Medical Training (Prioritisation) Bill
(1 day, 7 hours ago)
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Baroness Merron
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
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)
I hope the Minister does not mind. Does the Minister think that the agreement with Malta should be honoured as well?
Baroness Merron (Lab)
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)
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)
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)
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)
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.