Medical Training (Prioritisation) Bill

Lord Clement-Jones Excerpts

2nd reading
Wednesday 4th February 2026 Lords Chamber

[Lord Clement-Jones (LD)]

My Lords, I too thank the Minister for her introduction. I look forward to hearing from our two maiden speakers and add to the noble Earl’s welcome to the House to them. It is a pleasure to follow the noble Earl, and I agree with a great deal of what he said.

Let me say from the outset that we on these Benches support the underlying principles of the Bill. The Government’s impact statement makes the case that UK graduates are significantly more likely to remain in the NHS long term than their international counterparts. It is entirely reasonable that where the British taxpayer invests some £4 billion annually in medical education, there should be a secure pipeline for those graduates into our health service.

However, while the intent is sound, the execution is marred by serious flaws. Fairness requires that those who have relied on a long-standing government position are not disadvantaged by abrupt alterations. Six months’ notice is wholly inadequate for a decision with such a long lead-in time, and few could reasonably have expected such a significant change to be implemented with so little warning.

I want to highlight two specific areas where the Bill creates profound inequity—the treatment of UK university campuses overseas, specifically Queen Mary University of London in Malta, and the flawed criteria used to assess significant NHS experience for our international colleagues.

First, on the anomaly regarding Queen Mary University of London and its campus in Malta, until mid-last year, I was chair of Queen Mary University of London’s governing council. It is vital to understand that Queen Mary University in Malta is not a foreign institution or a private commercial venture; it is an integrated campus of a UK public university. Its students study a curriculum identical to that of their peers in London. They sit the same assessments, including the UK medical licensing assessment, and they are awarded the exact same GMC-approved primary medical qualification.

In her letter to noble Lords this week, and I welcome her correspondence, the Minister argued that these graduates should not be prioritised because they may lack familiarity with local epidemiology and NHS systems. With respect, that does not hold water. These students follow the exact same NHS-aligned curriculum as Queen Mary students in Whitechapel.

Contrast that with Clause 4, in which the Government rightly prioritise graduates from Ireland, but also prioritise graduates from Switzerland, Norway, Iceland and Liechtenstein. A graduate from Liechtenstein has no UK medical degree, has not sat the UK medical licensing assessment and has no training in UK epidemiology. Yet, under the Bill, they will be prioritised over a Queen Mary in Malta student who holds a UK degree and has been specifically prepared for the NHS. This is a manifest absurdity.

The Minister’s letter also suggests that including those students would undermine workforce planning because numbers are uncontrolled. That is incorrect. Queen Mary in Malta’s student numbers are capped by the Maltese Government at just 50 to 70 graduates a year—statistically negligible in a system of 11,000 places. To penalise them on such grounds is neither proportionate nor fair.

Furthermore, the Government’s own impact assessment justifies the Bill on the need to protect taxpayer investment, yet Queen Mary in Malta students are self-funded. This is not merely a matter of academic equivalence; these graduates provide the NHS with doctors trained to UK standards at no cost to the British taxpayer, representing a rare example of value without expenditure —precisely the kind of pipeline a fair system ought to support rather than disadvantage. By excluding them, the Government are working against their own value-for-money logic.

We also risk breaking a solemn international commitment. The Minister’s letter implies that our agreement with Malta is limited to ad hoc training. That downplays the reality. Since 2009, the UK and Malta have operated under a unique mutual recognition agreement regarding the foundation programme itself, explicitly renewed by the Department of Health and Social Care as recently as 2024. Malta is the only country in the world with this status. By unilaterally demoting these graduates, we are, in effect, tearing up a long-standing agreement with a Commonwealth partner—one that Malta’s own Minister for Health describes as having served both countries for over two centuries. Other universities, such as Newcastle University, which operates a similar campus in Malaysia, face similar predicaments. Its vice-chancellor has noted that its graduates too receive identical accreditation and transition seamlessly into the UK workforce.

Then there is the second critical flaw in the Bill: how it attempts to identify significant NHS experience for the upcoming 2026 recruitment round. Under Clause 2, the Government propose using immigration status, specifically indefinite leave to remain—ILR—as a crude proxy for NHS experience. This reveals a fundamental misunderstanding of medical training timelines. ILR typically, at the moment, requires five years of residence, yet UK graduates enter specialty training after just two years of the foundation programme. That creates a perverse experience gap. International doctors who have served on our front lines for three or four years, passed royal college exams, built a career portfolio and worked the same rotas as their UK colleagues will be treated as if they have no experience at all, simply because they have not yet clocked up the five years required for ILR. This, effectively, tells dedicated doctors that their three years of service counts for nothing.

In her earlier letter, the Minister defends this blunt proxy, as she did today, by claiming it was not operationally feasible to assess all applications for actual NHS experience in time for the 2026 cycle. We have received compelling evidence to the contrary. Doctors currently using the recruitment platform Oriel inform us that the system already captures data on months of NHS experience. The data exists, the mechanism to do this fairly exists, and to persist with the ILR requirement is to prioritise administrative convenience over the reality of clinical contribution. We should define significant experience not by visa status but by time served. A benchmark of two years of NHS experience would be equitable, and mirror the two years of core training required of UK graduates.

Furthermore, we have all received distressing correspondence regarding doctors on spousal visas. These are permanent residents, married to British citizens, with an unrestricted right to work, yet under the Bill they are placed in the lowest priority tier. We risk driving away not just those doctors but their British spouses who work in our public sector as families are forced to emigrate to find work.

There is a deep anxiety, in particular, regarding the mid-cycle implementation of these rules. We have received correspondence from doctors who have spent years building career portfolios and investing substantial resources based on published criteria, only to find the rules changing while the recruitment process is active. This creates procedural unfairness and huge instability for their families. If our guiding principle is, as it must be, fairness, then it cannot be right to introduce such consequential changes mid-cycle when candidates have already ordered their lives and careers around criteria that have stood in place for many years.

To cap it all, there is a glaring incoherence at the heart of the Government’s approach. Just days ago, the Education Secretary, Bridget Phillipson, announced a new strategy to grow our education exports to £40 billion a year by 2030. She explicitly encouraged our universities to expand transnational education and open campuses overseas. Yet in the Bill, the Department of Health and Social Care is actively undermining that very strategy. We cannot have the Department for Education urging universities to go global to boost the economy while the Department of Health and Social Care simultaneously pulls up the drawbridge against the very students who enrol. That is a fundamental contradiction.

For Queen Mary in Malta, the solution is simple: a minor amendment to Clause 4 to recognise its UK degree, or the inclusion of Malta in the priority list, honouring our 2009 agreement. For the broader issues affecting international medical graduates, we must abandon the blunt instrument of ILR and use the data we already have to recognise two years of service as the true mark of commitment. Let us not mar a necessary piece of legislation by failing to correct these obvious injustices.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I am most grateful to all noble Lords who contributed to this debate for the support given, including just now by the noble Earl, Lord Effingham, to working with us, because I think there is general recognition that we have a problem that needs to be dealt with. I am very glad, as I said at the outset, to have been the Minister at the Dispatch Box when my noble friends Lord Duvall and Lord Roe made their moving maiden speeches. They both have many years of distinction in public service, and I know that that will continue as they bring their own unique experiences and views on the world to your Lordships’ House, which will be much enriched by their presence.

A strong and consistent theme has come through today’s debate: a shared concern for the well-being of NHS staff, recognition of the importance of workforce planning and the need for a sustainable health service. I am grateful for the thoughtful questions, and I will endeavour to answer as many as possible—I have already referred to some in my opening remarks. I will of course review the debate, as always, and I will be pleased to write to noble Lords on those matters I was not able to get to.

This legislation is about giving future generations of doctors trained in the UK a clearer and more secure pathway into NHS careers. It is about sustainable workforce planning and, as the noble Earl, Lord Howe, referred to, about fairness—to those who train here, to taxpayers who fund that training and to patients. As many noble Lords acknowledged, significant public investment goes into medical education every year, so it is right that we ask ourselves how that investment can be best aligned to what we need.

I have listened closely to the concerns raised today, particularly about the Bill’s impact on those who will not be prioritised. To reiterate, the way I look at this is that the Bill is about prioritisation, not exclusion. I assure your Lordships’ House that all eligible applicants will still be able to apply, and they will be offered places if vacancies remain after prioritised applicants have received theirs. We absolutely expect that to be the case; that is our experience. To be more specific, there are likely to be opportunities in specialties such as general practice, core psychiatry and internal medicine, which historically attract fewer applicants than the groups we are prioritising for 2026. We still need those people.

The noble Baroness, Lady Hollins, asked about possible unintended consequences for the UK’s international reputation. I believe our proud history of welcoming colleagues from across the world will continue and, as I have just said, international colleagues can, of course, continue to apply after prioritisation has taken place and there are vacancies.

On new specialty training posts, we have committed to creating 1,000 of these new posts over the next three years, focusing on specialties where there is greatest need. This is on top of creating 250 additional GP training places each year. The noble Earl, Lord Howe, raised questions about the availability of training places. Expansion will be matched with training capacity. We have not yet confirmed which specialties will receive the new posts, but we will ensure that expansion is targeted where patient demand and workforce pressures are the most acute.

I am glad that the noble Lord, Lord Stevens, made reference to the cancer plan. It was a bright spot in today’s news—I am sure all noble Lords will understand —and has not had the airtime it ought to have had, so I am most grateful to him. What I can tell the noble Lord about the creation of new specialty training posts is that there will be a focus on those with greatest need. We will set out steps in due course and I look forward to keeping the noble Lord informed. Non-prioritised graduates will also continue to have routes into NHS careers through locally employed doctor roles, gaining experience that can support future progression and prioritisation.

Let me turn to some of the specific points that were raised by noble Lords. The noble Lord, Lord Patel, asked about British citizens who have graduated from medical schools outside the UK and will not be in the priority group. I understand why these concerns are being raised but, going back to the core of the Bill, to prioritise them would undermine our aim to build UK-trained capacity while ensuring we do not provide any more foundation programme places than we need. To reiterate, UK-trained doctors are more likely to work in the NHS for longer, and retention is an issue that is much discussed in your Lordships’ House. They will be better equipped to deliver tailored healthcare that suits the UK’s population because of what they understand. Reference was made to the provision extending also to the Republic of Ireland graduates. Their inclusion ensures consistency in workforce planning across both jurisdictions, which reflects the long-standing protocol rights for movement and employment. That was something in which the noble Lord, Lord Clement-Jones, was particularly interested.

On specialty training places starting in 2026, British citizens will be prioritised, because that is one of the prioritised immigration statuses being used as a proxy to indicate someone who is likely to have significant experience of the NHS. Why? Because applications for posts starting in 2026 have already been made. Prioritisation is only at offer stage because shortlisting is under way, so it is a timing matter about implementation. From 2027, immigration status will no longer automatically determine priority, but we have the ability to set out in regulations the persons who will be prioritised based on criteria which indicate they are likely to have significant NHS experience, or based on their immigration status. As I said earlier, we will be engaging with our partners to work out how best to define that.

On the point made by a number of noble Lords, including the noble Earl, Lord Howe, and the noble Lords, Lord Clement-Jones and Lord Stevens, about graduates of overseas campuses, including Malta, which I will turn to presently, having heard the noble Baroness, Lady Gerada, the UK foundation programme applications for 2026 show that there are almost 300 applicants from these overseas campuses, of whom 152 are UK nationals. This is a substantial number and, if we were to do what is being asked—to prioritise graduates of UK overseas campuses—our estimation is that this could encourage universities to establish further international partnerships which would simply increase pressure still further. It also risks creating a loophole that would encourage new overseas partnerships to seek preferential access to the foundation programme across the UK. The noble Lord, Lord Clement-Jones, picked out Liechtenstein in particular, but, as the noble Baroness, Lady Coffey, referred to, we are talking about the EFTA countries, which include Liechtenstein, and they are prioritised simply because of existing international agreements that we are obliged to honour. However, in practice, not all these countries are going to have eligible applicants.

[Lord Clement-Jones (LD)]

I hope the Minister does not mind. Does the Minister think that the agreement with Malta should be honoured as well?

[Baroness Merron (Lab)]

I am coming on to this, but the agreement in respect of Malta that I would refer to is a reciprocal health agreement. It does not apply in this area. It is about the reciprocal provision of healthcare. I will turn to Malta, however, after saying a brief word about overseas campuses generally.

Just to re-emphasise, overseas campus students are not part of the numbers that the Government are setting. We do not have that control. If we prioritised those graduates as well, that would eat away at the very core of the Bill and the things people actually want us to do.

The noble Baroness, Lady Finlay, and the noble Lord, Lord Clement-Jones, wanted an indication of how this would all align with the international education strategy. The Bill does not conflict with this, because the international education strategy supports universities expanding internationally. It does not prevent UK universities delivering medical degrees overseas. That strategy stays in place.

I turn to Malta for the noble Baroness, Lady Gerada—