Tobacco and Vapes Bill

Earl Howe Excerpts

Report stage
Tuesday 24th February 2026 Lords Chamber

[Earl Russell (LD)]

With the greatest of respect, there are degrees of risk. There is no electric bike or motor vehicle that we have allowed that kills 50% of people who get on a bike or in a car. The noble Lord is comparing apples with pears. The dangers of smoking are known and proven, and are far greater than anything else.

To conclude, we welcome this generational ban. There are particular issues that need to be looked at and the Bill will need to be regularly reviewed, but we will come to amendments on that. This is the most important thing that we must do. It is essential that we make progress to improve the public health of people in this country.

[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.

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Those reservations aside, can the Minister address the core point made by the noble Lord, Lord Udny-Lister: how will the Government help reduce the financial burden, especially on smaller retailers, of the very challenging and complex demands that this Bill will pose in relation to age checks? Surely we cannot just pass the Bill and then abandon retailers and tell them to get on with it. This amendment is therefore worth considering seriously.

[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.

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[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.

Medical Training (Prioritisation) Bill

Earl Howe Excerpts

Report stage
Monday 23rd February 2026 Lords Chamber

[Lord Clement-Jones (LD)]

My Lords, we ought to thank the noble Lord, Lord Patel, for having stimulated such an interesting and important conversation about how terrible our workforce planning in the NHS has been to date, and we have had some very wise words around the House on that subject. It is clearly not fit for purpose, and that is why we are where we are.

On these Benches, we have consistently accepted the Government’s central premise for the Bill: that where the British taxpayer invests heavily in training a doctor at a UK medical school, there is a logic in prioritising that graduate for employment to ensure a return on that public investment. However, although we sympathise with the desire of the noble Lord, Lord Patel, to ensure that UK graduates are prioritised—indeed, a lot of that derives from the fact that our workforce planning system is not fit for purpose—we must be careful not to make the legislation so rigid that it removes any flexibility for the system to function effectively, as we will argue in later groups.

By creating strict statutory tiering that places UK graduates above all other priority categories in every instance, we risk creating a system that cannot respond to realities on the ground. We have received correspondence from many doctors, as I am sure almost every other noble Lord in this House today has done, warning that absolute exclusion or rigid tiering could leave rotas empty in hard-to-fill specialties such as psychiatry and general practice, which rely heavily on international talent.

Prioritisation is a necessary tool for workforce planning but we must ensure that it does not become a blockade that damages the wider delivery of NHS services. As the noble Lord, Lord Stevens of Birmingham, said, we need answers about the future of workforce planning. What will the numbers be for training places? The Government need to answer that as we go through this Bill.

[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.

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My noble friend’s Amendment 7 offers a pragmatic solution, replacing the ILR requirement with a benchmark of at least two years of training or employment in the NHS. This would create parity with the UK foundation programme and tell doctors who have kept our hospitals running that their service actually counts. I urge the Government to have another look at whether they can utilise the Oriel system and accept this fairer metric. Otherwise, I believe the Government should accept Amendment 3, which would delay the Bill’s impact until 2027.

[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.

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[Lord Mohammed of Tinsley (LD)]

My Lords, briefly, I offer our support from these Benches to Amendment 11, in the name of the noble Baroness, Lady Lister, and to the amendments in the name of the noble Baroness, Lady Gerada.

I want to talk about the amendment in the name of the noble Baroness, Lady Lister. I am sure that other noble Lords will have had an email from a woman from Ukraine, who set out her concerns. We as a nation have proudly welcomed and given safe sanctuary to people from Ukraine, predominantly women and children. However, because of the conflict in her country she has not been able to fulfil her dream of being a doctor; she has tried to navigate the system, through working as a care worker, and would like us to be able to support her.

I plead to the Minister: can we not have some flexibility, at least when it comes to specific circumstances? We have been so generous as a nation in welcoming those people, who, if they had their way, would be in their country. They want to continue building on the education that they had in their nation. I am sure that there will be others as well. Is there some flexibility? I hope that the Minister can comment on that.

On the amendments tabled by the noble Baroness, Lady Gerada, when we had this discussion before the Recess it was clear that we were asking for those two overseas medical schools. They are the only ones that are active now. The amendments are clear that no other schools would be allowed to open up and go through the loophole that some noble Lords have talked about. We are talking about very small numbers. However, those numbers are important because we have also had emails from British nationals who have gone to study abroad with an expectation. As I said on my amendments in the previous group, we are changing the rules for them mid-cycle. There must be some level of flexibility.

We want the Bill to go through, but we would like it to be a bit fairer than it is. I talked previously about the unintended consequences of pushing this though. A lot of the funding for these two campuses comes from overseas. It is not costing the UK taxpayer money, but it is a pipeline, as my noble friend Lord Clement-Jones said. Having listened to the noble Lord, Lord Forbes, and spoken to my noble friend Lord Shipley, I know that they very strongly support the overseas campus that Newcastle University has in Malaysia. I hope that the Minister supports those two universities. There are no others in these circumstances.

[Earl Howe (Con)]

My Lords, the amendments in this group seek to change the definition of the priority group. We debated the principle behind the amendments tabled by the noble Baroness, Lady Gerada, and the noble Lord, Lord Darzi, in Committee. I shall come back to the amendment tabled by the noble Baroness, Lady Gerada, in a moment.

Meanwhile, the amendment tabled by the noble Baroness, Lady Lister, seeks to include a new group of people who should be prioritised for medical specialty training places. We have not, as she said, debated this precise issue before. She argued the case very powerfully. However, we need to come back to the object of the Bill, which is to resolve the specific problem of UK medical graduates having insufficient priority in accessing medical specialty training in UK workforce planning. Our prime focus should be on those young UK doctors who have put so much effort into their studies and who now want to progress further in the NHS.

I appreciate the force of everything that the noble Baroness, Lady Lister, said. I observed earlier that we are not living in an ideal world. However, for the reasons that I have given, I am not convinced that including an additional group—in this case, those who have come to the UK from Afghanistan, Ukraine, Syria or Hong Kong—will necessarily improve the Bill’s effectiveness in resolving the problem that it is designed to address. Those doctors are not, and surely cannot be, part of the NHS’s workforce planning framework.

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

I will say some brief but important things about the amendment from the noble Baroness, Lady Gerada, without, I hope, repeating what has been said. The merits of her case were ones which she powerfully presented in Committee, and she has done so again today.

I want to highlight three key points. First, QMUL’s campus on Malta and Newcastle University’s campus in Malaysia are not “foreign institutions”. Yes, they may be physically located abroad but, constitutionally, both are UK institutions and the qualifications they award are UK qualifications based on a UK-prescribed medical curriculum. Doctors have made career plans based on that long understanding. Therefore, badging graduates from those overseas campuses as international medical graduates, which is the implication behind the Government’s position, does them a grave injustice. In my submission, they are not international medical graduates in the sense that we normally understand the term—a point well made by the noble Baroness, Lady Finlay.

Medical Training (Prioritisation) Bill

Earl Howe 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.

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Moved by

[Earl Howe]

4: Clause 1, page 1, line 7, at end insert—
“(2) Nothing in this section shall be taken to negate or override a confirmed offer of a place on a UK Foundation Programme where the offer was made prior to the date on which this Act was first laid as a Bill before Parliament.(3) In this section “confirmed offer” means an offer in writing made by a person who has a function of deciding offers of places on a UK Foundation Programme.”

[Earl Howe (Con)]

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

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

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

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

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

[Lord Mohammed of Tinsley (LD)]

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

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

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

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

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

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

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

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

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

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

--- Later in debate ---

[Earl Howe (Con)]

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

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

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

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

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

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

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

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

Amendment 4 withdrawn.

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[Lord Mohammed of Tinsley (LD)]

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

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

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

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

[Earl Howe (Con)]

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 Mohammed of Tinsley (LD)]

My Lords, I know that it is late, but it is important that I move this amendment, which seeks for all regulations that are made under the Bill are subject to affirmative resolution procedures. In simple terms, after the Bill is passed, we would have a vote in both Houses on any changes made to allocation of spaces. This amendment goes to the heart of parliamentary accountability.

The Bill as currently drafted grants Ministers broad regulation-making powers, including the ability to amend key operational aspects of medical training with limited parliamentary oversight. My concerns are not with the intentions of the current Minister or the present Government but with the precedent that this sets. Delegated powers once granted outlive individual Ministers or Governments.

Medical training is an area where stability and predictability are essential. Doctors and medical students plan years in advance—sometimes decades. They make decisions about education, location, finances and family life based on the rules that Parliament sets. If those rules can be altered by secondary legislation without a positive vote in both Houses, we risk creating uncertainty and undermining confidence in the system.

The affirmative resolution procedure would provide a necessary safeguard. It ensures transparency, debate and accountability. It allows Parliament to examine whether proposed changes are proportionate, evidence-based and aligned with the original intent of an Act. Importantly, in this case, it would give affected shareholders—medical students, trainees, regulators and the NHS workforce—the assurance that changes will not be made without democratic consent and accountability.

This House has repeatedly expressed concerns about the expansion of executive powers through delegated legislation, particularly in areas with significant policy impacts. The Delegated Powers and Regulatory Reform Committee has, on numerous occasions, warned against the inappropriate use of negative or minimal scrutiny procedures where primary legislation confers wider discretion. My amendment responds directly to those concerns.

There is also a practical benefit. Requiring affirmative approvals encourages better policy-making. Ministers can explain, justify and defend their proposals in open debate. That process often improves the quality of regulations, identifies unintended consequences and builds broader support for necessary reforms.

This amendment would not prevent future Governments adapting the medical training system. It would simply ensure that, when they do so, they do so with Parliament, not without it and not by going around it. It would preserve flexibility while embedding accountability. At a time when trust in politics and political institutions is fragile, Parliament must demonstrate that significant changes to professional regulations are made openly and responsibly. Requiring a positive resolution in both Houses is a modest but important step in that direction. I therefore commend this amendment to your Lordships’ House.

[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.

National Cancer Plan

Earl Howe Excerpts

Monday 9th February 2026 Lords Chamber

[Earl Howe (Con)]

My Lords, I begin by welcoming the publication of the national cancer plan and make it clear we fully share the Government’s desire to tackle cancer and to succeed in the fight against a condition that has affected almost every family in the country in one way or another. The Government have set out a clear ambition in this area, and we support them in that endeavour. It is appropriate for me also to pay tribute to all those who have contributed to the development of the plan, particularly those with lived experience with cancer and those close to them. Their willingness to share their experiences with such openness—and in many cases, courage—has, I am sure, been invaluable in shaping the finished result, and they deserve our thanks and recognition.

The national cancer plan sets out a number of significant commitments, including improving early diagnosis, restoring performance against cancer waiting time standards, accelerating the set-up of clinical trials and rolling out targeted lung screening nationally. It also places a strong emphasis on modernising services through technology and innovation.

These are all laudable aims and, indeed, Cancer Research UK has said that there is “much to welcome” in the plan. However, it has also rightly noted that delivery, funding and accountability will ultimately determine whether patients see real change. It is easy to put ambitious plans down on paper, but what matter in the end are clear delivery milestones and accountability. In that respect, this plan echoes many of the ambitions of the 10-year NHS plan, which was strong on aspiration but lighter on detail about how improvements would be delivered on the ground. My first question is, therefore, straightforward. When will the Government publish clear, fully funded milestones setting out how and when patients can expect to see tangible improvements over the next year or two?

It is also clear that the success of the plan will depend on having a sufficient workforce of cancer nurses, radiographers, pathologists and oncologists to deliver its aims. Can the Minister say whether we will shortly see a fully funded long-term workforce plan to support the staffing required to expand diagnostic and treatment capacity, not just in NHS trust settings but within neighbourhood health centres? In particular, can the Government explain clearly who will staff these services and how they will be funded? Blood Cancer UK has highlighted the importance of ensuring that blood cancers are properly recognised in workforce and service planning, and that patients receive consistent support from the point of diagnosis, including access to a named healthcare professional. Staff also need to know that they will be supported in delivering this plan, given current strains on capacity. In that context, we hear anecdotally of the difficulties involved in ensuring that staffing by doctors is adequate in all parts of the country. Some doctors, especially doctors in training, make up their minds that they will not be sent to work in an area that is not to their liking, perhaps because it would locate them far from friends and family. Will the welcome announcement of more training places in rural areas be enough to get sufficient doctors working in those areas?

Alongside the important question of staffing levels sits the Government’s ambition to invest in up-to-date capital equipment and cutting-edge technology. Investment in this often expensive technology is best and most efficiently met through capital budgets managed centrally. That leads me to a question about accountability for delivery, and where such accountability will lie. With the planned absorption of NHS England into the department, can the Minister give a sense of how the national cancer plan as a whole will be steered and monitored, not only centrally but regionally?

One specific aspect of the plan that I would like to welcome is the dedicated chapter for children, teenagers and young adults. This has been described by the Teenage Cancer Trust as a crucial step and an important acknowledgement that teenagers and young people deserve care designed around them and not as an afterthought. The work that the Government have done in recognising this is welcome. One point that the Teenage Cancer Trust has made particularly clearly is the importance of involving young people at the policy development stage. Can the Minister set out how young people with cancer were engaged in the development of this plan and how their voices were reflected in its content? Looking ahead, what steps will the Government take to ensure this becomes an ongoing process: listening to young people with cancer and systematically taking their feedback into account as the plan is implemented and reviewed?

Another point that charities and campaigners have consistently emphasised is the importance of clearly distinguishing between children and young people. The needs and challenges facing a three year-old child are self-evidently different from those of a 17 year-old young person, and it is important that this distinction is properly recognised in both policy and practice. I would therefore be grateful if the Minister could set out for the House how these different groups within the broader category of children and young people are engaged with. In particular, it would be helpful to understand how mental health support is tailored to different age groups and how the impact of a cancer diagnosis at different stages of a young person’s educational journey is reflected in their treatment and support pathways. If the noble Baroness could confirm that this distinction is one which the Government actively make and which will be taken into account in future policy development, I should be most grateful.

Let me conclude by reiterating my support for this plan and for the ambitions it sets out. In particular, there are some welcome and promising commitments around improving access to clinical trials and speeding up diagnosis. As the Minister knows, we need to do better in both those areas, and we share the Government’s ambitions to do so. For our part, we will continue to play our role in opposition by scrutinising delivery closely to ensure that ambition is matched by action and that the Government’s very laudable commitments translate into tangible improvement on the ground for patients.

[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.

Terminally Ill Adults (End of Life) Bill

Earl Howe Excerpts

Committee stage
Friday 6th February 2026 Lords Chamber

[Baroness Berridge (Con)]

My Lords, I support Amendment 107 and just wish to ask a few questions regarding the amendment. Along with my noble friend Lady Coffey, I note that when the noble Lord, Lord Carlile, brought forth his “bring back the judge” amendments, the MCA exited the Bill under that requirement. In relation to the MCA, it was useful to hear the eloquent speech of the noble Baroness, Lady Cass, on the evidence of the Chief Medical Officer because, when you have someone so familiar like that, it would be useful for us to know when they last did an MCA assessment. She put that very eloquently.

In relation to the comments made by the noble and learned Baroness, Lady Butler-Sloss—this is something that again arose in a previous group—on the different statutory regimes of the Mental Health Act and the Mental Capacity Act, these are not, even now, separate. I served on your Lordships’ House’s Select Committee on the Mental Health Bill, and one of the first things that we had to look at was the situation in Northern Ireland, where the choice was made to fuse these parts of the law. That was not part of the independent review by Sir Simon Wessely, but it would have been one of the options at that time, because there is an overlap between the jurisdictions.

I know that the Minister said, on the previous group, that if she is silent, that is okay, but I ask the noble and learned Lord to invite the noble and learned Baroness, Lady Butler-Sloss, to the meeting that is planned for next week with Alex Ruck Keene KC, because at the moment it is not clear that we have patients under one regime and patients under another regime. When you are detained under the Mental Health Act, one of the bases of that, when you potentially want to take your own life, is that you are under the prevention of suicide regime, with psychiatrists and clinicians there. But under this Bill, obviously, you are not, so the clinicians are asking for that clarity. I hope that we will be able to come back to your Lordships’ House after the meeting next week with that clarity. I also hope that the sponsor of the Bill could outline this.

I am surprised that we are still talking about this, because the Royal College of Psychiatrists has been raising this issue since November 2024. If we had had the amendments that could deal with its concerns, they could have truncated the debate. We had this discussion in relation to the advertising amendments. With the concerns from professional bodies, why do we not have amendments at this stage of the Bill, even though the noble and learned Lord said that amendments would be forthcoming? A year or more has gone by since these concerns were raised. I hope that he will be able to clarify why that is, at this stage. It is imperative that we see these amendments in Committee.

[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.

Medical Training (Prioritisation) Bill

Earl Howe Excerpts

2nd reading
Wednesday 4th February 2026 Lords Chamber

[Earl Howe (Con)]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Terminally Ill Adults (End of Life) Bill

Earl Howe Excerpts

Committee stage
Friday 30th January 2026 Lords Chamber

[Baroness Grey-Thompson (CB)]

I would like to provide a brief clarification on the back of what the noble Lord, Lord Harper, said about the points raised by Ms Leadbeater’s comments about feeling uncomfortable. It came from a report on ITVX on 6 March 2025. An assessment was taking place with Dr Jess Kaan. I believe family members were there, and then she asked the patient’s family to leave the room so that she could privately ask the patient whether it was a settled wish. The patient said yes, it was. I quote directly from the ITV website:

“For Kim Leadbeater, the virtual consultations did not make for comfortable viewing—she says it has made her think about adding an amendment to make clear that consultations with doctors cannot be done via video call and that they should be done in person”.

[Earl Howe (Con)]

My Lords, in the interests of time I do not propose to summarise the many points and questions that have been raised in this debate. However, I wish to speak briefly to Amendment 320A in the name of my noble friend Lord Wolfson. The amendment seeks to set the presumption that the first assessment by the co-ordinating doctor

“must be undertaken in person, except in circumstances where this is not reasonably practicable”.

It is plain from everything that we have heard in the debate that the first assessment is a pivotal moment in the process set out in the Bill. It is the point at which a co-ordinating doctor must satisfy themselves not only of the diagnosis and prognosis but of the patient’s capacity and will and, crucially, the absence of coercion or pressure, as set out in Clause 10. These are human judgments that depend not simply on what a patient says but on the way that they say it, on physical cues and on the broader context in which the conversation takes place.

I listened carefully to the noble Baroness, Lady Finlay, in particular, as I did to other noble Lords, and an in-person assessment undoubtedly allows a clinician to observe matters that may not be apparent on a screen—for example, who else is present in the room, whether the individual appears comfortable speaking freely or whether there are signs, however subtle, of hesitation or external influence. At the same time, I suggest that we need to be patient-focused as well as doctor-focused, which is why my noble friend’s amendment seeks to recognise practical realities. There will surely, from time to time, be circumstances, perhaps in late-stage illness when a person may be in acute distress, where an in-person assessment is genuinely not possible. The reasons for that could be several, but in those cases we need to ask ourselves whether a live video and audio link would be preferable to a delay, or even a complete exclusion from the process.

I emphasise that the amendment is a probing one. If we decide that provision should be made for certain cases then that would surely be a classic area for guidance or codes of practice, but the key test in every instance would be what is reasonable in the circumstances. My noble friend wants to be clear that this amendment is about setting the right default for arguably the most consequential clinical judgment in the entire scheme of the Bill, while preserving professional discretion in response to the needs of the patient where circumstances require flexibility.

I have deliberately spoken in general terms when talking about what might not be reasonably practicable. The question is really the one posed by the noble Baroness, Lady Hayman: how rigid do we wish the Bill to be in prescribing how the system should work? I hope the noble and learned Lord, Lord Falconer, could set out his vision of how this mechanism will work in practice and how he will ensure that the safeguards that we all want to see can still be maintained if an in-person assessment is not possible.

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

My Lords, I am grateful to all noble Lords for their contributions to this debate. As ever, I will limit my comments to amendments on which the Government have major legal, technical or operational workability concerns.

First, I draw the attention of the Committee to operational workability concerns about Amendments 60 and 65. Under Amendment 60, professionals delivering the service would be responsible for checking whether the person was in England or Wales on multiple occasions before carrying out their duties, even if it had been confirmed that the person was ordinarily resident in England or Wales. That would place a significant burden on professionals delivering an assisted dying service.

--- Later in debate ---

[Baroness Grey-Thompson (CB)]

My Lords, this is a really interesting group of amendments, and it has probably raised more questions for me than it has answered. When we talk about injury, I immediately think about people who have had a spinal cord injury and who have become a quadriplegic or a paraplegic.

By the very nature of my former career, I know a lot of wheelchair users who have been through various compensation cases. Luckily, these days the survival rate for someone with paraplegia or tetraplegia is very high. We also have to take that into account. I had not thought before about the impact on anyone who has been in the military. I know quite a few people who are injured through the military. Generally, the public are very supportive of the military and what they have gone through, and we would not want any unintended consequences for them.

When I was looking at conditions such as asbestosis, and others that have been debated on this group, it became very clear that in many cases these conditions present quite late and treatment is then very difficult, and many patients die before the compensation claim has gone through. We have talked before about coercion, and I know that Ms Leadbeater has said in various debates and comments that she is concerned about people being coerced not to end their life.

This is a situation where I could see this happening. If you go online and google asbestosis compensation or spinal cord injury compensation, a plethora of websites come up straightaway with calculators, so that you can have an indication of how much you could possibly gain. I had a look; it goes from a couple of thousand pounds for a back injury—which obviously would not account for this—up to £493,000 for someone with quadriplegia. The figures given as a range for asbestosis were £50,000 to £1 million. That is a life-changing amount of money for many families in this country, and it will colour the decisions they make.

It is slightly strange, because we talk about someone being a burden, but people will make a different decision because they are thinking of their children and grandchildren and protecting them for the rest of their lives. So a lot of clarity is needed to make sure that coercion does not go either way. I would be very interested in understanding what the noble and learned Lord intends to do to offer greater clarification for this group of amendments.

[Earl Howe (Con)]

My Lords, as we have heard, my noble friend Lord Harper’s Amendments 70 and 78 seek to expand the definition of terminal illness beyond illness or disease to include terminal injuries. If this amendment were accepted, it would enable those who have suffered terminal injuries through military service or industrial accidents, for example, to access assistance under the Bill.

It seems to me that these amendments are helpful in at least two ways. First, they raise the question of how we should define a terminal illness or disease. If a person has been injured and has a prognosis of six months, should that person be described as terminally ill for the purposes of the Bill? I suggest that this is not just a question for the noble and learned Lord; it is also one of relevance to Ministers. As we have said on previous occasions, it will be state-run services that deliver assistance, and Ministers will need to be clear on what constitutes terminal illness.

Put another way, if, as the noble Lord, Lord Hendy, rightly said, an injury is legally distinct from an illness, why should people with six months to live for reasons other than an illness or disease be excluded from the scope of the Bill? My noble friend Lord Blencathra argued that adding injury to illness would be a slippery slope. I need to reflect on that. I was not wholly convinced by what he said, because there is a moral case around an injured terminally ill person that we need to resolve. By the same token, if the question remains open, are we happy that it will be left to the courts to expand the definition of illness, if that is what the court decides? One could envisage that happening.

The second way in which the amendments are helpful is the issue raised by my noble friend Lord Sandhurst’s Amendment 829, which seeks to address a specific problem caused by the interaction between this Bill and the Fatal Accidents Act 1976. Having listened to both my noble friends, I share their concern. As Amendment 829 rightly implies, it may not be possible to resolve this through a simple amendment to this Bill. It would be helpful if the Minister could explain whether the Government accept my noble friend’s argument that if the rights afforded to bereaved relatives under the 1976 Act are to be preserved within the terms of this Bill—as surely is equitable—it will depend on the Government to identify ways in which that can be achieved in a legally and politically acceptable way.

Perhaps Ministers and officials could look at this between Committee and Report, and advise the noble and learned Lord, the Bill’s sponsor, so that we can resolve the problem before the Bill gets any further.

Terminally Ill Adults (End of Life) Bill

Earl Howe Excerpts

Committee stage
Friday 12th December 2025 Lords Chamber

[Lord Deben (Con)]

Could I be vulgarly practical about this, because of a point the noble Baroness mentioned, which is the parallelism with the deposit return scheme that got into terrible trouble? I declare an interest as chairman of Valpak. We had to work through that, so it is burnt into me how extremely damaging it was because it was not decided beforehand. I know that we are talking about much greater issues here but, as I hope the noble and learned Lord will accept, this is a really serious issue; it brought about enormous cost and a vast misunderstanding, and it ended up destroying what the Scottish Government wanted to do. It is a very dangerous precedent. I am sure that the noble and learned Lord will want to make absolutely sure that we do not have a repetition of something that cost vast sums of money, in both the private and public sectors, and that has undermined an important measure ever since.

[Earl Howe (Con)]

My Lords, this group of amendments covers two distinct but connected questions. The first question, posed by Amendment 17, is, in my judgment, a very helpful one, because the answer will clarify the role—or lack of role—played by a person’s GP in the process being pursued by that person in seeking an assisted death. It seems to me, from reading the Bill’s provisions, that the involvement of a person’s GP in that process, although very likely, is not legally necessary provided that the patient fulfils all the conditions set out in Clause 1(1). Clarification from the noble and learned Lord would be very helpful.

The second question, posed by my noble friend Lady Fraser’s Amendment 62, is also one that I hope can be answered very simply by the noble and learned Lord. Am I correct that it is implicit in Clause 5 that the preliminary discussion between the patient and the registered medical practitioner need not involve a doctor physically situated in England and Wales and need not be face to face? Equally, am I correct that it is unnecessary to state in Clause 1(3)(b) that the steps set out in Clauses 8 and 19 must be taken

“by persons in England or Wales”,

because Clauses 8 and 19 already explicitly provide for this?

[Baroness Merron (Lab)]

My Lords, I thank noble Lords for their contributions to this debate. As I have said, I will keep my comments limited to the amendments on which the Government have major legal, technical or operational workability concerns.

On Amendments 17 and 309A, in the name of the noble Lord, Lord Beith, and introduced by the noble Baroness, Lady Fraser, Amendment 17 is a probing amendment that seeks to establish whether people who are registered with a GP in Scotland but live in England would be excluded from eligibility for an assisted death under the Bill. Noble Lords may wish to note that Amendment 17 would have limited effect as it amends only Clause 1, which is largely descriptive. Without further amendments to Clauses 10 and 17, which contain duties to assess eligibility criteria, Amendment 17 would not impact those criteria and would introduce conflicting provisions.

Amendment 309A would amend the corresponding eligibility criteria in Clause 10 to include a person registered as a patient with a general medical practice in England, Wales or Scotland. It would not amend Clause 17, which contains the assessment by the panel. Therefore, Amendments 17 and 309A would require further consequential amendments to ensure that the Bill is coherent. This would include amendments to ensure that data recording obligations and the associated criminal offences apply to Scottish GPs. These consequential amendments would likely require consultation with the Scottish Government, as the noble Baroness, Lady Fraser, referred to, in line with the guidance for Private Members’ Bills.

I thank the noble Baroness, Lady Fraser, for tabling Amendment 62. The purpose of this amendment is to establish why the Bill requires only the actions set out in Clauses 10 and 11 to be undertaken by people in England or Wales, and not the preliminary discussion under Clause 5. Our understanding is that the reference to the preliminary discussion in Clause 5 is not mentioned in Clause 1(3) because Clause 5(3) already requires that a person wanting to have a preliminary discussion must be in England and Wales. Amendment 62 would require steps under Clauses 8 and 19 to be taken by persons in England or Wales. As drafted, the Bill requires that most of the steps in Clauses 8, 10, 11 and 19 will already have to take place in England and Wales.

In addition, Amendment 62 would have the effect that, when the Secretary of State makes regulations under Clause 19, the Secretary of State must be in England and Wales at the moment they sign the regulations. This could lead to the regulations being improperly made and challenged should the Secretary of State not physically be in England or Wales at the time of signing the regulations. This raises a practical issue of workability, as I am sure the noble Baroness understands.

On the points raised by the noble Baroness, Lady Fraser, and the noble Lord, Lord Shinkwin, relating to Scotland and guidance that the Government have provided to the sponsor, as I am sure noble Lords will understand, and I have reiterated, we are providing technical and workability support to the sponsor on devolution issues, including those that have been raised. This is an evolving situation that will continue throughout the passage of the Bill.

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[The Lord Bishop of Gloucester]

My Lords, I will speak to these amendments because I want to make a new point. A very vulnerable population that we must continue to remember is the prison population. Although we will deal with the prison population more fully in the group coming up, we must remember that this Bill currently does not exclude prisoners from being eligible. That means we must consider how each issue is likely to play out in a prison setting.

As we have heard extensively, these amendments deal with two main issues: first, access to primary care; and, secondly, how well that primary care physician knows the details of your medical history. The first is very closely related to inequalities and making sure that those who have worse access to care are not more likely to choose assisted dying. The prison population are therefore a key group that must be considered, since their health and access to healthcare are worse than that of the general population. That is evidenced by the recently published report by the Chief Medical Officer.

That report also highlights access to healthcare for those in prison. There is no automatic or compulsory enrolment of prisoners into primary care on the prison estate. Over 20% of the prison population do not complete registration on arrival. For those who do, the service is often slow or inaccessible. According to the Nacro report on physical health in prison, two in five prisoners waited for a month or longer for a GP appointment and one in 13 never got one. According to the Chief Medical Officer’s report, one in three prisoners does not have their full electronic health record available to prison healthcare staff. These are not just statistics. When I visit and talk with prisoners about their well-being and purpose, access to healthcare is always spoken about.

Briefly, I do not believe that the issue of how well a primary care physician knows your medical history has been sufficiently considered from a prison context. If a GP may be the person to conduct a preliminary discussion to consider a person’s application for an assisted death, how will they do that safely with incomplete information about their patient’s health record? We must question eligibility along these lines. Before we talk about the next group of amendments, I hope that there will be important safeguards for prisoners on the issues raised in this group.

[Earl Howe (Con)]

My Lords, the noble and learned Lord has already been very helpful in the undertakings and clarificatory comments that he made earlier in the debate, so I shall be very brief. In following up those comments, I will return to the question that I raised on the previous group. The Bill seems consciously to steer clear of insisting that a person’s GP must always be involved in the process being pursued by that person in seeking an assisted death, other than the GP having a duty to note in the patient record that the preliminary discussion has taken place. The entire process, in other words, could be conducted by the patient in conjunction with hospital-based medical consultants.

Do I understand correctly that the noble and learned Lord is willing to look closely at ways of making sure, by whatever means, that the crucial judgments made by clinicians about a patient’s capacity, about coercion and about that person’s settled wish to end their life are firmly and soundly based? The route to achieving that may well be the GP practice and the multidisciplinary team within it, but, as we have heard, that source of information may not be practical or useful in every case. Will the noble and learned Lord therefore ensure that he will consider more generally in the round possible safeguards that will forestall the possibility of superficial or cursory assessments being made—especially, perhaps, assessments by hospital consultants, who may have enjoyed only a brief acquaintance with the patient?

[Baroness Merron (Lab)]

My Lords, I thank noble Lords for their contributions on proposed safeguards relating to general practice. I will keep my comments limited to the amendments on which the Government have major legal, technical or operational workability concerns. On that basis, I draw noble Lords’ attention to the operational workability concerns in relation to Amendments 19, 20, 21, 29, 30B, 265A and 443A.

Tobacco and Vapes Bill

Earl Howe Excerpts

Committee stage
Wednesday 26th November 2025 Grand Committee

[Earl Howe (Con)]

My Lords, my noble friends Lord Howard of Rising and Lord Udny-Lister, who is unfortunately not in his place, are to be thanked for enabling us to focus on the issues around the use of heated tobacco. We have touched on this subject at earlier stages but, when previously discussing heated tobacco, the Minister promised to write to noble Lords about the evidence that her department possesses of the harms caused by heated tobacco. I am sure that is high on her agenda, but the question is crucial in the context of these amendments since, whatever the answer is, it will have a direct bearing on the use of the Secretary of State’s powers to designate locations as heated tobacco-free.

There are various published studies, as she will know. A study published by UCL found that people who switched from cigarettes to heated tobacco had lower levels of exposure to harmful chemicals than those who kept smoking, but higher levels of these toxins than those who stopped using tobacco altogether, which I guess is not a surprising finding. Other studies state that it is too soon to know how using heat—not burn—products will affect someone’s health in the long term, since research looking at these tobacco products is still, I understand, in its early stages and, in the main, funded by the tobacco industry. We therefore need clear evidence, born of independent research, on both the relative harm of heated tobacco compared to burning tobacco, as well as the absolute levels of harm that result from its use.

I am a non-smoker. I understand the concern that heated tobacco should not be a loophole for large tobacco firms to get around the law, but I am also concerned that in the absence of long-term evidence, portraying heated tobacco as being in the same category as cigarettes carries the risk of failing to reduce harm for that small percentage of smokers who wish to quit but have not taken to vapes for one reason or another.

Pending fresh research findings, I think, alongside my noble friends, that there remains a legitimate question about how the Government intend to treat spaces, both indoors and outdoors, where heated tobacco is used, and about whether they believe there is a clear proven case for including heated tobacco in the generational ban. In particular, does the Minister consider uncovered outdoor areas to be different in this context from enclosed spaces, in terms of both health risk and social behaviour? As she knows, the hospitality industry has concerns about extending the indoor smoking ban to outdoor hospitality areas such as pub gardens, and I welcome the assurance she gave on that a few minutes ago. The indication from the Government thus far is that hospitality areas will not be caught by any outdoor ban, but if that is true of smoke tobacco, can the Minister confirm that there is no similar intention as regards the outdoor use of heated tobacco?

[Baroness Merron (Lab)]

My Lords, the amendments in this group relate to limiting the Government’s ability to create heated tobacco-free places in England. I am grateful for all the contributions to the debate.

The noble Lord, Lord Udny-Lister, opposes Clause 139 standing part of the Bill. Clause 139 provides the power to designate certain places and vehicles in England as heated tobacco-free. Places can be designated heated tobacco-free only if they are smoke-free. As I have mentioned, we plan to consult on making heated tobacco-free all indoor places that are currently smoke-free. We also plan to consult on making certain outdoor spaces heated tobacco-free. As with smoke-free places, the consultation will cover children’s playgrounds, the outdoor areas of schools and early years settings, and areas outside healthcare settings where medically vulnerable people may be present.

The noble Earl, Lord Howe, asked an important question about evidence, and I will write with more detail as soon as possible. However, I reiterate what I said in debates on previous groups and elsewhere: there is no safe level of tobacco consumption and all tobacco products are harmful, including heated tobacco products. I am grateful to the noble Baronesses, Lady Bennett and Lady Walmsley, for their supportive comments. Laboratory studies show evidence of toxicity from heated tobacco and that the aerosol generated by heated tobacco devices, like other forms of tobacco, contains carcinogenic compounds. Recent evidence has also indicated that exposure to second-hand emissions from heated tobacco products is associated with significant respiratory and cardiovascular abnormalities in bystanders.

The noble Lord, Lord Udny-Lister, also tabled Amendment 185. The noble Earl, Lord Howe, asked me to repeat—I am glad to do so—that, as I have made clear, we are not planning to consult on making outdoor hospitality settings in England heated tobacco-free.

Amendment 184A tabled by the noble Lord, Lord Howard of Rising, seeks to exempt areas where it would be reasonable to expect that only over-18s are present from any future restrictions on heated tobacco places. This amendment is similar to the one already discussed in relation to vape-free places, which would mean that some indoor areas, for example nightclubs, could not be made heated tobacco-free.

--- Later in debate ---

Moved by

[Earl Howe]

188: After Clause 157, insert the following new Clause—
“Strategy to reduce retail crime linked to tobacco and vaping products(1) The Secretary of State must prepare and publish a strategy to reduce offences against retailers of relevant products as a result of changes made by this Act.(2) The strategy must address—(a) violence and abuse against retail workers at work resulting from—(i) the refusal of sale of relevant products, and(ii) requests for identification by retail workers to a person attempting to buy relevant products;(b) theft of relevant products from retailers of relevant products, and(c) any other offence against retailers of relevant products relating to relevant products.(3) The strategy must be published before the end of the period of 12 months after the day on which this Act is passed and updated between 1 January 2027 and 1 January 2028.(4) In preparing the strategy the Secretary of State must consult—(a) retailers of relevant products,(b) representatives of retailers of relevant products,(c) elected local policing bodies, and(d) any other person the Secretary of State considers it appropriate to consult. (5) For the purposes of this section “retailers of relevant products” means a person who carries on a business involving the sale of relevant products by retail.(6) In this section—“elected local policing bodies” has the same meaning as section 101 of the Police Act 1996;“relevant products” means—(a) tobacco products,(b) tobacco related devices,(c) herbal smoking products,(d) cigarette papers,(e) vaping products, or(f) nicotine products;“retail workers at work” means a person who—(a) is working on or about retail premises, and(b) is working there for or on behalf of the owner or occupier of those premises, or is the owner or occupier of those premises.(7) In subsection (6) “retail premises” means—(a) premises used wholly or mainly for the purposes of the sale of anything by retail, or(b) premises used mainly for the purposes of the wholesale of anything, if the premises are also used for the purposes of the sale of anything by retail,and here “premises” include a stall or vehicle.”Member’s explanatory statement
This amendment requires the Secretary of State to publish a strategy to reduce retail crime against retailers of tobacco, vaping and nicotine products.

[Earl Howe (Con)]

My Lords, my noble friend Lord Kamall and I have previously raised the concerns of retailers in relation to several aspects of this Bill. Amendment 188 is intended as a probing amendment to ask the Government whether they have any plans to work with retailers and other partners to develop and publish a strategy to reduce retail crime against retailers of tobacco, vapes and nicotine products.

Noble Lords will be aware that these retailers are often the most affected by retail crime. Their businesses are often small, independent stores that lack the means to hire security, as larger retailers are able to do. The size of these businesses also means that retail crime has more of an impact, due to smaller profit margins. On top of that, by the very nature of selling age-restricted products, the likelihood of confrontation is heightened by the increased interaction with customers. This problem is being exacerbated by the rampant rise in shoplifting over the past year. Shoplifting offences across England, excluding London, have risen by 15%, and, in London, the number is almost unbelievable: 54%. That figure is now at a 20-year high, costing retailers £2.2 billion in lost profits.

Retailers, both large and small, are being pummelled by an increased disregard for the rule of law and, very often, a lack of response from the authorities. The department’s impact assessment acknowledges this when it says that the Bill

“could lead to an increase in aggression and abuse towards retail workers”.

That is why, in Amendment 191, I suggest that the Government have a responsibility both to oversee the transition that they are mandating in the Bill and to provide suitable guidance. Whatever noble Lords’ views on the provisions of the Bill, this amendment re-emphasises the need for clear consultation and for the Government to work with retailers to address their concerns.

For that reason, I support the principle behind my noble friend Lord Howard of Rising’s Amendment 200A. The policy set out in the Bill to prohibit those aged under 18 from buying nicotine products can be enforced only by age-verification checks. Where technology is involved in such checks, this will cost retailers money. Smaller retailers will find this burden commensurately heavier. This probing amendment from my noble friend— I hope he will allow me to call it that—allows us to ask the Minister how the Government intend to lighten the burden on those retailers.

I beg to move.

[Lord Howard of Rising (Con)]

My Lords, my Amendment 200A touches on a different theme from the other amendments that I have tabled. As my noble friend Lord Howe commented, it is a probing amendment to test the Government’s attitude to small shops and the burdens that they face. I endorse the remarks made by my noble friend about shoplifting because it no longer seems to be a crime—you just go in and help yourself to what you want.

This amendment is focused on the burden placed on businesses by their need for age-verification technology. The businesses that will have to comply with this Bill are not just major supermarkets or established tobacco specialists; they are also corner shops and convenience stores up and down the country. These are small businesses on which local communities rely. They are run by local businessmen who provide employment in our villages and towns. They are a place where essential services, such as postal services and phone or bill payment services, can be accessed.

Any additional burden on our corner shops must be considered in that context. Can the Minister please set out what assessment the Government have made of the impact of this Bill on small businesses, especially convenience stores? Can she assure us that, if the impact on these businesses is shown to be overly burdensome following the passage of this Bill, Ministers will look closely at how to support convenience stores further by reducing the regulatory burden that they face? I should declare an interest in that I own a convenience store, although I do not run it.

It is essential that we do not proceed blindly without a proper understanding of the impact that this Bill will have on small businesses, so I hope that the Minister will be able to address my concerns fully in her closing remarks.

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[Baroness Merron (Lab)]

My Lords, I am most grateful for this discussion. I say at the outset that, although I do not support accepting the amendments, I have a lot of sympathy with a number of the points made, which I will come on to. However, while I completely understand the pressure on small retailers—I will come on to that—I struggle to accept that the Bill is the fount of all evil, which I feel is the direction we are going in. I certainly agree with the noble Baroness, Lady Bennett, who spoke about the need to see the Bill in its overall context. I associate myself with those comments.

I absolutely agree with the intention behind Amendment 191, tabled by the noble Lord, Lord Kamall, and introduced by the noble Earl, Lord Howe. I hope I can reassure noble Lords that the Government are committed to supporting businesses to implement the measures in the Bill, which much of this discussion has been about. As I have said previously, we will continue —it is a continuing thing that is not in the past—to work closely with retail bodies such as the British Retail Consortium and the Association of Convenience Stores on the implementation of the measures, which will include the development of guidance.

I heard the concern of noble Lords about what guidance will be given. Again, I understand those points but, to say it in other words, we will support retailers through this transition. As the noble Baroness, Lady Walmsley, mentioned, what is being asked of retailers is not unusual for them; they are very familiar with age verification. I will come back to that later. The measures in the Tobacco and Vapes Bill will come into force across a range of dates and therefore it is important that the associated guidance is available at the appropriate time. In other words, there will be time to make this transition and there will be support for that. We are firmly committed to publishing the guidance in a timely manner.

Turning to Amendment 188, tabled by the noble Lord, Lord Kamall, I say to nearly all noble Lords who have spoken that, although I understand the intention of the amendment, it is unnecessary. As noble Lords have acknowledged, the Government are already taking action to tackle the absolutely unacceptable rise in retail crime. The Government will not stand for violence and abuse of any kind against shop workers. Everybody has a right to feel safe at their place of work and we have long championed specific protections for retail workers.

To protect the hardworking and dedicated staff who work in stores, the Crime and Policing Bill introduces a new offence of assaulting a retail worker, which the noble Baroness, Lady Fox, referred to. The Bill also removes legislation which makes shop theft of goods to the value of £200 or below a summary-only offence. That sends a clear message that any level of shop theft is illegal and will be taken seriously. I hope that that is helpful to the noble Lord, Lord Howard.

Alongside legislative action, we are also providing over £7 million over the next three years to support multiple policing bodies to help to tackle retail crime. As I have mentioned, we will continue to work closely with retailers and will utilise the lead-in time to best support them in preparing for and implementing the measures in the Bill. This will include government communications and information campaigns to inform both the public and retail workers.

The noble Baroness, Lady Fox, asked what assessment the Government have made of the impact on small businesses. Page 82 of the impact assessment specifically addresses this. As noble Lords are aware, an impact assessment should be expected and is required for any Bill. That means that the Regulatory Policy Committee also took a view; it published an opinion on the impact assessment and provided a fit-for-purpose rating. This included a green rating for the assessments of small and micro businesses’ assessments. I hope that will be useful.

I turn to Amendment 200A, tabled by the noble Lord, Lord Howard. This would require the Government to create a financial assistance scheme specifically to subsidise the cost of purchasing age-verification technology to enforce on the sale of nicotine products. I heard the comments of the noble Baronesses, Lady Walmsley and Lady Bennett, who spoke against that amendment.

There are no plans to mandate the use of age-verification technologies to enforce the age of sale of nicotine products. It will be for businesses to decide how they ensure that they sell only to people 18 years or over, including whether to use age-verification technology to support them in this. As I mentioned earlier, as did the noble Baroness, Lady Walmsley, checking that a customer is over a certain age is a well-established and well-trodden path for retailers. They should continue to take reasonable steps and exercise due diligence to ensure that they do not sell products to anyone underage. Most retailers already follow recommended practice, and I am grateful to them; they regularly ask for identification from customers to verify their age.

To provide clarity for retailers on the types of ID that can be used, the Bill provides powers to specify in regulations the steps that may be taken to verify a customer’s age and satisfy the age of sale defence. This will include the types of digital identities that can be used, and work will continue with the Department for Science, Innovation and Technology, which is leading on this work. I emphasise that the Government are absolutely committed to supporting retailers through the changes brought in by this legislation, including through the publication of clear guidance in which they will be fully involved.

I hope that I have provided helpful reassurances and that the noble Lord will feel able to withdraw the amendment.

[Earl Howe (Con)]

My Lords, I am grateful to all noble Lords who have spoken in this short debate, including the Minister for her reply. Perhaps I could repeat that my amendment was intended as a probe to raise a set of general concerns surrounding the retail sector. I was reassured by the Minister’s reply, including her references to the provisions of the Crime and Policing Bill. But we need to bear in mind, as we debate the Bill, that retailers are not the source of the problem that the Bill seeks to address—yet they will be the ones to lose out.

The Bill is projected to cost retailers more than £1 billion in profits over the next 30 years, plus what I am sure will be a considerable amount more from the reduced footfall that many will see over time. The noble Baroness, Lady Fox, was right: there is considerable worry in the sector, which is exacerbated by the uncertainty surrounding the timetable for the Bill’s implementation. It would be helpful, perhaps when we reach the next stage of the Bill, for the Minister to give us an idea of how the Government intend to proceed as regards the processes of consultation—consideration of submissions, as well as the actual implementation—and what the outline timetable will look like. The transition needs to be as inclusive and smooth as possible, and practical guidance and support will be essential, especially for small retailing businesses. I have no doubt that the Government have this in mind, but we may need to return to it on Report, just to underline the point. Meanwhile, I beg leave to withdraw the amendment.

Amendment 188 withdrawn.

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[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord Lansley, for Amendment 197 and the noble Baroness, Lady Fox of Buckley, for the robust debates that we have had during Committee; I thank the Minister and all noble Lords for that. I want to say just one thing in response to something that the noble Baroness, Lady Fox, just said. There is something wrong with vaping in the very limited circumstances when it hooks a 12 year-old on to something very addictive, which may last for the rest of their life—the noble Baroness did concede that point.

I turn to the amendment. The noble Lord, Lord Lansley, recognises that evidence and public opinion are likely to move forward as the measures in this Bill are implemented over a period of time. While the harms of smoking tobacco are well researched and evidenced, the impact or benefits of vapes and other nicotine products as smoking cessation tools are not yet so well evidenced. Besides, we can expect innovation in this area as the tobacco companies try to protect their profits. We must keep up with that. As the noble Lord, Lord Young of Cookham, just mentioned, Public Health England used to publish regular reviews on the impacts of vaping, but this has not continued; in any case, the reviews need to be a bit wider than vaping because we do not know what products are coming down the track.

The noble Lord is asking for an independent expert panel. I would certainly expect the Government continually to provide evidence themselves as they put the wide powers in this Bill into operation. However, just as the independent Climate Change Committee is well trusted in respect of the advice it gives to the Government, based on a wide range of scientific evidence—the Government benefit from that—so an expert advisory committee on the future implementation of the new regime for nicotine and vaping products, quite independent of the tobacco and vapes industry, would add to the Government’s confidence and to public confidence.

I do not want to predict what the findings of such an expert panel would be, but its deliberations could be very helpful when the operation of the Bill is reviewed at any point in future, as suggested by my noble friend Lord Russell in his Amendment 195. The noble Earl, Lord Howe, suggested a five-year review. However, it will be very important that its deliberations and advice to the Government are totally transparent. If that were not the case, it would not command the respect of the public, the research community or anybody else. I am sure that that is the noble Lord’s intention. This idea is well worth consideration by the Minister. I am sure that there will be more discussions about it, perhaps offline, and I look forward to her reply.

[Earl Howe (Con)]

My Lords, the Committee will be grateful to my noble friend, with his considerable experience in health policy, for the clear and cogent way in which he introduced his amendment. I am very supportive of the principles behind the amendment, as it seeks to ensure that decisions taken after the passage of the Bill are informed by robust, independent evidence and that Parliament is equipped with the relevant and authoritative information it needs to provide proper oversight of the regime for vaping and nicotine products, information that is constantly updated as the body of evidence evolves.

Critically, this principle applies equally to the Government. Proposed new subsection (5) in the amendment would require Ministers, when making regulations under the Act, to have regard to the proposed panel’s reports and recommendations. That is a sensible idea. My noble friend Lord Young of Cookham was right to remind us that there has for some time been a gap in the public health mechanisms regarding the production of such reports. If we were to recreate a mechanism of the kind suggested, the regulatory frame- work would evolve in response to the realities of science and the market rather than outdated information.

It is also important to recognise, as the amendment implicitly does, that although our primary concern here is health, regulation in this space cannot be viewed in isolation from the wider economy. When sales of currently legal products are restricted or prohibited, this inevitably impacts businesses, consumers and, sometimes, wider society, and those economic effects can themselves have unintended consequences for public health and people’s lives. There is also plenty of evidence of unintended consequences and the effectiveness of previous episodes of prohibition. The risk of a rise in consumption of illicit products is an obvious example, as is misinformation propounded on social media. The Government should make and review decisions with as clear a view as possible about those sorts of trade-offs.

For those reasons, I hope the Government will take on board the very sensible suggestion contained in this amendment.

[Baroness Merron (Lab)]

My Lords, I am most grateful for this debate, which concludes the work of the Committee. As I have said before, I certainly share the intention of the noble Lord, Lord Lansley, who tabled this amendment, to ensure that regulations are based on the best available evidence. I appreciate the consideration he has given to the amendment and the reason he put it forward.

I say in response that we continue to monitor emerging evidence, which we have much discussed, on vapes and nicotine products, including commissioning independent research through the National Institute for Health and Care Research. For example, we commissioned a comprehensive analysis of all youth vaping studies—referred to in the debate—which was published recently, and a five-year-long living evidence review that will collate the latest and most robust research into the health impact of vaping. This living evidence review is accompanied by a scientific advisory panel, which includes independent experts, appointed independently from the Government on merit, who the Government can call on for advice on the latest evidence. Further, as the noble Lord, Lord Young, mentioned, earlier this year we announced a landmark 10-year study that will include in its investigations the long-term health effects of vaping on young people’s health.

I agree with the noble Lord, Lord Lansley, that misperception of the harms of vaping is of concern; I take that point. Vaping absolutely can play a role in helping adult smokers to quit, as we have discussed, but children should not be vaping and nor should non-smokers. We are committed to carefully considering the scope of restrictions, to avoid unintended consequences and the misperception of harms, which is an area for further work.

We also fund a vaping expert panel, which provides valuable guidance for trading standards professionals on the enforcement of regulations. Under many of the powers in the Bill there is a requirement to consult before making regulations and, on 8 October, we published a call for evidence on issues where more evidence is needed before we can consult on specific proposals. We will monitor the impacts of measures brought in by the Bill and subsequent regulations. We will also be able to update regulations in future to ensure that policy is responsive to evolving evidence, should this be necessary.

It is our view that we have access to appropriate expert advice, which I know is the noble Lord’s intention, and we will consider the best available evidence in making regulations. I hope that he will feel able to withdraw his amendment.

Terminally Ill Adults (End of Life) Bill

Earl Howe Excerpts

Committee stage
Friday 21st November 2025 Lords Chamber

[Lord Mackinlay of Richborough (Con)]

My Lords, the debate on this matter this morning has been enlightening from all sides, with many with many distinctive speeches that will stay with me, including that of the noble Lord, Lord Griffiths, who brought a very personal account, though he is no longer in his place.

We are talking about concepts and words—whether it is encouragement, coercion or pressure. They are in a similar collective of words, and I worry that we are dancing with words a lot in this debate. The noble Lord, Lord Griffiths, brought the word “autonomy” to us this morning, which is very important. I know it has been described earlier in Committee and on the Floor here today. I would be significantly more encouraged and relieved if I could be absolutely sure that autonomy and freedom of action, freedom of movement, freedom of thought and of decision were clear, unambiguous and untainted. I cannot be assured by the Bill, as it stands, as it is weak on the coercion nature.

As I left the Chamber earlier—my wife had arrived— I thought back to the cases of Ruth Ellis and Derek Bentley, which were very significant as they stopped the death penalty in this country. It was a long time ago when the morality and thoughts of this country were in a very different place to today. One might talk about the deterrent effects of the death penalty—which is a whole different debate—but we were willing to put that aside because of the potential of getting things wrong, and we did not want miscarriages of justice. That was so powerful. However, here we are discussing this Bill with lots of suggestions on how we could strengthen the coercion measures and make sure that people are not being pushed towards an early death that they did not want. We are almost flippant about that because the unsaid words are, “They’re old and ill anyway, so they don’t really matter”.

In support of Amendment 58 in the name of the noble Baroness, Lady Grey-Thompson, my noble friend Lord Deben—with whom I do not always agree on everything—made a very powerful point. If you were to look at the bell curve of the wealth and status of us in this Committee, we are probably to the left of the public politically, but certainly to the right in terms of wealth and influence as a whole. There is a world of difference between how, if we were to face this, we would be treated—the voice we would have for ourselves and the way in which our families would know they have agency and power to speak—compared with others in society. It could be that the wealthy family would be in a different place, because they could afford the help at home and the support in a care home as necessary.

However, for those in the middle who perhaps have children who work away, which is increasingly likely in this country, the children are feeling guilty. There are lots of cases that have been talked about the real situation of how people feel. In cases of that type there may be no problem of wealth, but problems of support by children and others. The “I don’t want to be a burden” debate would be coming to the fore.

One of our Northern Ireland colleagues mentioned the issue of saying, “Do you know how much this costs the NHS?”. I will be exploring that in greater detail. I think Amendment 3 touched on having an independent person; I have laid amendments for another day examining whether the NHS should be part of this process at all.

I say to the noble Baroness, Lady Hayter, that I could be encouraged but I am not sure how we can overcome the facets and dimensions of autonomy and coercion, because people and families are complex. One’s situation in life is complex. Just as we were willing to change a major piece of criminal legislation on the back of two errors, we seem to be not so interested in looking after the vulnerable in this Bill. I wish I could advance an amendment that would satisfy me—a lot of these amendments would make me a little more satisfied—but, no matter what we do, I am tempted to follow the noble Lord, Lord Carlile, in saying that we need to look at this whole area of coercion and pressure all over again. It is absolutely apparent across this Committee that this is the sticking point for many of us, so please try to satisfy us.

[Earl Howe (Con)]

My Lords, in their various ways, the amendments in this group seek to protect those who are terminally ill from being coerced or pressured into a decision to seek an assisted death. One of the most worrying concerns that have been raised by opponents of this Bill is the risk of especially vulnerable people being encouraged or coerced into ending their own life. The noble Lord, Lord Dodds, was right about that. For that reason, I do not think the Committee should feel embarrassed about having spent the time on this debate that we have.

As has been pointed out, the Bill already seeks to cover the coercion issue in its existing drafting. However, given that it creates a totally new role for medical practitioners in a situation where a terminally ill person wishes to end their life, in my opinion noble Lords are surely right that a laser focus should be applied to delivering protections designed to prevent any such coercion or pressure.

As a number of speakers have pointed out, coercion can come from anywhere—family members, friends, neighbours, other trusted people in our lives or an institution—and it does not have to be overt. It can and often does take the subtlest of forms. The noble Baroness, Lady Finlay, and my noble friend Lord Deben vividly described situations of that nature. Of course, the vast majority of family and friends of someone suffering from a progressive terminal illness will act in good faith to support their loved one through what is in many if not most cases an incredibly difficult time. However, when framing legislation around a decision as momentous as whether to opt for an assisted death and, as the noble Lord, Lord Carlile, pointed out, human nature being what it is, it is doubly incumbent on us to look for ways of safeguarding those who might be most susceptible to external pressure.

Amendment 3 in the name of the noble Baroness, Lady Finlay of Llandaff, would state more clearly in the Bill that the decision to end one’s life must be made independently. I hope the noble and learned Lord, Lord Falconer, will look favourably on this amendment, as it seems to me in tune with the Bill’s aims and purpose.

The question, though, as posed by the noble Lord, Lord Pannick, is whether it is necessary. As far as I can see, in no part of the Bill is there any indication that where a person finds it difficult to make a decision about an assisted death, or where the possibility of an assisted death has not even entered their head, it would be appropriate for their thoughts to be influenced or guided by another individual. Indeed, the Bill contains specific prohibitions on advertisement and promotion, as well as the offences set out in Clause 34 in respect of inducing a person to seek an assisted death by dishonesty, coercion or pressure.