Medical Training (Prioritisation) Bill

Committee

Clause 1: UK Foundation Programme

Amendment 1

1: Clause 1, page 1, line 4, after “must” insert “first” Member’s explanatory statement This amendment, and others in the name of Lord Patel, seeks to ensure that UK medical graduates are prioritised above other categories of eligible applicants.

My Lords, my name is also attached to Amendments 3, 6, 7, 8, 12, 13 and 14, which are consequential, so I will not speak to them. This may be the briefest of introductions to any amendment.

My amendment tries to prioritise—which is the main theme of the Bill—UK medical graduates for training in UK programmes. The Bill’s Long Title says it is to:

“Make provision about the prioritisation of graduates from medical schools in the United Kingdom and certain other persons for places on medical training programmes”.

In Clause 1, this therefore also includes

“persons in the priority group”.

In Clause 2, it includes person not only in the priority group but also, in subsection (2), persons who are

“a British citizen … a Commonwealth citizen who has the right of abode in the United Kingdom … an Irish citizen who does not require leave to enter or remain in the United Kingdom … a person with indefinite leave to enter or remain … a person who has leave to enter or remain in the United Kingdom”

and so on. Similarly, Clauses 3 and 4 describe the priority group as including not only UK medical school graduates but many others, including those from countries with which the UK has made a trade deal.

All those priority groups will be able to apply for the same jobs as UK medical graduates. Add to that—several amendments on this are coming later—that the graduates of UK universities that have overseas campuses will also be included in the priority group. They are not all in the amendments today, but if these amendments are accepted, there are other universities not listed which have overseas campuses, such as the two I know—Dundee, for instance—although I did not table an amendment on that.

My amendment is because of the enormous number of emails that we have had, both from UK graduates and overseas graduates who cannot find jobs. I know there are subsequent amendments coming later about those international graduates who are now stuck in a bottleneck for this year, but that is a separate issue. My amendment does not refer to that; it refers to UK medical graduates.

My Lords, I have tabled Amendment 2. The clerks suggested changing the wording to what is now there. It is a probing amendment, and like those of the noble Lord, Lord Patel, it could be applied to other clauses as well. It is about the principle. My strong view is that we have opened up medical schools and made more placements because we want to make sure that we have an ongoing workforce. I am delighted to see the noble Lord, Lord Darzi, in his place. He will have done work not only for Health Secretary Wes Streeting recently but previously in making sure that we have a strong workforce pipeline.

I am conscious that many medical schools, by way of survival, by way of diversity, have opened up a number of places. Admittedly, this is still quite small compared with the number of UK citizens going to medical school. However, as the noble Lord, Lord Patel, said, we have a curious definition in this legislation—that a UK medical graduate is simply somebody who went to a UK medical school. I do not think that is what the public would think that this is about. From a lot of the emails, I do not think that it is what a lot of doctors appreciate either—although I appreciate that it is the position of the BMA, which does not want to differentiate in that regard.

We have young people taking on debt by investing in their own education and several billion pounds being put in by the UK Government, by the UK taxpayer, to have this pipeline. Therefore, it is vital to have what my amendment seeks—a set prioritisation in this legislation and not, as the Minister said the other day, a “just one group and then no more” kind of prioritisation. It is vital that UK citizens are given priority.

It is important to look at some of the analysis. It is not the case that all training posts could be filled by UK citizens who have trained to be doctors—far from it. We would not have GPs coming through. According to the 2024 analysis, only about half of the GPs going on the ST1 or CT1 were from UK medical schools. There is a whole series of issues, and we are seeing this in different elements including psychiatry and paediatrics—very few UK medical students, it seems, want to do paediatrics. I could go on with the series, but the point is clear: this is not about excluding people from the rest of the world coming to work in this country or to fill key roles in the NHS; it is about ensuring that our investment is prioritised on UK citizens.

My Lords, I am delighted to have the opportunity to support my noble friend in her excellent amendment. Broadly speaking, this is a very welcome Bill. I congratulate the Government on bringing it forward to address what is becoming an acute issue, but it could be better. My remarks fall into two separate parts: there is the philosophical issue and there are the practical, evidence-based matters, which I will elucidate in the course of my remarks.

First, it has to be said that British taxpayers fund medical education through universities and the NHS, and we should be thinking much more about the value for money that those taxpayers receive. Prioritising British citizens would ensure that the investment benefits the domestic healthcare system and would, I think, reduce the risk of brain drain, where trained doctors emigrate after completing training. Training costs are substantial—estimated at £200,000 to £500,000 per doctor—and British citizens would be more likely to remain and practise in the UK long term. There is a case that they perhaps provide better value for public investment in medical education.

The wider philosophical issue, as alluded to by the Nuffield Trust, is around the fact that, in recruiting international medical graduates, the NHS has a negative impact on the domestic healthcare sector and staffing shortages in many countries abroad, particularly in Africa and Asia and poorer countries generally. That point has been made over many years. There were issues too about cultural familiarity, language proficiency, better understanding of local healthcare practices and patient expectations, and easier integration into multidisciplinary medical teams.

Specialty training, competition ratios and bottlenecks have reached breaking point. Preliminary information for the 2025 specialty training application cycle is concerning. This year, there are over 33,000 applicants for just under 13,000 training posts. This means that up to 20,000 doctors will be left out of specialty training this August. Even if you are not directly affected, that is a public health and public policy issue.

Competition ratios have particularly worsened since 2019. Prior to 2019, the UK utilised a round 1/round 2 system for applications. Round 1 was open to those from the UK and the EU, as well as those with settled status in the UK, and round 2 was open to those who did not meet these requirements. As we know, the previous Government removed medicine from the shortage occupation list in 2019 within the previous resident labour market test rules. This meant employers could sponsor visas without having to prove that no suitable settled worker was available for the role. As a result, the round 1/round 2 system was effectively abolished. This meant doctors from anywhere in the world could now apply directly to specialty training in the UK without ever having worked in the UK.

The abolition of the RLMT and its replacement with a flat global entry to specialty training has led to an exponential increase in competition ratios and, if left unchecked, will directly drive unemployment of UK medical school graduates unable to emigrate from the UK. The figures show that the number of IMGs—international medical graduates—who are applying in the application cycles has risen in these years. In 2023, it was 10,402, but last year, it was 20,803. UK graduates have not gone up by the same amount; they have gone up from 9,273 to 12,305, the comparison being a 16% increase in UK graduates compared to a 40% increase for international medical graduates. UK graduates have remained relatively stable over the past decade. While there has been an increase in UK graduates as a result of increased medical school places over the past two years, that has been outstripped by exponential growth in the number of IMGs joining the workforce since medicine was added to the shortage occupation list in 2019.

The Government are right to address this issue, but, frankly, I am not sure that they are doing enough. This year, there were approximately two IMG applicants for every UKG applicant, and that includes IMGs who are applying from abroad having never worked in the UK. According to current projections, in 2026 we may well see over 40,000 applications for fewer than 13,000 posts. Almost every other country in the world has some form of prioritisation for local graduates. That includes comparable OECD countries such as Australia, Canada and France.

All of the above marks a disaster for workforce planning. Unless acted upon now, there will be knock-on effects to the consultant and GP workforces in years to come. Even if training posts were to be doubled tomorrow, there would not be enough for the number of applicants this year. Unless this is addressed immediately, here in primary legislation, there is likely to be mass unemployment of those unsuccessful training applicants this year—up to 20,000, as I have previously said, and these are some of the most driven, well-qualified, well-educated people in our country, whose talents will possibly be wasted and dissipated over time.

That leaves UK graduates in a unique position globally, due to having no recruitment programme that will prioritise them. The UK graduates worst affected, if action is not taken, will be those who are limited in their ability to emigrate—those with young families, disabilities, caring responsibilities or low heritage family wealth. We cannot sustain a policy of uncontrolled and exponential growth of specialty training applicants every year. That is why I am pleased to support the amendment in the name of my noble friend.

My Lords, I want to speak briefly to the amendments proposed by the noble Lord, Lord Patel, and the noble Baroness, Lady Coffey. The noble Lord, Lord Patel, mentioned that 7% of undergraduates who take medical degrees in the UK are from overseas. I briefly mentioned last week my conversations with the head of admissions at a Russell group medical school. An important point that I did not have time to raise then, but is appropriate to raise now, is the significant amount of money that that 7% contribute not only to that medical school but in additional payments to the local trust.

I wanted to make your Lordships’ House aware of that, but I also want the Minister to talk about the consequences if we accepted the amendment of the noble Baroness, Lady Coffey, and just had British citizens as opposed to the British graduates the noble Lord Patel talked about. What impact would there be? We have held our tuition fees static for a while in this country, while those overseas students have been paying a phenomenal amount. I am just worried that we might throw the baby out with the bath water. The unintended consequence of making some of those courses unviable is a serious concern, and I think it appropriate to raise it at this point.

My Lords, I too am a little bit concerned about unintended consequences. It is a real pleasure to see my noble friend Lord Darzi in his place, because I hope he will have comments on this issue.

I trained as a clinical academic. Indeed, we know that clinical academics have had a unique value to the health service. They work part-time in the health service with a reduced salary and do research at the same time. I am very concerned that many of the clinical academics we have had at Imperial College, for example, have been from overseas. They were medically qualified elsewhere but had not yet been in Britain and were still junior doctors, in a sense. I am really concerned that there are many such people who come to Britain, do a postdoctoral degree such as a PhD and, in the meantime, keep their medical skills flowing, as I did myself. I was seven years in this situation with the Wellcome Trust. I remember it very well. I was overseas but at least knew that I could come back to Britain. But I was a British subject—that was easy.

There are so many of these people. To give just one example, Professor Jan Brosens at Warwick University is undoubtedly one of the key people who have contributed massively to female health, particularly on implantation of the ovum and in his magnificent work on endometriosis. He came as a junior doctor from Belgium, from Leuven University, to what was then Hammersmith Hospital, which is now, of course, Imperial College. Now, he is a very distinguished professor at Warwick University with a very large team. His recruitment made a very big difference to the whole field. His is not an isolated example; there are many such people I can think of. I hope the noble Baroness can suggest some way of dealing with this problem of unusually good graduates from elsewhere, who may not be British citizens, perhaps, in the current priorities, but who would really be deserving of serious consideration for certain specialty jobs. Not to do that would be a great loss to the health service.

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.

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.