Medical Training (Prioritisation) Bill

Baroness Merron Excerpts

3rd reading
Wednesday 25th February 2026 Lords Chamber

Moved by

[Baroness Merron]

That the Bill do now pass.

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

My Lords, NHS staff told us through the 10-year health plan engagement that they were crying out for change. This Bill is but one step in delivering that change. It will ensure a more sustainable and resilient medical workforce. It will ensure that we make the best use of the substantial taxpayer investment in medical training, and it will give our homegrown talent a clear path to becoming the next generation of NHS doctors.

The issue of bottlenecks for postgraduate medical training has been growing since the removal of the resident labour market test in 2020. I am most grateful to Parliament for expediting the passage of the Bill to tackle this problem, while giving it the careful scrutiny it deserves. I express my gratitude to noble Lords across the House for their constructive engagement throughout its passage. I wish to thank and credit noble Lords for passing the Bill unamended. My thanks are also due to officials and leaders from the devolved Governments for their support and commitment to ensuring we have a process that works for all of the United Kingdom, and for their determination to ensure that all legislative requirements were met within what was, and is, a challenging timeframe. I thank my officials in the department, as well as our lawyers, for their tireless work over these past few months.

We are clear that this Bill does not and cannot resolve all the workforce issues within our National Health Service. It sits alongside a range of action that the Government are taking to ensure that the NHS has the right people in the right places, with the right skills to care for people when they need it. The changes that the Bill introduces for foundation specialty training are a crucial step forward and will lead to a more sustainable medical workforce that can meet the health needs of our population.

I again thank all noble Lords who contributed their knowledge and insight during the Bill’s consideration. I beg to move.

[Lord Kamall (Con)]

My Lords, although this was emergency legislation, we have had detailed and constructive debates on prioritisation. We have also had the opportunity to debate some of the deeper issues around the supply of medical specialty training places, and I am grateful to the Minister for her letter. We will continue to hold the Government to account on the delivery of these places over the coming years. As we have said previously, the Bill is not a complete solution to the problem, as the Minister graciously acknowledged. We accept that it is a step forward.

During our debates, we touched on a number of issues, including whether UK citizens who are graduates of UK medical schools should be given first priority. We discussed the issue of international medical graduates who chose to contribute to the UK system of healthcare rather than go to another country, but who may now find themselves at the back of the queue. We discussed graduates of overseas branches of UK medical schools, some of which follow the same curriculum as UK medical schools, and whether some could be granted so-called grandfather rights. We also pressed for secondary legislation to be subject to the affirmative procedure. We understand why the Government have come to their position and why Ministers have not been able to take action on these points in this emergency legislation. However, given more time, I hope Ministers will continue their work to resolve these concerns, which were eloquently set out by a number of noble Lords from all Benches.

There was some debate about whether this was really emergency legislation or whether, in reality, it was simply giving the Secretary of State a bargaining chip in negotiations with the BMA. That may be no bad thing in itself, but the question remains of whether emergency legislation should be used to give Ministers bargaining chips.

Before I sit down, I thank the Minister and her officials for all their engagement throughout the Bill. As His Majesty’s loyal Opposition, we look forward to working closely with the Minister as the Government press ahead with its implementation.

Tobacco and Vapes Bill

Baroness Merron Excerpts

Report stage
Tuesday 24th February 2026 Lords Chamber

[Earl Howe (Con)]

My Lords, I thank my noble friend Lord Murray for his amendments in this group and all noble Lords for their contributions to this important and lively debate.

Reducing smoking rates and, in particular, preventing young people from taking up tobacco, with its highly damaging and pernicious consequences, are goals that I believe command broad support across the House. My noble friend’s amendments present us with an opportunity to settle in our minds the best way those goals might be achieved. From our debates in Committee and again today, we know there is a dichotomy of views on that.

My noble friend has eloquently made the case for substantially lifting the age of sale such that the legal purchase of tobacco by anyone under the age of 21 would be rendered impossible. The Government, on the other hand, have proposed the much more radical step of initiating a complete ban on tobacco sales to anyone born after 1 January 2009, thus creating, year by year, a wider and wider cohort of individuals for whom access to cigarettes and other tobacco products in shops will be legally barred.

Neither of these proposals, whether that of my noble friend or that of the Government, provides an absolute block on young would-be smokers accessing tobacco; so long as cigarettes remain a legal product, nothing could. However, if the generational ban can be made to work as intended, there can surely be no doubt that the benefits to public health over the long term will be immense. My right honourable friend the previous Prime Minister arrived at that realisation during the last Government, and the present Government have seen fit to agree with him.

There are two main arguments against the generational ban: one relates to civil liberties; the other is that of practical workability. I will not repeat the points that have been made on those themes, but I acknowledge that what is proposed in the Bill is, by any standards, without precedent in our consumer law. For the first time, a permanent legal distinction will be drawn between two adults based solely on their date of birth. One person may lawfully purchase a legal product while another, perhaps a year younger, may not. This would be not because of any difference in capacity or circumstance but purely by virtue of when they were born. The question people ask is whether in a free country that is right.

Following on from that are the questions around enforcement and general practicability. There are major questions around verification. As the years go by, shopkeepers will need to satisfy themselves that the person in front of them seeking to buy tobacco is 42 as opposed to 41, and so on. That does seem very different from a straightforward age of sale cut-off, which is a rule that everybody understands. Would shops and customers get used to this rigmarole? How easy would it be? As my noble friend rightly said, a number of countries have chosen to adopt the course that he is advocating rather than the generational ban.

I must, however, declare my hand. This Bill, as I have said, is an opportunity—an opportunity to make a transformational change in an area of public health that successive Governments have agreed is one of the two or three most important and far-reaching in our midst. Indeed, I would say that it is the most important. I do not think that the civil liberties arguments stand up to scrutiny for very long when we are talking about the chance of preventing serious ill health across millions of our population. Smoking needs to be made deeply unfashionable. My noble friend’s amendments, although entirely well meant, are unlikely to achieve that scale of health benefits nor that kind of attitudinal change.

There is uncertainty in whatever we decide to do. I am content for my noble friends on these Benches to make up their own minds on these matters. My noble friend, whom I greatly respect, will urge colleagues to join him in the Lobbies if he chooses to divide the House. At the same time, I hope he will understand that it ill behoves me, as my party’s spokesman for health and social care and as a former Health Minister, to pass up what I see as a golden opportunity to do something imaginative and radical, which is why I support the Government in their excellent ambitions.

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

My Lords, I am most grateful for the contributions to this debate. I think we can safely say that there is no unanimity of view, as a number of noble Lords have commented. I am particularly grateful for the support from both Front Benches, as has been consistent throughout. I am also grateful for the support of a number of noble Lords, including the noble Lords, Lord Pannick, Lord Young, Lord Rennard, Lord Stevens and Lord Bethell, and the noble Baroness, Lady Gerada, and others.

--- Later in debate ---

[Earl Howe (Con)]

My Lords, I begin by thanking my noble friends Lord Moylan and Lord Udny-Lister for their amendments in this group. I welcome the fact that the Government have accepted my noble friend Lord Moylan’s amendments and congratulate my noble friend on pressing the point.

Turning to the amendment in the name of my noble friend Lord Udny-Lister, I will pick up the cogent points made by the noble Baroness, Lady Fox, because this brings us to the broader question of age verification. Our debates in Committee demonstrated the genuine concerns among retailers that a strict “no ID, no sale” policy could become a serious flashpoint for violence and abuse directed at shop workers—an issue that, I am sure the Minister will agree, cannot be dismissed lightly. There is also a risk of confusion among customers, particularly where different age thresholds already apply across tobacco, alcohol and other age-restricted products; any new requirement must not add to that complexity. The process for purchasing these products should remain clear and readily understood by all members of the public and, crucially, shopkeepers.

Against that background, it would be extraordinary if technology were not to play a part in making that process easier and less potentially fraught. Can the Minister tell us anything about the cost and affordability of such technology? What specific consideration was given to these concerns during the Government’s consultations, and what assessment has been made of the potential impact on retail workers of what could become a cumbersome and confusing set of procedures with, as I have said, the added risk of threats and abuse to shopkeepers? At the very least, is any guidance planned to ensure that new verification requirements do not create a patchwork of conflicting obligations at the point of sale?

[Baroness Merron (Lab)]

My Lords, I am grateful for the contributions to this short debate. I thank the noble Lord, Lord Moylan, for bringing back Amendments 3 and 12, which would change from negative to affirmative the procedure for making regulations to specify steps that may be taken to verify the age of customers.

In Committee I committed to returning with the Government’s response to the recommendations made by the Delegated Powers and Regulatory Reform Committee. We have carefully considered those recommendations and listened to the support within your Lordships’ House, and I can confirm that we are accepting the recommendations in full. Therefore, as noble Lords have observed, I have—I think we can say unusually—put my name to the amendments from the noble Lord, Lord Moylan. I can only counsel the noble Lord not to get used to it. I am very pleased to support his Amendments 3 and 12.

I have tabled government Amendment 105. For consistency, I have also tabled Amendment 110 to Clause 76, which is an equivalent amendment that provides the power to specify age-verification steps for Northern Ireland.

Amendment 26, tabled in the name of the noble Lord, Lord Udny-Lister, would require the Secretary of State to establish a financial assistance scheme for the acquisition of age-verification technology by producers and retailers of nicotine products. I absolutely understand that the noble Lord’s aim is to support retailers—something that I hope the noble Lord heard me saying on behalf of the Government—and to strengthen adherence to age restriction laws. But I say to the noble Lord and the noble Baroness, Lady Fox—it is important to clarify this point—that the Government have no plans to mandate the use of age-verification technologies to enforce age of sale.

Checking that a customer is over the age of sale is a well-established concept for retailers, and they should continue to take reasonable steps and exercise due diligence to ensure that they do not sell age-restricted products to anyone underage. To provide clarity for retailers on the types of ID that they can use, the Bill provides powers to specify in regulations the steps that may be taken to verify a customer’s age. This includes the types of digital identities that can be used.

On some of the points raised by the noble Earl, Lord Howe—I know that other noble Lords are, rightly, concerned about this—I confirm once again that the Government will work with the retail sector, as we are already doing, to publish clear, workable guidance to support it with these legislative changes. With that, I hope that the noble Lord, Lord Udny-Lister, understands the Government’s position, and I encourage noble Lords to support Amendments 3, 12, 105 and 110.

[Lord Moylan (Con)]

My Lords, I am grateful to noble Lords who have spoken in this short debate. Concerning the debate about enforcement, as somebody who in the past had political responsibility for trading standards in a local authority, which is the mechanism by which enforcement of underage tobacco sales is achieved, and having sat through the whole of Report so far this afternoon, I am surprised that there has been no mention of trading standards. Perhaps we will get to this later, but trading standards will need some help as well, because a considerable burden is going to be placed on it if this mechanism of a generational age limit is to go ahead. With that, I am grateful for the support for my Amendment 3.

--- Later in debate ---

[Earl Howe (Con)]

My Lords, I will speak to my Amendments 13A and 14A only as a means of thanking the Minister very much for her Amendments 14 and 15 in this group. As a number of us argued in Committee, including in particular my noble friend Lord Moylan, there is a strong case for saying that, in a secure mental health setting where staff often find themselves dealing with patients in a high state of agitation, a vending machine dispensing vapes or nicotine products not only would do no harm but could be of considerable benefit to the well-being of the individuals being treated, and potentially to staff as well, as a knock-on effect. I am very glad that the Minister felt able to reconsider this issue in the way that she has.

I confess I am troubled by Amendment 7 in the name of the noble Earl, Lord Russell, because, although its stated purpose is to future-proof the Bill, the signal that it sends is perhaps regrettable in the context of current public attitudes towards vaping as a means of quitting cigarettes. A substantial percentage both of the general public and of smokers mistakenly believe that vapes present a greater risk to health than smoking tobacco, extraordinary as that is. The NHS is unequivocal that vapes provide a far safer route to managing nicotine addiction than continuing to smoke. The prospect that they could at a later stage simply be swept into the same prohibition regime risks creating uncertainty, discouraging switching and undermining public health gains. We need to remember that the Bill already contains extensive regulation-making powers in respect of vaping and nicotine products—on advertising, flavours, packaging, display and sale—and those powers are wide-ranging and substantial. So adding a further power of this breadth is, I suggest, unnecessary overreach.

I am afraid that I think Amendment 16 is unnecessary as well. The Bill already contains extensive powers to regulate vaping products, from product standards and enforcement to environmental controls. The Government are already consulting widely and gathering evidence in these areas, and I am afraid I do not think there is any need for the creation of yet another statutory taskforce.

[Baroness Merron (Lab)]

My Lords, I am grateful to all noble Lords who have contributed to this debate. The Chief Medical Officer’s advice on vapes is quite clear: although vaping is less harmful than smoking and can be an effective quit aid for adult smokers, non-smokers and children should never vape. In the design of policy proposals, it is imperative, we feel, to get the balance right—I say this to noble Lords who raised this point—and we sought to get the balance right between protecting future generations from the risk of vaping and ensuring that vapes remain accessible for adult smokers. I hope the noble Baroness, Lady Fox, in particular will welcome that.

Amendment 7 from the noble Earl, Lord Russell, would add a new clause to the Bill to provide a regulation-making power that could be used to add vaping and nicotine products to the smoke-free generation provisions in England and Wales. I understand the aims of the noble Earl in bringing this forward, but I have to say—again, I hope this will be helpful to noble Lords who expressed concerns—that there is a fundamental difference in safety between vapes and tobacco products.

Tobacco is uniquely harmful. Up to two-thirds of deaths in current smokers can be attributed to smoking —so vaping, while it is not harm free, is significantly less harmful than smoking. Given the current research on health harms, the evidence base does not support extending smoke-free generation provisions to vapes or to nicotine products.

Also, to respond to the amendment, the Government should assume new powers only where there is clear justification for future regulatory change. Certainly, introducing a vape-free generation power, as suggested, would be a major step not currently supported by evidence. An age of sale restriction of 18 for vaping and nicotine products is therefore considered proportionate to protect children and young people, particularly as they may be more susceptible to the risks from nicotine use, including addiction.

On Amendment 16 from the noble Earl, Lord Russell, and to the points raised alongside this by the noble Baroness, Lady Bennett, I hope that I can provide a reassurance that the Government are already delivering a comprehensive programme to tackle youth vaping, strengthen enforcement and reduce environmental impacts, and have the relevant expertise required on these issues. It is our contention that it is not necessary to put this on a statutory footing.

The noble Earl, Lord Russell, as did the noble Baroness, Lady Bennett, asked how we would deal with the environmental impact of vapes. That is an extremely important area. What I can say is, as part of our upcoming circular economy growth plan, to which the noble Earl referred, the task force will consider circular design. That means including cross-government approaches such as would fit this Bill; it will consider regulation of product features and support increased recyclability—and I think that is the right place for it to be dealt with. We have to remember that last June we banned the sale and supply of single-use vapes, and from 1 October this year we will introduce a vaping products duty, which we know is effective at dissuading price-sensitive young people. Furthermore, we have a range of measures in this Bill that will tackle the drivers of youth vaping and allow us to take action on advertising, packaging, flavours and display. To support the development of future regulations, importantly, we have recently conducted a call for evidence to gather views on issues such as flavours, nicotine limits and tank sizes. There are differing opinions on all of these, so I think the call for evidence is the right approach.

The Bill also strengthens enforcement with powers that will enable us to introduce a licensing scheme and product registration scheme. Through our £10 million enforcement programme with National Trading Standards, which I referred to in the previous group, we will fund the vaping expert panel to provide valuable guidance for trading standards professionals on the enforcement of regulations.

We are also commissioning independent research through the National Institute for Health and Care Research. This includes a comprehensive analysis of all youth vaping studies and a five-year long living evidence review that will collate the latest research of vaping. Additionally, last year, we announced a landmark 10-year study that will include in its investigations the long-term health impacts of vaping on young people’s health. I consider that all these will greatly build on to the knowledge base and evidence base that we have.

Amendments 13A and 14A, tabled by the noble Lord, Lord Kamall, seek to exempt sales from vape vending machines in mental health hospitals for patients and staff aged 18 and over. I am very grateful to the noble Lord for raising this issue. As I am sure the noble Lord realises, we believe that the Government’s amendment covers what he is intending to achieve—and I am glad that he is indicating his agreement on that point.

I listened carefully to the concerns raised by noble Lords in Committee on patients in mental health facilities—something particularly close to my heart, as I am the Minister for Mental Health. These patients’ liberties may be restricted in terms of their being able to access vaping products to meet the public health need of helping them to quit smoking or manage nicotine addiction. Adults with a long-term mental health condition have much higher smoking prevalence rates than the general population, and this exemption takes into consideration the concerns that were raised by Peers, for which I am grateful, related to helping those people with a long-term mental health condition to quit where needed and it is appropriate.

In my reflection on these concerns, I am pleased to say that is why I have brought forward government Amendments 14 and 15, and I am very pleased to have the welcome of both Front Benches, as well as the noble Baronesses, Lady Bennett and Lady Fox. These government amendments provide an exemption from the ban on vape vending machines for adult mental health in-patient facilities in England and Wales. To be clear, the wording of the exemption has been very deliberately chosen. It is tightly defined to include only adult mental health in-patient settings and only in areas intended wholly or mainly for in-patients. By its nature, that means that staff will also be able to access these machines, but the exemption would not extend to areas that are not mainly for in-patient use, such as a visitors waiting room or a staff room. I hope that gives some indication to the noble Baroness, Lady Northover, on how this might work.

We are retaining the wider ban on vending machines to prevent young people from accessing age-restricted products, and to protect the next generation from being hooked on nicotine. I hope that this provides the necessary reassurance to the noble Earl, Lord Russell, and that he will feel able to withdraw his amendment.

[Earl Russell (LD)]

My Lords, I am thankful for all those who have spoken in this debate and for the Minister’s detailed response.

On government Amendments 14 and 15, I am grateful to the noble Lord, Lord Kamall, for bringing the issue forward, and I am grateful to the Minister for listening and bringing forward the Government’s own amendments. As the Minister has commented, they have been welcomed across the House; they are compassionate and sensible measures, so they are very welcome indeed.

On my Amendment 7, I tried to explain the journey that I had been on in terms of a general purpose clause. It might be that the wording of my amendment was still a little bit clunky. I want to be absolutely clear: it is not a relentless attack on nicotine, and I am not anti-vaping. The question is where we draw the line on these issues, which is probably for another Bill in future. I absolutely recognise the role of vaping in smoking cessation, but what I do not want is a new product line for big tobacco to create new nicotine addicts and to create future revenue. Where we sit between those two points is perhaps a matter for another Bill, but those issues will at some point need to be addressed. That should not be done in a way that is overly restrictive, but it should also not be done in a way that is overly free in allowing big tobacco to exploit young people and get them addicted to nicotine when that does not need to happen.

Turning to my Amendment 16, I listened to what the Minister said and I welcome the fact that the Circular Economy Taskforce is looking at these issues. We will look at those recommendations closely when they come forward. The Government say they have banned single-use disposable vapes. I must admit that, to my mind, to all intents and purposes, in the real world that is simply not the case. They are still single-use products. All that being said, I welcome the Minister’s response and I beg leave to withdraw my amendment.

--- Later in debate ---

Although I understand the intention behind Amendment 10—transparency in public health policy is, of course, a legitimate aim and I would like to see far more of it—I am afraid I am not drawn to the idea of imposing frequent and prescriptive reporting obligations on tobacco manufacturers and importers in the way it proposes. Obligations of this kind could be imposed on industry where there is a clear public health gain. I am prepared to consider this further, but I am afraid I am not yet convinced that the amendment passes that test. Having said that, I look forward to the Minister’s responses to other noble Lords.

[Baroness Merron (Lab)]

My Lords, I am most grateful for the contributions to this debate. I will start by addressing the government amendments tabled in my name. The issue of filters, as we have heard in this debate, has been raised throughout the Bill’s passage, both in the other place and in Committee in your Lordships’ House. As the noble Baroness, Lady Northover, said, action on filters has been proposed by parties from across the political spectrum.

However, there has not been a consensus on a single approach, and it is that that we have sought to deal with. That is why we are taking a suite of powers to enable secondary legislation to regulate filters, should evidence suggest that it is necessary. Although these powers could enable the banning of filters in the future, they also enable us to regulate filters in other ways, such as regulating their packaging, advertising, display in stores and free distribution.

As the noble Lord, Lord Young, referred to, there is evidence that people incorrectly believe that some cigarette filters make cigarettes less harmful. There is absolutely a risk that this could influence smoking behaviours. The fact of the matter is that cigarette filters provide no protection from the health risks of smoking.

The noble Earl, Lord Russell, asked about the Government’s intention to take action. On that point, and more broadly, the evidence base about the direct health impact is still in formation. We will explore commissioning further research to understand the harms and, based on that, consider further consultation. For these reasons, we are not able to accept Amendment 76 from the noble Earl.

Since we are taking these powers on filters in the Bill, Amendment 77, tabled by the noble Baroness, Lady Bennett, and Amendment 17A, tabled by the noble Baroness, Lady Grey-Thompson, are therefore not required—a point raised by the noble Lord, Lord Kamall. Should we choose to ban filters, we would indeed be the first country in the world to do so. It would be a significant step, and noble Lords will understand that, before making any such decision, we need to interrogate the issue fully and ensure that all potential consequences are considered. However, we will now have the powers to act through these government amendments if and when the evidence emerges.

Specifically on Amendment 17A, evidence currently suggests that filters labelled as biodegradable can still leach harmful chemicals into the environment, as the noble Baroness, Lady Bennett, said. There is also evidence to suggest that people who believe that cigarette butts are biodegradable are more likely to litter them, as noble Lords have said.

I turn to Amendment 10, tabled by the noble Baroness, Lady Northover. I am sympathetic towards attempts to increase transparency of the tobacco industry. I therefore understand why she brought this forward. However, Clause 95 already provides powers to make regulations that could require producers or importers to provide specified information. This could include sales data, as well as market research, from producers of any relevant products within the scope of Part 5, not just tobacco products. This clause also enables us to make provision about when and how the information must be provided, and the publication of any such information. I reassure the noble Baroness that we will consult on these requirements as we develop the necessary regulations.

I am sympathetic to the aims of Amendment 204, tabled in the names of the noble Earl, Lord Russell, and the noble Lords, Lord Young of Cookham and Lord Crisp. However, as I said in Committee, again in answer to the point the noble Earl raised, we already have a “polluter pays” tax on tobacco in the form of tobacco duties. The UK has some of the highest tobacco taxes in the world. Duty rates on all tobacco products were increased by 2% above inflation at the Autumn Budget 2025. This duty raises about £8 billion a year.

I appreciate that the amendment proposes combining a levy with regulating prices, but the reality is that, because of the ongoing structural decline in the UK tobacco market, we are sceptical that there is the suggested level of profit available in the system. Regulating pricing would also be a complicated and resource-intensive policy to design and implement, and which we believe is unlikely to be successful in meeting its objectives, such as raising additional revenue. It would be challenging to design restrictions that industry could not circumvent, for example, by shifting focus to products not included in the cap or avoiding tax through international transfer pricing. Therefore, as I stated previously, our preference is to continue with tobacco duties—an understood approach which incentivises those who currently smoke to quit and generates revenue that can be put back into a full range of public services.

Finally, Amendments 129 and 133 were tabled by the noble Lord, Lord Rennard. I am grateful for the noble Lord’s support for strong tobacco control. However, with respect to these amendments, we already have the ability to regulate the information provided on products which could enable us to mandate health warnings in the future. We already have some of the most stringent regulations in the world on cigarette packaging, emphasising health harms. They include the requirement for plain packaging and graphic picture warnings on the outside of cigarette packets. We have announced that we are introducing pack inserts to cigarettes and hand-rolling tobacco. Therefore, we do not plan to introduce dissuasive cigarettes. However, as the noble Lord, Lord Rennard, did acknowledge in his contribution, the Government will continue to monitor the evidence.

I hope that this provides reassurance to noble Lords that the Government are committed to evidence-based policy to tackle the harms from tobacco use and that the noble Baroness, Lady Northover, will feel able to withdraw her amendment.

[Baroness Northover (LD)]

My Lords, this is a vital Bill, even if we are seeking to improve it further. We have clearly made progress on filters and there are a number of other areas where progress can be made under the Bill. I note the Minister’s encouraging words in relation to my amendment on data and transparency. In the light of that, I beg leave to withdraw.

Tobacco and Vapes Bill

Baroness Merron Excerpts

Report stage
Tuesday 24th February 2026 Lords Chamber

[Lord Kamall (Con)]

My Lords, my noble friend has tabled a number of amendments on heated tobacco products. Although there may be some concern about what is behind them, they raise important questions that I am afraid the Government have yet to answer with any real precision.

As I noted in Committee, there appears to be some evidence that individuals who switched from conventional cigarettes to heated tobacco products show lower levels of exposure to harmful chemicals than those who continue smoking. I am just comparing them to cigarettes, not to vapes. To be clear, I do not suggest that this settles the question of harm—these are relatively new products, and the long-term evidence base is still developing—but it means that the Government cannot simply treat heated tobacco products as interchangeable with conventional cigarettes without explaining why they refuse to consider their relative harm compared to cigarettes. I am talking about not absolute harm, but relative harm.

There is also the practical question of where these products may be used. The position on indoor and outdoor spaces remains, as far as I can tell, unclear. Heated tobacco does not produce combustion or sidestream smoke in the conventional sense, and yet it is not obvious from the Bill how the Government intend to address that distinction—if they intend to address it at all.

More fundamentally, can the Minister explain what specific evidence underpins the decision to include heated tobacco in the generational ban? I am sure all noble Lords accept that current evidence shows that vapes are relatively safer than smoking. It may be that vapes are relatively safer than heated tobacco, but as yet, we have not seen definitive evidence. Unfortunately, as noble Lords have said, much of the research on heated tobacco is funded by the tobacco industry. I can understand the concern there. I hope the Minister will correct me if I am wrong, but there is no definitive independent research on the relative harms of heated tobacco. If there is definitive research, can the Minister write to noble Lords with links to the relevant academic papers? I think we saw one link to a meta study that was not very good, but there has been no meaningful in-depth research.

This reminds me of a conversation I had with a friend, who told me that when they tried vapes to quit smoking, it unfortunately did not do the job for them. When they went back to their doctor, he said that he was not supposed to do this, but he suggested heated tobacco as a relatively less harmful alternative. While he hoped his patient might have switched from cigarettes to vapes, since this had not happened—we do not live in a perfect world—he preferred his patient to use heated tobacco to going back to cigarettes. Once again, this was a practical approach based on relative harms.

I completely understand the concern that, if we overpromote heated tobacco, we might find that smokers switch to it rather than vapes. Given that the policy rationale rests substantially on reducing harm—we should be looking at absolute harm and relative harm— I would welcome clarity on whether the Government are satisfied that the case for treating heated tobacco like cigarettes is proven. It will be interesting to see that distinction between heated tobacco and cigarettes. Is the science still sufficiently uncertain to warrant a more cautious approach?

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

My Lords, I appreciate the contributions made in this debate. I will start by addressing government Amendments 217, 218 and 219, tabled in my name; I am grateful to the noble Baroness, Lady Northover, for her support.

The Bill updates the definition of a tobacco product in legislation relating to promotion and advertising, and in Scottish legislation, to

“a product consisting wholly or partly of tobacco and intended to be smoked, sniffed, sucked, chewed or consumed in any other way”.

Those last few words,

“consumed in any other way”,

are the key ones. What does this definition do? It ensures that all forms of tobacco products, regardless of how they are consumed, are captured by this legislation, including—this is important to the points raised by noble Lords—any future novel tobacco products.

These amendments bring forward the commencement of this updated definition to the day of Royal Assent, rather than two months after Royal Assent. That is because the Government’s view is that all tobacco products currently on the market are already captured in the current definition, so it is appropriate for this future-proofing amendment to come into force at Royal Assent because there is no change to the law for which notice would be required.

Amendments tabled by the noble Lord, Lord Udny-Lister, seek to redefine how heated tobacco products are captured within the Bill so that they are no longer treated in the same way as other tobacco products. These amendments also seek to prevent provisions being extended to heated tobacco devices in the future.

On the points raised by the noble Lord, as well as by the noble Baroness, Lady Fox, and the noble Lord, Lord Kamall, the Bill deliberately defines tobacco products expansively and includes heated tobacco. The reason for that is that there is no safe level of tobacco consumption and all forms of tobacco are harmful.

On the points raised about evidence, there is evidence of toxicity from heated tobacco in laboratory studies; the aerosol generated by heated tobacco devices contains carcinogenic compounds. Unlike vapes, there is limited evidence that heated tobacco can support smoking cessation, despite what is claimed by the tobacco industry. On the matters of evidence raised by the noble Lord, Lord Kamall, and the noble Baroness, Lady Fox, as has been set out by all four UK Chief Medical Officers in a technical note to noble Lords, any suggestion that heated tobacco products are safe or should be promoted as quit aids in some way is entirely misleading.

I say to the noble Lord, Lord Kamall, that, through the National Institute for Health and Care Research, we are funding high-quality research into tobacco products. Between 2020 and 2025, £25 million was invested in a NIHR research programme to research tobacco control, and that will help us develop the evidence base. Exempting heated tobacco products from the smoke-free generation policy and other provisions in the Bill would simply allow the tobacco industry to continue to find a way to addict future generations to harmful and addictive products. The Bill is completely geared to go the other way.

The noble Lord, Lord Kamall, asked about heated-tobacco-free places. We will return to the whole issue of tobacco-free places when we come to group 16, so I am sure that that will be debated then. I hope that I have been able to clarify the Government’s position for noble Lords, and that the noble Lord, Lord Udny-Lister, will feel able to withdraw his amendment.

[Lord Kamall (Con)]

Before the Minister sits down, she talked about research that was done on tobacco products between 2020 and 2025. In that time, was any specific research done on heated tobacco as part of tobacco products?

[Baroness Merron (Lab)]

The specific definition is “tobacco control research”, so it would be strange if it did not include what we know about already, which includes heated tobacco. I will be glad to confirm that to the noble Lord in writing.

[Lord Udny-Lister (Con)]

I thank the Minister for her reassurances, although I am afraid that I do not agree with her. However, I accept that we have taken this as far as we can. I beg leave to withdraw the amendment.

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Moved by

[Baroness Merron]

14: Clause 12, page 6, line 9, at end insert—
“(1A) But subsection (1) does not apply in relation to a vape vending machine made available for use in a mental health hospital if the machine is in an area that is intended wholly or mainly for inpatients.”Member’s explanatory statement
This amendment creates an exception to the offence of having management or control of premises on which a vape vending machine is made available for use. It applies where the vending machine is in a mental health hospital in an area intended wholly or mainly for inpatients.

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Moved by

[Baroness Merron]

15: Clause 12, page 6, line 12, at end insert—
““mental health hospital” means an institution (or part of an institution) maintained wholly or mainly for the reception and treatment of inpatients who—(a) are aged 18 or over, and(b) are suffering from mental disorder (within the meaning of the Mental Health Act 1983);”Member’s explanatory statement
This is consequential on my first amendment to clause 12.

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[Lord Kamall (Con)]

My Lords, my noble friends Lord Moylan and Lord Udny-Lister benefited this debate by coming forward with their amendments in this group based on their extensive experience in local government. I warmly welcome Amendment 17; counterfeiting nicotine products is not a victimless crime. It undercuts legitimate businesses that are already operating under considerable regulatory and financial pressure.

Let us be clear that the cumulative burden placed on small businesses, regulatory or otherwise, is already substantial. These businesses, as other noble Lords have said, are already playing by the rules. They pay their taxes and comply with an ever-increasing, complex regulatory framework. It is simply not fair that they should find themselves undercut by operators selling counterfeit products outside that framework entirely.

Beyond the commercial harm, there is a serious consumer safety dimension. Counterfeit nicotine products are unregulated, untested and potentially dangerous. I ask the Minister to confirm that the Government share the view that the robust criminal penalties for counterfeiting are not only appropriate but essential. I would be grateful to hear what steps are being taken to ensure that enforcement capacity exists to make sure that these penalties are meaningful.

At earlier stages of the Bill, I know there were some concerns about the capacity of trading standards, for example. The sum that the Government have made available for local trading standards is to be welcomed, but some still wonder whether it will be enough or whether it is a drop in the ocean.

My noble friend Lord Udny-Lister’s amendments reflect a sensible approach to fixed penalty notices. A step penalty structure that treats a first offence differently from repeated non-compliance is surely right. While some local authorities may already have discretion to issue a warning instead of a fixed penalty for first-time offenders, as my noble friend has raised, it is important that first-time offenders are not treated unduly harshly given the complexity of some of the regulations that these small retailers will have to face. I hope the Minister, if she feels that she cannot accept the amendments as they stand, can say some positive things about them.

[Baroness Merron (Lab)]

My Lords, this has been a helpful debate on an issue that concerns us all in this Chamber.

On Amendment 17 tabled by the noble Lord, Lord Moylan, I agree with his desire to take robust action against counterfeit products—I am sure we all do—but I cannot accept the amendment simply because I do not believe it is necessary, not because of specific objections. I heard his invitation for me to continue as I started, but, unfortunately, I cannot do so for this amendment. We believe it is not necessary, as referred to by the noble Baroness, Lady Northover, because protections against trademark infringement are already a matter for existing legislation.

On the point about necessary legislation addressing counterfeit products, which I accept, I say to the noble Lord and the noble Baroness, Lady Fox, that the Trade Marks Act 1994, as we have heard, already provides significant penalties for breaching these rules. They include: on summary conviction, imprisonment for a term not exceeding six months or a fine not exceeding the statutory maximum, or both; or, on conviction on indictment, a fine or imprisonment for a term not exceeding 10 years, or both. These are significant penalties.

[Baroness Fox of Buckley (Non-Afl)]

In terms of duplication, I argued on the Crime and Policing Bill that it was probably not necessary to legislate for assaulting a shop worker to be against the law, as assaulting anyone is. I asked why there was a specific point about shop and retail workers and was told that this would make a special case of shop workers to emphasise their vulnerability. The point about duplicating laws has never held the Government back before, because they keep doing it.

[Baroness Merron (Lab)]

I must admit that I have a different view. Where we already have legislation covering the specific points we are talking about, as we have here with the Trade Marks Act 1994, there is no reason to go further. The legislation is already working. It is fair to raise the example that the noble Baroness gave, but I do not share her view on that duplication, as it was important specifically to identify shop workers. Maybe we just need to disagree on the duplication or otherwise of legislation.

While trademark protection is not a matter for the Bill, powers in Part 5 will enable the Government to introduce regulations relating to packaging, product safety and product registration. Those who breach these regulations following their implementation may face significant penalties of up to two years’ imprisonment, a fine or both. The penalties broadly mirror the penalties provided by the noble Lord’s amendment, albeit I accept he proposes a slightly higher maximum term of imprisonment of three years instead of two.

The noble Lord, Lord Moylan, raised legitimate points about the scale of the illicit market and also potential connections to other illegal activities. On that point, HMRC and Border Force’s joint illicit tobacco strategy sets out the continued commitment to tackle and disrupt the organised crime groups behind the illicit tobacco trade, a commitment supported by over £100 million of new funding.

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[Lord Kamall (Con)]

My Lords, my noble friend Lord Lindsay’s excellent and persuasive arguments in support of the amendments in his name and that of the noble Lord, Lord Mendelsohn, who is not in his place, cannot be bettered, so I shall not try to, except to say that I support them.

Regardless of one’s attitude to smoking, there is a general recognition of the important role that specialist tobacconists play. They are small, highly regulated businesses that serve a discerning adult clientele. They are not engaged in the mass-marketing of cigarettes, nor are they driving youth uptake. Specifically, handmade cigars are not cigarillos. Premium handmade cigars are luxury products, purchased occasionally at a considerable cost by informed adult consumers. I was surprised to learn in Committee that they attract overseas visitors, who spend huge amounts of money here in the UK because these handmade cigars are packaged and marketed in a way that is unique to the United Kingdom. It is difficult to see how such establishments constitute a meaningful threat to the Government’s stated objective of reducing youth smoking and creating a smoke-free generation.

I stress that many of the criticisms made of cigars are made of cigarillos, but it is important that we distinguish between cigarillos and the unique products that are artisan cigars, whatever one thinks of them. I do not smoke; I think smoking is a disgusting habit. I do not drink alcohol; I think drinking alcohol is a terrible thing. But I am a liberal and I do not seek to impose my views on other people. It is important to distinguish between handmade crafted cigars and mass-marketed cigarillos, which may well be attractive to young people. I believe that cigarillos should be seen in the same light as cigarettes.

Since the introduction of the Bill, there has obviously been enormous anxiety among specialist tobacconists around the country about what the Government might choose to do to their day-to-day businesses. These amendments will, I hope, provide the Minister with an opportunity to reassure the sector. There is real concern that if plain packaging regulations were to be imposed on hand-rolled cigars, this would constitute an almost instant death for every specialist tobacco business. We heard about other countries where plain packaging has been imposed, but the UK continues to attract people who want to buy the packaging and all the marketing around it, whatever we may think of it.

For the good reasons already stated, these businesses enjoy special dispensations from the provisions of the law which apply to the generality of tobacco retailing. These dispensations are well founded, well understood and respected across the supply chain. As far as I am aware, they have not been abused. Many of the complaints about the uptake of cigar smoking are in relation not to these types of cigars but to cigarillos. This area of tobacco retailing is so niche that it is irrelevant to the vast majority of smokers. There is no reasonable case for the Government to choose to exercise powers to impede, restrict or otherwise alter the day-to-day lives of those involved in this specialist sector.

To be clear, I am talking about packaging. I am not referring to any of the amendments concerned with cigar lounges. I understand the concerns that have been expressed about workers who may not wish to be exposed to cigars but have no choice but to take that job and be exposed. I am talking about specialist tobacco manufacturers and retailers. Obviously, any attempts to restrict these businesses would involve some consultation with the Department for Business and Trade, so I sincerely hope that the Minister will be able to confirm that the Government have no intentions to restrict the specialist manufacturers in this way and to make their businesses unviable.

[Baroness Merron (Lab)]

My Lords, I am grateful to all noble Lords who have contributed to this debate. On Amendments 127 and 147, tabled by the noble Earl, Lord Lindsay, and Amendment 126, tabled by the noble Baroness, Lady Walmsley, I have listened to the points that have been raised by noble Lords, not just today in the Chamber but in engaging outside the Chamber, which I have been pleased to do, and I have listened to the calls for handmade cigars to be exempt from packaging provisions in this legislation.

I remind the House, as I have had to remind noble Lords in other discussions, that the powers to regulate the packaging of all tobacco products are not new; they already exist. They were first introduced under the coalition Government as part of the Children and Families Act 2014. At the time when the powers were introduced, the Government of the time rightly recognised the need to ensure that these powers applied to all tobacco products, future-proofing the legislation, so introducing an exemption for handmade cigars now would weaken what is in effect long-standing legislation. I remind noble Lords that one of the points about the Bill is to bring together legislation that is in other areas into a Tobacco and Vapes Bill, which is what we are doing.

As I have said on a number of occasions, all tobacco products are harmful. That includes cigars and those marketed as premium or handmade. When burned, all tobacco products release toxic compounds that pose a risk to the user. In fact, research has found that some toxicants, including carbon monoxide and certain carcinogens, are higher in cigar smoke than cigarette smoke, and of course the toxicants that are found in tobacco smoke in cigars increase the user’s risk of developing diseases such as cancer, heart disease or respiratory disease. As the four Chief Medical Officers of the UK set out in their technical note to noble Lords, any suggestion that cigars are substantially safer than other tobacco products is not accurate.

Given the health harms of all cigars, it is appropriate that they are in scope of the legislation and that the Government retain our current ability, introduced in 2014, to regulate the packaging of all tobacco products. Moreover, exempting product categories is likely to lead to exploitation by the tobacco industry, which will always find a loophole to exploit. For example, following the ban on menthol cigarettes in 2020, tobacco companies began marketing cigarette-like menthol-flavoured cigarillos.

I shall provide some assistance on the points being raised today. As I said, I have heard concerns from noble Lords about future packaging restrictions that could impact specialist tobacconists more significantly than other retailers, and concerns about potential unfairness arising from that. I can say, as I have said before, that it is absolutely not this Government’s intention for any future packaging requirements to put any small businesses, including specialist tobacconists, out of business. Our intent is that any future packaging regulations make the health harms of these products clear while minimising the impact on businesses.

The noble Earl, Lord Lindsay, asked about future regulation on packaging. If that is to be the case, further impact assessments will be prepared in advance, including the economic impact of any proposed regulations. The policy proposals for any packaging requirements will be a matter for consultation, and all businesses—including, I am sure, specialist tobacconists —will want to respond and will be welcome to. I want also to be clear that the Government will consider the impact any policy proposal has on small businesses, including specialist tobacconists, via future published impact assessments, as I just said. It is important, however, despite these points, that the Government retain their current powers to regulate the packaging of all tobacco products, as any carve-out would potentially create loopholes for exploitation, as other noble Lords have expressed concern about.

Amendment 192 from the noble Earl, Lord Lindsay, seeks to maintain the existing exemption to allow individuals to sample cigars and pipe tobacco indoors in an enclosed and ventilated area in a specialist tobacconist shop. The Government are, as noble Lords know, committed to protecting people from the harms of second-hand smoke, which is why we launched a consultation on expanding smoke-free places on 13 February.

On the point the noble Baroness, Lady Bennett, made, there are a number of exemptions to the current smoke-free legislation, including an exemption for sampling rooms—not smoking lounges, as the noble Baroness, Lady Northover, referred to—in specialist tobacconists, providing certain criteria are met, as outlined. The Government do not intend to remove this existing exemption for specialist tobacconists. The consultation explicitly states our intention for the exemption to remain.

Finally, Amendments 18 and 19, tabled by the noble Earl, Lord Lindsay, seek to maintain the existing exemption for specialist tobacconists to display tobacco products. There are several exemptions to the current tobacco display legislation, including an exemption for specialist tobacconists. In England, this allows specialist tobacconists to display tobacco products as long as they are not visible from outside the premises. The Government’s intention is not to remove this existing exemption for specialist tobacconists. This will be reflected when we consult on future display regulations later this year.

It is important that the Bill balances the public health aims with any disproportionate impacts on businesses, including specialist tobacconists. However, we will continue to monitor this niche market to ensure that it is not targeting young people or exploiting the existing exemptions. I hope that, on this basis, the noble Earl, Lord Lindsay, will feel able to withdraw his amendment.

[The Earl of Lindsay (Con)]

My Lords, I am grateful to the Minister for the thoughtful answers she has given to the various points my amendments have raised. I am also grateful for the time she allowed for discussions between Committee and Report to understand the issues better; my thanks to her. I am grateful to my noble friends Lord Johnson of Lainston and Lord Kamall for the support they have offered for these amendments.

Before coming back to what the Minister said, I say to the noble Baronesses, Lady Bennett and Lady Northover, that there is quite a lot of confusion over the statistics relating to cigars as a generic category. I remind both of them that my amendments deal solely with handmade cigars, not with cigars as a single generic whole.

As I said, handmade cigars are not inhaled. They are relatively expensive compared with other smoking options. A lot of cigars out there on the market are machine made; some of them are small enough to be cigarillos. The statistics about young people indulging in cigar smoking almost wholly relate to people who are smoking not handmade cigars but other types of cigar.

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Moved by

[Baroness Merron]

20: Clause 15, page 8, line 14, leave out “is” and insert “will be”
Member’s explanatory statement
This amendment, and my amendments to clauses 62, 80, 113, 114, 115, 116, 117, 118, 120, 122, 123 and 124, would ensure that the effect of a person’s action is considered by reference to what it will be, rather than what it currently is (for consistency with the mental element of these offences).

[Baroness Merron (Lab)]

My Lords, the amendments in this group are government amendments relating to the advertising provisions. They are in large part technical in nature, but they have a clear and important purpose: to stop the advertising and promotion of products that risk addicting a new generation to nicotine. They also ensure that the regime is clear and capable of being enforced fairly and consistently across all settings, whether online or offline.

We know why we are here today. In 2025, more than 1 million children reported having tried vaping. We have seen the brightly coloured and cartoon advertisements that have clearly appealed to young people. The Bill delivers on this Government’s mandate to stop the blatant advertising of vapes to children while continuing to support adult smokers to quit.

Government Amendments 20, 99, 111, 148, 150, 154, 156, 158, 160, 162, 164, 167 and 170 to 172 are minor and technical amendments. They simply update the wording across the clauses that create offences relating to free distribution, advertising, brand sharing and sponsorship. These amendments will ensure that the offence is committed, for example, as soon as an advert is published, which may not have been the case in some circumstances. That means that, for example, if a leaflet with an advert is put through a letterbox, the offence arises when it is delivered, not when the resident eventually reads it.

I have also tabled Amendment 165, which restores specific exceptions that already exist in current law. These make it clear that intermediaries—companies such as TalkTalk or BT—that provide passive internet services such as internet access cannot be liable for advertising offences in certain circumstances. This does not reflect a change in policy. The Bill does not intend to change the circumstance in which passive service providers may be liable. However, to put the matter beyond doubt, these amendments explicitly protect providers of passive services who have no ability to control, publish or remove adverts if they satisfy the circumstances prescribed in the exceptions.

Government Amendments 173 to 174, 179, 180 to 183, and 185 to 187 make it clear that the product placement provisions in Part 6 are not retrospective. They restate the existing law in relation to tobacco, and ensure that the new restrictions apply only going forward and do not affect programmes made before they came into force. This means that broadcasters or on-demand programme service providers will not be required to review or edit existing programmes. Finally, Amendment 184 removes now redundant amendments to video-sharing legislation that was repealed by the Online Safety Act 2023.

I turn to what is perhaps the most substantive amendment in this group—Amendment 166—and Amendments 175 to 178 on the public health defence. In Committee, I explained that the Bill already allows public health authorities to take certain steps to promote vapes as a means to quit smoking. Noble Lords raised important questions about how this applies to pharmacists, pharmacies and GP practices that both support smoking cessation and operate as businesses. I listened carefully to these concerns and, in response, I tabled an amendment creating a specific defence to provide clarity on how this will work in practice. This amendment allows businesses to promote non-branded vapes and nicotine products where it is done in arrangement with the public authority for public health reasons. In practice, this means that public authorities will continue to be able to partner with businesses such as pharmacies to run effective public health campaigns that promote vaping for smoking cessation.

We have also replicated this exception for on-demand programme services to ensure that public health authorities can continue to work with businesses to promote vaping for smoking cessation through these platforms. I hope this provides reassurance to noble Lords that healthcare professionals, including pharmacists and GPs, can continue to display smoking cessation materials. It also ensures that others, such as design agencies commissioned by public authorities, will not be caught inadvertently by the offence provisions when supporting this work.

I know that all these matters were of concern to noble Lords; I am therefore, as I said, glad to put forward amendments to tackle these very real points. I look forward to hearing the views and contributions of noble Lords in this debate, and I hope I can count on their support.

[Baroness Northover (LD)]

From these Benches, the Minister can count on our support.

[Lord Kamall (Con)]

My Lords, the hour is late and, given that some of my noble friends have left the Chamber—no doubt to enjoy a very expensive handcrafted cigar—it is left to my noble friend Lord Effingham and me to offer the opposition. If I had any temptation to call a Division, I can see that I am outnumbered.

I thank the Minister for tabling these amendments. I know that many of them are technical, but some are very important. I particularly welcome Amendment 165, which provides sensible protection for internet service providers acting merely as conduits, caching services or passive hosts. They are not really active in this space. They do not initiate, select or modify the content transmitted across their networks, and it would not be fair or practical to render them criminally liable for material of which they have no knowledge and over which they exercise no control.

Similarly, Amendments 166 and 178 ensure that legitimate public health campaigns are not inadvertently caught out by the advertising offences in the Bill. Where a person is acting in accordance with arrangements made by a public authority and for the purpose of promoting or protecting public health, it would be wrong for them to face criminal liability.

Finally, we welcome Amendment 183 because it ensures that the new restrictions do not apply retrospectively to programmes that were already in production before the new rules came into force. I suppose this is all a very long way of saying that we welcome the amendments from the Government.

[Baroness Merron (Lab)]

I am delighted to receive the support of both Front Benches, either in a few words or in a few more words. This is to fulfil a mandate to stop the blatant advertising of vapes to children, while continuing to support adult smokers to quit. I therefore commend the amendment to the House.

Amendment 20 agreed.

Medical Training (Prioritisation) Bill

Baroness Merron Excerpts

Report stage
Monday 23rd February 2026 Lords Chamber

[Earl Howe (Con)]

My Lords, I too am grateful to the noble Lord, Lord Patel, for leading the 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. 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 in Committee, when other noble Lords, including my noble friend Lady Coffey, tabled amendments that sought to introduce a different prioritisation hierarchy. I understand fully the case that the noble Lord is making and I agree that UK medical graduates should have a much fairer crack of the whip in access to medical specialty training places. Fairness has been our primary concern throughout our scrutiny of this Bill. However, I 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, a point that the noble Baroness, Lady Finlay, has consistently made.

I am 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 accept that Ministers have introduced this as urgent legislation with a specific purpose. In that context, 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.

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

My Lords, I am most grateful to noble Lords across the House for their considered contributions to this group of amendments and to the noble Lord, Lord Patel, for his introduction to this group. I have a third reason to be grateful—namely, for the understanding of the challenge that this Government are facing and the need to take action. I do not take that for granted. We are not able to support the amendments tabled by the noble Lord, Lord Patel, and I will go through the reasons.

In answer to the noble Baroness, Lady McIntosh, the Bill already sets clear priority groups without any further ranking within them. This is a binary system: applicants are either prioritised or they are not. It might be helpful to your Lordships House to say that the priority groups set out in the Bill have been agreed across the four Governments of the nation. They are best placed to support moving to what we all want—a sustainable workforce to meet the health needs of this population.

As I emphasised in Committee and at Second Reading, prioritisation does not mean exclusion. Non-prioritised graduates will still be able to apply, and they will be offered places if vacancies remain after prioritised applicants have received offers. For specialty training, there are likely to be opportunities in general practice, core psychiatry and internal medicine, which, historically, attract fewer applicants from the groups that we are prioritising for 2026.

Alongside UK graduates, the Bill prioritises graduates from Ireland—this reflects, as I have spoken of before in this Chamber, the special nature of our relationship with Ireland—along with graduates from Iceland, Liechtenstein, Norway and Switzerland, which reflects our obligations under international trade agreements with the European Free Trade Association countries to treat their graduates no less favourably. The amendments would mean that we would not be honouring these arrangements as we would be prioritising UK medical graduates over applicants from these countries.

The agreements with EFTA countries precede this Government. The agreement for Iceland, Norway and Liechtenstein was made in July 2021, and for Switzerland in 2019. The bottleneck issues that this Bill is designed to address were primarily driven by the removal of the resident labour market test in 2020. I know noble Lords will understand the need to uphold these international obligations, albeit we receive very low numbers of applicants from EFTA countries. As I noted in my recent letter to the noble Lord, Lord Mohammed, and to give noble Lords some idea of scale, there are a total of two applicants from EFTA countries for foundation and specialty training in 2026.

For specialty training, the amendments would mean we would be prioritising UK medical graduates over applicants with significant NHS experience. That 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 have 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 how many more students in the priority group would be able to enter specialty training. I will be pleased to write to the noble Lord on that matter.

My noble friend Lord Hunt and the noble Baroness, Lady Finlay, called for improvement of the broader approach to medical training, and that is something with which I would definitely concur. We have published phase 1 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 asks what is working well. Phase 2 of this work is already under way, and will focus on exploring those issues and developing options for change.

The noble Baroness, Lady Finlay, asked that I give an assurance that Oriel would, as an appointment process tool, have what she described as a more subtle way of looking at NHS experience. I can confirm that we will be engaging with stakeholders on what the best definition is and what is most appropriate for NHS experience. That will then allow us to update the system.

The noble Baroness, Lady Finlay, asked about merit-based selection and made a valid point about the quality of applicants. I assure your Lordships’ House that the Bill does not replace in any way a merit-based selection. Existing recruitment processes for foundation and specialty training already assess applicants against rigorous, merit-based criteria, including competence, performance and suitability for training, all of which I know are of concern, and rightly so, to the noble Baroness. The Bill sits alongside that process, not instead of that process.

The noble Lords, Lord Stevens and Lord Clement-Jones, asked about specialty training places. In the 10-year health plan, which the noble Lord, Lord Stevens, referred to, our commitment is to create 1,000 new specialty training posts over the next three years, focusing—importantly, in my view—on specialties where there is the greatest need. The Bill will not delay this process. There are some programmes and regions already at capacity for delivering properly supervised training posts. Expanding that training capacity will therefore need to be done gradually to ensure that placements remain of the high quality that we need and that appropriate supervision is in place to support it.

I hope that I have dealt with the main questions raised. For these reasons, I hope the noble Lord will withdraw his amendment.

--- Later in debate ---

[Earl Howe (Con)]

My Lords, with these amendments, the noble Lord, Lord Mohammed, has reprised proposals he made, and which we debated, in Committee. In Committee, the Minister emphasised a point that I must say resonated particularly strongly with me. She pointed out that the delay proposed in Amendment 3 sets the Government back in their timetable to address the bottlenecks in medical training. Although I acknowledge all that the noble Lord said about fairness, I must accept that a delay of a year would set the Government back significantly in their plans. Given our support for the main principle underpinning the Bill, we cannot, I am afraid, support that amendment.

However, I reiterate that prioritisation is only part of the solution to the problem we have 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 Minister’s answer in the previous group to the question about training places posed by the noble Lord, Lord Stevens of Birmingham, was helpful. However, can she go any further and indicate whether the Government consider 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 the coming months?

The noble Lord, Lord Mohammed, made a strong case for Amendment 7, and I endorse the powerful comments made not only by him but by the noble Lord, Lord Clement-Jones. Can the Minister provide us with further information on the Oriel system? 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 do not have leave to remain. It seems to me essential that we have clarity on the number of doctors that this amendment would affect. Has she had the opportunity to look into this in more detail between Committee and Report? If we are 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 does not 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?

[Baroness Merron (Lab)]

I am grateful to noble Lords on all sides of the House for their contributions today. I turn first to Amendment 3, tabled by the noble Lord, Lord Mohammed. As I explained in Committee, this is not an amendment that we are able to support. As has been emphasised, including today, a key aim of this Bill is to address the severe bottlenecks in medical training that have built up over recent years. These pressures are having real consequences, evidenced most starkly, I believe, through the most recent industrial action, where concerns about stalled career progression and training opportunities have featured and continue to feature heavily.

The noble Lord, Lord Mohammed, rightly spoke about the concerns of 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, although I absolutely understand the concerns, which we have discussed, these have been carefully considered and, at the end of it all, we have to make decisions about what it is we are trying to do. 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 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, Lord Howe, that another year of inaction would only deepen the frustration felt by UK-trained doctors and further destabilise the workforce. I do not think that is something 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 wait, as this amendment suggests, until 2027, it is projected that competition ratios will have risen 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 protecting the long-term sustainability of the NHS workforce, protecting patients and protecting patient care and services is what this Bill is all about. That is why we are not able to accept another year’s delay, although I understand why the noble Lord put his amendment forward.

In addition, there is a difficulty in terms of the drafting in respect of this amendment, because it would create two clauses related to the prioritisation of applicants to specialty training programmes for 2027, and each would have a different approach to prioritisation. I am sure that the noble Lord would not want to create operational confusion or undermine legal certainty, but I thought it important to point that out.

I turn to Amendment 7, also tabled by the noble Lord, Lord Mohammed. First, following our conversation earlier—I am grateful for the noble Lord’s flexibility in that regard—I want to reassure him and your Lordships’ House that we are absolutely committed to recognising those who have worked in the NHS for a significant period. There is a very good reason for this: as well as it being the right thing to do, 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, that is a core driver in this Bill. It is our intention to prioritise those with significant NHS experience for specialty training. However, we are unable to support Amendment 7, for a number of reasons. I appreciate that the amendment was changed, but I want to refer at this stage to the points made by the noble Lord, Lord Clement-Jones; I discussed these matters with him earlier today.

While the NHS Oriel recruitment system holds some information about an applicant’s NHS experience, it cannot be used consistently or fairly for the 2026 round. The data has been collected on the basis that it would be checked by employers before appointment, not for retrospective automated assessment. It is indeed the case that applicants enter their employment history on Oriel as free text, but with no consistent format. Yes, there is a tick-box to indicate NHS experience, but I have to emphasise that it is self-declared—and that is the problem. There is no mechanism for verification to confirm that the employer listed is an NHS organisation, or any other relevant detail. That is why I spoke about this in Committee: it would require a manual review of tens of thousands of applications. That means a high risk of error, potentially delaying offers and start dates: again, nothing that any of us would wish to do. It would of course be destabilising for applicants and trusts, so it is not operationally feasible and nor would it be fair.

The noble Earl, Lord Howe, asked for more information on the Oriel system. I would welcome speaking to him at great length about it as, having looked into it in a practical sense, I can absolutely see the limitations. In my letter to the noble Lord, Lord Clement-Jones, which I have placed in the Library, more detail has been provided on the system, which may be of help to the noble Earl, Lord Howe. But if the noble Earl would like a more in-depth acquaintance with the Oriel system, he and other noble Lords are most welcome to benefit, as I have done.

The noble Baroness, Lady Finlay, spoke of voluntary experience as a possibility for being NHS-significant experience, and I understand why she 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. The fact is that views on this differ widely, as evidenced today by the noble Baroness. That is why we have committed to full engagement on this issue for future years, rather than rushing through 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 is the key—to support fair assessment in future recruitment rounds. Our aim is to have this in place in time for the next specialty training round, which will open for applications in autumn 2026.

For the current recruitment round, the Bill uses a set of carefully chosen specified immigration statuses, as this is a practical and proportionate proxy for identifying applicants most likely to have significant NHS experience. After careful consideration, we have concluded that this is the best approach for the 2026 recruitment round.

On the question from the noble Earl, Lord Howe, about the potential for additional training places and the likelihood that the ones I referred to earlier will be sufficient, we are keeping the numbers under review, as we always do. The noble Earl asked me to look at particular cases, and I am always happy to do that. We should bear in mind that it is often difficult to comment on very specific individual cases, but I am pleased to look at the broad point that he makes.

On the basis of the reasons I have outlined, I hope the noble Lord will withdraw his amendment.

--- Later in debate ---

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.

[Baroness Merron (Lab)]

My Lords, I am most grateful to noble Lords from across the House for their thoughtful contributions in this group. The noble Earl, Lord Howe, reminded us to come back to the prime focus in respect of Amendment 11, which I will start with. It is about supporting and being fair to UK medical graduates in whom we have invested, but that is also a group from whom we seek so much, and we are grateful to them. It is also about providing safe and appropriate care.

I appreciate the intention behind Amendment 11, tabled by my noble friend Lady Lister, but the Government are unable to support it, for the reasons I will outline. The Bill, as noble Lords will be familiar with, prioritises applicants based on certain specific immigration statuses for specialty training in 2026. These statuses have been carefully chosen for the reason that I have said a number of times: as a practical and proportionate proxy for applicants who are most likely to have significant NHS experience. I reiterate, as I have said a number of times, that the Bill is not about exclusion of any groups or individuals but about prioritisation.

Referring to the request by my noble friend Lady Lister, which was emphasised by the noble Lord, Lord Mohammed, perhaps I could make one point to remind your Lordships’ House. For 2027 onwards, those statuses will not automatically apply. Instead, there will be the power to make regulations to capture and prioritise persons with significant NHS experience based on other criteria or by reference to immigration statuses. I reassure my noble friend that we have already committed, and do so once again, to a proper engagement process—subject to the Bill’s passage, of course—to ensure that any future definition is fair, evidence-based and deliverable.

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 foundation and specialty training. The applicants with the immigration statuses 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 specialty 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. On this basis, I hope my noble friend will feel able to withdraw her amendment.

I turn now to Amendments 12, 13 and 15, tabled by the noble Baroness, Lady Gerada. I appreciate the intention behind these amendments, as many of us do, and I am most grateful to the noble Baroness for her work in bringing these amendments back in the way that she has on Report, having heard the arguments previously in Committee. I appreciate her work on them, both inside this Chamber and outside, and the way in which she made her case so clearly and powerfully, as other noble Lords have said. I know the noble Baroness is aware, as I emphasised in my letter that I sent out to Peers, that the Government are unable to support these amendments.

Let me explain to your Lordships’ House why this is the case. The Bill rightly prioritises doctors for foundation and specialty training based on where they are trained. It also prioritises internationally trained doctors with significant NHS experience for specialty training. We are doing this because these doctors are more likely to work in the NHS in the long term and to be better equipped to deliver healthcare that is tailored to the UK’s population, because they will better understand the UK’s health system and epidemiology.

On my noble friend Lord Hunt’s point, which I believe he also spoke to in the previous group, while assessments and course learning at overseas campuses may well be the same—I accept that—as in UK-based medical schools, students will not have undertaken the same number of clinical placements in the NHS in the United Kingdom.

I note that the noble Baroness, Lady Gerada, argued in her email to all Peers—or to a number of Peers, I am not quite sure which—that her amendment would not widen eligibility for prioritisation beyond the Government’s intentions. This is not the case. To reiterate, the Bill intends to prioritise home-grown doctors and put them at the front of the queue for training posts. It is unashamed, for the reasons that I have explained and 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 they serve than a doctor who has studied the same curriculum but not in the UK.

However, the Bill recognises that this experience can be gained 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 the UK, it is right that those graduates are not prioritised equally alongside UK-trained medical graduates.

To pick up the point about future-proofing that the noble Baroness, Lady Finlay, raised, we recognise the risks of this creating a loophole in the legislation if medical schools purposefully change their curriculum to ensure that their graduates come from within the priority status. However, as we discussed earlier today, this risk would exist at whatever threshold we set. I can, however, assure the noble Baroness that we will continue to monitor the data carefully in future years, for all the important reasons that the noble Baroness said.

The Bill prioritises all graduates of UK medical schools who have studied for their degree in this country. That is the right thing to do for our health system, because we recognise that 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 as equals, regardless of where they are from.

As the noble Lord, Lord Patel, noted, prioritising graduates from overseas campuses would also undermine—these are my words, not the noble Lord’s—our aim of greater social mobility and access into medicine. We need dramatically to improve access to this profession for those from disadvantaged backgrounds across our communities in order that our medical practitioners can be more representative and serve the communities from where they come. The campuses that we are speaking of are commercial ventures 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.

I will make a number of points to deal with the points that the noble Lord, Lord Clement-Jones, raised. I understand that the proposed amendments 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 that would enable us to limit the number of eligible applications under this provision. However, the establishment and operation of these overseas campuses 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 talk—not just in the Chamber, but outside—about figures. 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 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 specialty 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, so would conflict with provisions in the rest of the Bill, which treat Ireland graduates on the same basis as UK graduates, reflecting the unique relationship between the two countries.

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It has been suggested by a number of noble Lords that there appears to be some tension—perhaps a contradiction—between these two statements, which may create a confusing situation for all. To help noble Lords, I ask the Minister to please be a little clearer today and answer three specific questions. First, when will the provisions of the Bill be implemented? Secondly, if the Minister cannot say that because of external factors, such as strike action, can she tell the House when they will be implemented assuming strike action continues? Thirdly, when will they be implemented if strike action comes to an end? I suggest that it would be to the benefit of all involved to know a little more clearly how the Government intend to proceed from here. I hope that I have offered an opportunity for the Minister to clarify for all concerned.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lords, Lord Kamall and Lord Mohammed, for their contributions in this group of amendments.

I turn first to Amendment 14, tabled by the noble Lord, Lord Mohammed. As I stated in Committee, we are unable to support this amendment. It might be helpful to your Lordships’ House if I am clear about our intention. As your Lordships are aware, the Bill sets out on its face the groups of people who are to be prioritised for specialty 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 in the Bill the specialty training programmes excluded from the prioritisation scheme. Again, I give the reassurance that the delegated power about which we are speaking is limited to amending this list and gives necessary operational flexibility for future changes in recruitment, training and workforce needs—something that noble Lords raised in an earlier group.

As I hope noble Lords are aware, I am always supportive of parliamentary scrutiny. However, due to the very limited scope of these powers, we believe that the negative procedure is appropriate, not least as the regulations will not have the effect of excluding anyone from applying for a training post. I hope it is helpful 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 such regulations. With that explanation, I therefore hope that the noble Lord will feel able to withdraw his amendment.

Turning to Amendment 16, tabled by the noble Lord, Lord Kamall, in Committee I spoke to why, as he said, we cannot support this amendment: because it removes an important element of operational flexibility. Let me say at the outset that I completely understand why the noble Lord has raised again the points he raised previously. He mentioned a tension; yes, in lots of ways there is a tension and that is what we are trying to manage.

As I stated previously, the commencement provision in the Bill is absolutely not a mechanism for delay. We want to proceed with this as soon as possible. That is the non-specific answer to the noble Lord’s very reasonable questions, but I think he will understand that not knowing the timetable on which I am commenting or the possibility of strike action means that I am not readily in a position to give exact answers; I wish I were. The main thing is that it is absolutely our intent to commence the Bill as soon as possible. That is why we are dealing with it on the planned timescale.

The commencement clause is a safeguard. It is to ensure that all the planning, capacity and systems are in place before the Act is brought into force, because it will be impossible to do it otherwise. Noble Lords will also appreciate—the noble Lord, Lord Kamall, raised this—that the question of whether it is possible to proceed if industrial action continues, given the strain that strikes put on the system, cannot be ignored.

Although preparations for the implementation of the Bill as introduced have been progressing and are undergoing quality assurance testing, should the Bill be amended it could impact on operational readiness that could delay offers and disrupt staffing preparations. We have to avoid such disruption; although we do not expect such issues to arise, it is important that we retain what we regard as a fail-safe provision.

Any Secretary of State would be right to take all the circumstances, including operational readiness, into account in deciding when the Act should come into force. I cannot restate often enough that the intention is to bring this in as soon as possible; that is what we all want to do and that is what we need to do. For the reasons I set out, I hope that the noble Lord will feel able to withdraw his amendment.

[Lord Mohammed of Tinsley (LD)]

I thank noble Lords who have contributed to the debate. Given what I have heard from the Minister, both in the Chamber and in my previous conversations with her, I beg leave to withdraw my amendment.

Medical Training (Prioritisation) Bill

Baroness Merron Excerpts

Committee stage
Thursday 12th February 2026 Lords Chamber

[Earl Howe (Con)]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Lord Patel (CB)]

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

[Baroness Merron (Lab)]

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

[Lord Jackson of Peterborough (Con)]

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

[Baroness Merron (Lab)]

Yes, we are.

[Lord Mohammed of Tinsley (LD)]

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

[Baroness Merron (Lab)]

I shall be very pleased to do that.

[Lord Patel (CB)]

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

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[Lord Clement-Jones (LD)]

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

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

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

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

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

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

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

[Baroness Merron (Lab)]

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

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

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

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

--- Later in debate ---

[Lord Clement-Jones (LD)]

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

[Baroness Merron (Lab)]

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

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

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

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

[Lord Stevens of Birmingham (CB)]

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

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[Baroness Merron (Lab)]

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

[Lord Clement-Jones (LD)]

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

[Baroness Merron (Lab)]

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

[Lord Clement-Jones (LD)]

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

[Baroness Merron (Lab)]

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

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

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

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

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

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

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[Earl Howe (Con)]

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

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

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

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

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

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

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

[Baroness Merron (Lab)]

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

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

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

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[Lord Stevens of Birmingham (CB)]

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

[Baroness Merron (Lab)]

The noble Lord kindly raised this with me before, and I did test it out. I am grateful that he has given thought to this, because it is an important point. However, I am advised that, unfortunately, the solution that he has come up with would not deal with all the concerns we have and would still give us difficulty. The noble Lord talked about the thin end of the wedge, and I fear that we are still in the same place. I am happy to write to the noble Lord, and to make that letter available, to explain further detail. I am grateful that he has given consideration to a solution for what is undoubtedly an issue.

[Baroness Finlay of Llandaff (CB)]

I understand the comments that the Minister has made to my noble friend Lord Stevens. Would she consider wording in the primary legislation that expands on the fact that the campus must be extant and includes that the number of students studying medicine for the UK degree must be the same as when the Bill passes? That would provide rigid guidelines in primary legislation and would not rely on another body, where a quota could possibly be negotiated.

[Baroness Merron (Lab)]

Again, I understand that the noble Baroness is coming forward with a solution and I appreciate her thoughts. I always reflect on what is said, but my initial reflection is that that does not deal with the fact that we already have a number of people. I asked this very question about continuing to prioritise them. It is significant even currently and that is part of the problem, although I understand what she is suggesting.

[Lord Clement-Jones (LD)]

My Lords—

[Baroness Merron (Lab)]

I will take one more intervention, but it might be helpful to hear all that I have to say.

[Lord Clement-Jones (LD)]

I am sure that it will, but I just wanted to follow up the Minister’s pledge to deliver a letter to us in which she will set out precisely what her concerns are. Will the timing of that letter be early next week so that there is time to table amendments for Report to meet some of those concerns?

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[Baroness Merron (Lab)]

As I always do, I will seek to engage in sufficient time before Report. I will not promise the beginning of next week, but we all know the deadlines that noble Lords are working to and I am very respectful of that.

Amendment 17 could create the loophole I have referred to and risks existing international overseas campuses expanding their intakes further. I am grateful that noble Lords acknowledge the concern and are considering how to deal with it. That would be outside any UK workforce planning.

Amendment 21 would provide a regulation-making power to limit the number of applicants who could be prioritised from these overseas campuses. Going back to my earlier comments, it is not clear how such a requirement would be implemented effectively and fairly in practice but, in any event, it would not provide an appropriate safeguard for UK workforce planning.

The Bill rightly prioritises those whose education and placements the UK taxpayer has supported, who are most likely to work in the NHS in the long term—I emphasise this point—and are better equipped to deliver healthcare tailored to the UK’s population because they understand the UK’s epidemiology. However, I hope my noble friend Lord Forbes and the noble Lord, Lord Mohammed, will take back to the university that graduates from international overseas campuses are not excluded and will continue to be able to apply to the foundation programme and specialty training.

Amendment 18 tabled by the noble Baroness, Lady Finlay, relates to the prioritisation of medical graduates from institutions in Ireland. The Government cannot accept this amendment, and I thought her own assessment of it was most honest and helpful. Throughout the development of this Bill, we have been clear that graduates from the Republic of Ireland are prioritised on the same basis as UK medical graduates. This reflects the long-standing and unique relationship between our countries, including the arrangements under the common travel area, which supports reciprocal rights of movement and employment. It also ensures coherence in workforce planning across both jurisdictions, where medical education and training pathways have been closely aligned for many years.

Introducing different criteria for graduates from the Republic of Ireland, as this amendment proposes, would risk disrupting those shared arrangements. It could also create an uncertainty in the provision of postgraduate training in Ireland.

Amendment 19, tabled by the noble Baroness, Lady Gerada, seeks to add Malta to the list of prioritised countries set out in Clause 4. This would require that those who hold a primary medical qualification from any institution in Malta, irrespective of their nationality, are prioritised for foundation and specialty training. I address this particularly to my noble friend Lord Mendelsohn, to whom I listened closely, as I did to the noble Baroness, but we cannot accept this amendment.

I refer particularly to the European Free Trade Association countries, as they have been mentioned a number of times, including by my noble friend Lord Mendelsohn, the noble Lord, Lord Clement-Jones, and others. Those countries listed in Clause 4 are those with which the UK has signed agreements that include offering parity of access to the workforce. I have looked back at when those agreements were made: for the EFTA countries of Iceland, Norway and Liechtenstein, the agreement was made in July 2021, and Switzerland was in 2019. I make these points because they certainly precede this Government. In practice, as I have said before, not all these countries will have eligible applicants in any case.

The 1975 UK-Malta reciprocal healthcare convention will continue and is not affected by the Bill. I emphasise that that agreement is wholly related to reciprocal access to healthcare, not access to training or employment related to medical training. I hope it is helpful to say that the Bill includes a power to amend the list of countries in Clause 4 to reflect any future international agreements that the UK may enter into. As I have also stated previously, the Government set UK medical school places based on future health system needs. I emphasise that there is no disrespect intended here and we very much value the long-standing partnership with Malta on healthcare, and that will continue to be valued. However, prioritising international graduates would undermine our ability to keep foundation training numbers aligned with the NHS workforce that we are planning for and manage those bottlenecks in specialty training, about which there is concern across the Committee. This is about focusing on patient care and ensuring that those whose education and experience best prepares them to practice safely and effectively in the NHS are the ones who are prioritised.

For specialty training, prioritising these individuals would not support our aim to prioritise doctors with significant NHS experience who understand how the health service works and how to meet the needs of the UK population. I reassure the Committee that this Bill will not affect existing fellowship arrangements with Malta, and the affiliation of the UK foundation programme and Malta foundation programme, to which the noble Baroness, Lady Gerada, referred, will still stand. Senior officials in my department have met with the high commissioner of Malta to the United Kingdom to assure him of this and last week I received a positive letter of acknowledgement from the Health Minister in Malta.

To be absolutely clear, individuals with a primary medical qualification from Malta will still be able to apply for foundation and specialty training places, and they will be considered for any places that are left after prioritisation. But it would still be the case that it would be at odds with the aim of the Bill for them to be prioritised for these places. For the reasons I have set out, I hope the noble Baroness will feel able to withdraw her amendment.

[Lord Winston (Lab)]

The NHS is a complex organisation which is going to be rapidly changing, with increasing issues regarding its employees and all sorts of new technologies that will develop in a way we have never seen before. In view of that, does the Minister think there might be some reason for the Government to consider looking at this situation in, say, five years’ time to see the effect of the Bill on the health service?

[Baroness Merron (Lab)]

My noble friend is right about the pace of change, and many of the changes we cannot even imagine as we discuss this today. We keep the impact of legislation under review, and the Bill will be no different to any other Bill in that regard.

[Baroness Finlay of Llandaff (CB)]

I do not want to put the Minister too much on the spot now, so could she clarify in her letter whether Clause 4(3)(b) means that the Bahrain campus is within the allocation for prioritised places, whether any other Irish campuses are, and how the limit would be held on other campuses developed from Ireland, given that the response we have had seems to exclude Malta and Newcastle?

[Baroness Merron (Lab)]

I am happy to set it out in a letter, but I can say immediately that graduates of the Royal College of Surgeons in Ireland’s Bahrain campus are not necessarily prioritised just because part of their programme takes place in Ireland. The Bill is clear that prioritisation applies to graduates of Irish medical schools who complete the majority of their medical education in Ireland, but I am happy to add to that in my letter.

[Baroness Gerada (CB)]

I am grateful to the Minister for the care with which she has addressed my amendments. I will be very brief. I must say I am disappointed, and I have a few points.

I will address Malta first. These are not international medical graduates; these are UK-trained doctors training in a UK university, albeit overseas. As I said, they are trained for the NHS. The Minister mentioned several times that it is not exclusion, it is prioritisation. I have already had emails from two doctors, one of whom is being excluded from applying for a postgraduate examination until the UK cohort has applied. I will not say their specialty, because it might identify them, but it means that the tiny island of Malta will not have this particular specialty because this doctor cannot finish his training until he does that. They are already being excluded from fellowship posts that have been long standing over decades—that is of last week.

Given the fact that the Bill is being taken through the House at such pace, as well as writing a letter—which I understand we will get in our post next week—would the Minister be willing to meet me and several Peers who have already raised some amendments so that we can explore this in more detail and work constructively towards a solution? I am sure these issues will be considered further on Report but, in the light of the Minister’s reply today, I beg leave to withdraw the amendment.

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[Lord Clement-Jones (LD)]

My Lords, I support Amendment 22, standing in the name of the noble Lord, Lord Kamall. He absolutely made the case but, having heard what the Minister had to say on the previous group, I have a terrible certainty about what her response will be.

I assure the Minister that many of us want to find solutions, in the way that the noble Lord, Lord Stevens, mentions. The principles of the Bill are supported across the Committee; it is some of the detail that is in contention. We must be honest that the Bill deals with the symptom—competition ratios—not the cure, which is the bottleneck of insufficient specialty training places. I go back to the phrase that the noble Lord, Lord Stevens, used at Second Reading. We are simply reshuffling the queue.

This amendment places a necessary duty on the Secretary of State to review the adequacy of training places. We have received warnings from doctors in shortage specialties such as psychiatry and general practice, who fear that the Bill will drive away the international talent that we rely on. We need to know whether this legislation will succeed in retaining UK graduates or whether it will inadvertently exacerbate shortages by signalling to the global medical community that the NHS is closed for business. We cannot manage what we do not measure.

[Baroness Merron (Lab)]

My Lords, I welcome the debate that we have just had and I appreciate the support for what we are seeking to do, particularly from both Front Benches, as in the other place. I am most grateful for that.

The amendment tabled by the noble Lord, Lord Kamall, seeks to require the Secretary of State to review the impact of this Act within six months of Royal Assent and to require that that review is published and laid in Parliament. I understand the intent behind this amendment, but we do not feel that there is a need to accept it because the Government have already set out their impact-monitoring and evaluation plans within the published impact statement on 14 January.

The noble Lord’s amendment also specifies requirements that are not compatible with how recruitment cycles operate. He will understand that I want to report to your Lordships’ House only on the basis of proper information, as he would expect. However, data as specified in the amendment would not be available to allow us to meet those requirements or to allow sufficient time and flexibility for the investigation of impacts. However, I give the assurance that, should the Bill be passed, the Government will ensure that appropriate data is collected and investigated to facilitate the already proposed impact evaluation. I hope that this will be helpful.

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[Earl Howe (Con)]

My Lords, I am grateful to the noble Lord, Lord Mohammed, for his amendment and his very helpful introduction. From these Benches, we have consistently raised our concerns about the downsides of emergency legislation. The Constitution Committee chairman, my noble friend Lord Strathclyde, wrote in his letter to the Minister that the Constitution Committee has

“repeatedly raised concerns about the fast-tracking of legislation, highlighting in particular the need to ensure that effective parliamentary scrutiny is maintained”.

We are all of us, I hope, doing our utmost in the short time available to scrutinise the Bill fully, but, with such a short period of time available, we cannot discount the possibility that this legislation will have unintended consequences. The noble Lord, Lord Clement-Jones, posited one particular example in his speech during the last debate.

It is true that the Delegated Powers and Regulatory Reform Committee has not brought anything in the Bill to the attention of the House. However, in the light of the fact that the Bill has been fast-tracked through Parliament, there is, I believe, a case for making all regulations under this Act subject to the affirmative procedure, allowing for additional future scrutiny. Like the noble Lord, Lord Mohammed, I look forward to hearing the Minister’s reply.

[Baroness Merron (Lab)]

My Lords, I am grateful not just for this brief debate but for the efforts of noble Lords to expedite this legislation. I acknowledge the short timeframe—it is not as short as in the other place but, nevertheless, noble Lords have been most co-operative, and I value that.

Amendment 23, tabled by the noble Lord, Lord Mohammed, seeks to require that all regulations made under the Act are subject to the affirmative procedure. This is an amendment we are not able to accept. To reiterate our intention, the Bill sets out the groups of people who are to be prioritised for specialty training from 2027 onwards. I reassure the noble Lord that the delegated power is limited to adding to this list by reference to significant experience working as a doctor in the health service or immigration status.

Similarly, we have set out in the Bill specialty training programmes excluded from the prioritisation scheme. The delegated power is limited to amend this list, and it gives necessary operational flexibility to respond to future changes in recruitment, training and workforce needs—something that I know noble Lords are very attuned to the need for.

I am sympathetic to the desire for parliamentary scrutiny and I always try to ensure that it is provided but, because of the limited scope of these powers, we believe that the negative procedure is appropriate. As the noble Earl, Lord Howe, just referred to, the Bill has been assessed by the Delegated Powers and Regulatory Reform Committee, and no suggestion has been made that the negative procedure was inappropriate for this regulation.

I have spoken in a previous group to why we are dealing with emergency legislation. I hear what is said about the downsides, but we have to balance that with the scale of the problem and the urgency that it demands. That is why we decided to introduce emergency legislation.

The noble Earl spoke about the Constitutional Committee letter. We will be responding formally to the committee to address its concern. With that, I hope the noble Lord feels able to withdraw his amendment.

[Lord Mohammed of Tinsley (LD)]

I thank the Minister for that timely response. I particularly welcome the support of the noble Earl, Lord Howe, for the principle that I was trying to establish. However, on this occasion, I beg leave to withdraw the amendment.

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[Lord Clement-Jones (LD)]

My Lords, I will speak to Amendments 26 and 27 on commencement, proposed by the noble Lord, Lord Kamall. I confess that we are conflicted on these. This brings us back to the tension at the heart of the Bill. We have UK graduates urging immediate implementation to resolve their uncertainty; conversely, we have international medical graduates asking for delay or transition because the rules are changing mid-cycle. If the Government eventually accept the amendments in group 2, providing a fair transitional arrangement for those with NHS experience, then immediate commencement becomes less punitive. However, if they persist with the blunt ILR proxy for 2026 then rushing to commencement simply accelerates an injustice.

I urge the Minister to clarify when precisely the regulations for the 2026 cycle will be laid if this Bill passes and whether they will include the transitional protections we have argued for. I am somewhat pessimistic on that. Certainty is needed, but it must not come at the expense of fairness.

In that context, as we are at the end of Committee, I must ask the Minister to confirm that she is going to meet the cross-party group of those of us who have spoken at Second Reading and in Committee before Report takes place. I have kept my diary free for the Monday before Report and I know that the noble Baroness, Lady Gerada, mentioned that earlier. We would all welcome a face-to-face meeting with the Minister. She talked about us being co-operative, and we all realise the Government’s desire for speed, particularly in the context of the industrial dispute, but, quite frankly, it takes two to tango.

[Baroness Merron (Lab)]

I am grateful for the noble Lord’s advice in his last comment.

I thank noble Lords for their contributions. The noble Lord, Lord Kamall, spoke about what I am going to call the tension between emergency legislation and the commencement clause. I will start on that point. I hope he is aware that our intent is, of course, to commence the Bill as soon as we possibly can, subject to its passage through Parliament. That is why I am so grateful to noble Lords and to Parliament more broadly—both Houses—that they have agreed to expedite the progress of this Bill.

I will come back on to this later in a bit more detail but, as I have already stated, there is a genuine question about operational feasibility, if strikes are ongoing, due to the strain that they put on the system. I am sure everybody in your Lordships’ Chamber would understand that. I will now refer to the amendments, and I have some other points to answer some of the questions that were raised.

Amendment 26, tabled by the noble Baroness, Lady Coffey, and spoken to by the noble Lord, Lord Kamall, and Amendment 23, tabled by the noble Lord, Lord Mohammed, and spoken to by the noble Lord, Lord Clement-Jones, relate to the date upon which the Act comes into force. Both would remove the provision that allows the Secretary of State to appoint the commencement date.

We cannot accept these amendments, as they remove an important element—and I emphasise this point—of operational flexibility, should it be needed. The commencement provision within the Bill is not a mechanism for delay. It is, we believe, a necessary safeguard to ensure that systems planning and operational capacity are in place before the Act is brought into force. Noble Lords will also appreciate that it is a material question, as referred to by the noble Lord, Lord Kamall, about how possible it is to proceed if industrial action continues, given the strain that strikes put on the system.

It is our intention to commence the Bill as soon as we are able, but it is essential that the Secretary of State is able to take all the circumstances, including operational readiness, into account when deciding when the Act should come into force. I think that it is honest to say this. Amendment 26 also seeks to require the Act to come into force one month after it is passed. Specialty training offers must be made from March. Delaying commencement by even one month would leave insufficient time to implement prioritisation for this year’s application round. In short, fixing a commencement date one month after Royal Assent, as Amendment 26 suggests, would create a situation where the Bill comes into force too late to tackle the bottleneck problem that we seek to resolve—the one that it is designed to remedy for the 2026 year—while also removing our ability to commence the Act only when systems are ready to deliver it effectively.

On the comments about industrial action made by the noble Lord, Lord Kamall, I reconfirm that the Government have been in intensive and constructive discussions with the BMA resident doctors committee since the start of the new year. The aim is to try to bring an end to the damaging cycle of strikes, and to avoid what is undoubtedly further, unnecessary disruption for patients and NHS staff. We continue to hope that those talks result in an agreement that works for everyone, so that there will be no more strike action by resident doctors in 2026.

With regard to the noble Lord’s request for more detail on operational readiness, I know he understands that introducing reforms to such a large-scale recruitment process is a big undertaking. We do not want the risk of creating errors that could lead to further uncertainty for organisations, for educators and, most importantly, for our trainees. An effective commencement demands clear processes for delivery across the health system. The reality is that industrial action will put this at risk because it is a diversion of resources, as it always is.

The noble Lord, Lord Clement-Jones, asked about further engagement. I have already had engagement with a number of noble Lords, including both Front Benches. If it is possible to do so before Report, I will write again. Time is extremely short, so while I am always glad to do so, if the noble Lord will allow me to look at that in a practical sense, I will be pleased to. With that, I hope that the noble Lord will withdraw the amendment.

[Lord Kamall (Con)]

I thank the noble Baroness for that considered response to the discussions. I thank all noble Lords who have spoken, not only to this group of amendments, but today. I also thank the staff for being here to look after us while we stay to this hour.

I should perhaps clarify for the noble Lord, Lord Clement-Jones, that when I laid the amendment it was with the amendment from my noble friend Lord Howe in mind. If we can address some of the perceived injustices or unfairness in the system, we should implement as soon as possible. I was not seeking to create a tension there.

I am grateful to the Minister for explaining that there are operational issues. I think that it would help the Government, and help this Bill to go forward, if the Minister were able to explain in a letter to noble Lords some of those operational issues, because sometimes it may be that we think that it is quite easy. I know, having been in government, that there are a number of issues. I can see that the Minister is looking forward to spending her Recess formulating that letter with her officials. The noble Lord, Lord Mohammed, talked earlier about a holiday, but I do not think that Ministers ever get a holiday. I am giving the Minister a challenge during the Recess to explain some of the operational challenges that lead to the Government not being able to accept this amendment to implement the Bill as soon as possible.

With that, I thank the Minister for her response. I thank all noble Lords who have spoken today and I beg leave to withdraw the amendment.

Tobacco and Vapes Bill [HL]

Baroness Merron Excerpts

Wednesday 11th February 2026 Lords Chamber

Moved by

[Baroness Merron]

That the amendments for the Report stage be marshalled and considered in the following order: Clauses 1 to 16, Schedule 1, Clauses 17 and 18, Schedule 2, Clause 19, Schedule 3, Clauses 20 and 21, Schedule 4, Clauses 22 to 40, Schedule 5, Clause 41, Schedules 6 and 7, Clauses 42 to 64, Schedule 8, Clause 65, Schedule 9, Clauses 66 to 83, Schedule 10, Clause 84, Schedules 11 to 13, Clauses 85 and 86, Schedules 14 and 15, Clauses 87 to 126, Schedule 16, Clauses 127 to 140, Schedule 17, Clauses 141 to 145, Schedule 18, Clauses 146 to 151, Schedule 19, Clauses 152 to 156, Schedule 20, Clauses 157 to 159, Schedule 21, Clauses 160 to 170, Title.

Motion agreed.

Better Start Longitudinal Programmes

Baroness Merron Excerpts

Tuesday 10th February 2026 Lords Chamber

[Baroness Thornton]

To ask His Majesty’s Government whether, and if so when and how, the learning from the results of the Better Start longitudinal programmes will become pregnancy and early years policy and be implemented.

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

My Lords, we welcome the valuable learning that is emerging from the five Better Start partnerships and we look forward to the national evaluation report in the spring. The programmes provide important insights into early-years support in highly disadvantaged areas. Best Start Family Hubs and Healthy Babies already deliver a place-based prevention focus model. We will consider Best Start evidence, alongside other evaluations, as we develop policy to deliver a new neighbourhood health service and raise the healthiest generation of children ever.

[Baroness Thornton (Lab)]

I thank the Minister for that and declare an interest: my sister, Gill Thornton, is the director of Better Start Bradford, which is part of the £250 million programme funded by the National Lottery, with local funding too, for the last 10 years. The model, which places children and family at the heart of service design, focuses on the first 1,001 days, which is critical because of the developmental window from conception to a child’s second birthday. I would like to hear how the Government will integrate this into their Best Start for Life programme.

[Baroness Merron (Lab)]

The work in Bradford is to be commended. I can assure my noble friend that, through Best Start Family Hubs and Healthy Babies, local authorities will be expected to do exactly what the noble Baroness says is happening in Bradford: that is, to establish very inclusive and diverse routes for parent and carer participation. We want families to shape how services are set out and I absolutely agree that the first 1,001 days of a child’s life is a crucial and critical developmental window.

[Lord Russell of Liverpool (CB)]

My Lords, the Minister may not have had the time that I have had to read the first report from this programme, which is called Exploring School Readiness. These projects have been going in five different areas, with 16 different programmes. In going through all 16 programmes, does she share with me the slight concern that there is only one mention of mobile phones and screen time? That was in Nottingham, where adults were asked to leave their mobile phones outside an area where their children were learning how to play, in order that the adults could concentrate and pay attention to their children, rather than pay attention to their phones. Given the rising concern generally in the country about the effect of screens and phones, not only on the very young but on the ability of parents to be parents, could that not be integrated and taken into account as this programme is taken forward?

[Baroness Merron (Lab)]

It is an important point that the noble Lord raises. This is being dealt with by the Government’s proposal to have a three-month consultation, so that we get it right in terms of acknowledging the concerns and challenges of screen time for children. So, I take the point that the noble Lord has made. This is of course a matter for DSIT. I will ensure that it is aware of the noble Lord’s comments, as well as the relevant departments—my department and the Department for Education—in respect of the programme that we are talking about.

[Baroness Walmsley (LD)]

My Lords, while I welcome today’s announcement about protecting special educational needs funding, I would like to ask about support for very young children with special needs and those with physical disabilities. Parents often find it difficult to find an early-years place or childcare suitable for these special children. Can the Minister point them towards any real, properly funded, properly resourced help from people with the right training looking after these special children?

[Baroness Merron (Lab)]

I hope I can be helpful to the noble Baroness. In the Best Start for Life strategy, we committed that each Best Start Family Hub will have a children and family services practitioner to support children and families who have additional needs. I feel that this new offer will help parents to understand their child’s development and identify emerging needs sooner. Importantly, it will also support vital join-up across the services, keeping children who have particular needs at the very centre.

[Baroness Rafferty (Lab)]

My Lords, would my noble friend the Minister confirm what the Department of Health and Social Care has taken from the Better Start work to inform its maternity and baby strategy?

[Baroness Merron (Lab)]

As my noble friend knows, we are absolutely focused on improving quality and consistency of care for women throughout pregnancy, birth and the critical months that follow. That is why we have appointed the noble Baroness, Lady Amos, to lead an independent investigation and why the Secretary of State will chair a maternity and neonatal taskforce to address the recommendations of the investigation. It is very much part of our work to give babies the very best start in life.

[Baroness Deech (CB)]

My Lords, the Minister has expressed the commendable ambition of raising the healthiest generation of young children ever. So why have the Government done nothing to condemn and educate about, if not prohibit, cousin marriage, the babies from which suffer twice the number of birth defects as those from non-cousin marriage?

[Baroness Merron (Lab)]

My recollection from debating that point previously is that we are looking at the evidence and the best way to tackle the issue that the noble Baroness raises: in other words, what best supports children to have that healthy and best start in life? We are looking at this in the round and I am sure that we will return to it, but I will also be pleased to follow up in writing to the noble Baroness.

[Lord Kamall (Con)]

My Lords, many noble Lords would support the objectives of the Better Start longitudinal programme, with its focus on improving children’s diet and nutrition, social and emotional development, and speech, language and communication skills. But can the Minister explain how, rather than with a top-down, Whitehall or Westminster-knows-best attitude, it is working with local civil society organisations, such as BRITE Box, which works with families and local communities to help them learn how to cook healthier meals on a budget to improve their nutrition and well-being?

[Baroness Merron (Lab)]

This will not be a top-down approach. We are ensuring that Best Start Family Hubs and Healthy Babies are in every local authority area. That is a major development, because from April it will reach more than 500,000 more children. It will also help us transition to neighbourhood health services. However, all of this will, as ever, be more successful by working together with other groups, including third-sector organisations such as BRITE Box.

[Lord Watts (Lab)]

My Lords, does the Minister agree with me that we would have had much healthier children if the previous Government had not shut down all the Sure Start centres and caused the poverty that they did?

--- Later in debate ---

[Noble Lords]

Oh!

[Baroness Merron (Lab)]

I think I heard what my noble friend said: I got the gist. What matters is not just that we are in a position where children’s health and well-being is not where it should be but that we are pulling together all the best examples of practice, including Sure Start and family hubs, and investing in provision, services and information. This will take us forward to a situation where we genuinely have the healthiest generation ever. That is not something we have now, particularly in the more disadvantaged areas.

[Baroness Manzoor (Con)]

My Lords, I am sorry if I sound like a broken record, but what are the Government doing to ensure that we retain the health visitors and midwives that we have? There are not sufficient midwives or health visitors in the service and they play a vital role in supporting young mothers and fathers in the care of their babies and children.

[Baroness Merron (Lab)]

They do: I completely agree. That is why they are very much part of our delivery plan. It is part of the move from hospital to community: part of the neighbourhood service model. We will be publishing the workforce plan in the spring; that will take account of it. This is a multidisciplinary approach. We are seeing more midwives. We are also seeing more consultants in obstetrics, for example, although I know that the noble Baroness was not referring particularly to that. We are also developing stronger health visitor teams. They all matter, because they bring the care closer to home in a way that will make the greatest impact.

Under-16s Energy Drinks Ban

Baroness Merron Excerpts

Tuesday 10th February 2026 Lords Chamber

[Baroness Walmsley]

To ask His Majesty’s Government when they expect to publish a timeline for legislation banning the sale of energy drinks to under-16s.

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

My Lords, we are taking decisive action on obesity, easing the strain on our NHS and creating the healthiest generation of children ever. As part of this, we will fulfil our commitment to ban the sale of high-caffeine energy drinks to children aged under 16, introducing the ban within this Parliament. Our consultation has closed. We are analysing the responses and will set out further information on our timelines in due course.

[Baroness Walmsley (LD)]

My Lords, the Government promised to ban the sale of energy drinks in this Session. The consultation has ended but we have not seen the results yet. When will the responses be published and when will the Government publish the regulations? Will the ban extend to all under-18s and all retailers, including vending machines and schools? There is still time to pass the regulations before Prorogation. Will the Government get on with it? Otherwise, it will be a promise made but a promise broken.

--- Later in debate ---

[Baroness Merron (Lab)]

I hear the noble Baroness’s counsel but, as I said, we have committed to introduce the ban within this Parliament, as the Secretary of State said. He also said ideally sooner, if possible. I can confirm that all sellers, retailers and businesses of all sizes in England, including in-store and online sales, should be in scope of the ban.

[Lord John of Southwark (Lab)]

My Lords, in addition to the harms of energy drinks, the 156 cans of fizzy drink that the average child consumes in the UK each year can and do contribute to higher rates of childhood obesity and dental problems. With that in mind, will my noble friend the Minister commend the work of —would you believe—Southwark Council, which introduced the Fizz Free February public health programme in 2018, which has now been taken up in 25 other areas and aims to significantly reduce the consumption of fizzy drinks among children and young adults? Will she also explore ways in which Fizz Free February can be supported and introduced more widely across the country?

[Baroness Merron (Lab)]

I am very pleased to commend this initiative by Southwark Council. It was developed by the council’s public health team and is a good example of what local action can do. My noble friend talked about the extension of this initiative across the country. I very much support that. What struck me, having looked online at Fizz Free February, was the importance of the information that reminded us that more five to nine year-olds are hospitalised due to issues with their teeth than anything else. That is a very sobering thought.

[Lord Ahmad of Wimbledon (Con)]

My Lords, I declare an interest: my wife and I have constant battles with our children over the downsides of energy drinks and caffeine. Energy drinks can lead to type 1 diabetes. What processes and programmes are being undertaken to ensure that schools, in particular high schools, are part of this process in educating students? Once they are out of the door it is very much a decision that they make themselves. I also support the noble Baroness, Lady Walmsley, in that every outlet should be part of this regulation.

[Baroness Merron (Lab)]

I agree on that last point, not least because that makes a level playing field, but it is also the right thing if we are to make that ban. The noble Lord describes a battle that I am sure goes on in many households. Schools are crucial. The incentive for schools is that children and young people will be much better placed to learn. One of the most disturbing things about this, and a message which we need to continue to get across, is that more headaches, difficulty with concentration and greater anxiety are all potential consequences of energy drinks. We work very closely with schools to ensure that the message gets through.

[Baroness Winterton of Doncaster (Lab)]

My Lords, one of the real successes of the previous Labour Government’s Sure Start programme was teaching families about healthy diet and how to prevent obesity. Can my noble friend the Minister assure me that the new family hubs will take an equally robust approach?

--- Later in debate ---

[Baroness Merron (Lab)]

I can certainly confirm that to my noble friend. The new Best Start in Life hubs will take the best from previous programmes, including Sure Start. We are providing information through an online service that has had 4.5 million hits so far, and we are working closely with the Department for Education on that. But yes, we will be taking the best of Sure Start.

[Lord Kamall (Con)]

My Lords, when a Government restrict the sale of products to some but not all customers for whatever reason, it is essential to pre-empt the effects on businesses that will be at the sharp end of enforcing this ban, especially corner shops and small retailers. What engagement have the Government had with small retailers, especially small corner shops, some of which do not always feel represented by the Association of Convenience Stores, to understand their concerns over violence or abuse when they ask for ID from customers who may appear to be underage?

[Baroness Merron (Lab)]

As we discussed on the Tobacco and Vapes Bill in this Chamber, the whole issue of age verification is crucial. I feel that businesses are used to seeking age verification. What matters is that they feel empowered to ask for it and that staff are trained. That is why we are indeed working with businesses in the way the noble Lord says. Many of them responded to the consultation and we are very pleased to have their voice in that.

[Lord Hampton (CB)]

My Lords, does the Minister agree with me—working, as I do, with children as a teacher—that there is a certain irony in banning sports drinks for sale to children yet allowing those drinks to sponsor sports teams?

[Baroness Merron (Lab)]

I understand the noble Lord’s point. We are focusing on those energy drinks that contain 150 milligrams of caffeine per litre as the way of making the greatest impact to children aged under 16. When I think that over 100,000 children aged 11 to 15 consume at least one high caffeine energy drink per day, I believe that that is the right thing to do, as some of those drinks are equivalent to four cans of Coke or two espresso shots. That is how seriously we need to take this. I hear his point about going further, but it is important that we focus on the absolute immediate.

[Baroness Manzoor (Con)]

The Government introduced voluntary guidelines for manufacturers to reduce salt and sugar in baby food and milk food products for ages up to 36 months. How has that gone? Will they introduce statutory guidelines after the first 18 months? Have companies complied with the guidelines?

[Baroness Merron (Lab)]

We were glad to introduce the voluntary measures. To be proportionate and evidence-based, they will in the first instance be voluntary. We will review along the way how we are getting on and whether there is a need for statutory action, as the noble Baroness asks.

[Baroness Bull (CB)]

My Lords, the noble Baroness’s Answer referred to obesity. There is a risk of obesity from these high-sugar drinks, but caffeine is perhaps the bigger danger, particularly for smaller bodies, which cannot deal with the excessive caffeine. Are the Government monitoring the use of caffeine pouches that are now available, which are inserted between the gum and the lip to give a hit of caffeine, which can be dangerous for young people?

[Baroness Merron (Lab)]

I actually do not know the answer to that, so I cannot confirm it is the case, but I will certainly look into it. I take the noble Baroness’s point about caffeine. That is the problem here, but it is also right that we consider sugar intake.

[Lord McColl of Dulwich (Con)]

My Lords, is the Minister aware that combating the obesity epidemic has been seriously impaired by a number of pseudo- scientists who have put forward the idea that obesity is inevitable and that we cannot do anything about it, so it must be government that does something about it? Does the Minister agree that there is only one cause of obesity and that is eating too much?

[Baroness Merron (Lab)]

The noble Lord always tempts me to agree with him. The causes of obesity are complex and include what people eat, how much they eat and who they are. It is the reason that the Government have taken on the responsibilities they can, such as restricting junk food advertising on TV and online, giving local councils stronger powers to block new fast food outlets, and announcing changes to the soft drinks industry levy. All these support people in making better choices.

National Cancer Plan

Baroness Merron Excerpts

Monday 9th February 2026 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, from these Benches, we very much welcome the national cancer plan and support its ambitions—and it is very ambitious. Many organisations and committees have called for an integrated, long-term plan, so it is very good that the Government have listened and, in particular, have taken note of the views of patients and their families—the people with lived experience of all these problems. However, may I reiterate Cancer Research UK’s response to the plan? It said:

“The key question that patients and their loved ones will ask, however, is how quickly will they see progress in cancer survival and outcomes? The improvements they are waiting for will depend on how this plan translates into delivery. Funding must match the ambition of what has been promised, or the NHS will struggle to expand its diagnostic capacity or introduce innovation at scale. And clear leadership and accountability are also crucial”.


Many of those points have also been mentioned by the noble Earl, Lord Howe, just now.

We know that outcomes in England have lagged behind comparable countries for decades, so it is positive to see improving cancer survival at the centre of the plan. However, it is going to be tough to achieve and will require much faster progress than what we have heard so far indicates. The key, of course, is improved diagnosis at an early stage, so I welcome the renewed commitment to earlier diagnosis and to meeting all cancer waiting time targets by 2029. It is outrageous that 92% of trusts do not reach the target for starting treatment. I welcome the full rollout of lung screening by 2030 and increasing the sensitivity of the tests used in bowel screening by 2028. However, what about breast screening? There have been problems in some parts of the country in getting that done. Can the Minister say whether these plans will be fully resourced? There is no point in doing the screening and tests unless an expert is there to interpret them. There are bold promises, but will they be matched with the resources and training required?

The plan talks about AI tools and liquid biopsy tests, which could certainly hold real potential for increasing productivity. However, before they are introduced, they must be robustly tested so that only safe and effective innovations reach patients and those that do not work can be dropped.

While there is a focus on diagnosis and treatment, I was pleased to see that the plan includes a commitment to increase action on lifestyle factors which we know cause cancer. Smoking tobacco, being overweight or obese, alcohol and UV exposure still cause many cancers that could be prevented. Fortunately, the Tobacco and Vapes Bill should certainly have a positive effect over the coming years in stopping people smoking in the first place. It is also positive to see action to strengthen protections on sunbed use and measures to drive HPV vaccination uptake, particularly in underserved groups. The new ad hoc committee on childhood vaccine rates is, I hope, going to contribute to that.

More action is needed to drive the shift from sickness to prevention, which is one of the Government’s core objectives in their 10-year health plan. There is still more to do to help millions of existing smokers quit smoking and to prevent someone becoming overweight or obese in the first place. Tightening regulation on alcohol through introducing minimum unit pricing, as implemented in Scotland and Wales, was a missed opportunity. Will the Government reconsider?

Rare cancers make up about 24% of cancers diagnosed in the UK and the EU every year. This includes cancers of children and young people, because they are less likely to suffer from the cancers caused by the lifestyle issues I have just mentioned. This is where research comes in, and the ability to implement research findings into the NHS. It is a sad fact that the NHS has been slow in the past to implement new cutting-edge treatments, so it is welcome that the plan has some important commitments in that respect. However, as with other aspects of the plan, the devil is in the detail.

The focus on ending delays in cancer treatment is a step forward, but funding 28 new radiotherapy machines is not enough when the treatment is so cost-effective and successful. We need to end the radiotherapy deserts. Will the Minister extend her ambition to the 200 extra radiotherapy machines that the Liberal Democrats have proposed? Another 28 will probably only replace the old machines that need to be replaced anyway—it will not take us forward. Can the Minister tell us about the plan to train the operatives for these new machines? Resources, training and accountability are at the heart of this. We have not had a lot of detail yet, so I look forward to getting more.

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

My Lords, I am grateful for the warm welcome from both Front Benches for the national cancer plan. This is a moment when we transform our cancer care and we make it personalised—we wrap it around the person instead of expecting it to be the other way around. The 62-day treatment standard has not been met since 2015, and outcomes, as we have talked about a lot in this Chamber, continue to lag behind those of comparable countries. That is what has driven us to this point to ensure that, by 2035, three in four people diagnosed with cancer will be alive five years later, whereas at present, the figure is three in five. That represents 320,000 more lives saved, with all the effects on their friends, families and communities, as well as themselves. That will be the fastest improvement in cancer survival this country has ever seen.

I will try to deal with some of the Front-Bench questions. I agree with much of what has been raised, including the recognition of all those, including those with lived experience, who contributed to what is, in my view and experience, a very bold 10-year strategy that actually sets out how we will do this. Both the noble Earl, Lord Howe, and the noble Baroness, Lady Walmsley, asked about clear milestones. I am glad to say that those are set out at the end of each chapter, with dates and the responsible organisations for all key actions and commitments.

The noble Earl raised the workforce plan. It will be published in the spring and will set out guidance—this goes to the point raised by the noble Baroness—not just on expanding numbers but on ensuring that staff are properly trained and supported. This will require a multidisciplinary team approach. We will use training directly as a lever to prioritise training places in trusts, often in the rural and coastal areas that the noble Earl asked about, as it is indeed the case that vacancy rates are higher and performance is lower. Training doctors of course takes time, but this is about long-term sustainable change and about turning around the whole of the cancer pathway. It is the exact opposite of us tinkering here and there. We are working with the royal colleges to boost the numbers of doctors specialising in clinical and medical oncology.

The noble Earl asked about bringing NHS England into the department. I see that as a great opportunity. Within the plan, we have set out a reformed national cancer board. It will be comprised of cancer experts, and it will be accountable—this is so important, as the noble Baroness said—for the overall delivery of the plan. Regionally, we will keep and strengthen the role of cancer alliances, which will work hand in glove with NHS regions to deliver cancer improvements.

The noble Earl asked how young people are being engaged. We worked with the Children and Young People Cancer Taskforce to ensure their voices were heard through its patient experience panel. Importantly, we will appoint a lead for children and young people with cancer to be part of the revamped national cancer board. We want their voices to continue to be heard. We definitely recognise the distinction between children and young people; they have different needs. For example, the plan highlights the importance of play for children, as well as the role of youth support co-ordinators in providing educational, emotional and fertility support for teenagers and young people. I agree with the noble Earl that cancer has a profound psychological impact on all patients and those supporting them. The plan sets out how that support must be standardised for children and young people, including the provision of longer-term support.

The noble Baroness asked about improving early diagnosis. We are providing £2.3 billion of investment in diagnostics to deliver 9.5 million additional tests by 2029 across screening and symptomatic diagnosis. The noble Baroness asked about seeing change; I say go to a community diagnostic centre. That epitomises where we are going with our National Health Service. We will also spend more than £650 million to complete the rollout of lung cancer screening by 2030, which is one of the things that can make the biggest difference in more disadvantaged areas, as well in prevention.

On radiotherapy machines, the responsibility lies at a local level. We expect local systems to continue to invest in new machines to meet the ambitious targets. Through the spending review, providers have been allocated with £15 billion in operational capital for local priorities and £5 billion to support a return to constitutional standards, including for radiotherapy machines.

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare my interests in palliative care over the years. I will not list them all now, but I had the pleasure of working on the palliative care commission under the chairmanship of Sir Mike Richards. From speaking to him, I am glad to learn that he will have a role in the modern service framework.

My concern about chapter 4 is that action 7 seems to compound palliative care with end-of-life care. It does not recognise the benefit of someone receiving interventions early. It has been shown that patients benefit maximally from having at least three months of involvement with palliative care, rather than it coming in too little too late. Therefore, when we have integrated services in a cancer centre, time is allowed for a recurrence—when there is a crisis—to be dealt with immediately, rather than patients going home and being told, “Oh, you will see somebody later”. You have to be on the spot and you have to be available 24/7. I hope that there will be recognition that palliative care services save money.

I was glad to see that that the RIPEL study in Oxford was referred to. I ask the Minister whether she recognises the figures that have come from Hull York which show that, where you have fully integrated specialist palliative care services, you can save about £800 million a year by avoiding wasted interventions. I should declare an interest in that I have a young family member with an extremely rare cancer.

I also hope that the Minister will be able to provide reassurance that the speedy processes for modern and semi-experimental treatments will be available much more rapidly because, at the moment, many patients are having to pay privately through fundraising schemes because there are treatments that are emerging but are not yet available on the NHS.

[Baroness Merron (Lab)]

I am sorry to hear about the member of the noble Baroness’s family.

To the point about treatment, by 2028, every cancer patient will have access to a personal cancer care plan via the NHS app. Tailoring treatment and support through the whole care journey is important, including before the care journey starts. It will be a complete innovation that we are not talking about rehabilitation but what we are now calling “prehabilitation”, to support people.

We are also investing £80 million in four new NHS aseptic medicine production hubs, which will be operational by next year, to increase the supply of chemotherapy and immunotherapy, using advanced automation.

To the points about hospices and palliative care, for some, treatment is not enough; it is about the timely and proactive availability of palliative and end-of-life care. That is what is going to make the difference to their quality of life. We are working with the royal colleges to deliver enhanced levels of care, known as acute and supportive oncology, to consistent standards, and that will integrate palliative and end-of-life care while supporting clinicians to provide the best treatment. We are delivering the biggest investment in hospices in a generation—some £100 million to upgrade buildings, facilities and digital systems.

[Lord Bethell (Con)]

My Lords, I echo the praise of other noble Lords for the report. Professor Peter Johnson has done an enormously worthwhile job, and there is so much richness and so many good things in the report.

I will put a spotlight on the unfortunate framing that catching cancer is, largely speaking and for the majority of people, simply a matter of bad luck. The report says quite clearly, under prevention:

“As much as a third of cancers are preventable”.


That is a very conservative estimation of the proportion of cancers that are preventable. Modern analysis would point to systemically preventable exposure to multiple risk factors, which are entirely clustered around class. This framing is incredibly important, because it leads to consequential decisions in the Treasury, among health colleagues and in the rest of government about what we should and could be doing as a society and as a Government to try to reduce the prevalence of cancer.

In Europe, the European Code Against Cancer puts prevention absolutely at the centre of the cancer plan. In countries such as Malta, Portugal and Spain, cancer reduction is not seen as something that is relegated to a paragraph in the introduction: it is absolutely front and centre of the whole cancer plan. It embraces all of health.

The noble Baroness, Lady Walmsley, mentioned screening and vaccines, but it is a shame that those are not much more front and centre and that the Government’s ambitions are not greater. Where are the targets on things such as obesity and clean air? These are the kinds of things that one would expect to see built into a cancer plan. In terms of the “all of government” approach, where is taxation and the planning system, mentioned in the plan as important levers for reducing cancer?

The bad-luck attitude to cancer is an old-fashioned clinicians’ bias that is no longer supported by the epidemiology. So, I ask the Minister, first, is it possible to perhaps review the research framework that has led to that kind of understatement of the preventability of cancer? Coming out of that, secondly, I ask the Minister whether she could perhaps consider looking at a cancer prevention plan, as they have in other countries?

[Baroness Merron (Lab)]

I am grateful for the noble Lord’s support for the cancer plan. I should have mentioned this. I will be honest: even as a Minister, I do not always pay full attention to the foreword, and I am sure that other former Ministers might share that, within a plan, but I commend this one to noble Lords, not least because the Secretary of State himself talked about his own experience of being told he had kidney cancer. He described his world being turned upside down. He talked about fear and foreboding, as does our Minister, Ashley Dalton MP. They both talked about fear and foreboding and the need to turn that round with action. That kind of drive, as well as the facts before us, drive this plan.

On the point about a cancer prevention plan and the question of where the strategy is for the reduction of obesity and so on, I say that this is a plan to be read alongside our other commitments. It builds on the 10-year health plan, which laid out the way we would be going forward with our shifts. This is about turning round the whole cancer pathway.

To the point specifically about prevention, I heard what the noble Lord said. We do not take the view that it is “just bad luck”. Where there is prevention, we should absolutely tackle that.

The plan tackles the causes head-on, not just by talking but with government action to cut smoking with the Tobacco and Vapes Bill, reduce obesity, act on alcohol harm and protect people from dangerous UV exposure, including through sunbeds. No one should lose someone to cancer that should have been prevented. We will not ignore the communities that are hit hardest. By having those preventions, we are supporting the communities that are hit hardest. Rolling out lung cancer screening more extensively will be one of the areas of importance.

I referred earlier to cancer alliances. They will promote, for example, new catch-up schemes to enable young people who have missed out on the HPV vaccination at school. They can have it administered at their local pharmacy. We are not leaving matters to chance. We are rolling out home testing kits for cervical cancer for those who do not go to appointments for a range of reasons, rather than offering only one opportunity.

In all these ways, the national cancer plan tackles the causes of cancer. We will continue to see that through. As the noble Lord knows, moving from sickness to prevention is a key factor in our 10-year plan.

[Lord Patel (CB)]

My Lords, I too support the national cancer plan, but I am not here to blow the Government’s trumpet. I will pick up on some of the points.

This is an ambitious plan, and that is good, because it might act as a catalyst for some progress. However, if that progress is to be achieved, the Government need to commit much more than what the cancer plan suggests. The plan suggests:

“Every patient will get a personalised assessment of their needs and a personal cancer plan—a complete support plan complementing their diagnosis and treatment”


and focusing on their wider needs. It goes on to say:

“Every patient will have a named neighbourhood care lead to coordinate their care and support after treatment”.


If that can be achieved, it will be fantastic. Apart from all the technological advances that we will have to fund in research terms, it is ambitious to suggest that liquid blood tests and cancer vaccines could be developed, be tested and be available tomorrow. It could be a long-term shot. Without investment, that will not happen. One of the key areas of deficiency is that there is nothing on what the manpower requirements would be and how this will fit into the manpower plan that the Government already have.

I heard what the Minister said about prevention. I heard nothing about developing cancer centres; we know from experience that outcomes are best when patients are treated in cancer centres, rather than in every hospital in the country. We have no targets to eliminate cancer. For example, it is possible to eliminate cervical cancer by a proper immunisation programme of HPV vaccines.

I am allowed only to ask questions, but it would be nice to have a longer debate. We never had one on the national health plan either. I hope that could be managed somehow.

[Baroness Merron (Lab)]

That last point will, of course, be drawn to the attention of the usual channels. I too would welcome a debate on this. Noble Lords might wish to note that when they have an opportunity to suggest or apply for debates.

The noble Lord’s last point was about elimination of cancer. That is possible in some cases. I am glad that he mentioned cervical cancer. I mentioned in my answer to the noble Lord, Lord Bethell, that we have committed to catch-up HPV vaccination campaigns from this year, to eliminate cervical cancer by 2040. That is absolutely the right thing to do, and to introduce the Tobacco and Vapes Bill, which I hope will become an Act, to phase out smoking and reduce youth vaping, which can be a gateway to smoking. That will also reduce risk factors.

The noble Lord, Lord Patel, is always right to press us to go further. I understand that. This is a plan for the long term but with staging posts along the way. We have already made progress. For example, I was very pleased when we announced a trial called EDITH for breast cancer screening, to harness the benefits of AI, working with operatives for sped up and more accurate diagnoses. This is one example and is to the point that the noble Baroness, Lady Walmsley, raised about AI.

I hear what the noble Lord says about cancer centres. We are seeking to move treatment and diagnosis from hospitals to community. That is one model, but there are others, as the noble Lord would acknowledge. It is right to push us to go further, but what sets this plan apart is not just its level of ambition and its recognition that all is not right in the world but that it is setting out how we will get there. However, I welcome the transparency and leadership which is attached to this—which noble Lords have called for. This plan merits a lot of attention and support. I shall be pleased to discuss it in this Chamber further.

[Baroness Swinburne (Con)]

My Lords, I too recognise that this plan is a really good step forward in terms of the long-term plan for cancer sufferers. Many of our families have been touched by this awful disease, which is many and varied. However, I would like to focus on the innovation and research side of this, our speed of uptake within the NHS across the United Kingdom and how quickly, relative to other places in the world, we get some of the testing that is available out to our UK nationals.

A test called an Oncotype DX test, which is used to determine whether or not it is suitable for breast cancer sufferers to have chemotherapy, has recently been brought to my attention. In many cases, people can avoid chemotherapy if the test is actually telling the clinician that it is not necessary. In fact, the majority of patients with a particular type of breast cancer will not need chemotherapy, and that test will tell them and identify them.

The reality is that that test was available in the US from 2004. It was adopted by NICE in its guidelines in the UK in 2015. It is only now being widely adopted in the NHS across the whole country, rather than just in specialist teaching hospitals. That speed of adoption means that many people are actually having unfortunate treatment that they may not have required.

Therefore, I urge the Minister to look at how quickly we adopt these new genomic tests and how quickly we can actually improve that patient path for each and every patient. This was personalised medicine that was designed 20 years ago and we are only just starting to see it roll out nationally.

[Baroness Merron (Lab)]

The noble Baroness makes a very good point, particularly as we are in what I regard as a whole new area of scientific and technological advancement, and we have the chance to harness it.

In general terms, I can say to the noble Baroness that where, for example, there are regulatory problems with getting new treatments out there, we are working to remove all those blocks. That work is going on.

With regard to genomics, the plan does talk about routine genomic testing to match patients to targeted therapies and trials, and it also talks about investment in AI-guided radiotherapy, in cell therapy and in novel immunotherapies. There is also going to be the establishment of a cancer trial accelerator programme by next year, to increase trial access and speed.

My last point, which I hope will be helpful, is that six national research priorities are established, including early detection, mRNA vaccines, rare cancers and paediatric therapies. I take the point that the noble Baroness is making. The cancer plan addresses that, as well as seeking to remove blocks that should not be there.

Terminally Ill Adults (End of Life) Bill

Baroness Merron Excerpts

Committee stage
Friday 6th February 2026 Lords Chamber

[Lord Markham (Con)]

Building on from that, that is correct: there are two different approaches here. There are those among us who believe that choice should come first, and within that choice there should obviously be protections and safeguards. Then there are those people who have equally very firm beliefs that the restrictions should be in place first as protections. To summarise, a lot of the amendments in this group are about having certain illnesses and certain groups, such as disabled groups, that should be excluded from the Bill, and that you should be allowed to have this only if you have unbearable pain or suffering, or if there is no chance of treatments to extend life.

I will bring two points in here. Public opinion is overwhelmingly in favour of choice, at 70% in all the different opinion polls. I include disabled groups in that: they show that 70% of disabled people are in favour of it. Then, there are the personal experiences of people who are terminally ill: first, they do not want to die. They would be delighted if there were treatments that would extend their lives beyond six months, or for much longer. But, for them, getting the opportunity to have a death of their choosing is a great comfort and insurance. It does not mean that they are going to rush out and take it as soon as they have it. In a lot of cases—about 30% in other countries—they will not use it at all.

However, the fact is, those people want it to be there, like an insurance policy, so that if, towards the end of their life, they really do have unbearable suffering, however they define it—which might be pain, a loss of dignity, a feeling that they really do not want to go on—then they can have that choice and reason for wanting to do it, whatever their choice is. That is the important thing that we are trying to ensure. Yes, there will be protections, but giving people the ability and autonomy to have the comfort and the choice of being able to die in the way they wish is the most fundamental right of all.

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

My Lords, I am grateful for the contributions on eligibility and definition of terminal illness. Once again, I will keep detailed comments limited to amendments on which the Government have major legal, technical or operational workability concerns.

First, I will give a reassurance to your Lordships’ House in response to the observations of the noble Lord, Lord Harper, and the noble Baroness, Lady Grey-Thompson, about the modern service framework on palliative care and end-of-life care. We acknowledge that there has been a drafting error, which the noble Lord and the noble Baroness picked up on. The drafting error is in the national cancer plan. I reassure your Lordships’ House that, as has been stated previously, the interim update will be published this spring and the full modern service framework will follow in the autumn. That issue was purely down to a drafting error.

I turn now to the amendments. Amendments 71, 77 and 79 were tabled by the noble Lady, Baroness Finlay, and Amendments 83A, 104 and 105 were tabled by the noble Lord, Lord Polak, my noble friend Lord Hunt of Kings Heath and the noble Baroness, Lady Grey-Thompson. Noble Lords may wish to note the Government’s workability concern with this set of amendments. Key terms and concepts in the amendments are undefined, which may introduce uncertainty when determining who is eligible under the Bill and, particularly under Amendments 71, 77 and 79, what it means to slow a disease. There is a risk that unclear eligibility criteria could result in ambiguity for those applying the legislation, which may give rise to legal challenges to decisions made under it.

Amendment 105 could also give rise to legal challenge on the basis that excluding people with particular conditions from assisted dying may not be justified under Article 2 or Article 8 of the ECHR and may amount to unjustified discrimination under Article 14. Any differential treatment would need to be objectively and reasonably justified in order to comply with ECHR obligations.

Amendments 74 and 94, tabled by the noble Lord, Lord Taylor of Holbeach, would exclude from the definition of “terminal illness” any individual whose condition can be meaningfully halted or controlled by available treatment. Clinically, it may be difficult to determine whether an illness or disease can be “meaningfully halted, or controlled” by treatment, and it is possible that an illness or disease could have a short halt before deterioration starts again. This will make it difficult for clinicians to decide whether a person is “terminally ill” and eligible for assisted dying and is likely to lead to challenges to decisions. These amendments may result in a person becoming ineligible, irrespective of whether they choose to take the available treatment.

Amendment 75, tabled by the noble Baroness, Lady Finlay, would amend the definition of “terminally ill” by removing the test of death being reasonably expected in six months, and replacing it with a requirement that the rate of progress of the disease, with treatment in line with NICE guidelines, indicates that death can be expected within six months. Introducing the concept of treatment in accordance with NICE guidelines may create difficulties, as the amendment would require clinicians to assess the patient’s prognosis as if they were treated in accordance with NICE guidelines. This may result in a person becoming ineligible, irrespective of whether they chose to have treatment in accordance with NICE guidelines. This amendment therefore requires clinicians to make a judgment on a potentially hypothetical basis.

Amendment 80, tabled by the noble Baroness, Lady Lawlor, would provide that a person is “terminally ill” where their death has an 80% likelihood of occurring within six months, according to the written opinion of two specialist, consultant-level hospital doctors. These doctors must be knowledgeable about and have experience of treating patients with the progressive illness in question. This amendment would create significant operational workability concerns. It would require the clinician making a determination about the person’s prognosis to meet a high threshold of certainty. The criteria could be especially difficult to meet for a person who has a rare progressive illness or disease, about which there may not be widespread clinical knowledge or experience.

Amendment 82, tabled by the noble Lord, Lord Polak, would require two consultants to provide a view on an individual’s life expectancy, and for them to determine that their death can be “highly probable” within six months, rather than the current drafting of, can be “reasonably expected”. Several terms are not defined in the amendment and are likely to lead to ambiguity, including operational issues, around which doctors are to assess life expectancy and to what standard.

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[Lord Moylan (Con)]

May I pursue a point the Minister made about my Amendment 85? My understanding of the Bill, as drafted, is that one has to have an inevitably progressive illness or disease, not that one has to have a six-month prognosis of one’s death. The two might be quite separate.

One might, as the noble Baroness said, have a combination of circumstances that means one is likely to die within six months without having a specific, identifiable disease. The Minister seems to be saying that the Government’s interpretation of this clause is that one does not need to have a specific, identifiable terminal illness; one simply needs to have a set of circumstances that together might result in a prognosis of death within six months.

If that is the case—and that is the Government’s view of the meaning of that clause, as the Minister seems to imply—that widens to an astonishing extent the conditions that might qualify for the Bill. I would like to hear the Minister say—and the noble and learned Lord, Lord Falconer, may possibly want to comment on this when he speaks—whether it really is their interpretation that it could be any set of circumstances that lead to a six-month diagnosis without there being an identifiable illness.

[Baroness Merron (Lab)]

I will briefly look at the actual amendment. As I said in my response, the workability concerns are about the specification of a list of illnesses or diseases. I have already outlined why that would be unworkable—because it is often a combination of illnesses, as well as the complications of those illnesses, that are interacting, rather than there being just one. I referred earlier to why it would be extremely difficult. I have been looking at the specifics of the amendment, but to do what it says would create more ambiguity than there is currently. In reality, my response is covering our concerns; where I do not make a comment, there are no workability concerns.

[Lord Taylor of Holbeach (Con)]

As the Minister will know, I have made it clear that I am concerned about suffering in the last days of life. One of the key elements of that is palliative care. When one talks about treatment, one of the incentives for death is suffering. Does the Minister have anything to say to the Committee about the status of palliative care within the National Health Service? Are there any plans afoot, and when will this particular course of treatment be available to people? Otherwise, many people faced with terminal illness will be tempted to seek assisted suicide, which I think should be discouraged.

[Baroness Merron (Lab)]

We are discussing a group of amendments about the definition of terminal illness. I have already placed a letter in the Library of the House outlining all the work in respect of palliative care. I have also made reference to the modern service framework.

[Lord Harper (Con)]

Having listened to my noble friend Lord Moylan respond to what the Minister said, I confess to being a little confused. The Minister seemed to be saying, in her comments about some of the amendments in this group, that the problem with having a list of conditions is that you could quite often have a terminal diagnosis as the result of a group of conditions, circumstances or illnesses. In my reading, the Bill does not say that. The Bill says:

“For the purposes of this Act, a person is terminally ill if … (a) the person has an inevitably progressive illness or disease”—


not lots of them; one—

“which cannot be reversed by treatment, and … (b) the person’s death in consequence of that illness or disease can reasonably be expected within six months”.

I carefully read the amendment, which talks about a specified list of conditions. Incidentally, coming back to the point made by the noble Lord, Lord Markham, twice as many members of the public support that approach than a terminal illness. The Minister’s answer to my noble friend Lord Moylan seemed to be disagreeing with what is actually in the Bill, so I am now more confused than I was before she got to her feet. Can she clear that up?

[Baroness Merron (Lab)]

I am sorry the noble Lord is confused. I know that my noble and learned friend Lord Falconer will be pleased to assist him with any confusion that there is in the case of this amendment.

[Lord Pannick (CB)]

I suggest to the Minister that the answer to the noble Lord, Lord Harper, is very simple. An unfortunate person may have more than one inevitably progressive illness or disease, each of which will lead to their death within six months. It is a standard principle of statutory interpretation that the singular includes the plural.

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Debate on Amendment 87A (to Amendment 87) resumed.

[Baroness Merron (Lab)]

My Lords, I am grateful to noble Lords for their contributions to this debate. Amendment 87, tabled by my noble and learned friend Lord Falconer, the sponsor of the Bill, would clarify the intention of the current Clause 2(2), which is to prevent someone becoming eligible for an assisted death due to an eating disorder. Amendment 87 replaces Clause 2(2). The Bill’s sponsor in the other place indicated that they would look to improve the clarity on who is and who is not eligible in this clause. The noble Lord, Lord Harper, asked about interpretation. I hope those comments will be helpful, because the eligibility of people with eating disorders under the Bill is, of course, a policy decision, not one for government. I am sure that my noble and learned friend heard the noble Lord’s point.

This amendment, as is usual practice, has been drafted with the technical support of the Government, within the policy intent of the sponsor and of the other place. The amendment excludes from the definition of “terminally ill” any illness or disease caused by the person not eating or drinking, where not eating or drinking occurs as a result of a mental disorder. It also makes it clear that this expressly covers cases of limited eating or drinking. Given that Amendment 87 replaces Clause 2(2), if noble Lords accept it, a number of the other amendments in this group will, of course, fall away.

I turn to detailed comments on amendments that the Government consider have major legal, technical or operational workability concerns. Amendment 89, tabled by the noble Lord, Lord Polak, would lead to a person not being considered terminally ill under the Bill solely as a result of withdrawing medication, hydration or life-sustaining devices. Amendment 91, tabled by the noble Baroness, Lady Finlay, would mean that those whose refusal of nutrition is due to a mental illness would not be considered terminally ill under the Bill.

Amendment 92, tabled by my noble friend Lady Debbonaire, would exclude a person from eligibility if their terminal illness was

“solely as a result of standard medical treatment being refused or withheld”.

This amendment could have the potential undesirable impact of undermining a person’s autonomy and right to make informed choices about their own medical care. The definition of “standard medical treatment” is unclear here: the exclusion from eligibility could apply to a patient who refuses one standard medical treatment in favour of an alternative standard medical treatment. A refusal of standard medical treatment would mean that a person would become ineligible for ever, even where their refusal had no impact on their prognosis.

Amendment 101, tabled by the noble Baroness, Lady Parminter, would prevent people with physical effects or complications of a mental disorder being eligible for an assisted death. This may be difficult for clinicians to apply, as “physical effects” is an undefined term. The current drafting also layers a “for the avoidance of doubt” provision on top of another “for the avoidance of doubt” provision, which could lead to ambiguity about how the legislation should be interpreted. I heard the noble Baroness say that she was concerned about the drafting, so I hope those comments will be helpful to her.

Amendment 103, tabled by the noble Baroness, Lady Fox, would remove from eligibility people who, because of the effect of a mental disorder, refuse life-saving treatment and develop a terminal condition. Where amendments limit eligibility for specific groups, they could give rise to legal challenge under Articles 2 or 8, with Article 14, of the ECHR if such restrictions are not objectively and reasonably justified. As I have said, it is for noble Lords to consider the amendments in that light, should they wish to.

[Lord Falconer of Thoroton (Lab)]

First, I detect that the mood of the Committee is that I should put my Amendment 87 into the Bill, but subject to the amendment tabled by the noble and learned Baroness, Lady Scotland, and by the noble Baroness, Lady Berger, so I am minded, unless anybody indicates to the contrary, to let that process go ahead. I accept that, in putting it in, there are those who would like to build on it on Report, but I think we should put it in now.

I will deal very quickly with the other amendments in the group. Amendment 88, tabled by the noble Baroness, Lady Grey-Thompson, would leave out “solely”.

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[Earl Howe (Con)]

My Lords, before the Minister rises to speak, I have a question for her about workability arising from one of the amendments included in this debate. In his Amendment 581A, my noble friend Lord Sandhurst posed a specific question on capacity at the moment when a person is given the substances with which they will take their own life. He is surely right that at that critical moment appropriate safeguards are needed where, for any reason at all, there is doubt about the person’s capacity—for example, where there is a history of fluctuating capacity. The doctor should clearly know how to respond to that situation. Can the Minister say whether she believes that the situation that my noble friend has described would require specific guidance to be issued by the Government over and above guidance already issued under the Mental Capacity Act?

[Baroness Merron (Lab)]

My Lords, I thank all noble Lords for their contributions on mental capacity and eligibility. As usual, I will keep my comments limited to those amendments on which the Government have major legal, technical or operational workability concerns. Indeed, if I do not refer to an amendment, clearly that is not the case, as was just suggested.

I wish to make a point to the noble Baroness, Lady O’Loan, who asked about consideration about compliance with ECHR. It is probably helpful for me to re-establish the consideration about that. It is the role of the Government—this is what I am doing—to highlight where there is a risk of issues in respect of the ECHR. However, it is for the House to decide whether policy choices might create a risk and whether that amount of risk is acceptable or not. The other thing, if it is helpful to the noble Baroness, is that, if it is found that primary legislation is incompatible, there could of course be a declaration of that incompatibility. It would not invalidate legislation. That is probably the main point that I want to emphasise, but this is ultimately a matter for decision by the House.

Amendments 117 and 892, in the name of the noble Baroness, Lady Hollins, would remove Clause 3 and insert a new clause requiring the Secretary of State to make regulations that establish an alternative framework for assessing and determining capacity, based on a psychological assessment, rather than reliance on the Mental Capacity Act. How to make that assessment on capacity—noble Lords have referred to this—is a policy choice and is therefore a matter for Parliament. However, as drafted, Amendment 117 uses a number of undefined terms such as “validated, standardised instruments” and “evidence-based methodology”, which, without further clarification or definition, are likely to create workability concerns. Amendment 892 would mean that the majority of provisions under the Bill could not come into force until the regulations under Clause 3 were made. This would make the backstop provision in Clause 58(4) ineffective.

I turn to Amendment 108, tabled by my noble friend Lord Hunt of Kings Heath. It would introduce a departure from the MCA framework by linking a lack of capacity in one area, to consent to care and treatment arrangements that amount to a confinement, to lack of capacity around another decision, the decision to end one’s life. This could create confusion and require additional guidance and training for practitioners.

It appears that Amendment 119 in the name of the noble Baroness, Lady Grey-Thomspon, would introduce a separate specialist capacity assessment process for adults with a learning disability. This departs from the MCA framework, which requires proportionate, decision-specific assessments, rather than separate processes for particular groups. Operationally, this could create significant training and resource demands, as specialist assessors would need to be identified. The Committee may wish to note that the amendment restricts any publicly funded provider from undertaking the mental capacity assessment, which would mean that individuals with learning disabilities would have to self-fund the assessment from a private sector provider. There are also technical drafting issues, including a lack of definition for “learning disability” and other terms such as “relevant professional regulator”, which could lead to uncertainty in how the legislation is applied.

Amendments 117, 892, 108 and 119 would all involve introducing differential treatment, by treating different groups of people differently. As such, they could give rise to legal challenge on the basis of ECHR obligations, specifically Article 14, which prohibits discrimination when read with Article 8. Any differential treatment, as I said more broadly earlier, would need to be objectively and reasonably justified in order to comply with ECHR obligations.

I turn to Amendment 235 in the name of the noble Lord, Lord Moylan. The effect of this amendment is that certain groups of people would not be able to make a valid first declaration, as the noble Lord said. This could exclude people with learning disabilities, mental disorders, as per Section 1 of the Mental Health Act 1983, and autism from accessing assisted dying. An individual who may experience substantial difficulty in understanding processes or communicating their views, wishes or feelings would also be excluded under this amendment from accessing assisted dying. The definition of “mental disorder” in the Mental Health Act is extremely broad and will include those with conditions such as ADHD, dyslexia, anxiety and sleep disorders. The Committee may wish to note that these groups would be excluded, even if their condition had no impact on their ability to fully understand the relevant information.

--- Later in debate ---

[Baroness Merron (Lab)]

I am sure that both I and my noble friend will be very pleased, together or separately, to reply to the noble Baroness.

[Lord Falconer of Thoroton (Lab)]

I shall deal with the issues raised in this debate under the following heads. First, what is the correct test and legal framework to apply in relation to mental capacity? Secondly, how do we deal with the question of particular conditions that people have? Does it make it inappropriate, or should there be exceptional protection? Thirdly, what about Clause 22, which is the independent advocate provision?

First, on capacity, as noble Lords know, the Bill provides that the tests under the Mental Capacity Act 2005 shall be applied to determine whether or not the person seeking an assisted death has the capacity to make such a request. Remember as well, for what it is worth, that, in addition to having the capacity to make that request, the person, in order to get an assisted death, also has to have a clear, settled and informed wish to end their own life, and has made that decision to end their own life voluntarily and has not been coerced or pressured by any other person into making it. Those last two protections—a clear, settled and informed wish, voluntary and no coercion—are separate from the question of capacity.

The question of capacity is: is that person capable of making the decision? The Mental Capacity Act, which has been in force for approximately 20 years, starts from the assumption that a person does have capacity to make a particular decision, and only if it is shown that the person does not have that ability are they not able to make that decision themselves.

Should we change that assumption? There are two big proposals in front of us. First, there is Amendment 115 in the name of the noble Baroness, Lady Findlay of Llandaff, and supported in particular by the noble Viscount, Lord Colville of Culross, who made a speech in favour of it. Subsection (1) of that proposal says:

“In this Act, a person has capacity to make a decision to end their own life if they do not lack capacity to make that decision, and references to “capacity” are to be read accordingly”.


I shall read that again for those who did not get it first time round. In this Act, the proposal is that

“a person has capacity to make a decision to end their own life if they do not lack capacity to make that decision, and references to “capacity” are to be read accordingly”.

That looks almost identical to the existing provisions, and I am quite unable to see what the difference is that is being proposed.

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[Lord Wolfson of Tredegar (Con)]

My Lords, I am grateful to my noble friend Lord Blencathra for opening the debate on this group. He is right that we should consider carefully how the most vulnerable will be protected under this legislation. Having a multidisciplinary specialist review before a person in a care home is certified to have capacity seems an interesting and a sensible safeguard. It was not clear to me whether the five working days is from the date of the review or from the date of the findings of the review, but no doubt that could be looked at and clarified.

Of course, generally, social care is a policy area that needs attention. We know that too many older people receive inadequate care in old age, and I must say that it seemed to me that the personal experience of the noble Baroness, Lady Hayter, and that of my noble friend Lord Deben can both be right. It is likely that there are excellent care homes and care homes that need improvement. I am afraid that that is probably the society we live in.

Effective communication is a challenge that older people face. This is an obstacle for the process under the Bill for assessing capacity. It therefore seems sensible for specialists to be involved when the person requesting assistance is in a care home. We also have to consider the risks of institutionalisation, which I know from experience can certainly be a factor for people in care homes. I would be grateful if the Minister could confirm what the Government’s conclusions are on this proposal and its workability. Would it be prohibitively costly or could it be delivered?

On the amendment from my noble friend Lady Eaton, this additional process and heightened evidential standard for persons in care homes is a constructive and interesting suggestion. I invite the Minister to update the Committee on whether the Government have considered the two separate proposals in this group and come to a view on which would be the more workable and effective if implemented. That assessment would not only be helpful to the Committee but might enable the House in due course to make a more informed decision on the best way to improve this part of the Bill on Report. If that assessment has not yet been made, perhaps the most appropriate way forward would be for Ministers to write to the Committee to update it, at some point between now and Report.

[Baroness Merron (Lab)]

My Lords, I am most grateful to all noble Lords who have contributed to this debate on assessing capacity in care homes. As noble Lords will be aware, my remarks will be limited to areas where the Government have assessed that there may be major technical or operational workability concerns.

I say to the noble Lord, Lord Blencathra, that that will include matters relating to the ECHR. The noble Lord, Lord Carlile, already picked that up in his own characteristic way, but I gently say to the noble Lord, Lord Blencathra—I know he is aware of this because of his experience—that Government Ministers have a duty to advise your Lordships’ House of implications. As I explained in the last group, decisions on the ECHR are ultimately for Parliament. I am sorry to frustrate him with repetition, but it is appropriate to the relevant considerations. I will just ask him not to listen if he feels it is very irritating.

This may be helpful to the noble Lord, Lord Wolfson, as well. Amendments 112 and 111, in the name of the noble Baroness, Lady Eaton, spoken to by the noble Baroness, Lady O’Loan, aim to strengthen safeguards for care and nursing home residents by ensuring that capacity in these cases is established through specialist clinical assessment and that capacity assessments seek to rule out reversible medical causes of impaired or fluctuating capacity. The Government consider that Amendment 111 may be inconsistent with the Mental Capacity Act’s assessment framework, which does not require enhanced assessment for certain groups. I dealt with this in more detail in the last group. By requiring expert psychiatric input before capacity is confirmed, Amendment 112 could create inconsistency with the MCA’s presumption of capacity and the principle of proportionate, decision-specific assessments.

Amendment 110A, tabled by the noble Lord, Lord Blencathra, would affect care home and nursing home residents’ capacity assessments and require expert psychiatric input before capacity is confirmed. Again, this could create inconsistency with the MCA’s presumption of capacity and the principle of proportionate, decision-specific assessments.

If passed, each of these amendments would lead to a difference in treatment between care home and nursing home residents and all other citizens in assessments for assisted dying. That difference in treatment—the noble Lord, Lord Blencathra, may wish to close his ears at this point—could give rise to challenge under the ECHR, particularly Article 8, which refers to respect for private and family life, and Article 14, which concerns the prohibition of discrimination. The differences in treatment would need to be justified, necessary and proportionate.

[Lord Deben (Con)]

If the Committee decided that the conditions in a care home were such that it would be better to have a system there that was slightly different from the one for those who were not in a care home, surely that is justification enough. As the Minister knows, I am entirely in favour of the ECHR and disagree very strongly with my noble friend, but this seems a bit of a red herring, frankly. The fact of the matter is that, if this was the policy that was put forward, I think it very unlikely that anyone would find it possible to stop it under the ECHR.

[Baroness Merron (Lab)]

It would not be possible in any case to stop it in that way, because it would not invalidate legislation. I am just drawing the Committee’s attention to the fact that it would require further work. As the noble Lord will know, if a court finds that primary legislation is incompatible, it may make a declaration of incompatibility. As I said, although it does not invalidate legislation, it is usual practice for the Government to consider and address these matters.

[Lord Carlile of Berriew (CB)]

I am afraid that the Minister is between a rock and a hard place here. If these amendments are not passed, she might find that the Government are in breach of Articles 9, 10 and 11. I would be grateful if she could consult her lawyers in relation to that matter.

[Baroness Merron (Lab)]

I will consult my lawyers with pleasure.

Lastly, all the amendments in this group address complex issues and, if they were passed, considerable further policy and drafting work would likely be required.

[Lord Falconer of Thoroton (Lab)]

I thank the noble Baronesses, Lady Smith of Newnham and Lady Hayter of Kentish Town, for sharing their significant and painful experiences. I thank the noble Baroness, Lady Fox, for doing the same in relation to the last months of her mother’s life.

This group deals with the question of whether there should be special provision for people in care homes. Two routes are suggested: first, in the amendment from the noble Baroness, Lady Eaton, which was spoken to by the noble Baroness, Lady O’Loan, that there be a higher evidential standard; and, secondly, that a series of additional tests should be raised.

I think that everybody in the Chamber is agreed that care homes vary across the country; there are those of the highest possible standards and those that do not have the same high standards. It is also the case—a point made forcibly and effectively by the noble Baroness, Lady Watkins—that one should not confuse the fact that there are people in long-term care and people in high-tech nursing homes who are being rather elided here. People become institutionalised and may suffer long-term cognitive problems from being in care homes for a long time. The question raised is whether additional steps beyond those provided for in the Bill should be put in place to check that such people, particularly those who have been in care homes for the long term, have capacity.

The current arrangements require that the co-ordinating doctor is satisfied, after discussion with the patient and anybody else, that they have capacity, and similarly in relation to the independent doctor. Then, the panel has to be satisfied, and then the co-ordinating doctor has to witness the second declaration of the patient. The co-ordinating doctor can witness that second declaration only if he or she is satisfied that, among other things, the patient has capacity. Fifthly, the doctor providing the assistance also has to be satisfied that the patient has capacity. The question posed is whether, despite the fact that there are five separate occasions on which a doctor or a panel have to be satisfied of capacity, for somebody in a long-term care home, one should make additional provision for separate assessments or have a higher evidential standard.