Lords Chamber

Monday 23rd February 2026

(began 2 weeks, 6 days ago)

Share Debate
Watch Live
Skip to latest contribution
This debate has concluded
14:37
None Portrait Oral questions: Findings of the Nature security assessment on global biodiversity loss, ecosystem collapse and national security, published on 20 January
-

My My Lords, My Lords, I My Lords, I should My Lords, I should like My Lords, I should like to My Lords, I should like to notify
14:37
14:37
None Portrait Oral questions: Findings of the Nature security assessment on global biodiversity loss, ecosystem collapse and national security, published on 20 January
-

14:37
14:38
14:39
14:40
14:40
14:41
14:41
14:43
14:43
14:44
14:44
14:44
14:45
14:46
14:46
14:46
14:47
14:47
14:47
14:48
14:48
14:49
14:49
14:50
14:51
14:51
14:52
14:53
14:53
14:54
14:54
14:55
14:55
14:55
14:56
None Portrait Oral questions: Implementing the recommendations of the LGBT Veterans Independent Review, published in July 2023, with particular regard to the Financial Recognition Scheme
-

Oral Question Lord Cashman. question. Standing in my name on the Order Paper. My Lords, can I just start answering this question
14:56
14:56
14:58
14:59
15:00
15:00
15:01
15:02
15:02
15:04
15:04
15:04
15:05
15:05
15:06
15:07
None Portrait Oral questions: Communicating the purpose and value of the newly-introduced V-Levels to students, parents, and employers
-

McNicol of West Kilbride. >> I beg leave to ask the question. >> Standing in my name on the Order Paper.

**** Possible New Speaker ****

Paper. Question. My Lords V-levels will deliver a
15:07
15:07
15:08
15:09
15:09
15:10
15:10
15:11
15:11
15:12
15:13
15:13
15:14
15:14
15:14
15:15
15:16
15:17
15:17
15:18
15:18
15:18
15:20
Lord Stockwood Portrait Lord Stockwood, Minister of State (Department for Business and Trade) (Labour)
-
-
Well, the noble Lord raises a number of challenging and fast moving issues here, so I'll try and moving issues here, so I'll try and respond as fully as I can. What's worth stating is that the UK secured that preferential deal last year, driven by the Prime Minister's direct engagement with President Trump and trying to give British businesses that certainty and competitive advantages, the ruling of the weekend does not affect our preferential treatment in key sectors like pharma, cars and steel that the noble Lord mentions.

The business secretary spoke to US Trade Representative Jameson Greer this weekend, making it clear our concerns about uncertainty and the degree of confidence in honour those agreements that we needed and had those reassurances. UK officials across Whitehall and Washington are engaging intensively with the US as we speak, and this will continue those discussions all of this week, at which time we can update the House. It's worth stating to my noble friend that we've always had a cool headed and pragmatic approach to trade deals, and whilst I wouldn't comment on other governments policies, we do have a competitive advantage globally in those sectors that we set out in the original negotiation, the biggest beneficiaries of this weekend's announcement are those trade barriers coming down for other countries.

But we still have the best deal globally, and we continue to negotiate to retain that preferential position.
15:21
15:21
15:22
15:22
15:23
15:24
15:24
15:24
15:25
15:25
15:26
15:27
15:27
15:27
15:28
15:29
15:29
15:30
15:31
15:31
15:32
15:33
None Portrait House Adjourned During Pleasure
-

My Lords, may I suggest a short
15:34
15:34
None Portrait Legislation: Medical Training (Prioritisation) Bill – report stage
-

Lords, I beg to move that this report be now received.
15:34
Lord Patel Portrait Lord Patel (Crossbench)
-
-
The question is this report be now received as many of that opinion say content the contrary, opinion say content the contrary, not content. The contents have it in clause one, amendment one Lord Patel.

**** Possible New Speaker ****

Thank you, my Lords.

**** Possible New Speaker ****

I like to speak to my amendments listed in the Group one. My Lords, my amendment should be underpinned by the status of UK medical graduates. The the competition to get into medical schools in United get into medical schools in United Kingdom is one of the toughest of any countries. The ratio of success is about 4 to 1, with the highest A-level grades that are obtained, including many at A Stars. But requirements are higher than that at the completion.

On average. UK medical graduate has a loan of about £72,000 and it's important that we discuss this debate, this bill. In that context. I have reinserted my amendments that I had at Committee stage for two reasons. One, that the debate that we had at the Committee stage rightly maybe concentrated more on international medical graduates or graduates from UK university campuses, and not so much on the UK medical school graduates who seem to be losing out on getting training posts.

But the following debate, which we have all received many, many emails from both UK graduates and also international medical graduates, I have, presumably because I had amendments under my name, seem to receive many, many more from UK medical graduates and some of you may see a petition on the internet addressed to US Members of Lords to pass this bill unamended from UK medical graduates. And I gather that over 4500 names attached to that petition now.

So why are my amendments again? Most other countries my Lords, USA, Canada, New Zealand, Australia, Singapore and EU prioritise their graduates for further training and even employment. Data from GMC, NHS England, Royal Colleges, BMA professional journals and accept that there is variation in how the and also how this data could be interpreted. However, it does show that graduates from UK find it difficult to get into core and specialist training programmes for a variety of reasons increased output from medical schools and that will increase even more in future years.

Increase post visa 2019 from international medical graduates. The training slots have not increased and the workforce plan increased to accommodate more doctors. The UK doctors pay negotiations. One of the primary reasons they stated, was training as an issue. The second issue was working condition and the third issue was pay. Now I have said it publicly in this chamber before and I repeat it. I do not subscribe to any doctor at any time. Withdrawing their services from patients for no matter what reason.

So I do not agree with junior doctors going on strike, despite the fact that they may have a legitimate reason to complain about their training issues, but that is no reason as far as I'm concerned, to withdraw services from patients. UK training of doctors is in three stages Foundation years one and two, core training and speciality including GP speciality training. GMC informs me that foundation one year training is available to all graduates who graduate from UK universities, although sometimes they find it difficult and the slots are not available till the last minute.

That usually ought not to be a problem. In my case, it was two weeks before I had to start the job that I secured a position to the surgery in Penzance, having qualified in Saint Andrews, so it was not a place I visited before, but I got through it. Foundation year two, the GMC says in 2024 reports that in 2023, 77% of doctors completing Foundation Year two did not or cannot enter core training. A lot of them, 13.14% had decided not to, I gather, had gone maybe overseas.

The international medical graduates whose primary medical qualification was overseas. In 2017, there were 47% registered with GMC. In 2023, there were 68% GMC report. In 2023, 40% of doctors entering speciality training are international medical graduates. Of course, it's important that we have opportunities for international medical graduates to come and train in United Kingdom and in fact have employment status in the NHS. But UK doctors should have a fair slot, sir, able to compete fairly.

UK doctors comment that after year five, Foundation year two to enter speciality training is like falling off a cliff that is difficult for them to get into specialist training. NHS England in the training information Medical Training (Prioritisation) Bill this bill at annexe three said to potential impact that the application totalled 21,000 from for about 10,000 posts of ratio of 2 to 1 in 2025. Round one 28,000 of Where Appointable, despite lower competition ratios, over 2000 Appointable UK grads, did not receive an offer.

In round one of 2025. The expectations, therefore, there will be 16,000 UK graduates, slight increase from last year applying for core and speciality training in 26,000 international medical graduates. Again, slight increase from last year. That is 42,000, although NHS England numbers are 47,000. There's always variation numbers for reasons I cannot explain, my Lord. The ratio nonetheless is 4 to 1 for 10,000 slots. Estimate, therefore, is in the prospect of 8000 UK graduates forced out of the current rotation year coming rotation year that may not have appointments with the passage of the bill, it will mean priority groups of doctors in the bill will apply also for these training slots.

Now, I could not find a number of what effect that would have, but maybe the noble Baroness, the Minister has numbers, or if the priority groups in the current bill were included, how many more doctors will be able to enter the specialist training? So the UK graduates, with the expansion of priority Group, will have further competition to to compete for the current bottlenecks. And I quote from a publication of NHS England with a foreword from both Doctor Powis and the and the Chief Medical Officer.

And the quote is the current bottlenecks in training do not benefit any anyone. While some competition has always been necessary part of medical training and career progression, the current ratios are making sensible career planning and assessment for and that is my words, UK doctors very difficult. I think that's why I put my amendments that I have. I know the later amendments will discuss about other graduates from other UK campuses being eligible in the priority group, but I'll refer to that later.

I beg to move.
15:44
Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Labour)
-
-
Amendment proposed clause one, page one. Line four after must page one. Line four after must insert first. My Lords, I thought the noble Lord Patel made some very, very interesting points and I'll be interested in my noble friend's response to specific amendments. But like the noble Lord, I doubt if I've had as many emails as he has in view of his expertise in the whole area of medical training and development, particularly at postgraduate level. But my Lords, it's hard not to feel sympathetic to both sides of the argument.

And of course, my Lords, I feel for those doctors trained overseas who were on, they thought, on a pathway to being accepted for speciality training in this country and have now, if you like, had the rules of the game changed halfway through. But my Lords, equally we've got a situation as as my the noble Lord, Lord Patel pointed out, really a ridiculous situation of growing competition from overseas doctors. UK trained doctors finding it very, very hard to get specialist training.

My Lords, it also goes, I think, into a wider question about this country's overreliance on doctors from overseas and I must say, my Lords, the current recruitment from Africa is one that gives me particular concern in terms of the whole ethics of this process. And my Lords, I think we need to recognise what is the problem. And there's no question, isn't it, that the last government, as you know, my Lords, they wasted years trying to develop a workforce plan.

They eventually came up with a proposal to increase the number of medical training places. But of course, my Lords, it wasn't fully funded for the long term. Hence, my Lords, we had more medical training places, but the number of speciality training places did not keep pace with the actual number of medical undergraduate training places. And so, my Lords, we have this ludicrous situation of UK trained medical graduates funded by the state not being able to get a post.

As for speciality training and of course, like the noble Lord Patel, I don't. I've never prescribed to the view that just because you qualified as a UK trained medical doctor, you have an automatic right to go into speciality training. Clearly you have to have some bars and people have to get through those bars. But my Lords, to actually for the state itself to fund so many additional training places and then not being able to allow them to access speciality training is clearly ludicrous.

And so, my Lords, I do think the government, I'm afraid, had to do something. I think it's not it. It's had to make a hard choice here, and one which in the end, my Lords, I have to support. But I do think, my Lords, that this also poses real concerns about the whole medical training programme in this country. We've clearly got to bring an A line undergraduate medical training places with speciality training. But I think we also Lord Patel referred to the current dispute with resident doctors, and I agree with him in relation to the issue of pay.

But, my Lords, anyone who has met a newly trained doctor in the UK at the moment will know they're not treated right. They know that they're not given the right leadership. And my Lords, if you talk to more experienced doctors, they talk about the Old Firm system. They talk about the impact of the working time directive on training. They talk about the way partnerships can be broken up because doctors are sent to different parts of their deanery when they're in a relationship, and how difficult it is for them, particularly if they then have children.

And my Lords, you, we all hear about the lack of support for those doctors within NHS trust, a lack of sympathy by employers to some of the pressures they're under. And I think, my Lords, as I see it, the action the government are taking today is part of a general programme of trying to turn this around. And I would say, my Lords, that I do think the leadership of the profession has much to answer in terms of the way these resident junior doctors have been treated in the past.

It's about time the colleges actually took stepped up to the plate to actually sort some of these issues out in conjunction with the GMC, and I hope, my Lords, I don't pretend this is not easy. This is, I think, a difficult decision. It's a hard decision. And I do feel great sympathy with some of the doctors caught in the current situation. But my Lords, it's surely the right way to go. But I hope my noble friend will assure me that this is the foundation in which to improve our whole approach to medical training.
15:49
Baroness McIntosh of Pickering Portrait Baroness McIntosh of Pickering (Conservative)
-
-
My Lords, I would like to speak in support of the amendment in the name of Lord Patel and thank him for the research he's done as background to this amendment. The noble Lady will be aware that I work for the Dispensing Doctors Association. My father and brother were GPS. My uncle was a surgeon. I couldn't stand the sight of blood for the greater good. I went to the law profession, the legal profession instead, the noble Lady and the lady alongside her know of my interest in this subject, particularly for junior doctors in training, who, as we've heard, don't have the number of job vacancies for speciality offered to them, but also have no security of tenure.

And they are sort of of an age, probably in the late 20s and early 30s, where they would be hoping to to put down roots, form relationships and start families. So it's particularly key that I think we look after them. I had one point of difference with the noble Lord Patel. I just say I thought the consultants were quite well rewarded in their pay round, and I hope that they will support the junior doctors in in their pay round, because I think it's very important that the profession stick together in this regard.

But I agree with them. It's very unfortunate if they feel that they have to go on on strike. And obviously patients, hospitals and other staff are disadvantaged in that way. Could the noble Lady, the Minister, will respond to the debate on this amendment, explain to me, if we're not to adopt this amendment, what there is in the bill to cover the specific set of circumstances that is identified by Lord Patel's amendment? And if there's nothing in the bill, would she come forward at Third Reading with something that covers these points? Because this is something that exercises a number of us very deeply to give the right message, particularly, may I say to to young male white doctors that I think may otherwise leave the procession profession.

And I know in general practice, a number of partners are leaving and going to work in in Australia, New Zealand and Canada after they've completed their training and possibly after 5 or 10 years experience. So I think for the future of the profession at every level, we do need to take this set of circumstances very seriously indeed.
15:52
Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (Crossbench)
-
-
I must declare an interest as a UK graduate and also as Pro-Chancellor of Cardiff University, which has a very large medical school. I think the issues raised already over the ethics by the noble Lord, Lord Hunt of Kings Heath are really important when we look at this bill in terms of what is our ethical role in attracting people, literally attracting and pulling from places which have a terrible shortage of any medical provision whatsoever. And the other aspect which my noble friend Lord Patel brought out so clearly has been the problem of career progression altogether.

And I hope that in summing up the noble Lady, the Minister will be able to reassure us that this bill is step one in sorting out the medical career progress for people in this country. Only this weekend I heard of large teaching Hospital that has two consultant posts coming up for which they had 28 Appointable applicants, many of whom actually are already consultants. So there is a real bottleneck for trainees who've gone right through their training program, done all their exams.

And there are two ways of progressing. Broadly, there is run through training, which provides some security, and there's other training at a postgraduate level where they have to reapply before they move on. And the problems of geography for people who are young, who are parents, who have got children who are settled, are absolutely massive, I have worried that the pay story hides a huge amount of problem and unhappiness, particularly in relation to the lack of teams now in the way that training has been organised.

And I don't refer to internet teams, I must say, but clinical teams where people know that they belong, where they know the person who they can contact and where there is longer continuity. And I think the there has been a fault by the medical Royal Colleges, and I would hold up my hand in there, having been involved in some curriculum in palliative medicine, that we overstepped different bits of experience and undervalued the importance of people coming through. But in support of these amendments from my noble friend Lord Patel, I do think it's also important to remember that on international medical training programmes, some have no or almost no communication skills training, almost no or no training in medical ethics.

And in fact there are some where they have no clinical experience of of any note whatsoever until they pass. They're almost totally theoretical exams. And then they have to gain all the clinical experience later. Now, I'm not passing any judgement on the quality of their medicine later on, and they may actually have a better scientific foundation. But I do think we're not comparing like with like in the process. And the last point that I would like to make is that I hope that the noble Lady will be able to assure us that Oriel, as an appointments process and selection process, will have a much more subtle way of looking at the experience that people have, and not just crude categories, because it will be really important that we don't select away excellence in the name of the medical school that somebody graduated from, because there is a spectrum of quality in every medical school output cohort, there are some who are absolutely superb, and there are some who, frankly, might have done better not getting into medicine in the first place.

It may be a small number, but there will be in those other graduates from other medical schools, people with absolutely superb experience and who turn out to be excellent. And we see some of those in very senior positions in medicine at the moment across the UK. So I think the prioritisation prioritisation message needs to be subtle, needs to look at the full employment history from graduation and including their NHS experience, but the quality of their work during that, and apparently the system can actually automatically calculate a lot of this drawing on GMC data as well.

So there is a lot of work to be done by this system in relation to the data held by the GMC, and there is a lot of work to be done by the Royal Colleges.
15:57
Lord Stevens of Birmingham Portrait Lord Stevens of Birmingham (Crossbench)
-
-
My Lords, I declare my interest >> My Lords, I declare my interest as chair of a King's College London. I think there's a welcome consensus I think there's a welcome consensus that the UK should be aiming for self-sufficiency in the production self-sufficiency in the production of new doctors through medical school, through speciality training and into the NHS. And in fairness, I think the last government deserves credit for having taken the decision to expand medical school undergraduate intake to put us on that path, and it was also not unreasonable to, as a temporary measure, make use of selective international recruitment.

While those new doctors came through the system, not least as the Independent Migration Advisory Committee reported that at the time, in respect of doctors, quote, there is sufficient and overwhelming evidence of a UK wide shortage. Close quotes given it takes perhaps 15 years for new medical students to come into independent clinical practice, telling patients to hang on for 15 years while that intake feeds through the system would not have been good, certainly for patients. However, the question now is that clearly there does need to be a better prioritisation during the transitional system, and we've spent a lot of time in committee discussing the pros and cons of what that transitional prioritisation might look like.

But one question I think that has not yet been completely resolved, that would aid the House in assessing the proposals that Lord Patel has put before us, is whether we could have a clear answer from the noble Baroness, the Minister, as to what is the increase in the pipeline, the increase in the availability of speciality training places going to be for the current year and over the next three years, as she has pointed out to us in correspondence last week, during recess, the long term, the NHS ten year plan that they published last July talked about an additional 1000 speciality training places over three years.

However, the Secretary of State for Health and Social Care put on the table the proposition of not 1000 but 4000 additional speciality training places over three years, of which an additional 1000 would become available in this coming year. That's what was put on the table in the discussion with the BMA on the 10th of December. Given this is only a few months until these posts are filled, presumably the Minister must know the answer to the question exactly how many speciality training places? Additionally, are we going to get for the year ahead so as to reduce the prioritisation problems with whichever criteria this act puts forth.

forth.
16:00
Baroness Gerada Portrait Baroness Gerada (Crossbench)
-
-
As the probably the only person in this chamber that has headed up a Royal College not once but twice, the Royal College of General Practitioners. I feel the urge just to defend and correct what's been said twice. In fact, three times in this chamber, the Royal Colleges set the standards, the curriculum. They do not oversee workforce planning funding. They do not oversee what the actual training looks like. Once you get into an organisation, I have to correct the house and correct those speakers by saying that is the job that the that is not their job.

For the Royal College of GPS. I don't disagree that there needs to be

**** Possible New Speaker ****

reform. Absolutely. It's a mess. It's a complete mess and. Would give way. I mean, would

**** Possible New Speaker ****

Would give way. I mean, would you accept that the Royal Colleges certainly can give moral leadership? Secondly, I would refer her back to the last junior hospitals doctors dispute about 10 or 11 years ago. dispute about 10 or 11 years ago. She will remember, I think it was the Academy of Medical Royal Colleges set up a group to look at Colleges set up a group to look at all these issues, and it seemed to me, my Lords, the outcome of that

**** Possible New Speaker ****

was very disappointing in terms of tangible results in improving the situation. Thank you very much. I have to

**** Possible New Speaker ****

Thank you very much. I have to also tell you that I, for the last 20 years, have led what's called Practitioner Health Programme, Practitioner Health Programme, which has looked after the mental health of the medical workforce. And to date, I no longer lead it, And to date, I no longer lead it, but to date about 40,000, mainly doctors have passed through that service, most with mental health service, most with mental health issues relating to burnout, depression and anxiety, and some a new diagnosis which I call NHS itis.

I do know about this endless reviews that were done. It's not just the Academy, medical, Royal Colleges, Health Education England, the General Medical Council, CQC, many of the Royal Colleges looked at the issues of the decline in mental health and some of these have been raised here around firms, around loss of control, around your training, around the intensity of the workload. Fundamentally, we don't make it easy for any of these doctors. And by the way, we don't make it easy for the international medical graduates either, who have always fared worse.

So I agree with you. There are solutions that that are there that we don't need another review. The answer is blowing in the wind. We have them. But and I'm very happy to discuss that at a further time.
16:02
Lord Clement-Jones Portrait Lord Clement-Jones (Liberal Democrat)
-
-
My Lords, I think we ought to thank Lord Patel for having stimulated such an interesting and important conversation about how terrible our workforce planning in the NHS has been to date, my Lords, and we've had some very wise words around the House on that subject. My Lords, it's clearly not fit for purpose and that's why we are where we are, my Lords, on these benches, we've consistently accepted the government's central premise for the bill that where the British taxpayer invests heavily in training a doctor at a UK medical school, there is a logic in prioritising that graduate for employment to ensure a return on that public investment.

But while we sympathise with the noble Lord Patel's desire to ensure UK graduates are prioritised, and indeed a lot of that derives from the the the fact that our workforce planning system is not fit for purpose. My Lords, we must be careful not to make the legislation so rigid that it removes any flexibility for the system to function effectively, as we will be arguing in later groups. My Lords, by creating strict statutory tiering that places UK graduates above all other priority categories in every instance, we risk creating a system that cannot respond to realities on the ground.

And my Lords, we've received correspondence as indeed I'm sure almost every other noble Lord in this House today that from many doctors warning that absolute exclusion or rigid tearing could leave rotas empty in hard to fill specialities like psychiatry and general practice, which rely heavily on international talent, prioritisation is a necessary tool for workforce planning, but, my Lords, we must ensure that it does not become a blockade that damages the wider delivery of NHS services.

And, my Lords, as the noble Lord Stevens of Birmingham, said we need answers about the future of workforce planning, you know, what are the numbers going to be, my Lords, for training places and I believe that the government really need to answer that as we go through this bill, my Lords.
16:05
Earl Howe Portrait Earl Howe (Conservative)
-
-
My Lords, I too am grateful to the noble Lord, Lord Patel, for the noble Lord, Lord Patel, for leading this debate on his amendments, which seek to establish a new prioritisation hierarchy that puts UK medical graduates first, ahead of those in the priority group who are not UK medical graduates. And I should have prefaced my speech by reminding the House of my interest as an honorary Fellow of the Royal College of Physicians. We debated this proposal at Committee stage and other noble Lords, including my noble friend Lady Coffey, had amendments that sought to introduce a different prioritisation hierarchy.

My Lords, I do understand fully the case that the noble Lord is making, and I do agree with him that UK medical graduates should have a much fairer crack of the whip in access to medical speciality training places. Indeed, fairness has been our primary concern throughout our scrutiny of this bill. However, I do agree also with the noble Lord Lord Hunt of Kings Heath. The government have had some hard choices to make. In an ideal world where the House had been given more time to consider these matters in the round, we might have been able to improve on the approach that Ministers are taking.

For example, there is surely a place for guidance to make clear that the prioritisation process should incorporate considerations of medical and academic excellence, which is a point that the noble Baroness, Lady Findlay, has consistently made. May I say I'm grateful to the noble Lord Lord Stevens of Birmingham for putting the decisions made by the last government into their proper context. However, given where we are, we do accept that Ministers have introduced this as urgent legislation with a specific purpose.

And in that context, and having accepted that the government's approach will have the effect that they are seeking to achieve, we are satisfied that the Minister's proposed method of prioritisation is acceptable.
16:07
Baroness Merron Portrait Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)
-
-
My Lords are most grateful to noble Lords across the House for their considered contributions to this group of amendments, and grateful to the noble Lord, Lord Patel, for his introduction to this group. I have the third reason to be grateful, and that is for the understanding about the challenge that this government is facing and the need to take action, and that is certainly something that I don't take for granted. My Lords, we are not able to support the amendments tabled by the noble Lord Lord Patel.

If I can go through the reasons for that. Also, in answer to the noble Lady Baroness McIntosh, the bill does already set clear priority groups without any further ranking within these groups. This is a binary system, and applicants are either prioritised or they are not. It might be helpful to your Lordships House that I do say that the priority groups set out in the Bill have been agreed across the four governments of the nation. Those, I believe, are who are best placed to support moving to what we all want, which is a sustainable workforce, to meet the health needs of this population.

Again, as I emphasised in Committee stage and also in Second Reading prioritisation, my Lords, does not mean exclusion. Non prioritised graduates will still be able to apply and will be offered places if vacancies remain after prioritised. Applicants have received offers for speciality training. There are likely to be opportunities in general practice, course psychiatry and internal medicine, which historically attract fewer applicants from the groups that we are prioritising for 2026 and alongside UK graduates, the bill does prioritise graduates from Ireland.

This reflects, as I've spoken of before, in this chamber, the special nature of our relationship with Ireland, along with the graduates from Iceland, Liechtenstein, Norway and Switzerland, which reflects our obligations under international trade agreements with the European Free Trade Agreement. Countries to treat their graduates no less favourably. This amendment. The amendments would mean that we would not be honouring these arrangements, as it would mean we are prioritising UK medical graduates over applicants from these countries.

My Lords, the agreements with Efta countries do precede this government for Iceland, Norway and Liechtenstein, the agreement was made in July 2021 and Switzerland in 2019. And the bottleneck issues that this bill is designed to address were also primarily driven by the removal of the resident labour market test in 2020. I know that noble Lords will understand the need to uphold these international obligations, albeit we do receive very low numbers of applicants from Efta countries. As I noted in my recent letter to the noble Lord Lord Mohammed, there are there.

There are a total of two applicants from Efta countries for foundation and speciality training in 2026 to give noble Lords some idea of scale for speciality training. The amendments would also mean we are prioritising UK medical graduates over applicants with significant NHS experience, which would undermine the effective delivery of our policy intention, for which there is much sympathy in this chamber to prioritise applicants with significant experience working in the NHS. The government has rightly committed to prioritising those who have made a considerable contribution to our health service, because they better understand how the health service works and how to meet the needs of the UK population.

The noble Lord Lord Patel asked about the numbers of how many more students in the priority group can, would be able to enter speciality training and I will be pleased to write to the noble Lord on on that matter the my noble friend Lord hunt and the noble Lady. Baroness Finlay asked about the broader approach and called for improvement of this broader approach to medical training. And that's something which I would definitely concur. And we have published phase one of the Medical training Review, which identifies the key challenges and the areas for improvement across postgraduate medical training.

As noble Lords are inquiring about. And and not just the key challenges, but also what is it that is working? Well, phase two is already underway of this work, and that will focus on exploring those issues and developing options for change. And the noble Lady Baroness Finlay also asked that I gave an assurance that oriole would, as an appointment process tool, would have what the noble Lady described as a more subtle way of looking at NHS experience, and I can confirm that we will be engaging with stakeholders about what the best definition and what is most appropriate for NHS experience.

That will then allow us to update the system. The noble Lady Baroness Finlay also asked about merit based selection and made a point, which is very valid about the quality of those who are applicants. Let me assure your Lordships House that this bill does not replace in any way a merit based selection. Existing recruitment processes for foundation and speciality training already does assess applicants against rigorous merit based criteria, including competence, performance and suitability for training, all of which I know that is of concern, and rightly so to the noble Lady.

So this bill sits alongside that process, not instead of these processes. The noble Lord Lord Stevens and the noble Lord Lord Clement-Jones asked about speciality training processes. Places. Forgive me. In the ten year health plan, as the noble Lord Lord Stevens referred to, our commitment is to create 1000 new speciality training posts over the next three years, focusing importantly, in my view, on specialities where there is the greatest need and this bill will not delay this process.

There are some programs and regions already at capacity for delivering properly supervised training posts, so expanding that training capacity will therefore need to be done gradually to ensure that placements do remain of the quality, the high quality that we need and that appropriate supervision is in place also to support it. I hope that I have dealt with the main questions that have been raised, and for these reasons, I hope the noble Lord will withdraw his amendments.
16:16
Lord Patel Portrait Lord Patel (Crossbench)
-
-
I thank the noble Baroness, the Minister, for her comments. Also Minister, for her comments. Also thank the other noble Lords who spoke. I do not take the points that Lord hunt made quite important, that there needs to be much more wider review of the whole issue about medical training and workforce planning that is linked together, and I hope that the review that the NHS England carried out, published in October 25th, with a more recent update on 18th of January 26, which was the first phase, so-called diagnostic phase of the medical training, plus other phases to come, will promote that review of medical training to come, and I hope the government will back that.

As far as Lord Clement-Jones comments, and I think he made a similar comment at the Committee stage that we should not prioritise UK medical graduates above others because the others may, who do provide us with good service and care. And I accepted that. How would I not? Because in my own department we regularly on a yearly basis took overseas doctors for training in United Kingdom and some of them remain in this country and others held high positions overseas. But the fact is that 30% of training slots at Core and speciality training do go to international medical graduates, 70% to the UK graduates.

So that's not small number. That's quite a significant number of training positions. Nevertheless, I do accept that we do need international medical graduates to come here, study and work here. Thanks for the other comments made. And I know the Lord Stevens of Birmingham asked a very important question. I know that the government says there will be 1000 new posts, but these over three years, so it might be three years hence that we might get those. In the meantime, we do have a problem of UK medical graduates, and I will single that out because I hope this bill will help in the process of more UK graduates getting the jobs.

I thank the noble Earl Earl Howe, who was stronger in his support last time than this time. I can understand why now. My Lords, I had no intention of putting my amendments to the vote. I hope that the noble Baroness will accept those, but she's not. She's made it quite clear she's not. And I do wish this bill to be concluded speedily, because this urgent bill, and I hope the prioritisation, as in the Bill, would help UK graduates.

On that basis, I beg to is it your Lordships.
16:19
None Portrait AMDT: 3 Lord Mohammed of Tinsley (Liberal Democrat)
-

Pleasure that the amendment be withdrawn? It is by leave withdrawn. withdrawn? It is by leave withdrawn. Amendment two Lord Patel not moved, not moved. And then in clause two, amendment three Lord Mohammed of Tinsley.

**** Possible New Speaker ****

Thank you, my Lords, and I rise to speak to both amendments in this group in my name. But could I start, group in my name. But could I start, my Lords, by just speaking to despite the fact that we've had a despite the fact that we've had a short break since we last discussed this previously, we've all had a this previously, we've all had a lot of emails and and commentary on the bill as it goes through your the bill as it goes through your Lordships House.

And one point in particular, people have queried, particularly around the amendment freeze. Why is Lord Mohammed doing this? He must have some declarations of interest. He must have some, you know, personal gain to do what he's doing. So can I. For the record, my Lords say that simply. I do have three children. One works for Northern Rail, the other despite our best efforts. In particular, his mother tried to ask him to go to medical school. We failed. He went to become a paramedic and at the moment he's absolutely loving it.

So there's highly unlikely that this bill will affect him. And my daughter's not studying medicine or anything related. So therefore the purpose and the motive of me moving this amendment is around fairness and equity, my Lords. And I start by actually saying that this is a modest postponement in rejecting this policy. We're not doing it by outright. It's necessarily safeguards to ensure fairness for those who have already applied under the rules that existed when the current application cycle opened, as we heard at Committee stage, the core purpose of this bill is to prioritise graduates with strong links to the UK and NHS experience.

As Baroness Finlay said earlier, and it has broad support in terms of the route to legitimate concerns about the balance between health, workforce, supply and demand. However, My Lords, the government's own planning documents indicate that for the 2026 recruitment prioritisation is applied only at the offer stage because shortlisting has already occurred, my Lords and the post need to be filled by August. In other words, the legislation would apply part way through an active application cycle. It is this timing that gives rise to the compelling fairness concerns at the heart of my amendments.

My Lords medical appointments make decisions in advance, far in advance. They invest years of study, financial costs, personal sacrifices based on published criteria to change that criteria in mid application with potential effects on eligibility, shortlisting, scoring or final offers. Risks penalising those who comply fully with the rules as they stood when they applied. They cannot rewind their applications, my Lords, they cannot be judged against a different standard. This is not theoretical. I have been contacted just as many members of your Lordships' House directly by candidates who face exactly this prospect.

Under the current system, the core principle of procedural fairness and legitimate expectation is well established. Legislation, however, is however well motivated, should not expect to disadvantage applicants who acted in good faith. It should not reshuffle the deck once the cards have already been dealt a delay until 2027. My Lords allows for clarity. It allows for proper stakeholder engagement and ensures that no doctor is unfairly caught between two regimes. I emphasise this amendment does not delay the policy Lords indefinitely or dilutes its intention.

It simply aligns implementation with the natural application cycle. And therefore, I really hope when the Minister stands up to respond that she responds favourably. Can I now turn to the other amendment in my name is my Lords Amendment seven, which replaces the government's proposed immigration status criteria in prioritising framework with with a test based on completion of at least two years training or employment in the medical capacity within the NHS. The intent of the original Bill to prioritise those who have strong links with us sorry US, UK medical training and health services is not controversial, but to use indefinite leave to remain my Lords and other immigration categories as proxies for NHS experience is deeply problematic for me and I'm sure for many others it risks both unfair outcomes and loss of clinical value for patients.

At committee stages. House heard detailed arguments about the unsuitability of immigration status as a measure for meaningful NHS experience, my Lords, not least because it does not reflect who actually worked, trained or contributed in the UK. Under the government's current drafting, international medical graduates with indefinite leave to remain settled status or citizenship would be prioritised, irrespective of whether they ever actually have worked in NHS. Experience counts only if it fits within residency categories. Yet many doctors who arrived earlier on shorter visas have worked for years in NHS.

My Lords delivering frontline care through the pandemic pressures and workforce shortages. Their contributions contribution is real, sustained and beneficial. My Lords. The British Medical Association have repeatedly emphasised that speciality training prioritisation should reflect clinical experience in NHS, not simply legal status. Residency status. In its response, the BMA set out its position and I quote international medical graduates who were GMC, registered and participated in the NHS and have at least two years experience should be prioritised, my Lords, and I quote this amendment aligns with that evidence based and professional grounded approach.

My Lords, two years experience is clear, objective and legitimate and is demonstrated threshold of contribution far more meaningful than a stamp in your passport. My Lords, in recognising those who have already invested in the UK system, who understand our clinical pathways and workforce needs, and who have delivered care for our patients. Critically, it also avoids the injustice noted at Committee stage by several Lords, noble Lords, about the category for either arbitrarily including or excluding applicants with negligible NHS ties.

Doctors who arrive with ILR but have not delivered NHS care, should not be automatically advantaged ahead of colleagues for with years of service here that simply cannot be justified on the grounds of fairness or work place workforce planning. Nor does the amendment prejudice the aim of prioritising UK medical graduates. It supplements the bill with additional criteria that strengthens how NHS experience is recognised, supporting not undermining the long term sustainability of training pipeline. My Lords, this amendment strikes the right balance between policy ambitions and practical fairness.

It honours the contribution, supports retention and strengthens NHS workforce. I therefore urge noble Lords to support it, and I really hope that when the Minister rises to speak that she will speak

**** Possible New Speaker ****

in favour of this amendment. Thank you. Yeah. Mr. Clause two, page one, line

**** Possible New Speaker ****

Mr. Clause two, page one, line ten, leave out 2026 and insert 2027.
16:26
Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (Crossbench)
-
-
ten, leave out 2026 and insert 2027. >> I would just like to go back to the question of Oriel and the the question of Oriel and the prioritisation processes, because it does collect a full employment history from graduation and requires applicants to confirm whether each post was paid NHS experience. So I hope in responding the noble Lady, the Minister will be able to recognise that some have worked in a voluntary capacity before they were able to get paid employment in the NHS and some people, in trying to build up their criteria for eligibility to apply, have worked in non-medical posts such such as other positions, in order to gain the background NHS experience that they need.

And I have been sent a copy of a response that was sent by the Department of Health and Social Care in response to a query about the specified immigration status, where indeed it does state, and I quote in 2026, the government is using these immigration statuses as a proxy to capture applicants who it believes will be most likely to have significant experience of working in the health service in the UK, and that prioritisation, it then goes on to state, will be applied at the office stage because shortlisting is already underway, which of course does create a lot of problems for people, although I can see that there are difficulties in postponing this because all the applicants are already in such a state of turmoil that actually to have a second year of turmoil may not be particularly helpful to them in any sense.

But there was a worrying sentence at the end of this second paragraph that I was sent, which stated it will be aiming to have regulations in place for the autumn 2026 application round, subject to parliamentary timetable, and I hope that in summing up the noble Lady, the Minister will be able to assure us that given that this has been emergency legislation brought forward, that the regulations will be treated with a similar degree of urgency to remove any uncertainty for the next round of applicants.
16:29
Lord Clement-Jones Portrait Lord Clement-Jones (Liberal Democrat)
-
-
My Lords, I rise to offer my strongest support to amendments three and seven. In the name of my noble friend Lord Mohammed of Tinsley. These amendments addressed a single biggest injustice in this bill the decision to implement major changes mid-cycle for 2026, using the blunt instrument of indefinite leave, to remain as a proxy for commitment. My Lords in committee. The Minister defended this decision by arguing that assessing actual NHS experience for 2026 was not operationally feasible and would require manual attention to thousands of applications.

My Lord, since that debate, we've received categorical evidence from doctors currently using the system that contradicts this assertion. Multiple applicants have provided proof that the Oriel recruitment platform already captures granular data on NHS experience. The application form explicitly asks candidates to confirm if they have more than six months of experience in the NHS. It also captures their current visa status. My Lords, the digital data field exists. My Lords, the Minister in meetings and I do thank her for her engagement, albeit that the way that this bill has gone through means that it's been difficult to engage too frequently in my Lords.

But I do thank her for having arranged a meeting. The Minister's claim that that the data on Oriel is not verified. But, my Lords, if the if the department had moved fast enough from last July, it could have they could have commissioned the software necessary in order to do that verification, my Lords. So, my Lords, by clinging to the blunt instrument of ILR, the government is choosing to change the rules mid-cycle, pulling the rug from under doctors who've served on our front lines for two, 3 or 4 years.

This includes doctors on spousal visas who are permanent residents married to British citizens, yet are now deprioritised. It includes mothers who've spent months living apart from their infants to study for the exams, only to find the goalposts moved days after sitting the paper. My noble Friend's amendment seven offers a pragmatic solution, replacing the requirement with a benchmark of at least two years of training or employment in the NHS. My Lords, this would create parity with UK Foundation programme, and it tells doctors who have kept our hospitals running that their service actually counts.

My Lords, I do urge the government to have another look at whether it can utilise the Oriel system and accept this fairer metric. Otherwise, my Lords, I believe the government should accept amendment three, which is delay the bill's impact until 2027.
16:32
Earl Howe Portrait Earl Howe (Conservative)
-
-
My Lords, with these amendments, the noble Lord Lord Hameed has. Muhammad has reprised proposals he made in which we debated at Committee stage. In committee. The noble Baroness, the Minister, emphasised a point that I have to say resonated particularly strongly with me when she pointed out that the delay proposed in amendment three sets the government back in its timetable to address the bottlenecks in medical training. So while acknowledging all that the noble Lord said about fairness, I must accept the that a delay of a year would set the government back significantly in its plans.

And, given our support for the main principle underpinning the bill, we can't, I'm afraid, support that amendment. I would, however, reiterate that prioritisation is only part of the solution to the problem we've been talking about. It is a logical and sensible step, but the bottlenecks in medical training, which are having such a pernicious effect on the future opportunities of young doctors, will not be ameliorated until the number of training places is increased significantly. The answer given by the Minister to the question posed by the noble Lord Lord Stevens of Birmingham, about training places in the last group, was helpful.

However, I wonder if the noble Baroness can go any further. Can she give us an indication of whether the government considers that the additional training places, which have already been announced are likely to be sufficient, or is there a possibility that more may be announced in coming months? Turning to amendment seven, in the name of the noble Lord, Lord Muhammad, again he made a strong case for his amendment and I endorse the powerful comments made not only by him but also by the noble Lord.

Lord Clement-Jones can the Minister provide us with further information on the Oriel system, because there is a sort of fog surrounding this subject. When we last debated this issue, I was surprised that the Minister was unable to give clarity on the number of individuals who have demonstrated an established commitment to the NHS, but who don't have leave to remain. It seems to me essential that we have clarity on the number of doctors that this amendment would affect. Has the noble Baroness had the opportunity to look into this in more detail between committee and and report? If we're not able to get greater clarity on the issue today, will the Minister at least give a commitment to look at any cases where a doctor has demonstrated that commitment but doesn't have indefinite leave to remain, so that we can ensure that any injustices that may arise as a result of this emergency legislation are resolved swiftly at ministerial level.



**** Possible New Speaker ****

I'm grateful to noble Lords and all sides of the House for their all sides of the House for their contributions today. And if I could turn first to amendment three, tabled by the noble Lord Lord tabled by the noble Lord Lord Mohammed. My Lords, as I explained Mohammed. My Lords, as I explained at the Committee stage, this is not an amendment that we're able to support. As has been emphasised, including today. A key aim of this
16:36
Baroness Merron Portrait Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)
-
-
Bill is to address what are severe bottlenecks in medical training bottlenecks in medical training that have built up over recent years. And these pressures, my Lords, are having real consequences. Lords, are having real consequences. Evidence most starkly, I believe, through the most recent industrial through the most recent industrial action, where concerns about stalled career progression and stalled career progression and training opportunities have and continue to feature feature heavily. The noble Lord Lord Mohammed rightly spoke about the concerns of those applicants mid-cycle, and I do recognise the concerns about this group and the impact on them, particularly where applicants did not know how prioritisation might affect them.

But I do have to say that whilst I absolutely understand the concerns, as we have discussed, these have been carefully considered and that the end of it all, we have to make decisions about what is it we're trying to do, and there will be people who are affected in ways that none of us would have chosen, but it has not been possible to make a change in legislation, particularly at this pace, without some effect on some groups. So yes, it is a choice and it is one that we have made.

But I do want to acknowledge, of course, the impact on those who are in the middle of a cycle of application. With regard to the proposal in the amendment, I can only endorse the comments by the noble Lord Earl Howe, that another year of inaction would only deepen. I believe the frustration felt by UK trained doctors and further destabilise the workforce. I don't think that's anything that any of us want to see. So we do believe that applying prioritisation to the 2026 intake is both necessary and justified.

If we waited, as this amendment suggests, to 2027 competition ratios are projected to rise even further. That would mean more UK graduates unable to progress their careers on time, with greater risk to the long term sustainability of the NHS workforce. And it is to protect the long term sustainability of the NHS workforce, protect patients and protect patient care and services that this bill is all about. And so that is why we're not able to accept another year's delayed.

Although albeit I understand why the noble Lord has put it forward. I should say that, in addition, there is difficulty in terms of drafting in respect of this amendment because it would create two clauses related to the prioritisation of applicants to speciality training's training programmes 2027, and each would have a different approach to prioritisation. I'm sure that the noble Lord would not want to create operational confusion, nor, I'm sure, would he want to undermine legal certainty, but I thought it important to point that out.

Turning to paragraph. Sorry, forgive me. Turning to amendment seven, also tabled by the noble Lord, Lord Muhammad. Firstly, following our conversation earlier, and I'm grateful for the noble Lords flexibility in that regard, I do want to reassure the noble Lord and your Lordships House that we are absolutely committed to recognising those who have worked in the NHS for a significant period. There's a very good reason for this as well as it's the right thing to do, but those individuals are much more likely to stay in the National Health Service for the long term, and they are much better equipped to understand how the health service works and how to meet the needs of the UK population.

Again, a core driver in this bill, it is our intention to prioritise those with significant NHS experience for speciality training. However, we are unable to support amendment seven for a number of reasons. Let me turn and I appreciate that the amendment did change, but I do want to refer, if I might, at this stage to the points made by the noble Lord Lord Clement-Jones, who and I discussed these matters with him earlier today, that whilst the NHS Oriel recruitment system does hold some information about an applicant's NHS experience, it can't be used consistently or fairly.

For the 2026 round. The data collected has been collected on the basis that it would be checked by employers before appointment, not for retrospective automated assessment. So it is indeed the case that applicants enter their employment history onto Oriel as free texts, but with no consistent format. So yes, there is a tick box to indicate NHS experience, but I do have to emphasise this is self-declared and that's the problem. There isn't a mechanism for verification to confirm that the employer listed as an NHS organisation or any other relevant detail, and that is why I spoke about this at Committee stage.

It would require a manual review of tens of thousands of applications. That means a high risk of error and potentially delaying offers and start dates. Again, I know nothing that any of us wish to do. That would of course be destabilising for applicants and for trusts, so it is not operationally feasible, nor would it be fair. And the noble Lord Earl Howe asked for more information. On the Oriel system. I'd be very welcome to speak to my great length about it.

Having having looked into it myself in a practical sense, and I can absolutely see the limitations. So in my letter to Lord Clement-jones, which I have placed in the library, more detail has been provided on the system that may be of help to the noble Lord. But if the noble Lord Earl Howe would like a more in-depth acquaintance with the oral system, he and other noble Lords are most welcome to benefit. As I have done, the noble Lady Baroness Finlay spoke of voluntary experience as a possibility for being NHS.

Significant experience, and I understand why the noble Lady raises this on this point, and also to the point about the amendment. There is currently no agreed threshold for what constitutes significant NHS experience, and the fact is that views on this, as evidenced today by the noble Lady views, do differ widely. But that is why we have committed to full engagement on this issue for future years, rather than rushing the changes for 2026. Once we have agreed the parameters around experience, the Oriel system will be updated to ensure that data is collected in a consistent, verifiable format.

That's the key to support a fair assessment in future recruitment rounds. Our aim is to have this in place in time for the next speciality training round, which will open for applications in autumn 2026. For the current recruitment round. My Lords, the Bill does use a set of carefully chosen specified immigration statuses. The reason being it's a practical and proportionate proxy for identifying applicants most likely to have significant NHS experience. After careful consideration, we have concluded this is the best, best approach for the 2026 recruitment round.

With regard to the noble Lord Earl Howe question about the potential for additional training places, how likely are the ones I've referred to earlier to be sufficient? We are keeping numbers, of course, as we always do, under review, and the noble Lord Earl Howe asked me to look at particular cases. Of course, I'm always happy to do that, bearing in mind it's difficult often to comment on very specific individual cases. But I'd be pleased to look at the broader point that he makes.

So, my Lords, I hope that the noble Lord will withdraw his amendments on the basis of the reasons I've outlined.
16:45
16:47
None Portrait AMDT: 11 Baroness Lister of Burtersett (Labour)
-

Lords, I rise to move amendment 11. And this would add to the list of priority groups people who have been recognised as in need of international protection, who have arrived as a Hong Kong British national, or who have arrived on a safe and legal humanitarian route. And I simply speak to this amendment. But I do have some sympathy for the amendments in the name of the noble Baroness, Lady Gerard Gerada. I apologise for popping up at this late stage of Bill's passage, but the issue was brought to my attention by the Refugee Council, who recently spotted that the bill, as it stands, would exclude those recognised as refugees from prioritisation for medical training posts.

This will potentially make it harder for people with medical backgrounds who have been displaced and given protection in the UK to contribute fully to the NHS. This resonates with me because my father, as a young man with a medical qualification, came to the UK in the 1930s as a refugee from Nazi Germany. He was able to requalify at Glasgow University and went on after the war, eventually to have a long career as a medical officer in Manchester in what was then the.

As such, he contributed British society in a way that would now be difficult for medically qualified, medically qualified refugees. Programs such as the Refugee Council's Building Bridges Programme support qualified refugee doctors and other health professionals to be able to utilise their skills and experience in the UK. These programmes are based on close collaboration between charities and the NHS. This is beneficial for the refugees themselves, as well as for the UK. That support can include helping refugees to pass the necessary language requirements and get professional registration.

In the UK. Some refugees will also progress to accessing medical training posts. This has included foundation programmes specifically designed to support refugee doctors into the NHS workforce during Second Reading. In the other place, the Secretary of State said that the UK must break our overreliance on international recruitment. For my Lords, this amendment does not run counter to that aim. Refugees have not come to the UK because they've been recruited. First and foremost. They have sought protection and have been given it.

My amendment would simply ensure that those refugees who are also doctors, would be able to put their medical backgrounds to good use and continue to develop their expertise for the benefit of the wider community, as well as to themselves. At the same time as this Bill is progressing through Parliament, the government are proposing significant changes to settlement for refugees as part of the settlement plans. Ministers have said that these changes are supposed to incentivise integration and ensure that settlement is earned, ensuring refugee doctors are not placed at a disadvantage because of this bill would help the government meet those aims.

Second Reading. My noble friend the Minister here explained that internationally trained doctors were significant. NHS experience will continue to be prioritised for speciality training, recognising the service that they have given this year. Immigration status will be used as a practical proxy for NHS NHS experience in order to allow prioritisation prioritisation to begin swiftly. The following years, we have taken powers and regulations to enable us to refine this approach in consultation with key partners. I've been asked by noble Lords what this means for those with refugee status.

The status is not a standalone priority group, although refugees will be prioritised for speciality 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 priority group prioritised group may still apply for speciality training posts and the Bill will not change their eligibility. Eligibility to apply for locally employed doctors roles now the noble Lord, Lord Patel, responded positively with particular reference to Ukrainian refugees.

But I'm not sure that my noble friend's response was as quite as reassuring as he perhaps thought, especially as Ukrainians who have arrived on the Ukrainian scheme won't be in any of the priority groups. If I understand the proposals correctly, indefinitely, for remain is being used for places on speciality, and this relates to the previous amendment on speciality programmes in 2026, as a proxy for recognising doctors who have been trained abroad, but who have been employed within the NHS for some time, is not such a useful proxy for anyone who, like those on Ukrainian schemes, have no route to settlement, or who, under the proposed settlement changes, could have to wait for ten years or even longer to qualify for indefinite leave to remain.

My amendment also addresses the impact of the bill on doctors who have come to the UK as part of the Hong Kong Bno visa scheme. As with other refugee doctors, they have sought safety in the UK. Indeed, it's a scheme frequently described by frequently described by government as a safe and legal route. The case for their inclusion has been put to me eloquently in an email from an anaesthetist, and I don't know how to pronounce it. Anaesthetic registrar, who is a bno visa holder and is currently working in the NHS.

Like many colleagues in the similar position, he he migrated to the UK for political reasons before completing his training and now regards the UK as his permanent home. Wishing to dedicate his career to the NHS, they argue that De-prioritization, to the point of exclusion, would leave us without any pathway to complete training, despite our qualifications and NHS contributions, effectively ending specialist careers for a group formally invited to settle here. They also point out that bno doctors in the NHS form a small, finite cohort.

Their main argument is that, unlike many other international medical graduates who can return home to complete training, those of us on the Bno scheme face unique barriers due to the political situation in Hong Kong. Returning is not realistic nor possible for many of us. The UK is now our only place to practice medicine and pursue specialist training. Now, although the situation is not quite the same, the argument applies also to other displaced persons covered by this amendment. My Lords, at a time when the government are making it much more difficult to achieve refugee status, should they not at the very least ensure that those who are so recognised and who are medically qualified are able to requalify and use their medical expertise to the benefit of our society? I hope my noble friend will be able to accept this amendment, but I suspect she won't.

And so, at the very least, I would ask if she could give a commitment to further consultation with a view to giving serious consideration to including the groups specified in the amendment, even if only in modified form, in the regulations to which you referred a Second Reading and which have been mentioned earlier in today's debate, I beg to move.
16:55
Baroness Gerada Portrait Baroness Gerada (Crossbench)
-
-
Proposed clause four, page three. >> Proposed clause four, page three. Line four. Leave out the words as printed on the master list. My printed on the master list. My Lords, I stand to speak to amendments 12, 13 and 15 in my name. In this group my name and that of Lord Mendelsohn I repeat my conflicts of interest. I am of Maltese heritage. I'm a doctor and I'm co-chair of the APPG. So my amendments are narrow, they are practical, and they respond directly to the concerns raised by the Minister in committee.

And I'm grateful to the Minister and I respect her and for the time that she's given me for her letter and for engaging seriously with this issue. So thank you. I fully accept that we must find a solution to the difficulties faced by the UK medical graduates. As so eloquently pointed out by Lord Patel, but in doing so, we must ensure that we don't unfairly disadvantage a small, specific group of students that we do not strain valued relationships with an EU member state and a Commonwealth partner, or inadvertently undermine the long standing transnational higher education commitment.

And that is the purpose of my amendments. This is not about opening floodgates, nor is it about creating a new route for offshore medical schools. I am speaking here about just two long established UK universities with overseas campuses Queen Mary University of London in Malta and Newcastle University in Malaysia. They are the only two that, upon Royal Assent, meet the criteria for delivering UK primary medical qualifications overseas. The same curriculum, the same examinations, the same degree until and until now the same eligibility for the UK Foundation Programme.

Historically, there was a third city, Saint George's, which is now teaching its final cohort of seven students in Cyprus, and that arrangement is closing. So in reality, my Lord, we are speaking about two mature well-governed partnerships with capped, predictable numbers of no more than 190 students per year. So let me address Malta, which I obviously know best. Since 2009, Queen Mary has operated a British medical school in Malta on the understanding that its graduates would be treated in the same way as its London cohort for entry into the UK Foundation Programme, and that reassurance was reaffirmed as recently as 2024.

Each year, My Lords, about 90 students enrolled at the university, many of them are UK nationals, often with a clear intention of serving in the NHS. Students such as Michael, who comes from Essex, who's a final year medical student who worked as a nurse during the pandemic before deciding to train as a doctor at Qmul Malta. He's not a rich kid, but someone who's dedicated his life to working in the NHS and worked and saved and borrowed money to achieve his passion of becoming a doctor.

What can he hope for now, if we imply that a UK degree somehow becomes less UK because a lecture theatre is in Malta rather than Whitechapel, we sent an unfortunate signal not only to those students, but also to a close education and historic partner. The Minister has quite properly raised concerns about NHS exposure, and it is true that most clinical placements take place in Malta, but almost all the students undertake NHS attachments and the health challenges they face are strikingly similar to ours, I would attest, much more so than the health challenges from Iceland, Liechtenstein or Norway.

Non-communicable diseases dominate diabetes, cardiovascular disease and obesity. There's a growing burden of mental illness, especially amongst children and young people, and their population is ageing and their society is increasingly diverse. The weather may be warmer, but the medicine is not fundamentally different. And this is not merely an assertion. My Lords, Shmuel has now got four completed cohorts, 147 graduates who have transitioned safely into the NHS and are performing exceptionally well. Why would they not? More than half of them are UK nationals.

All are fluent in English. All have been trained to practice in the NHS. These doctors or these students seek no advantage. They only ask not to be disadvantaged because the campus of the UK university is overseas. The numerical impact on domestic graduates would be negligible. The government's target competition ratio of two applicants per foundation place would still be met. There is also, my Lords, and a question of consistency. These campuses are not are not independent foreign providers. They are integral parts of UK public universities.

Any surplus is ploughed straight back into the London campus. It is difficult to justify a framework that prioritises graduates trained in wholly separate third country systems, while excluding graduates of UK universities who deliver identical GMC approved programmes that risk prevailing geography over substances equivalent. A smaller but equally as important point. The bill also places at risk a reciprocal arrangement under which approximately 30 Maltese doctors undertake speciality training in the UK each year, 33 around 70% of their salaries are covered by the Maltese government.

They work in non-numbered posts and are contractually required to return home. This has been a mutually beneficial arrangement for decades and it would be unfortunate if it were lost unintentionally. My Lords, I have listened carefully to the concerns about capacity, workforce planning and fairness, and I do not dismiss them. But the numbers here are small, stable and capable of oversight. This is not about drawing red lines. It's about correcting a narrow and unintended consequence. The essentials are simple recognition of these two GMC approved UK programmes, overseas ministerial oversight of numbers, fair treatment of a very small cohort of UK qualified graduates who have demonstrated that they can serve well in the NHS.

My Lords, I do not intend to divide the House today as I agree with the principle of the Bill and do not wish to delay, but instead I invite the Minister to confirm from the despatch box that she will work with colleagues across government, universities and interested parties to agree a clear mechanism, whether by guidance or memorandum, that secures consistency for Maltese doctors needing to finish their training, and also to commit to renewing to reviewing the impact of this legislation on the small numbers of affected students, including the refugee doctors we have just heard from, while fully preserving the government's policy intent.

And I look forward genuinely to working with the Minister to get this right together. Thank you.

**** Possible New Speaker ****

My Lords, I'd like to speak in support of these amendments so ably introduced by the noble Lady Baroness Lister of Burtersett and Baroness Lister of Burtersett and by my noble friend Baroness Gerada, who've outlined the very distinct and different problems from these groups. The Newcastle curriculum is one that I know more about than the one that I know more about than the other, but it really does appear to be identical. And there are problems for therefore those graduates in terms of feeling that because of geography, their qualification is effectively second rate rather than of equal status.

And that becomes particularly important when we go back to the point I made earlier about recruiting for excellence for our NHS and for people to work here. The other point that I would like
17:04
Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (Crossbench)
-
-
to make, and I am most grateful to the noble Lady, the Minister, for having had such an open door, both having had such an open door, both to a face to face consultations and to telephone conversations, which to telephone conversations, which have been helpful in clarifying issues in terms of the asylum seeking and refugee doctors. There seeking and refugee doctors. There are eight schemes at the moment in the UK, and they are coming the UK, and they are coming together to coordinate to meet the needs of this very particular group.

This group are different to many of the others who've come here to train, because many of these doctors have been working in their home countries and gained a great deal of experience clinically, their experience in trauma in particular, can be particularly useful given major accidents and the fact that they have often managed trauma in very, very difficult situations. But when they come here, they need effectively to retrain from the beginning. And that takes a huge commitment. I did ask about the role of working as a care assistant deliberately, because I know of UQ of Ukrainian refugee doctor who is currently working as a care assistant and has been almost from the time that she arrived here, although she was a very senior consultant paediatrician in Ukraine.

she's working as a care assistant in order to be able to pass homes and the stages that she needs to to get through. So I think it will be very helpful in summing up, if the noble Lady, the Minister, can tell us if she knows how many of these doctors there are and at what level their experiences. And if she can't today, perhaps she could write to us with that, but also looking forward to future proofing. I can see the difficulty, although I find it hard to accept over both Newcastle and Queen Mary curricula.

But we also had the point raised at Committee stage over Bahrain, where again, that curriculum is effectively identify identical to the Irish based qualifications. And in the Bill in clause 43B it's there is a statement that the person in that subsection did not spend all or a majority of their time training for that qualification outside Ireland, and therefore, I hope that the Minister will be able to provide us with very firm reassurance that this bill is future proofed.

The Bahrain curriculum will not be easy to change so that students spend 51% plus of their time in Ireland, but I do see a potential danger over the years ahead that if this is not carefully monitored, another medical school could open a curriculum which is offshore and potentially 51% versus 49%, which would mean it would come in under this bill as a prioritisation, but actually would then disadvantage the two medical schools which we have been debating and to which my noble friend Baroness Gerada has spoken so powerfully today and has argued so powerfully for so.

I hope that the future proofing aspect will also be addressed. In her summing up.

**** Possible New Speaker ****

I would also like to. Support amendments 12, 13 and 15, and amendments 12, 13 and 15, and particularly to echo the points made about the more general implications of the issues here. And I declare an interest as an employee of King's College London. What we are talking about here are effectively English medical degrees. effectively English medical degrees. That's what they are approved as effectively, and that's what they are seen as by the world. And I think we should pause and think very hard before we give the impression to the world that we don't actually take our own legislation and our own regulations very seriously, because this really strikes at the heart of the reputation of our higher education system, which has been long earned and I think is still well deserved.

We're talking here about courses of
17:08
17:09
Lord Patel Portrait Lord Patel (Crossbench)
-
-
My Lord. >> My Lord. >> I might end up sounding like a broken record, but I hope he's broken record, but I hope he's still playing well. Before I say what I have to say, can I first declare my interest? Although it's probably quite irrelevant that I am an emeritus professor at University of Dundee and have been previously as Chancellor. There are fellow of the Royal Medical Colleges, and that I'm associated with several universities in the United Kingdom that have medical schools.

Having said that, and I congratulate Baroness Gerada on her most eloquent and powerful case she made for Malta and Queen Mary to be considered a special case. I think she just about succeeded in doing so, that that is a special case aside that the broken record bit about me is going back to the UK. Medical graduates, 7.6% of graduates of United Kingdom University are overseas citizens, but they're all trained in the same curriculum with the same degree from UK universities.

And there are several universities who take these students to longer list to list my Lords. And UK overseas campuses. Universities, of course, have the same curriculum because the GMC recognised institution and therefore is curriculum GMC does not give recognition to any training programmes that are not not same as the curriculum they wish for the graduates that graduate. So whether it's a campus or whether it's associated with the university, the curriculum is what GMC approves and therefore it approves the institution.

Now there are other universities, UK university campuses apart from Newcastle that has 107 trainees. Doctors in in Malaysia. Barts London has university association in Malta. I'm told by GMC that has 69 graduates. Queen Mary in London as we heard 49. So that Southampton Medical School is approved for a medical course in Germany with 23 candidates. Saint George's, London, as we already heard, had quite a small number. I was told it was nine, but I did Baroness Gerada point there were seven.

There are two more schools who are seeking GMC approval Swansea and Mauritius and Exeter in Athens. I have no doubt that other medical schools will also jump on the same bandwagon. And after today's debate, no doubt they'll make sure that their curriculum is similar to the ones that are followed in UK. So there are degrees from overseas campuses are also recognised now. No objections to any of these. And as I said, Baroness Gerada have made a very strong case for Malta and Queen Mary.

But I do make the point that if you add all these up, we're increasing the priority groups that challenges UK medical graduates further. And that's the only case I'm making.
17:13
Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Labour)
-
-
But my my Lords like Lord >> But my my Lords like Lord Roborough Lord Patel, I apologise for coming back to the substance of the debate in the first group. the debate in the first group. First of all, I think we should pay tribute to noble Baroness Brady Gerrard for the way she's approached these issues, her amendments, which I actually agree with, are very tightly drawn to Mortar and Newcastle and the fact that, my Lords, that she's been engaged with my noble friend, she's asked for certain assurances from my noble friend, and I hope my noble friend will be able to respond to it.

But what this identifies is the madness of the situation that we have with UK universities, with their campuses abroad, the students often coming from the UK, going over there to study in the hope that they then can come back to the NHS and apply for speciality training places. And if ever, my Lords, one wanted a reason for why we need a fundamental wholesale review and reform of the whole gamut of medical training. This is it and my fear, my Lords, here is this I chided Baroness Gerada about the Royal Colleges leadership in this area, because I actually think I do think the colleges should take leadership.

And can I say that under her leadership of her college and indeed Lord Patel, we had the examples of the kind of leadership that we desperately need now from the medical Royal colleges. But, my Lords, more than that, there is so much to be done about the way newly qualified doctors are dealt with and supported or not supported within the NHS, which we cannot run away from. And Baroness Gerada is so right. There have been so many endless reports about this, but when you get down to it, when you get down to actually discovering what CEOs and medical directors are actually doing, what the senior consultants in these individual hospitals are doing, you find an abdication of responsibility.

So, my Lords, in a sense, I very much support the government in their approach. I think Baroness Gerada has done a great service to the House in the way she's approached. What incredibly difficult issues, particularly for the the medical graduates involved at the moment. But, my Lords, I hope my noble friend can assure us that this, if you like, is a start of a process of moving towards a wholly improved system of medical training, education.

The link between undergraduate medical places and the speciality training. In order that we get ourselves out of this very, very difficult situation.
17:16
Lord Clement-Jones Portrait Lord Clement-Jones (Liberal Democrat)
-
-
Is a pleasure to follow. The thoughtful contributions of the noble Lord Hunt of Kings Heath and noble Lord Hunt of Kings Heath and I rise to give our strong support for amendments 12, 13 and 15, which have been so convincingly spoken to by the noble Baroness Gerada, and indeed by other noble Baroness noble Baroness Finlay of Llandaff and Baroness Wolf of Dulwich, my Lords, and like the noble Baroness Gerada I, I want to thank the Minister for her engagement with us on this particular issue.

Despite the swift passage of this bill and her rather disappointing response during the course of those meetings. My Lords, as I've declared at previous stages, I'm the former chair of the Council of Queen Mary, University of London, and my concern is for many of the medical students at Queen Mary Malta's campus and Newcastle's Malaysia campus who are affected by this bill, for that is the most pressing issue at hand. The human cost of this legislation in this current form.

Over the past few weeks, we've received deeply distressed correspondence from these medical students. Many of these students are British citizens who went overseas to study precisely because of the lack of medical school places here. These students enrolled in these GMC approved courses on the explicit, documented understanding that their degrees were completely identical, delivered in London or Newcastle, and that they would enter the UK Foundation Programme on equal terms to pull the rug from under them. Now changing their status to international midcycle, just as they prepare to graduate is procedurally unfair and totally unacceptable.

They made irreversible life and financial decisions based on over a decade of consistent UK government practice. We cannot treat the futures of our own UK registered university students with such disregard during the Committee stage and in her subsequent letter to peers dated 20th February, the Minister sets out her reasons for resisting the inclusion of these students. And on these benches we've listened carefully. The amendments before the House today have been entirely redraughted to address and dismantle every single one of those technical concerns.

First of all, the Minister argued that the government cannot control the numbers from overseas campuses, fearing a loophole that would place financial pressure on the NHS and undermine workforce planning. My Lords, we can fix this. Amendment 12 explicitly restricts eligibility only to overseas campuses of UK registered institutions that are extant on the day on which this act is passed, the door is firmly shut to future creep. No university can open a new campus tomorrow and exploit this route in the way that Lord Patel has described.

Furthermore, to address the minister's specific fear of uncontrolled numbers, amendments 13 and 15 grant the Secretary of State a new statutory power to explicitly cap the maximum number of eligible persons from these campuses, with roughly 50 to 70 graduates a year from Malta and around 120 from Malaysia. We're talking about fewer than 200 students in a system of over 11,000 places. They represent zero threat to workforce planning. And with this amendment, the government now holds the absolute lever to control the volume.

The Minister believes that this would mean opening the door to Irish university campuses from our conversations, and it would mean a total of 300 students because of the Windsor Agreement. My Lords, my Lords, I hope the Minister will explain why they need to be linked when she speaks directly to the noble Lord. Darcy's amendment 12 a secondly, the Minister argued in her letter that these students should be excluded because they lack familiarity with local epidemiology in UK clinical placements.

And with the greatest respect, my Lords, this argument simply does not hold water either, as the noble Baroness Gerada, with her immense medical experience, has explained the primary conditions driving NHS demand are fundamentally the same across these nations. Crucially, these students study exactly the same curriculum, take the same UK medical licensing assessment and graduate with the identical GMC approved primary medical qualification as their peers in the UK. And we have the evidence of four graduated cohorts from Malta and over ten years from Malaysia who've transitioned seamlessly and safely into NHS practice.

And my Lords, as we've discussed before, if the government truly believes these students lack clinical familiarity, how can it justify clause four of its own bill? The bill prioritises graduates from Switzerland, Iceland, Norway and Liechtenstein. A graduate from Liechtenstein has no UK medical degree, has not sat the UK assessments and has no training in UK epidemiology. And we're told that this is due to free trade agreements requiring us to recognise comparable qualifications. It's legally, diplomatically absurd to voluntary prioritise comparable qualifications from the EU, while rejecting identical qualifications from our own UK public universities.

Thirdly, my Lords, the Minister cites the need to protect the British taxpayer's investment. My Lords, the students at Queen Mary, Malta and Newcastle, Malaysia are self-funded. They provide the NHS with fully trained UK aligned doctors at zero educational costs to the public purse, turning away a pipeline of debt free UK trained doctors is economically illiterate and contradicts the government's own value for money logic. And finally, my Lords, as I said at Second Reading, we risk breaking a solemn international commitment.

Since 2009, the UK and Malta have operated under a unique mutual recognition agreement regarding the Foundation Programme, which was recently renewed by the Department of Health as recently as 2024. To sever this now, even in spirit, damages our bilateral relations and actively sabotages the Department for Education's own strategy to export British higher education globally. My Lords, these amendments are safe, narrow and pragmatic, as has been described. They offer the government exactly what they asked for control caps and the closure of loopholes.

And they protect a tiny cohort of students from unacceptable mid-term uncertainty. And they honour our international agreements. So, my Lords, I do strongly urge the Minister to accept this solution.

**** Possible New Speaker ****

My apologies. Lord Darzi emailed me at noon

**** Possible New Speaker ****

Lord Darzi emailed me at noon today to apologise that he couldn't be here because he had a patient to look after, but I think the look after, but I think the Baroness Finlay had covered his amendment adequately. So thank you
17:24
Lord Mohammed of Tinsley Portrait Lord Mohammed of Tinsley (Liberal Democrat)
-
-
amendment adequately. So thank you sir. I will. >> Rise briefly to offer our support from these benches to both support from these benches to both the amendment number 11 and Baroness Lister name, but also the amendments in Baroness Gerada. I want to just briefly talk about the amendments in Baroness Lister name, particularly if I'm sure other noble Lords would have had this email from the young, the woman from Ukraine who set out her concerns having so gratefully, you know, we as a nation proudly welcomed and gave safe sanctuary to particularly just women and children, predominantly from Ukraine and therefore, because of the conflict in our country, she has not been able to, you know, fulfil her dream of being a doctor and has tried to navigate through the system, through the care, working as a care worker, and would like us to be able to support her and all.

I want to plead to the Minister when she does rise to speak is, can we not at least have some flexibility in terms of when it comes to specific circumstances? We've been so generous as a nation, welcoming these people who are, you know, if they had their way, would be in their country, and they want to continue to build on the education they had in their nation. And I'm sure there'll be others as well. Whether there is some flexibility on that. And I really hope when the Minister does rise that she's able to comment.

And in terms of just the amendments by Baroness Gerada, can I just say, when we had this discussion before the holiday break, it was very clear that what we were asking for is those two overseas medical schools, they are the only ones that are active. Now we're being clear, the amendments are being cleared, that no other schools will be allowed to actually open up and take go through the loophole that some members of your Lordships' House has talked about, and we are talking about some very small numbers.

But those numbers are important because we've also had those emails from British nationals who have gone to study abroad with the expectation. And like my previous group discussion mid-cycle, we are now changing the rules for them. And I think there has to be some level of flexibility. And I really hope that when the Minister does rise, that we can OK, fine. You know, we want this bill to go through, but we would like this bill to be a bit more fairer than it is at the moment.

And I did talk about previously, my Lords, about the unintended consequences of pushing through this, because if you know, a lot of the funding for these two campuses comes from overseas, so it's not actually costing the UK taxpayer money, but it is a pipeline. As my noble friend Lord Clement-Jones spoke about. And I know when we heard Lord Forbes previously, and I know when I've spoken to Lord Shipley of Newcastle, they've both been very strong in supporting the overseas campus that Newcastle University has in Malaysia.

So I really hope when the Minister arises that she is supportive of these two universities, only these two universities, because there's no other in this particular circumstances.
17:27
Earl Howe Portrait Earl Howe (Conservative)
-
-
Yeah.

**** Possible New Speaker ****

Fair. My Lords, the amendments in this group all seek to change the definition of the priority group. We debated the principle behind We debated the principle behind Lady Girardis and Lord Darzi of Denham amendments in committee. And I shall come back to Lady Gerada, I shall come back to Lady Gerada, if I may, in a moment. Meanwhile, the noble Baroness, Lady Lister's the noble Baroness, Lady Lister's amendment is seeking to include a new group of people who should be prioritised for medical speciality training places.

We've not, as she said, debated this precise issue before and she argued the case. I thought very powerfully, but I would just observe briefly that we need to come back to the object of this bill, which is to resolve the specific problem of UK medical graduates having insufficient priority in accessing medical speciality training in UK workforce planning. I do think that our prime focus should be on those young UK doctors who have put so much effort into their studies, and who now want to progress further in the NHS.

I appreciate the force of everything the noble Baroness, Lady Lister has said, and I observed earlier that we aren't living in an ideal world, but for the reasons given, I'm not convinced that including an additional group in this case, those who've come to the UK from Afghanistan, Ukraine, Syria or Hong Kong will necessarily improve the effectiveness of the bill in resolving the problem. It's designed to address that those doctors are not, and surely cannot be part of the NHS workforce planning framework.

That said, I think we can all agree that where an individual comes to the UK through a safe and legal route as a legitimate refugee, and they have skills to offer our country, we should welcome them offering those skills. It would therefore be helpful to know from the noble Baroness, the Minister, what support her department is giving and will give to medically trained people who've come to the UK legally and who wish to serve in the NHS.

I want to say some brief but important things about Lady Gerrard's amendments without I hope, repeating what has been said. The merits of her case were ones which she powerfully presented in committee, and she's done so again today. I just want to highlight three key points. The first key point to my mind is that Shmuel's campus on Malta and Newcastle University's campus in Malaysia are not, quote, foreign institutions. Yes, they may be physically located abroad, but constitutionally both of them are UK institutions and the qualifications they award are UK qualifications based on a UK prescribed medical curriculum.

Doctors have made career plans based on that long understanding. Therefore, to badge graduates from those overseas campuses just as international medical graduates, which which is the implication behind the government's position is, I think, doing them a grave injustice in my submission. They're not international medical graduates in the sense that we normally understand the term a point well made by the noble Baroness, Lady Findlay. Secondly, the graduates from those two campuses are very few in numbers.

We've heard fewer than 200 in a given year, which is a drop in the ocean when it comes to factoring them in to UK workforce planning. And make no mistake, they could be factored in if there was the political will to do so. Now, of course, the numbers should not be allowed to get out of hand. It should be perfectly possible, as Lady Gerada suggests, for the government to cap the overall totals by means of an order making power, which was an idea I actually put forward in in committee.

Thirdly, and following on from that, I'm advised that Shmuel and Newcastle University are the only examples of a UK institution with overseas campuses constituted in precisely this way. And lastly, my Lords, if we look at Malta in particular, the historic relationship that the UK has had with that noble island across so many fields, not just medicine, is by any standards a special one. So again, I believe that all that's needed is a bit of political will to get those Malta trained graduates over the line so as to be counted alongside graduates from the Efta countries really isn't much to ask.

So like the noble Lord, Lord Hunt of Kings Heath, I hope the Minister will regard all these matters as unfinished business, which she and her department will wish to pursue and resolve. Yes,
17:33
Baroness Merron Portrait Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)
-
-
My Lords, I'm most grateful to noble Lords across the House for their thoughtful contributions in this group. And the noble Lord Earl Howe reminded us to come back to the prime focus. This is in respect of amendment 11, which I will start with, and I do feel that's important. It is about supporting and being fair to UK medical graduates and whom we have invested. But it is also a group from whom we seek so much and we are grateful to them.

And it's also about providing safe and appropriate care. So to continue on the matter of amendment 11, tabled by my noble friend Baroness Lister, I do appreciate the intention behind this amendment and the government, for the reasons I will outline, is unable to support it. The Bill, as noble Lords will be familiar with, does prioritise applicants based on certain specific immigration statuses for speciality training in 2026, these statuses have been carefully chosen for the reasons that I have said a number of times, which is as a practical and a proportionate proxy for applicants who are most likely to have significant NHS experience.

And I would also want to reiterate, as I've said a number of times, that this bill is not about exclusion of any groups or individuals, it is any groups or individuals, it is about prioritisation and to refer to the request of my noble friend Baroness Lister, which was emphasised by the noble Lord Lord Mohammed. Perhaps I could make this point just to remind your Lordships House that for 2027 onwards, these statuses will not automatically apply. Instead, there will be the power to make regulations to capture and to prioritise persons with significant NHS experience based on other criteria or by reference to immigration statuses.

To reassure my noble friend, we have already committed, and I'll do this once again to a proper engagement process, subject to the bill's passage, of course. But to ensure that any future definition is fair, evidence based and deliverable. My Lords, this amendment 11 would prioritise groups with different immigration statuses which are not an appropriate proxy for significant NHS experience. This is not consistent with the aims of the Bill. The amendment would also have the effect of permanently prioritising applicants on the basis of immigration status, for both foundation and speciality training.

The applicants with the immigration status is listed in the amendment. Who are not otherwise prioritised are, as I have already said, but it bears repeating, not excluded from applying for foundation or speciality training. They may still be offered a post if there are places remaining. Once all prioritised applicants have been allocated posts, they also remain eligible to apply for locally employed doctor roles. So on this basis, I do hope that my noble friend will feel able to withdraw her amendment.

Turning to amendments 12, 13 and 15 tabled by the noble Lady Baroness Gerada. My Lords, I do, as many of us do, appreciate the intention behind these amendments, and I'm most grateful to the noble Lady for her work on bringing these amendments in the way that she has back at Report stage, having heard the arguments previously at Committee stage, and I appreciate her work on them both inside this chamber as well as well as outside, and the way in which she so clearly and powerfully as other noble Lords have said, have has made her case.

I know the noble Lady is aware, and also my letter that I sent to all out peers. This has also been emphasised. The government is, however, unable to support these amendments. Let me just explain to your Lordships House why this is the case. This bill prioritises doctors for foundation and speciality training based on where they are trained. It also prioritises internationally trained doctors with significant NHS experience. Speciality training. Why are we doing this? Because these doctors are more likely to work in the NHS in the long term, and also to be better equipped to deliver health care that is tailored to the UK's population, because they will better understand the UK's health system and epidemiology.

My noble friend Lord hunt and he spoke to this point. I believe also in the previous group. While assessments and course learnings at overseas campuses may well be the same and I accept that as in UK based medical schools, students will not have undertaken same amount of clinical placements in the NHS in the United Kingdom. I know that the noble Lady Baroness Gerada in her email to all peers or to a number of peers, I'm not quite sure.

Did argue that her amendment did not widen eligibility for prioritisation beyond the government's intentions. This isn't the case. The bill, to reiterate, intends to prioritise home grown doctors and put them at the front of the queue for training posts. It's unashamed for the reasons that I have explained in noble Lords, understand doctors who have trained here and undertaken their placements in our hospitals and health settings will have more familiarity with the NHS and the needs of the patients that they serve than a doctor who has studied the same curriculum, but not in the UK.

The Bill recognises that this experience can be gained, however, without spending the entirety of one's degree. In the UK, however, the line has to be drawn somewhere and where the majority of a degree has been studied outside of the UK, it is right that those graduates are not prioritised equally alongside UK trained medical graduates. And to pick up the point about future proofing that the noble Lady Baroness Finlay raised, we do recognise them. The risks of this creating a loophole in the legislation.

If medical schools purposefully change their curriculum to ensure their graduates come from within the priority status. However, as we discussed earlier today, this risk would exist at whatever threshold we set. But as the noble Lady has raised, I can give the assurance we will we will continue to monitor the data carefully in future years. For all of the important reasons that the noble Lady has said, My Lords, the Bill does prioritise all graduates of UK medical schools who have studied for their degree in this country.

That's the right thing to do for our health system because we recognise, as I said, these doctors are well prepared to work in that system and are more likely to stay. It is also right and fair to do this for graduates of our medical schools. It treats all graduates of equals, regardless of where they're from. As the noble Lord, Lord Patel referred to, prioritising graduates from overseas campuses would also undermine. And these are my words, not the noble Lords would also undermine our aim of greater social mobility and access into medicine when we need to dramatically improve access to this profession.

For for those from disadvantaged backgrounds, from across our communities, in order that our medical practitioners can be more representative and serve the communities from where they come, these campuses are commercial ventures that we are speaking of, and students are generally self-funded, including these graduates in the priority group would undoubtedly undermine the efforts of the bill to support home grown talent to the noble Lord Clement-jones. And I'll make a number of points to deal with the points that the noble Lord has raised.

I understand that the proposed amendments do seek to restrict future eligibility by prioritising only those campuses that are extant on the day the act is passed, and also to create a power which enables us to limit the number of eligible applications under the provision. Under this provision, it is, however, the case that these overseas campuses establishment and operation do sit outside the UK government's workforce planning and commissioning decisions. We have previously set out that we expect that all eligible prioritised applicants for the Foundation programme in 2026 will get a place.

So accepting these amendments, even with the suggestion of capping the numbers that could be prioritised from these campuses, would mean we would have to fund more foundation programme posts than we need. There has been a talk, not just in the chamber, but outside about figures. So let me clarify that. Current UK Foundation Programme applications for 2026 show almost 300 applicants from overseas campuses of UK and Ireland medical schools. This is my Lords, a significant number and to prioritise all of this group would require substantial additional expenditure for these posts.

A rough estimate is around 25 million over two years. This is funding which, if it went in this direction, could not be spent on other priorities, including increasing speciality training places which I know is of great interest to noble Lords. In addition, the proposed amendments would not have any effect on overseas campuses of Republic of Ireland medical schools and so would conflict with provisions in the rest of the bill which treat Ireland graduates on the same basis as you as UK graduates.

Reflecting the unique relationship between the two countries. That's said by Lords. The government does recognise the concern that have been concerns that have been expressed about students who are approaching graduation from overseas campuses. While these graduates will not be prioritised under the arrangements set out in the bill, they will continue to be eligible to apply for Foundation programme places and will be able to secure a place where posts remain available. In addition, many will have the opportunities to undertake foundation or equivalent training overseas, not least in the countries where they have studies studied, meaning they are not left without progression.

Routes. The noble Lady Baroness Gerada did ask about an assurance which I hope I, the noble Lady, feels I'm able to offer. Whilst we can't agree to any amendments to prioritise graduates from overseas campuses, the government will of course, as for all legislation, keep this bill under review after it has been commenced to ensure that it delivers its policy intent and does not create any unintended consequences. And as I set out in committee, my Lords, I would also like to reassure the noble Lady and noble Lords that the UK's long standing partnership with Malta on healthcare, on healthcare is highly valued and will continue the affiliation of the UK Foundation Programme and Malta Foundation Programme will still stand.

I also do recognise the noble Lady Baroness Gerada as concerns about the impact of the Bill on existing fellowship schemes with Malta. I would like to reassure the noble Lady that this Bill will not impact on such schemes. As I set out at committee, my officials had a very constructive discussion with the Commissioner of Malta to the United Kingdom earlier this month, as agreed at that meeting, which I am also glad to confirm and perhaps go beyond for the noble Lady in terms of explanation, as was agreed at that meeting, officials will be working on an agreement with counterparts in Malta that safeguards existing arrangements and does enable Maltese doctors to gain valuable experience and training in the NHS through sponsored Non-numbered local fellowship posts.

For the reasons that I've stated, we are unable to support these amendments and I hope the noble Lady feels able to withdraw them. Turning to amendment 12, a tabled by the noble Lord Lord Darzi, who is not able to be in his place. And I'm grateful to the noble Lord, Lord Patel, for explaining the work, and we wish him well in his work today. Why that is the case. And it was also referred to by the noble Lord Lord Clement-Jones.

The government is unable to support amendment 12 a for these for the following reasons. Under the amendment, graduates of overseas campuses of Irish medical schools would be prioritised on the basis of course equivalence alone. These graduates would be prioritised for UK Foundation programme posts equally with UK medical graduates, whereas in Ireland they are not prioritised for the internship year. The equivalent of the Foundation programme. I don't want to repeat the arguments that I've already made about why we're unable to support Baroness, the noble Lady Baroness Terada's amendments on UK overseas campus graduates.

However, many of the same considerations are relevant to amendment 12 a including the creation of what would be a financial and operational pressure on the foundation programme, undermining efforts to widen access into medicine on those from disadvantaged backgrounds and prioritising home grown doctors. I should say that the government has already gone to considerable lengths in the bill, considerable lengths to prioritise graduates from the Republic of Ireland who have studied there. That is the right thing to do in the context of this bill, and it does reflect the nature of the relationship between the UK and Ireland, which is unlike its relationship with any other country.

Equivalent treatment for graduates of Irish universities reflects this relationship. Perhaps to develop that a little further for the noble Lord Clement-Jones without the equivalent treatment of Irish medical graduates, a person educated in the Republic of Ireland would be denied employment opportunities in Northern Ireland or Great Britain on the same terms as a person educated in Northern Ireland that would limit the ability to move freely across the island of Ireland and across Great Britain and Ireland for education.

However, if taken in isolation, amendment 12 a if taken in isolation from the amendments tabled by the noble Lady Baroness Gerada this amendment would, as I've said, introduce an inconsistency in respect of how graduates of overseas campuses of Irish medical schools would be prioritised where graduates of overseas campuses of UK medical schools are not prioritised. So whilst these graduates will not be prioritised again, they will remain eligible to apply for Foundation Programme places and may secure posts where places remain available, including opportunities to train overseas, and that the noble Lord Earl Howe asked the general point about the support that the department gives to medically trained people who come to the UK legally and wish to serve the NHS.

And forgive me for not doing this in the right place, but I didn't want to miss the opportunity. But we do recognise the unique and very difficult circumstances that are faced by applicants for with refugee and other humanitarian based immigration statuses, and we are grateful for the contribution that many make to the NHS along the way. I hope that my reference to what will happen following 2026 can be helpful in that light. So for all of these reasons, the government can't support, as I said, amendment 12 A and I hope if it is to be considered for moving, that the noble Lord will whoever noble Lord or noble Lady will feel able to withdraw.

Amendment 12 I.
17:52
Baroness Lister of Burtersett Portrait Baroness Lister of Burtersett (Labour)
-
-
My Lords, I'm very grateful to the noble Baroness, Lady Findlay of Llandaff, and the noble Lord Lord Mohammed of Tinsley for for their support for amendment 11. And I'm grateful to the noble Lord Howe, which I thought was very fair response that he gave to it. I, I mean, I'm there was clearly very strong support for the noble Baroness, Lady Gerada, who I think made a very good case for for why it was a very what she was asking for was very limited, but clearly can't.

It's not something that the government feel able to support, where I take some comfort from is what the noble, my noble friend said in regard to future engagement, and particularly with regard to refugees. What she said at the very end, in response to noble Earl, Lord Howe, because it is. I just think I would want to say emphasise that. I really hope that this process of engagement will include the groups working with refugee doctors so that there may be, perhaps hope at for, if not this year in future years, that their needs may be recognised, and similarly that the that what's the case has been made today by the noble Baroness Brady gerada will be taken into account when this engagement process starts.

I mean, perhaps I won't, not now, but perhaps the noble my noble friend could write to us about, give us a bit more idea about what this engagement process will involve, when it will take place, who will be engaged, and so forth. But with that, I beg leave to withdraw the amendment.

**** Possible New Speaker ****

Mr. Lord Prentis amendment be withdrawn. The amendment is withdrawn. The amendment is withdrawn. Amendment 12 Baroness Gerada not moved. Not moved. Amendment 12 a Lord Darzi not moved. Amendment 12 a Lord Darzi not moved. Amendment 13 Baroness Gerada not moved in clause seven, amendment 14

**** Possible New Speaker ****

Lord Mohammed of Tinsley. And I wish to speak to amendment
17:54
None Portrait AMDT: 14 Lord Mohammed of Tinsley (Liberal Democrat)
-

14 to clause seven in the Bill, which would ensure that all regulations under this act are subject to affirmative resolution, procedure, or, in simple terms, any procedure, or, in simple terms, any changes that a future Minister or government makes that both houses government makes that both houses of Parliament get to have a say in and get to have a vote? This is not a narrow technical point. It goes to the heart of parliamentary accountability and to a fair and transparent governance or medical training policy.

The bill confers broad powers to Ministers to determine key aspects of how prioritisation will operate. These include. Potentially definition, ability, scoring frameworks, exemptions, transitional arrangements and other detailed rules that will shape the careers of tens of thousands of doctors. At the Committee stage, noble Lords expressed concerns about the breadth of delegated powers in the Bill and the limited parliamentary oversight of these powers, and during committee. It was evident from the debate that members of your Lordships' House share the view that regulatory power make decision making powers is vast and open ended.

Yet the bill envisages only a negative procedure for most regulations, meaning the regulations can come into force less actively and this falls short of the level of scrutiny appropriate for measures of such significance. My Lords, it's precisely because of the impacts of this legislation on individuals career and NHS workforce planning that affirmative resolutions is a right standard. Ministers should be required to lay each Statutory Instrument before both houses, and obtain explicit parliamentary approval before they can take effect.

This gives the House the opportunity not merely to debate, but to approve or reject the detailed rules that give effect to the policy to ensure that changes are not made by default or through omissions, but by the conscious decisions of Parliament. Medical training policy is not static. It will evolve in response to workforce needs, technical standards and educational practices. There is nothing wrong working with flexibility. There is something wrong with flexibility. Exercise without open scrutiny. My Lords, doctors plan years ahead.

They make life choices on the basis of published criteria to allow Ministers to adjust those criteria by regulation without positive endorsement by this Parliament, risk unpredictability and unfairness. Affirmative resolutions does not prevent governments from acting. It simply ensures that Parliament is properly informed and engaged in strengthening trust in the process and respect the role of this House is scrutinising public policy. Given the far reaching nature of these measures that could be set in regulation. And affirmative procedure is not just desirable, it is necessary, my Lords, for these reasons, I really hope that noble Lords will back my amendment.
17:57
Lord Kamall Portrait Lord Kamall (Conservative)
-
-
Yeah, yeah. >> Amendment proposed clause seven, page four, line 39. Leave out subsections 1 to 4 and insert. Regulations under this act are subject to the affirmative procedure. My Lords, I should advise the House that if this amendment is agreed to, I cannot amendment is agreed to, I cannot call amendment 15 by reason of

**** Possible New Speaker ****

pre-emption. My Lords, can I thank the noble

**** Possible New Speaker ****

My Lords, can I thank the noble Lord Lord Mohammed of Tinsley for opening debate on this group and the numerous noble Lords who spoke the numerous noble Lords who spoke to it. Can I also, I perhaps should at this stage also declare redeclare my interest. I am a professor of politics and international relations at Saint Mary's University, Twickenham, and I have been I teach a module on I have been I teach a module on healthcare policy and strategy, and I have been helping them with their new medical school.

I also work with the Vincent Centre for the centre for the Public Understanding of Entrepreneurship at the University of Buckingham, who also have a medical school. But I have no direct connection with the medical school there. Hopefully I touched all potential conflicts there. Both his amendment and amendment 16 in my name were debated at Committee stage, so I do not intend to repeat the arguments that were made then. However, I think it would be helpful if we reminded ourselves that we are dealing with emergency legislation, and I think this is the key.

The Constitution Committee has warned that the government's overuse of emergency legislation, not least because when we legislate in this way, we risk creating unintended consequences. So we should be very careful and selective in using emergency attestation. So in that context, it does not seem unreasonable that your Lordships House should be given an opportunity to scrutinise secondary legislation in more detail through the affirmative procedure. And I very much hope that the Minister will take on board the concerns about the about it, about an affirmative procedure rather than other procedure.

Turning to amendment 16, which I retabled for the debate today, and I retabled it because I'm afraid I was not completely satisfied with the response from the noble Lady, the Minister at Committee stage. I'm sorry to say that, but I wasn't completely satisfied on that occasion. The noble Lady, the Minister, explained that the government's view is that commencement commencement may not happen with Royal Assent because the changes introduced by the bill are, and I quote, a major undertaking and quote, there is a material consideration about whether it is even possible to proceed if the strikes are ongoing.

However, in the same speech, the noble Lady, the Minister explained that this is emergency legislation which has been brought forward as quickly as possible rather than wait another year to do so. So on the one hand, this is a major undertaking that, in the words of a noble Lady, the Minister cannot be switched on overnight. Yet at the same time it is emergency legislation that cannot wait. My Lords, it has been suggested by a number of noble Lords that there appears to be some tension, perhaps contradiction, between these two statements, which may create a confusing situation for all.

So, to help noble Lords, could I ask the noble Lady Minister to be a little bit clearer today and to answer three specific questions? When will the provisions of this bill be implemented? If the noble Lady, the Minister, cannot say because of external factors such as strike action, can the noble Lady, the Minister, tell the House when they will be implemented assuming strike action continues? And question three when will they be implemented? If strike action actually comes to an end, I would suggest that it would be to the benefit of all involved to know a little bit more clearly how the government intends to proceed from here, and I hope I've offered an opportunity to the noble Lady, the Minister, to clarify for all concerned.
18:01
Baroness Merron Portrait Baroness Merron, The Parliamentary Under-Secretary for Health and Social Care (Labour)
-
-
Well, my Lords, I'm grateful to the noble Lord, Lord Carmel and the noble Lord Lord Mohammed for their contributions in this group of amendments. And if I can turn first to amendment 14, tabled by the noble Lord Lord Mohammed, as I stated, Committee, we are unable to support this amendment, so it might be helpful to your Lordships House. Have I am clear about our intention, which is, as your Lordships' House is aware, the Bill does set out on its face the groups of people who are to be prioritised for speciality training from 2027 onwards.

The delegated power about which we are speaking is limited to adding to this list. By referring to the significant experience of working as a doctor in the health service or immigration status. So it is, in my view, tightly drawn. Similarly, we have set out on the face of the bill, speciality training programmes excluded from the prioritisation scheme. So again, I can give the reassurance that the delegated power about which we are speaking is limited to amending this list and gives necessary operational flexibility to future changes in recruitment, training and workforce needs.

Something that was raised in an earlier group by noble Lords. I am, I hope noble Lords are aware, always supportive of parliamentary scrutiny. However, we do believe that due to the very limited scope of these powers that the negative procedure is appropriate. Not least, the regulations will not have the effect of excluding anyone from applying for a training post. Helpful. I hope to remind noble Lords that the Bill has been assessed by the Delegated Powers and Regulatory Reform Committee, and no suggestion was made that the negative procedure was inappropriate for this regulation.

I therefore hope that the noble Lord will, with, with that explanation, feel able to withdraw his amendment. Turning to amendment 16, tabled by the noble Lord, Lord Carmel, as I spoke to at committees, the noble Lord said, we can't support this amendment because it does remove an important element of operational flexibility. And let me say at the outset, I completely understand why the noble Lord, Lord Carmel, has raised the points again that he raised previously he mentioned attention.

Yes, in lots of ways. There is a tension and that is what we're trying to manage. The commencement provision within the bill, as I stated previously, is absolutely not a mechanism for delay. We want to proceed with this as soon as possible, which is perhaps the non-specific answer to his questions that he has asked me. Again, they're very reasonable questions, but I think he'll understand that not knowing the timetable on which I am commenting or the possibility of strike action, does mean that I am not readily in a position to give exact answers I wish I were, but the main thing is it is absolutely our intent to to commence this bill as soon as possible.

That is why we're dealing with it on the timescale that we are. So the commencement clause is a safeguard. It's to ensure that all systems, all planning and capacity are in place before the act is brought into force because it will be impossible to do it otherwise. Noble Lords will also appreciate. And the noble Lord, Lord Carmel, raised this about whether it is possible to proceed if industrial action continues, given the strain that strikes put on the system that can't be ignored.

So whilst preparations for the implementation of this bill as introduced have been progressing and are undergoing quality assurance testing, should the bill be amended, this could impact operational readiness, which could delay offers and disrupt staffing preparations. We have to avoid such disruption and whilst we don't expect such issues to arise, it is important we've retained what we regard as a fail safe provision. So I think any Secretary of State would be right to take all of the circumstances, including operational readiness, into account in deciding when the act should come into force.

But I want to restate, and I can't restate it often enough, the intention is to bring this as soon as possible. That is what we all want to do. That's what we need to do. For the reasons I set out. I do hope the noble Lords will feel able to withdraw their amendments. withdraw their amendments.
18:06
This debate has concluded
Return to start of debate - Return to top of page