Medical Training (Prioritisation) Bill

Baroness Merron Excerpts

Committee stage & Report stage
Monday 23rd February 2026 Lords Chamber

[Earl Howe (Con)]

My Lords, I too am grateful to the noble Lord, Lord Patel, for leading the debate on his amendments, which seek to establish a new prioritisation hierarchy that puts UK medical graduates first, ahead of those in the priority group who are not UK medical graduates. I should have prefaced my speech by reminding the House of my interest as an honorary fellow of the Royal College of Physicians.

We debated this proposal in Committee, when other noble Lords, including my noble friend Lady Coffey, tabled amendments that sought to introduce a different prioritisation hierarchy. I understand fully the case that the noble Lord is making and I agree that UK medical graduates should have a much fairer crack of the whip in access to medical specialty training places. Fairness has been our primary concern throughout our scrutiny of this Bill. However, I agree also with the noble Lord, Lord Hunt of Kings Heath. The Government have had some hard choices to make.

In an ideal world, where the House had been given more time to consider these matters in the round, we might have been able to improve on the approach that Ministers are taking. For example, there is surely a place for guidance to make clear that the prioritisation process should incorporate considerations of medical and academic excellence, a point that the noble Baroness, Lady Finlay, has consistently made.

I am grateful to the noble Lord, Lord Stevens of Birmingham, for putting the decisions made by the last Government into their proper context. However, given where we are, we accept that Ministers have introduced this as urgent legislation with a specific purpose. In that context, having accepted that the Government’s approach will have the effect that they are seeking to achieve, we are satisfied that the Minister’s proposed method of prioritisation is acceptable.

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

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

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

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

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

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

For specialty training, the amendments would mean we would be prioritising UK medical graduates over applicants with significant NHS experience. That would undermine the effective delivery of our policy intention, for which there is much sympathy in this Chamber, to prioritise applicants with significant experience working in the NHS. The Government have rightly committed to prioritising those who have made a considerable contribution to our health service because they better understand how the health service works and how to meet the needs of the UK population.

The noble Lord, Lord Patel, asked how many more students in the priority group would be able to enter specialty training. I will be pleased to write to the noble Lord on that matter.

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

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

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

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

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

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[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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Like the noble Lord, Lord Hunt of Kings Heath, I hope the Minister will regard all these matters as unfinished business, which she and her department will wish to pursue and resolve.

[Baroness Merron (Lab)]

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

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

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

Amendment 11 would prioritise groups with different immigration statuses which are not an appropriate proxy for significant NHS experience. This is not consistent with the aims of the Bill. The amendment would also have the effect of permanently prioritising applicants on the basis of immigration status for foundation and specialty training. The applicants with the immigration statuses listed in the amendment who are not otherwise prioritised are—as I have already said, but it bears repeating—not excluded from applying for foundation or specialty training. They may still be offered a post, if there are places remaining, once all prioritised applicants have been allocated posts. They also remain eligible to apply for locally employed doctor roles. On this basis, I hope my noble friend will feel able to withdraw her amendment.

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

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

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

I note that the noble Baroness, Lady Gerada, argued in her email to all Peers—or to a number of Peers, I am not quite sure which—that her amendment would not widen eligibility for prioritisation beyond the Government’s intentions. This is not the case. To reiterate, the Bill intends to prioritise home-grown doctors and put them at the front of the queue for training posts. It is unashamed, for the reasons that I have explained and noble Lords understand. Doctors who have trained here and undertaken their placements in our hospitals and health settings will have more familiarity with the NHS and the needs of the patients they serve than a doctor who has studied the same curriculum but not in the UK.

However, the Bill recognises that this experience can be gained without spending the entirety of one’s degree in the UK. However, the line has to be drawn somewhere and, where the majority of a degree has been studied outside the UK, it is right that those graduates are not prioritised equally alongside UK-trained medical graduates.

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

The Bill prioritises all graduates of UK medical schools who have studied for their degree in this country. That is the right thing to do for our health system, because we recognise that these doctors are well prepared to work in that system and are more likely to stay. It is also right and fair to do this for graduates of our medical schools. It treats all graduates as equals, regardless of where they are from.

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

I will make a number of points to deal with the points that the noble Lord, Lord Clement-Jones, raised. I understand that the proposed amendments seek to restrict future eligibility by prioritising only those campuses that are extant on the day the Act is passed, and also to create a power that would enable us to limit the number of eligible applications under this provision. However, the establishment and operation of these overseas campuses sit outside the UK Government’s workforce planning and commissioning decisions. We have previously set out that we expect that all eligible prioritised applicants for the foundation programme in 2026 will get a place. So, accepting these amendments, even with the suggestion of capping the numbers that could be prioritised from these campuses, would mean we would have to fund more foundation programme posts than we need.

There has been talk—not just in the Chamber, but outside—about figures. Let me clarify that current UK foundation programme applications for 2026 show almost 300 applicants from overseas campuses of UK and Ireland medical schools. This is a significant number and to prioritise all of this group would require substantial additional expenditure for these posts. A rough estimate is around £25 million over two years. This is funding which, if it went in this direction, could not be spent on other priorities, including increasing specialty training places, which I know is of great interest to noble Lords.

In addition, the proposed amendments would not have any effect on overseas campuses of Republic of Ireland medical schools, so would conflict with provisions in the rest of the Bill, which treat Ireland graduates on the same basis as UK graduates, reflecting the unique relationship between the two countries.

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

[Baroness Merron (Lab)]

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

I turn first to Amendment 14, tabled by the noble Lord, Lord Mohammed. As I stated in Committee, we are unable to support this amendment. It might be helpful to your Lordships’ House if I am clear about our intention. As your Lordships are aware, the Bill sets out on its face the groups of people who are to be prioritised for specialty training from 2027 onwards. The delegated power about which we are speaking is limited to adding to this list by referring to the significant experience of working as a doctor in the health service or immigration status, so it is, in my view, tightly drawn.

Similarly, we have set out in the Bill the specialty training programmes excluded from the prioritisation scheme. Again, I give the reassurance that the delegated power about which we are speaking is limited to amending this list and gives necessary operational flexibility for future changes in recruitment, training and workforce needs—something that noble Lords raised in an earlier group.

As I hope noble Lords are aware, I am always supportive of parliamentary scrutiny. However, due to the very limited scope of these powers, we believe that the negative procedure is appropriate, not least as the regulations will not have the effect of excluding anyone from applying for a training post. I hope it is helpful to remind noble Lords that the Bill has been assessed by the Delegated Powers and Regulatory Reform Committee, and no suggestion was made that the negative procedure was inappropriate for such regulations. With that explanation, I therefore hope that the noble Lord will feel able to withdraw his amendment.

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

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

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

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

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

[Lord Mohammed of Tinsley (LD)]

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