Medical Training (Prioritisation) Bill

Lord Clement-Jones Excerpts

2nd reading & Committee stage
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.

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[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—

Medical Training (Prioritisation) Bill

Lord Clement-Jones Excerpts

Committee stage
Thursday 12th February 2026 Lords Chamber

[Lord Darzi of Denham (Non-Afl)]

My Lords, many of you will know that I did my medical training in Ireland. In fact, I exercised some of my skills in this Chamber back in 2007. Irish medical education is excellent, and many of its graduates have gone on to distinguished careers in the NHS. I speak today to ensure we strike the right balance in this Bill, specifically by securing fair treatment for doctors who hold degrees approved by the Irish Medical Council.

As drafted, the Bill would exclude graduates of the Royal College of Surgeons in Ireland at its medical campus in Bahrain, for example—a campus that was established more than 20 years ago. Let me be clear about what that institution delivers: it has the same curriculum, the same examinations and the same quality assurance as Dublin, leading to a single national University of Ireland degree. Its programme and clinical training sites are also accredited under Irish regulatory oversight by the Irish Medical Council. I urge that, on Report, wording be introduced to bring graduates of this institution within the priority group. Such a clarification would sit squarely alongside the amendments from the noble Baroness, Lady Gerada, and the noble Lords, Lord Clement-Jones and Lord Mendelsohn. These seek to ensure that medical graduates of a UK university holding a GMC-approved degree and following the same curriculum and assessment, but studying outside the British Isles, are included in the priority group. It would also be consistent with the similar amendment tabled by the noble Lords, Lord Forbes and Lord Shipley, and the noble Baronesses, Lady Finlay and Lady Hollins.

I draw a further anomaly to your Lordships’ attention. The unamended Bill would place graduates of the Royal College of Surgeons in Ireland’s campus in Penang, Malaysia—a joint programme with University College Dublin—within this priority group. These students study an Irish Medical Council-accredited, GMC-recognised degree, completing half their education in Ireland and half in Malaysia. Yet the well-intentioned clarifying amendment of the noble Baroness, Lady Finlay, requiring at least 60% of the time to be spent in Ireland, would inadvertently exclude them.

[Lord Clement-Jones (LD)]

My Lords, it has been many years since I last spoke in a health debate. There is a sense of déjà vu in seeing the noble Earl, Lord Howe, on the Opposition Front Bench. It is also an absolute pleasure to hear from the noble Lord, Lord Darzi, and to hear the arguments he has made, which are very consistent with those we will be making later in the group of amendments from the noble Baroness, Lady Gerada.

I rise to speak to the amendments in this group, but particularly to Amendment 2, in the name of the noble Baroness, Lady Coffey, and the amendments tabled by the noble Lord, Lord Patel. On Amendment 2, while I understand the intent of the noble Baroness to protect the domestic workforce, we on these Benches cannot support the introduction of citizenship as a primary filter for medical training priority. To do so would undermine the central logic of this Bill, which is to protect the taxpayers’ investment in training, not to police the passport of the trainee. If a non-UK citizen comes to this country, trains in our medical school for five years, often paying significant international fees—my noble friend made an extremely good point about the value of that to our universities—they cross-subsidise our universities and then commit to the NHS. They are a UK medical graduate in every sense that matters to workforce planning. Their training is identical; their clinical exposure is identical. We on these Benches believe that to deprioritise them, based purely on nationality, would send a disastrous signal to the global talent pool that our NHS has always relied upon. It would also contradict the argument we will make later regarding the amendments from the noble Baroness, Lady Gerada, on the Queen Mary University of London Malta Campus: that it is the content and quality of the qualification that matters, not the geography or the nationality.

Regarding the amendments in the name of the noble Lord, Lord Patel, I sympathise with his desire to ensure that UK graduates are prioritised. That is, after all, the purpose of the Bill, and while we can argue about the definition of a UK graduate, we must be careful not to make the legislation so rigid that it removes any flexibility for the Secretary of State to address shortages in specific specialties, or where international talent is essential. Several noble Lords have mentioned that we have all received correspondence from doctors in hard-to-fill areas who warn that absolute exclusion could leave rotas empty. Prioritisation must not constitute a blockade.

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[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my role as a pro-chancellor of Cardiff University, and that I have until recently been an observer on the Medical Schools Council; I am still in touch with it.

This group of amendments seems incredibly important for our international reputation for fairness and consistency in what we commit to, but also in wanting excellence in our NHS. Therefore, there needs to be a sophisticated way of prioritising. One of those important areas is the contribution to the NHS, especially during Covid and major events, when some have gone way above what is normally expected and come back from holiday or maternity leave, or whatever, to deal with a major incident, while others have perhaps not always been quite so flexible.

We certainly have a crisis and must deal with it, so this is not in any way to say that we should not be doing this, but the timing is the worry. I will come on to the other degrees in the next group. Can the Minister explain whether the Oriel system itself is a block to incorporating the flexibility that these amendments ask for? There is a real worry among some that the Oriel system is a rate-limiting step, rather than being flexible enough to be rapidly reprogrammed appropriately to allow the intention of these amendments to be incorporated at great speed, and therefore redress the accusation of unfairness.

[Lord Clement-Jones (LD)]

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

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

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

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

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

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

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

[Baroness Merron (Lab)]

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

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

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

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

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It is worth acknowledging that a number of people have written to noble Lords, including to me, very much in support of the Bill and have urged us in our considerations to look at passing this in an unamended form. It is important to acknowledge their voices too.

[Lord Clement-Jones (LD)]

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

[Baroness Merron (Lab)]

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

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

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

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

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[Baroness Merron (Lab)]

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

[Lord Clement-Jones (LD)]

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

[Baroness Merron (Lab)]

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

[Lord Clement-Jones (LD)]

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

[Baroness Merron (Lab)]

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

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

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

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

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

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

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[Lord Clement-Jones (LD)]

My Lords, I strongly support Amendments 15, 16 and 19, tabled by the noble Baroness, Lady Gerada, which I have signed, and which she spoke to so convincingly. These Benches also support Amendment 17 in the name of the noble Lord, Lord Forbes, and signed by my noble friend Lord Shipley, and Amendment 20 in the name of the noble Earl, Lord Howe.

As I said at Second Reading, I am the former chair of the council of Queen Mary University of London and now, for my sins, an honorary professor. Amendments 15, 16 and 19 seek to correct a category error in the Bill: namely, the classification of students holding a UK primary medical qualification from a UK public university as “international”, solely because their classroom is in Malta. I am sure the noble Lord, Lord Forbes, will say the same in respect of Malaysia. The Minister has argued that these students lack “clinical familiarity” with the NHS, but that does not withstand scrutiny. These students follow the exact same curriculum as their peers in London, as the noble Baroness said.

The Bill prioritises EEA nations, because it seems that our trade deal requires us to recognise “comparable” qualifications. It is legally incoherent to accept a “comparable” qualification from Liechtenstein while rejecting an “identical” and “affiliated” qualification from Malta. We are treating a formal UK affiliate worse than a trade partner. These students sit the UK medical licensing assessment and they are taught by UK-trained consultants. As I said at Second Reading, it is a manifest absurdity that, under this Bill, a graduate from Liechtenstein with no UK degree and no UK training is prioritised over a Queen Mary student who holds a UK degree and is specifically prepared for our health service.

I strongly endorse the point made by the noble Baroness, Lady Gerada, regarding our free trade agreements. We are in an absurd position whereby a treaty obligation forces us to prioritise these “comparable” qualifications. This is not workforce planning; it is a diplomatic and regulatory own goal. As the noble Baroness explained, Amendment 19 offers a simple solution by adding Malta to the priority list. This honours the mutual recognition agreement held between the UK and Malta since 2009—an agreement the Department of Health explicitly renewed in 2024.

Amendments 15, 16 and 17 offer a broader solution based on the qualification. If a student holds a UK degree from a UK-registered institution and passes identical UK assessments, they should be treated as a UK graduate. The Minister fears displacement of domestic talent, yet the majority of these Maltese trainees are contractually obliged to return to Malta after their training. They are what can be described as a circulatory workforce: one that supports the NHS during their training years, without permanently blocking the consultant pipeline. They are the ideal workforce partner. As stated by the noble Baroness, Lady Gerada, Maltese surgeons have been licensed by our royal colleges since the 1830s. This is not a new or risky pipeline; it is a two-century year-old bond that the Bill carelessly severs.

Furthermore, we support Amendment 20 in the name of the noble Earl, Lord Howe, regarding people who qualify in the British Islands but who have trained abroad. We are all on the same page in advocating for these well-qualified students, who should be eligible to have the same priority in obtaining training jobs as those currently set out in the Bill. We have received heartbreaking correspondence from British nationals studying in eastern Europe, often because of the cap on places here, who intend to return to the NHS. One correspondent highlighted that we allow British dentists to return without these barriers. Why do we treat our future doctors differently?

[Lord Winston (Lab)]

My Lords, it is an honour to support the noble Baroness, Lady Gerada. The best surgical training I had was with a Maltese surgeon, who was absolutely fantastic and taught me lessons I have never forgotten. One has to see that that cross-fertilisation happens across the NHS very often.

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[Baroness Merron (Lab)]

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

[Lord Clement-Jones (LD)]

My Lords—

[Baroness Merron (Lab)]

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

[Lord Clement-Jones (LD)]

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

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[Lord Stevens of Birmingham (CB)]

My Lords, to help the Committee to assess the need for this further report that the noble Lord, Lord Kamall, just set out, it would be helpful if we could hear from the Minister when the Government will produce their replacement long-term workforce plan for the 2023 edition, which itself was deemed to be long term but ended up having a half-life of less than two years. How imminent is that and will it deal with the sorts of points that the noble Lord, Lord Kamall, rightly brings to our attention? When will we see the follow-on to the excellent Medical Training Review: Phase 1 Diagnostic Report, authored by the Chief Medical Officer and the previous National Medical Director of NHS England, published in October, which sets out these issues extremely well? The clue is in the title: it is the diagnosis. But when do we get the prescription? When does the treatment begin?

In a sense, the problem that we are dealing with through the Bill—again, as the noble Lord, Lord Kamall, just set out for us—owes its antecedents to the disconnect between the provision of NHS services and the ability to make smart, long-term workforce decisions. Unfortunately, for the period 2012 to 2022, those decisions on medical training were outwith the NHS and in effect were being controlled by the Treasury, which was constantly saying no to Health Ministers who were at the time trying to bring forward constructive solutions. Indeed, it was only when a former Secretary of State for Health became Chancellor that the situation was unblocked and we got the medical school expansion. Perhaps that is an inspiring example for the current Health Secretary—I do not know; perhaps he aspires higher. The fact is that we need that whole-government engagement on these kinds of questions to bring coherence and deal with these problems at root. Therefore, in responding to the noble Lord, Lord Kamall, any light that the Minister can shed on when precisely we will have line of sight to these sorts of questions would be, I think, of great benefit to the Committee.

[Lord Clement-Jones (LD)]

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

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

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

[Baroness Merron (Lab)]

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

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

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

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[Lord Kamall (Con)]

My Lords, in the absence of my noble friend Lady Coffey, who is not in her place, I hope it is acceptable if I move Amendment 26 and speak to Amendment 27. Both amendments seek to bring forward the commencement of the Bill rather than leaving its provisions to be implemented by regulations.

The Government say they need the Bill to pass as soon as possible but then refuse to commit to a date for commencement. Given that there is no date for implementation, noble Lords will rightly ask: what is the hurry with this Bill? There is a fundamental constitutional point here. Emergency legislation should be avoided as far as possible and, where it is necessary, it should be delivered urgently. In this case, we have been asked to fast-track the Bill without there being any apparent urgency to implement it.

The Minister sought to partly address this concern at Second Reading. Could she please explain exactly why the training allocation system will be unable to cope with the changed prioritisation arrangements introduced by the Bill if the BMA continues with its strike action during the coming months? What factors would frustrate the rollout? Would it be systems? Would it be the availability of officials? Would it be the ability of trusts and institutions to engage with the Department of Health and Social Care in a timely way? Or are there other reasons that noble Lords should be aware of? I hope this gives the Minister the opportunity to explain some of those reasons.

While we agree with the principle of giving UK graduates priority, and many noble Lords across the Committee have said this, we should take the time to have a proper debate on whether any other students should also be prioritised and in what order. We should have a debate to consider and debate questions such as: while qualifications may be similar, whether graduates from overseas branches of UK universities really do have similar experience to those who studied in the UK and worked in the NHS, or whether the country in which they studied has a patient profile similar to the UK, and whether in fact any of these distinctions are actually important. Another possible question that we should be looking at is whether historical prioritisation is still valid for today’s world, and whether it is worth while or too much effort to revisit some international agreements.

Instead of this much more considered debate, the Government tell us that they need to get the Bill on the statute book as soon as possible, but they are not forthcoming—perhaps not transparent—when it comes to implementation. Given this lack of clarity, I must say that there is a suspicion that the timing of the Bill and the Government’s rush to get it on to the statute book may appear to be not entirely unconnected with negotiations with the BMA resident doctors.

Whatever our politics and whichever Bench we sit on, legislation should be about making the lives of British people better. Although this Bill has the potential to help British citizens who are graduates of UK medical schools, the lack of transparency on implementation gives the impression that this legislation is more about giving the Secretary of State a negotiating chip in discussions with the BMA. I gently suggest that this is not a good enough reason for rushing such legislation, which is why my noble friend and I tabled these amendments. I look forward to hearing the Minister’s response.

[Lord Clement-Jones (LD)]

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

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

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

[Baroness Merron (Lab)]

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

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

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

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

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

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

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

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

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