a recent convenience but a deep historic alignment. It is a relationship that has shaped both systems for generations, creating an instinctive alliance in training, practice, standards and expectations.

The Maltese education system is modelled on the UK system and aligned to British clinical and ethical standards. Training is delivered in English, and the Maltese healthcare system closely mirrors the NHS. That is why my father was able to come to this country in 1963 and devote his working life to serving patients in the east of England, and why others from Malta have done the same, performing well above their weight in serving patients in this country.

Furthermore, postgraduate membership and fellowship remain aligned with the British royal colleges, reflecting a deep and enduring professional loyalty. Indeed, many of these doctors have become trainers, educators and examiners, helping to uphold the quality of UK postgraduate education—some have had daughters who became presidents of royal colleges. Malta and the UK are therefore historically, culturally and educationally linked.

I turn to the comparison of the Malta foundation programme, an affiliated programme to the UK foundation programme, and I shall reflect on the free trade agreements that the UK holds with the countries in Clause 4. Government documentation for the UK’s free trade agreement with these countries requires regulators to

“recognise qualifications or relevant experience of a professional who applies for recognition and possesses comparable professional qualifications”.

The language in that documentation, which recognises reciprocal arrangement, strongly aligns to the UK-Malta affiliate programme and, on that basis, it should be treated no less favourably than these other nations.

Since 2009, our foundation programmes have been formally aligned, sharing the same curriculum and e-portfolio. This alignment was renewed in 2024, confirming that the Malta programme met the same standards and outcomes as the UK foundation programme. To the best of my knowledge, no other country anywhere in the world has that level of mutual recognition.

At the centre of this is Queen Mary University of London’s campus in Malta, a UK public university delivering an identical UK GMC-approved MBBS degree to that which it delivers in its east London campus in Tower Hamlets. The students follow the same curriculum, complete the same statutory mandatory training, take the same UK national qualification exams and graduate with the same UK primary medical qualification. They are registered by the GMC as graduates of Queen Mary University of London.

During Second Reading, the Minister, the noble Baroness, Lady Merron, addressed Malta as a distinct case, and indeed it is. The QMUL training programme is a UK programme delivered overseas under a framework recognised by and supported by the UK Government. More than half the students are UK citizens. The equivalence of training between the UK and Malta is complete, not approximate. It is not close; it is identical. Even the patient profile is the same. Malta’s population, diversity, healthcare system and disease patterns share extraordinary similarities with the UK, particularly compared with any other international training environments. Moreover, most students undertake NHS attachments during their training. These graduates enter the UK workforce fully prepared for UK foundation training, trained at no cost to the UK taxpayer.

The impact of a medical school goes beyond the students. QMUL has made a not insubstantial professional and financial investment in the campus and the Government of Malta have invested in the school’s construction. This aligns with the UK Government’s wider objective of developing international UK university campuses, as outlined in the recent strategy document from the Department for Education. This Bill, if not amended, puts this at risk.

The numbers are small, as the foundation years are capped at between 50 to 70 graduates. This is less than 0.6% of the UK foundation programme places. This is simply no workforce threat, no substitution effect or planning distortion. There is, however, a real risk of unfairness in the Bill as it stands. These students have a legitimate expectation, grounded on 15 years of consistent government practice, and the experience of all preceding QMUL medical graduates, that they should be treated comparably with other holders of UK primary medical qualifications. The Bill as drafted removes that status and places these graduates behind Norway, Iceland, Liechtenstein and Switzerland—jurisdictions whose graduates do not hold a UK primary medical qualification, do not sit the medical licensing or prescribing exams and are not trained on an NHS-aligned curriculum. This is difficult to explain, let alone to justify. This amendment simply corrects this anomaly. It protects a uniquely successful partnership, anchored in history, quality and equivalence.

Going beyond foundation years, a few Maltese doctors come to the NHS every year to fill gaps in their own medical training—so-called finishing school. These are in non-numbered posts. Malta provides 70% of their pay and these doctors are contractually required to return to Malta. This is not a pipeline of overseas doctors displacing domestic graduates. It is a small group, maybe 30 or 40, who meet our standards, all of whom have been examined and trained specifically in UK practice.

Finally and briefly, I turn to Amendments 15 and 16 again in my name and the names of the noble Lords, Lord Clement-Jones and Lord Mendelsohn. These suggests a carefully defined exception in Clause 4 for UK universities operating overseas campuses that deliver an identical UK-approved medical degree as in the British islands. These are exceptionally narrow amendments confined, to the best of my knowledge, to only two programmes in the world—Queen Mary University of London’s campus in Malta and Newcastle University Medicine Malaysia.

At Second Reading, the Minister referred to

“almost 300 applicants from … overseas campuses”,—[Official Report, 4/2/26; col. 1679.]

and noted that the Government need to control this number to “avoid opening the floodgates”. I stress, as I have already said, that the number of QMUL graduates applying for UK jobs is capped by the University of Malta at between 50 and 70, with around 120 from Newcastle University Medicine Malaysia bringing the total to 190. These caps would enable the Government to control the number of overseas applicants.

I also want to make clear my support of the amendment in the name of noble Lord, Lord Forbes, which provides a similar solution. Only institutions operating overseas campuses that meet the criteria set out in the amendments and that are in operation at the time the Act is passed should be included. I beg to move.

Lord Clement-Jones (LD)

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My Lords, I strongly support Amendments 15, 16 and 19, tabled by the noble Baroness, Lady Gerada, which I have signed, and which she spoke to so convincingly. These Benches also support Amendment 17 in the name of the noble Lord, Lord Forbes, and signed by my noble friend Lord Shipley, and Amendment 20 in the name of the noble Earl, Lord Howe.

As I said at Second Reading, I am the former chair of the council of Queen Mary University of London and now, for my sins, an honorary professor. Amendments 15, 16 and 19 seek to correct a category error in the Bill: namely, the classification of students holding a UK primary medical qualification from a UK public university as “international”, solely because their classroom is in Malta. I am sure the noble Lord, Lord Forbes, will say the same in respect of Malaysia. The Minister has argued that these students lack “clinical familiarity” with the NHS, but that does not withstand scrutiny. These students follow the exact same curriculum as their peers in London, as the noble Baroness said.

The Bill prioritises EEA nations, because it seems that our trade deal requires us to recognise “comparable” qualifications. It is legally incoherent to accept a “comparable” qualification from Liechtenstein while rejecting an “identical” and “affiliated” qualification from Malta. We are treating a formal UK affiliate worse than a trade partner. These students sit the UK medical licensing assessment and they are taught by UK-trained consultants. As I said at Second Reading, it is a manifest absurdity that, under this Bill, a graduate from Liechtenstein with no UK degree and no UK training is prioritised over a Queen Mary student who holds a UK degree and is specifically prepared for our health service.

I strongly endorse the point made by the noble Baroness, Lady Gerada, regarding our free trade agreements. We are in an absurd position whereby a treaty obligation forces us to prioritise these “comparable” qualifications. This is not workforce planning; it is a diplomatic and regulatory own goal. As the noble Baroness explained, Amendment 19 offers a simple solution by adding Malta to the priority list. This honours the mutual recognition agreement held between the UK and Malta since 2009—an agreement the Department of Health explicitly renewed in 2024.

Amendments 15, 16 and 17 offer a broader solution based on the qualification. If a student holds a UK degree from a UK-registered institution and passes identical UK assessments, they should be treated as a UK graduate. The Minister fears displacement of domestic talent, yet the majority of these Maltese trainees are contractually obliged to return to Malta after their training. They are what can be described as a circulatory workforce: one that supports the NHS during their training years, without permanently blocking the consultant pipeline. They are the ideal workforce partner. As stated by the noble Baroness, Lady Gerada, Maltese surgeons have been licensed by our royal colleges since the 1830s. This is not a new or risky pipeline; it is a two-century year-old bond that the Bill carelessly severs.

Furthermore, we support Amendment 20 in the name of the noble Earl, Lord Howe, regarding people who qualify in the British Islands but who have trained abroad. We are all on the same page in advocating for these well-qualified students, who should be eligible to have the same priority in obtaining training jobs as those currently set out in the Bill. We have received heartbreaking correspondence from British nationals studying in eastern Europe, often because of the cap on places here, who intend to return to the NHS. One correspondent highlighted that we allow British dentists to return without these barriers. Why do we treat our future doctors differently?

Lord Winston (Lab)

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My Lords, it is an honour to support the noble Baroness, Lady Gerada. The best surgical training I had was with a Maltese surgeon, who was absolutely fantastic and taught me lessons I have never forgotten. One has to see that that cross-fertilisation happens across the NHS very often.

Lord Mendelsohn (Lab)

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My Lords, I support Amendments 15, 16 and 19, in the name of the noble Baroness, Lady Gerada, and supported by the noble Lord, Lord Clement-Jones. It is my first opportunity to speak in the presence of the noble Baroness, Lady Gerada, in this Chamber. She is one of the more extraordinary and fantastic additions to this House in recent years. She has made a massive contribution to our country in medical expertise. The case that she made for these amendments was utterly compelling. I hope the Minister has felt the same inspiration as I did from her words. I also commend the noble Lord, Lord Clement-Jones, who I realise I have now known for 29 years, for another great speech, which again I think added to the strength of these points.

The amendments address an important omission, which has a couple of concerning issues underlying it. The case for why we should continue with this relationship is compelling. We seek to add Malta to the list of jurisdictions whose primary medical qualifications are recognised for prioritisation. As stated, Malta’s medical education system is not merely comparable to that of the United Kingdom; it is formally and historically integrated, through decades of regulatory alignment, shared training structures and sustained institutional partnerships, including the Queen Mary University of London’s Malta campus.

A substantial proportion of the graduates from this campus are United Kingdom nationals and many others hold UK domicile or indefinite leave to remain status. This is a cohort that can be planned for with confidence and absorbed without difficulty within the normal operation of the system, while making a real and practical contribution to the NHS. As the noble Lord, Lord Clement-Jones, said, they provide a valuable workforce capability that does not undermine the consultant pipeline, which is something we have to manage very well. Excluding this cohort of medical students disrupts an established pipeline, separates training from deployment and leaves capacity unused within a system that is under constant pressure. That is not disciplined workforce policy; it is a misalignment between regulation and operational need.

Medical education is one of the United Kingdom’s most significant strategic assets and a central pillar of our global impact in healthcare. It is very important that we maintain alignments and partnerships where they exist. Undermining them does nothing to enhance our reputation as a stable partner for any form of business, let alone the important thing of building relationships in medical research. I hope the Government reflect very carefully on this. A category error has led to a position where, even as recently as 2024, we undertook another solemn commitment—as you do in contracting—which we have now backed away from. That is a terrible place to be in.

The historic connections we have with countries—where we align these things over years and people invest with confidence—must not be undermined, especially when we, essentially, use a free trade agreement as a mechanism to undermine it. This is the wrong way around. This is not strategic planning; it is dodging and weaving between different and vacillating policies. We cannot be subject to this.

I hope the Minister will encourage the Government to reflect very carefully on this. I hope that there will be some positive news about how we can make sure that the countries we have aligned with most closely and have a formal UK affiliation can be brought into this arrangement and that some form of these amendments can be accepted.

Lord Forbes of Newcastle (Lab)

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My Lords, I must begin my contribution to this debate with two formalities. First, I declare that I am an honorary member of the court of Newcastle University. In fact, I am a recent recipient of an honorary doctorate from Newcastle University—although I must stress that I in no way compare an honorary doctorate in civil law with the range of national and international medical expertise in the Chamber this afternoon.

I also apologise to the Committee for tabling the probing amendment in my name without speaking at Second Reading. I hope that your Lordships will excuse my inexperience in the procedures of the House and be assured that there was no intended discourtesy to the Committee on my part by this inadvertent breach of procedure. Previous contributions to the debate have demonstrated that I may have got off somewhat lightly in terms of email traffic by not speaking at Second Reading; I have no doubt that there will be more email traffic to come on this subject.

I congratulate the Government on bringing this Bill forward and acknowledge the legitimacy of its core purpose. Prioritising doctors trained in the United Kingdom for foundation and specialty training is a necessary, reasonable and understandable aim, particularly given the sustained workforce pressures in certain parts of the NHS.

I was motivated to table this amendment by a number of representations that I received from concerned students who had been studying at the NUMed campus in Malaysia, which I had the great privilege of visiting shortly after it opened about 10 years ago. Many graduates of the NUMed Malaysia campus have gone on to serve with great distinction in the NHS. As the noble Baroness, Lady Gerada, said, the numbers are very small, but their impact on our National Health Service is very great. That sense of pride in the NUMed campus is felt deeply by Newcastle University, which is how I know and have been contacted about this issue. However, in a number of the representations that I have received, there has been a mistaken interpretation that the intent of the legislation is to exclude rather than prioritise. I wish to comment on these points in the debate on this group.

I was very surprised to see figures demonstrating that, in some specialties, competition ratios for specialty training have now exceeded 20 applicants per post, making the urgency of the Bill ever more apparent. I listened very carefully to the debate and have been greatly reassured by my noble friend the Minister’s assurances, particularly on the prioritisation of UK students rather than the exclusion of overseas students, and the intention of the Bill to smooth out bottlenecks in medical training and focus on homegrown talent as a priority. This does not mean denying the NHS appropriate international talent when it is appropriate to deploy it. I am also very reassured by my noble friend the Minister’s reassurances on the concerns about unintended consequences being addressed by subsequent regulation and review.

The Government have expressed a clear intent to continue to engage with relevant UK universities with international campuses to further explain the intention of the Bill and the way that it will operate in practice, and to support them as they adjust to the Bill’s very legitimate and important requirements as it progresses towards enactment.

Baroness Finlay of Llandaff (CB)

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My Lords, it was with great pleasure that I added my name to the amendment so nobly introduced by the noble Lord, Lord Forbes of Newcastle. I am most appreciative to my noble friend Lady Gerada for the way that she introduced this whole group, because she flagged up very clearly that Malta and Newcastle are different from other places.

I also reassure the noble Lord, Lord Darzi, that my probing amendment was simply to probe. I was worried that the Bill’s wording could inadvertently leave UK-based universities unable to develop other outreach campuses, but not Irish medical schools and universities, and that those graduates could then be included in the future. I wanted to make sure that we had a level playing field, but I accept that the wording is clumsy and does not work.

I think the key word in the amendment that the noble Lord, Lord Forbes of Newcastle, tabled is “extant”, when it says that the

“medical school … is extant on the day on which this Act is passed”.

That would allow those schools currently in place, particularly Malta-Newcastle and, if the Government are so minded, the RCSI in Bahrain, to be able to be included because those degrees are taught to the same curriculum and examined at the same level, and those taking it undertake the medical licensing exam and prescribing exam—which I know is changing, but it will still be important that there is a completely level playing field. It would stop the mushrooming that could occur from other universities.

The word “extant” is really important, and I hope that the Minister will be able to take it on board and that it is completely compatible with the compelling case made by my noble friend Lady Gerada.

Lord Stevens of Birmingham (CB)

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My Lords, I speak in support of the thrust of the amendments in this group. I start by acknowledging the concern that I think is animating the Government on this point, which is that they do not want to see a thin end of a wedge that opens up substantially with a lot of newly created international programmes that then end up further displacing UK-trained graduates and undermining the ability to effectively plan the medical workforce of the future.

Fortunately, however, none of these amendments actually constitutes the thin end of the wedge—there is no wedge. As we have just heard, these amendments grandfather the current, very modest arrangements at QMUL Malta and Newcastle University, which are so numerically small, with a couple of hundred students relative to 12,800 for the other training programmes. So those are not the programmes that have caused the problem that the Bill is seeking to address, nor should they therefore be collateral damage as the Bill progresses.

As discussed at Second Reading, particularly in respect of Malta we have a long-standing relationship, and we have a series of diplomatic and other ties of bilateral agreement that the British Government and the Maltese within the last 12 months have renewed, which are of continuing and considerable significance to us, including on defence, security and other aspects. So the Government would be well advised not to throw the baby out with the bathwater and to take seriously the concerns that these amendments represent.

Lord Mohammed of Tinsley (LD)

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I shall speak to the Amendments 15, 16 and 19 to add my support to the amendments on the issue of Malta from the noble Baroness, Lady Gerada, as well as Amendment 17 from the noble Lord, Lord Forbes, and Amendment 20 from the noble Earl, Lord Howe.

Given that we have had a substantial discussion on Malta, particularly from the noble Baroness, Lady Gerada, and the noble Lord, Lord Clement-Jones, I shall speak more towards Newcastle, forging the northern alliance that we may have—and more importantly because my mentor, the noble Lord, Lord Shipley, who cannot be here, made a particular point of visiting my office to say, “You are going to be speaking on Newcastle on Thursday, aren’t you?” So here we go.

The amendment from the noble Lord, Lord Forbes, would ensure that graduates from overseas campuses, and United Kingdom medical schools in particular, are treated fairly and consistently. I think that the amendment is precise and proportionate. It applies three conditions: first, that the primary medical qualification is awarded by a United Kingdom medical school—in this case Newcastle, but there will be others; and, secondly, that the qualification is obtained through study at an overseas campus that existed at the point of this Act being passed. The noble Baroness talked about potential creep when we discussed this last week in terms of other institutions being able to take advantage and open that back door. With this very timely amendment from the noble Lord, Lord Forbes, it is very clear that—

Lord Stevens of Birmingham (CB)

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Is it the noble Lord’s understanding that there would be the opportunity for creep as is currently set out in the Bill? For example, if Queen Mary University of London wished to establish a medical school in Liechtenstein, which currently lacks one, it would be able to do so with an unlimited number of places. All those new students would then be passported into the NHS.

Lord Mohammed of Tinsley (LD)

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The noble Lord, Lord Stevens, has given people ideas. Possibly, this could happen, yes.

Thirdly, both courses and study for the convocation are approved by the GMC as being equivalent to the UK medical qualification. This is not about lowering standards or creating a new route through the back door. On the contrary, this is about recognising the standards that already exist and are regulated by the GMC. The GMC is determined that these courses are equivalent in content assessment and outcome. It is difficult to justify why we should exclude them, given the numbers that we heard about earlier.

Universities such as Newcastle—and there may be others as well—rely heavily on this partnership. These programmes have not just happened overnight. They have existed for some time. They are run by UK institutions, aligned with UK curricula and assessed identically to UK standards and subjects. Graduates receive UK-awarded degrees, not foreign substitutes. Such programmes contribute to the NHS. Only yesterday, we heard from Newcastle University that they have had up to 150 students on their Malaysian campus. As we heard earlier, some of those students have come back to the United Kingdom and, in particular, have served for many years as GPs when we have had an acute shortage. We need to take heed of that contribution and also the long-standing relationships that exist both with Newcastle and Queen Mary.

We are only asking for a very small change. We are not asking for tens of thousands of students to come here. We are asking for a small number through long-established partnerships that have existed and stood the test of time. We are asking the Minister for some flexibility. This is being heard from all sides of your Lordships’ House. We are about to go on a holiday. I hope that the Minister will take this time to reflect on our debate and come back on Report with government amendments that we can all support. I look forward to the debate that we are going to have in less than a fortnight’s time.

Earl Howe (Con)

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My Lords, I shall speak to my Amendments 20 and 21 and in support of the other amendments in this group.

My amendments are intended to work together and to return us to one of the salient themes of our debates at Second Reading, a theme which has been persuasively developed today by the noble Baroness, Lady Gerada, the noble Lord, Lord Forbes, and other speakers. At the heart of their concerns is why the Government have chosen to adopt a definition that threatens to undermine high-quality workforce capacity in the NHS, that jeopardises the sustainability of medical education delivered overseas by UK institutions, and that runs completely counter to the Government’s stated ambitions on promoting British standards of education internationally.

The Bill prioritises graduates based on strict geographic criteria, rather than on the provenance of their qualifications. UK academic institutions such as Queen Mary University of London and Newcastle University have campuses respectively on Malta and in Malaysia which train doctors to GMC-approved standards, using the same curriculum and the same assessments as those employed on their campuses in the UK.

The noble Baroness, Lady Gerada, has eloquently made the case for Maltese-trained students. I can add little to that. The noble Lords, Lord Clement-Jones, Lord Mendelsohn, and Lord Forbes have also spoken very powerfully on the same theme. The amendments of the noble Baroness, Lady Gerada, speak of the two qualifications—in other words that gained in Malta and that gained in London—as being identical in character. The amendment from the noble Lord, Lord Forbes, uses the word “equivalent”. I would go further by saying that the degree issued by the Queen Mary University of London Malta campus is not merely equivalent to a UK degree: it is a UK degree.

Not only that, but Queen Mary University is able to state that cohorts of its students trained in Malta frequently outperform their contemporaries who have studied and trained on the London campus. The intervention from the noble Lord, Lord Winston, has confirmed that that is not an isolated claim. The same claim could be made of many graduates of Newcastle University’s campus in Malaysia. These are excellent doctors, so there is not an issue of quality here.

Nor should there be an issue around numbers. In total, as we have heard, the number of these overseas-trained graduates is modest in comparison to the overall NHS training intake in a given year. The numbers really ought to be treated as de minimis. We have heard from Ministers that, if they were to flex the rules in the way that I and others are proposing, there would be no way for them in the future to control the total numbers of eligible applicants from these sources. My question is: why? It would seem perfectly possible to grant Ministers a power to cap total numbers at a figure corresponding to recent experience. It would then be up to the relevant universities concerned to collaborate year by year to ensure that the cap was not exceeded. That is what my Amendment 21 is intended to do.

Finally, we return to the issue of legitimate expectations. For all the reasons that I have given, students trained on overseas campuses of UK institutions have never dreamed of questioning whether the status of their qualification would differ in the slightest from the status of the qualification gained by their student colleagues in London. They are, in consequence, not to put too fine a point in it, appalled that, through this Bill, they are suddenly to be regarded as less deserving of a medical career in the NHS. I ask the Minister to think again.

Baroness Merron (Lab)

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My Lords, I am grateful for this debate, as I have been grateful for the time that noble Lords have given to discussing their concerns about various aspects of the Bill in advance of today. I can say to both the noble Earl, Lord Howe, and the noble Lord, Lord Mohammed, that I always reflect on what they and other noble Lords say. Indeed, I reflect on what every noble Lord says—it is true that I may listen to some more than others, but that would be telling. I am genuinely grateful. In my view, it really does assist the passage of legislation and I take it very seriously. I will of course reflect, as I have before, not just on what is said in the Chamber but on what we have discussed outside.

The noble Earl, Lord Howe, said previously that people will be watching and reading this debate, and I absolutely agree and am glad that they do. So I must emphasise the point that this is not about excluding people from their applications; it is about prioritising. The reason we are in this position is the removal of the resident labour market test in 2020, which changed the whole landscape. In 2019, there were 12,000 applicants; now, there are nearly 40,000 applicants, which means four resident doctors for every specialist training post. I believe that noble Lords understand the scale. Internationally trained doctors make a huge contribution and will continue to do so. We are aiming to bring forward those internationally trained doctors who have significant NHS experience for training posts in the future, which I think is absolutely right.

Let me turn to the amendments in this group: Amendments 15 and 16, tabled by the noble Baroness, Lady Gerada; Amendment 17, tabled by my noble friend Lord Forbes; and Amendments 20 and 21, tabled by the noble Earl, Lord Howe. Each of these amendments seeks to ensure that graduates of overseas campuses of UK medical schools are prioritised for foundation and specialty training. I understand why this is being raised, and it is quite right to probe this whole area, in my view. While I appreciate the intention behind these amendments, and the manner in which they have come through, the Government are unable to accept them.

Lord Stevens of Birmingham (CB)

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I want to come in on the point about whether or not the UK Government would lack the ability to control the expansion of international places in the grandfathered campuses. Is it not the case that, in fact, the UK Government do have such a tool at their disposal, through the Office for Students? The OfS has to agree the number of undergraduate medical places that a university can operate here in the UK and can cap those, and could therefore introduce an off-setting mechanism so that any additional place created outside the UK would see a reduction in the UK authorisation. That would be incentive enough, I suspect, to ensure that universities did not behave in the way that the Minister is concerned about.