Medical Training (Prioritisation) Bill

This has created intense competition, uncertainty and frustration for many at the start of their careers. At the same time our NHS has become increasingly reliant on international recruitment. This Government deeply value the contribution made by doctors from all around the world, many of whom have played and continue to play a vital role in patient care, and nothing in in this Bill diminishes that contribution. However, it is neither sustainable nor ethically comfortable for the UK to depend so heavily on recruiting doctors from countries that themselves face serious workforce challenges while a growing number of UK-trained doctors struggle to access training posts. Competition for medical staff has never been fiercer. The World Health Organization estimates a shortfall of 11 million health workers by 2030. Shoring up our own workforce will limit our exposure to such global pressures without depriving other countries of their homegrown talent, and this Bill seeks to address that imbalance.

Let me turn to the Bill itself. The Medical Training (Prioritisation) Bill gives effect to the Government’s commitment to place UK-trained doctors and other defined priority groups at the front of the queue for medical training posts. It does so while continuing to allow internationally trained doctors to apply for and contribute to the NHS. Let me emphasise that the Bill is about prioritisation. It is not about excluding people, but it is unashamedly about prioritisation. For the UK foundation programme, the Bill requires that places are allocated to UK medical graduates and those in priority groups before being offered to other eligible applicants. For specialty training, it introduces prioritisation initially at the offer stage for 2026 and from 2027 at both the short-listing and offer stages. That will significantly reduce the level of competition being faced by UK-trained applicants, and it will provide greater certainty at a critical point in their career.

Internationally trained doctors with significant NHS experience will continue to be prioritised for specialty training, recognising the service that they have given. This year, immigration status will be used as a practical proxy for NHS experience in order to allow prioritisation to begin swiftly. For following years, we have taken powers in regulations to enable us to refine this approach in consultation with key partners. I have been asked by noble Lords what this means for those with refugee status. This status is not a stand-alone priority group, although refugees will be prioritised for specialty training in 2026 if they fall within another priority category, such as holding indefinite leave to remain or having completed the foundation programme. Refugees who do not fall within a prioritised group may still apply for specialty training posts and the Bill will not change their eligibility to apply for locally employed doctors’ roles.

I am seeking to address up front some of the concerns that will quite rightly be raised in the course of the debate. One of those is a concern I have heard about why British citizens who have graduated from medical schools outside the UK will not be in the priority group, including some doctors who would be eligible only for provisional GMC registration. I understand the reasons why this is being raised, and I have heard how some would prefer all British citizens, in a blanket sense, to be prioritised. The problem with that is that it would undermine the very intent of the legislation, which is to enable effective workforce planning and the development of our future medical workforce.

The principle is to create a sustainable domestic workforce. It is not about where a student is born; it is about where they are trained, and the fact is that UK-trained doctors are more likely to work in the NHS for longer. In addition, the Government set UK medical school places based on future health system needs. Student intakes and graduate outputs of overseas medical schools are not included in our domestic workforce planning. If we prioritised British citizens in a blanket sense for foundation training places regardless of where they studied, that would undermine our key aim to build UK-trained capacity while ensuring that we do not provide more foundation programme places than we need. I reiterate that this Bill is about prioritisation and not exclusion. All eligible applicants will still be able to apply and will be offered places if vacancies remain after prioritised applicants have received offers, which we expect to be the case on the basis of our long experience.

I have also listened to colleagues expressing concerns around the treatment of applicants graduating in Malta. The UK’s long-standing partnership with Malta on healthcare is valued and will continue. Doctors training in Malta will still be able to come to the UK to gain NHS experience to support their training, for example through fellowship schemes. These arrangements are not affected by the Bill. However, as I stated earlier, for recruitment to specialty training places in the UK, the Government assess that it is important to prioritise to ensure a sustainable workforce that meets health needs.

I turn to the matter of public health specialists, who are particularly identified in the Bill. Public health is a unique medical specialty that draws applicants from medicine and other professional backgrounds who all undergo the same rigorous training. All public health specialists, regardless of professional background, complete the same rigorous medical specialty training programme and are subject to the same high professional standards. The Bill excludes from prioritisation any specialty programmes wholly in the field of public health, as it would undermine the multidisciplinary public health specialist workforce. The Government will monitor the impact on the public health specialist training programme, which currently accepts very small numbers of international medical graduates.

I am aware that there are concerns relating to terms and conditions and mobility for some specialists. We have set out the actions we will take to make the NHS a better and great employer. However, a focus on the NHS alone will not support the whole health workforce, as many public health specialists work outside the NHS with differing employment arrangements. But we are committed to working with the BMA, employers and professional bodies to make public health careers more attractive.

On timing, the Bill includes provisions to allow prioritisation to apply to the current application cycle, with posts commencing this August. That requires Royal Assent by 5 March. It is therefore important to seek timely passage for this Bill to avoid disruption for trainees who need sufficient time to find somewhere to live, sort out childcare and arrange any other aspects of their lives before their posts start, and for NHS trusts that are planning the front-line services. I hear the concerns of some noble Lords about the impact on those applying in the current application cycle, particularly where applicants report that they did not know how prioritisation might affect them. As I said earlier, these concerns are understandable, and they have been carefully considered. However, delaying action would only prolong the current problem by further entrenching the existing imbalance in training competition and it would weaken our ability to plan a sustainable workforce.

The commencement provisions provide necessary flexibility, ensuring that implementation can be carried out in an orderly and workable way, taking account of operational realities. On that point, there is a material consideration, which I am sure will be raised and understandably so, about whether it is possible to proceed if strike action is ongoing. The disruption strikes cause, and the pressure they put on resources, would undoubtedly make it a lot harder operationally to deliver the important measures in this Bill. It is our intention to commence as soon as we can, subject to the Bill’s passage through Parliament, but it is vital to have a safeguard to ensure that the systems planning and operational capacity required for successful implementation are firmly in place.

I conclude by saying that the Bill will not solve every workforce challenge, but it is a very important step towards a more coherent, ethical and sustainable approach to medical training and workforce planning: something that has been called for for many years.

It is estimated that four resident doctors will be competing for every specialty training post in 2026. With the delivery of this Bill, this number can reduce to two resident doctors per place. British taxpayers spend £4 billion training medics every single year. It will be by better aligning public investment, training capacity and long-term service needs that the Bill will give UK-trained doctors a fair chance to serve in the health service they train to support, and to do so in a way that benefits us, the public, across the country. I beg to move.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

There is a wider significance, as has already been alluded to. The Government’s international education strategy states the importance of universities seeking global opportunities, such as developing branch campuses. To avoid opening the floodgates, do the Government envisage capping UK healthcare degrees delivered offshore? This year, there were over 25,500 UK applicants for just over 10,000 UK medical school places. Selection at 18 years old is difficult. Each year, having invested in years of their schooling, we reject highly capable home applicants who would be excellent doctors. Many of them choose to study abroad, determined to return to work in the NHS. Should they be required to pass the UK medical licensing assessment, so that UK citizens studying in the EU after school are not left stranded?

For postgraduate trainees who applied through the previous recruitment framework and are currently working in the NHS, with several years’ experience, would recognising service from Covid onwards be considered in the eligibility in the current round? Where is the expansion of specialty training posts and academic posts for some of these graduates?

Lastly, all UK health expertise benefits international development. Many countries lack their own training expertise, and historically the UK has trained specialists to go back to develop services in their home countries. This altruism improves global health and creates opportunities for the NHS, universities and pharmaceutical and tech companies to gain international contracts. Without routes for overseas doctors to train here, our international partners will look elsewhere.

The Bill apparently aims to secure a reliable supply of doctors for the future, ensuring that those with a UK medical link are more likely to progress to current consultant roles and continue their careers in the NHS. Will international medical student places here be further limited? Otherwise, the Bill could mean that UK students forced to train overseas through limited home student places will not be prioritised, whereas international medical students at UK medical schools will. In passing the Bill with speed, we must avoid penalising our own graduates, jeopardising international partnerships, or appearing hostile to international excellence or unreliable by suddenly changing the rules. Will the Minister consider widening the priority group or adding other tiers to recognise the importance of medical graduates?

I believe that I am the first firefighter in history ever to sit in your Lordships’ House. Serving for half my life in, and eventually commanding, the brigade, one of the world’s largest and busiest emergency services, and one of this country’s last great remaining working-class institutions, was the most enormous privilege. It gave me an education in life and membership of a club that you cannot pay to be part of. I hope that I can therefore give firefighters and their families some voice in my contributions here.

I would also like to speak to the role boxing has had in my life, first as a competitive fighter for many years, then as a coach, still now as a club chair and—unbelievably to me, as that young kid walking into a boxing club in south London all those years ago—sitting on the national board that supports our great British Olympic team. The support and the safe space that boxing clubs provide young people, particularly in some of the poorest places in this country, must not be underestimated. Boxing gave me confidence, fitness, discipline, purpose and a structure.

At a time when the politics of division seem to be painting a picture of Britain, characterising Englishness in particular in a way that, as a proud Englishman, I simply do not recognise, boxing clubs are still very much beacons of openness, tolerance and unity. I have fought and trained in clubs and halls the length and breadth of these islands, and I can say that without exception my experience is that in boxing your faith, race, background and nationality are irrelevant, as what is shared in a boxing club is a common respect for anyone who has had the courage to take that first step into the squared circle and face their own fears. In that sense, the sport and its spaces both epitomise and set the standard for true British values.

In respect of today’s debate, addressing the quality and accessibility of the training we give our doctors, I believe that my experiences bear some relevance. Having responded alongside so many medical colleagues over the years, I know that, like being a firefighter or a soldier, a career in medicine is profoundly rewarding and has the greatest benefit to both the individual and their community. It seems clear to me that, by ensuring that our graduates are given priority access to the best available training, we will help to sustain and protect our health service while also providing important opportunities to young British people of all backgrounds to make a difference.

Lastly, and perhaps most personally to me, in my working life, both as a soldier and as a firefighter, I have been repeatedly and directly involved in the tragedies that befall ordinary people when politics, institutions and systems simply fail to protect them, often with catastrophic loss of life. I have been a witness in those moments, standing on streets from Portadown to inner London—witness to the unbelievable heroism of my fellow soldiers and firefighters in their actions in responding to those failures. Some of them made the ultimate sacrifice, whether then or in later years. They are never very far from my mind, and I must pay tribute to them today.

Equally, I recognise the resilience, courage and decency of survivors and families, particularly those I saw suffer so much following the Grenfell Tower fire. In their continued drive for justice and a safer built environment for everyone, they provide me with a lesson in dignity, resolve and clear purpose every time I meet them. I hope I might give them a voice in your Lordships’ House too.

It is in that context that I understand my privilege and responsibility in the House, as what gets said and done here and in the other place can, for better or worse, have the most profound consequences for our fellow citizens. With that in mind, I hope I can contribute with some value, give voice to those I met on the way and avoid adding, in the powerful words of Bishop James Jones following the horror of the Hillsborough disaster, to

“‘the patronising disposition of unaccountable power”.

I thank noble Lords again so much for their warm welcome and this incredible opportunity.

To give an example of what I mean, I ask my noble friend Lady Merron: how do His Majesty’s Government intend to implement the Council of Europe Committee of Ministers’ recent recommendation on equal rights for intersex persons? I declare an interest as a person born with hypospadias, which is an intersex condition. Implementing this recommendation could require significant changes in the academic training of our doctors and surgeons, which surely need to be monitored. For example, it includes: prohibiting non-consensual medical interventions on intersex children, ensuring such procedures are postponed until the individual can provide informed consent; strengthening anti-discrimination measures and ensuring access to justice, including protection from hate speech and crime; addressing inequalities in healthcare, education, employment and sports, including the need for inclusive policies and safe environments for children; ensuring that family laws, including those relating to legal recognition and parentage, are accessible to intersex people without discrimination; and calling on member states to take concrete legal and non-legal measures to uphold the dignity and rights of intersex people.

Some of these recommendations have already been legislated for in the UK, most notably the law against female genital mutilation. But the recommendation is seen by many people as a landmark, as it shifts the focus from medicalising what are often seen as disorders towards protecting fundamental human rights and ensuring equal participation of intersex people in society. It seems important that these things are fed into the medical curriculum, and I look forward to hearing the Minister’s response to that.

I appreciate that this is a complex issue and that this Bill may not be the most appropriate place to introduce such changes but, when she comes to respond, I hope my noble friend will recognise that my underlying point is about how the content of the courses provided within the foundation programme and medical specialty training in the UK can take account of policy initiatives of this type. I would of course be happy to meet with her to discuss how best to take the issue forward.

Clause 4 refers to a “UK medical graduate”, and says:

“‘UK medical graduate’ means a person who holds a primary United Kingdom qualification”.

It does not say a “UK citizen” who is qualified. Does that mean that an overseas student attending medical courses in our universities, who is therefore a graduate of our universities, qualifies or not? I might be wrong in my interpretation. The clause continues:

“but does not include a person”

with

“a majority of their … training for that qualification outside the British Islands”.

Some of our universities run joint courses. I am a professor emeritus of the University of Dundee, which, for instance, runs one course for Malaysian students. They do part of their training in Malaysia and finish their clinical training in the UK, at Dundee. The Bill refers to a majority of their training but, in a five-year course, if the overseas student does three years in a UK university, does that count as a majority of their training in the United Kingdom?

I am glad that the Minister alluded to refugee status and was pleased to hear what she said. That was to be one of my points, because I have had representation from Ukrainian refugees who are already working in the NHS, and whose status would otherwise have been removed.

Clause 4(5) says:

“‘primary medical qualification’ means a qualification that is treated by the General Medical Council as equivalent to a primary United Kingdom qualification within the meaning of the Medical Act”.

There are lots of institutions which the GMC recognises as equivalent, but we do not regard their graduates as UK graduates, although they do the same curriculum. Universities such as Newcastle have already been mentioned several times. They have been encouraged by the education department to open campuses, as other universities have been, and to provide the same curriculum. There are then graduates of Queen Mary University, Newcastle University or Dundee University. Their status is not quite clear.

I am concerned about these issues and hope that we will be able to have greater clarification. But I accept that, in principle, prioritising postgraduate medical training for UK graduates is correct.

There is the transitional 2026 concern and then, relatedly, there is the question of whether, by just changing the prioritisation, the Government actually have a game plan to deal with the more fundamental, underlying problem of the bottlenecks. This piece of legislation by itself does not widen the bottlenecks, it just changes who will occupy them. As the noble Earl, Lord Howe, I think, asked, it would be very useful to know, of the 1,000 additional specialty training places over three years promised in the 10-year plan, or the 4,000 put on the table in December as part of the Government’s negotiation with the BMA—of which 1,000 extra were to be in place for the coming year—what is their current assumption about the expansion in specialty training that will go alongside this reprioritisation for 2026 and 2027?

Today, we have seen the publication of the cancer plan, which, quite rightly, says that the Government

“will work with the Royal Colleges to encourage resident doctors and internal medicine trainees to specialise in clinical and medical oncology”—

where there are significant shortages—and will prioritise

“training places in trusts … where vacancy rates are higher and performance is lower”.

Can the Minister tell us whether the Government will give effect to that commitment in the cancer plan with the 2026 and 2027 increases in specialty training places, which are clearly required?

To circle back to a point that the Minister made—and, indeed, the Health and Social Care Secretary made at Second Reading in the Commons on 27 January—the Government’s estimate appears to be that even with this tighter, or reshaped, prioritisation, there will still be a ratio of two applicants to every place for specialty training. Just stand back a moment—that means we will be turning away half the doctors who would be able to fill those places. Are the Government sure that they are going pedal to the metal on the expansion in specialty training to reduce that oversubscription rate?

How does that connect with the upcoming rebadged, or refreshed, long-term workforce plan, given that the undergraduate doctors who start their training this year will be, in practice, coming out to deliver clinical care as consultants from 2040 and training their successors up to 2070? We really do need a long-term plan here, rather than the constant chopping and changing that, sadly, we have seen.

Finally, I completely endorse the comments about Malta. Three collective institutions have been awarded the George Cross—Malta and the NHS are two of them. We should sustain those relationships. The idea that we have less in common with the Maltese than with the good people of Liechtenstein—I have just had a quick look and Liechtenstein has one 35-bed hospital and a per capita GDP more than three times that of the UK—misses the point. We have to see the wood for the trees; the Department of Health and Social Care needs to raise its gaze and value these historic relationships that are so important for us.