Moved by Lord Grimstone of Boscobel
2: Clause 1, page 1, line 4, after “or (3)” insert “and any other specified condition”Member’s explanatory statementThis amendment would enable regulations to specify additional conditions that must be met by an individual in order to be treated as if they have a specified UK qualification or specified UK experience.
My Lords, I rise to move Amendment 2 and to speak to Amendments 3, 6 and 10 in this group.
I have set out the need for a framework for the recognition of individuals with overseas qualifications and experience that focuses on addressing unmet demand for professional services in the UK. Clause 1 brings in an important part of that framework. It means that regulations can be made which require regulators to have a route in place to determine whether to recognise overseas-qualified professionals from around the world. Where such regulations are made under this clause as amended, they would require a regulator to make a determination as to whether an individual has substantially the same knowledge and skills to substantially the same standard as the UK qualification or experience. These regulations would not and cannot alter the standards required to practise professions in the UK, and UK regulators would still decide who can practise here. Regulations would be made by an appropriate national authority, meaning the Secretary of State, the Lord Chancellor, or the devolved Administrations where within devolved competence. I reassure noble Lords that, where Clause 1 is not exercised—it can be exercised only when particular conditions are met—regulators will be free to continue recognising qualifications from overseas in line with their existing powers and any reciprocal agreements in place.
On Second Reading, several noble Lords spoke to the concerns of healthcare regulators. They highlighted that Clause 1, as it appears in the Bill, could limit the ability of regulators to assess knowledge and skills as they see fit. I committed at Second Reading to table an amendment to Clause 1 to ensure that regulators can assess knowledge and skills as they consider most appropriate. I assure noble Lords that the Government take the views of regulators very seriously. This brings me to the detail of Amendments 2, 3, 6 and 10 in my name.
First, the amendments recognise that, where Clause 1 regulations are used in relation to a given profession, additional criteria may need to be satisfied before an individual may become eligible to practise—for example, criminal record checks to ensure public protection. As raised by a number of noble Lords at Second Reading, this could also be used to ensure overseas-qualified professionals have suitable levels of English language proficiency in appropriate cases—something that, where appropriate, could also be addressed as a compensatory measure under Clause 1(3)(b)(ii). The amendment to Clause 1(1) and the addition of new subsection (3A) would allow these additional regulatory criteria to be specified in regulations made under Clause 1. These criteria would need to be met before an individual with an overseas qualification or experience is treated as having a UK qualification or experience.
Secondly, there are of course a variety of ways that regulators may wish to assess the knowledge and skills of an overseas-qualified applicant. These might include an assessment of their qualifications or a test of competence. The amendments to subsections (2) and (3) of Clause 1 and the addition of new subsection (3A) provide reassurance that, when the power in Clause 1 is used, regulators can assess an applicant’s knowledge and skills in whatever way they consider appropriate. I hope, in my first step in assuaging the concerns of noble Lords, that that is the start of the practice.
I have been clear since introducing the Bill that we must protect regulators’ autonomy. This includes autonomy over decisions about who practises a profession and flexibility in assessment practices, in line with regulators’ own rigorous standards. The methods used to determine whether a professional qualified overseas is similarly qualified to work in the UK should rightly be identified and implemented by regulators. Through these amendments, the Government want to ensure that regulators can use a full range of approaches to make this determination. This could include making judgments only on the basis of qualifications or experience, or on such other bases as a regulator considers appropriate.
I have discussed my amendments with the General Medical Council and Nursing and Midwifery Council, who raised this issue directly with me. I am pleased to say that, in a very good discussion we had yesterday, both the GMC and the NMC welcomed these amendments to the Bill.
At this juncture, it is right to address a point I have discussed with several noble Lords and which touches on the point of the noble Lord, Lord Purvis, about the interaction of the Bill with other matters—in particular, the interaction between this Bill and the Department of Health and Social Care’s consultation on regulating healthcare professionals, which also touches on international recognition of professionals. I reassure noble Lords that there is no reason whatsoever why any proposals resulting from the ongoing consultation and requiring legislative changes could not be implemented through legislation led by the Secretary of State for Health and Social Care and his Ministers. I have no doubt that that legislation would be the appropriate vehicle for upgrades to UK healthcare regulators’ legislative frameworks. This is my second point of assuagement.
To conclude on this point, I hope that noble Lords will agree that the amendments address the challenges raised at Second Reading. The amendments will ensure that flexibility and autonomy for regulators is preserved in the event that the power in Clause 1 is used. I beg to move Amendment 2.
My Lords, I apologise that I was not able to be present at Second Reading, so I will not detain noble Lords with my views about the Bill in general terms. However, I hope that I will be forgiven if I have not been able to say those things previously.
Amendment 11 in my name seeks to amend government Amendment 10. My noble friend the Minister has explained helpfully and clearly how the Government have brought forward amendments even before the Committee stage to points made at Second Reading and by the regulators. That is extremely helpful, and I agree with them. There was always a risk that if there was a generic recognition of overseas qualifications or experience, an individual would be deemed to have met the required standard in the United Kingdom, but not necessarily by that individual’s experience, qualifications or other factors. My noble friend referred to things such as language assessment. When I was Secretary of State for Health, we were closely engaged in our dealings on this with other countries in the European Union. It is simply not the case that because someone undertakes qualifications that are deemed to be the equivalent of those in the United Kingdom, people are able to practise here in a way that is not impaired. We set about trying to remedy that and we need to make sure that we do not introduce legislation which would reintroduce the same kind of problem.
I encourage noble Lords to look at government Amendment 10. I understand what is intended, but I think that there is a drafting problem. The determinations set out in proposed subsections (3A) (b) (i) and (ii) state that the qualifications and experience are substantially the same or may fall short. Those determinations are to be made
“(i) only on the basis of the overseas qualifications or overseas experience concerned, or (ii) on such other basis”.
The inclusion of the word “only” means either qualifications and experience on the one hand or on another basis on the other hand, but it cannot be both. I do not see why that is the case. To me, it is transparent that we may be looking for an individual to have overseas qualifications and experience, but the regulator should have the flexibility to look at other assessments or experience. For example, I can think of someone I met while I was in hospital not so long ago who looked after me. He was a medically qualified practitioner from overseas, but he was working as a technician in the NHS because his qualification was not recognised for our purposes. However, his experience here in the United Kingdom treating patients should have been taken into account in assessing, for example, his linguistic competence and other experience.
If, for example, a regulator wanted to look at overseas qualifications and experience, as well as UK experience, why should it not be able to do that? The inclusion of the word “only” precludes such a combination on its plain meaning. That may not be the Government’s intention, and obviously I will not press this amendment, but I hope that, at the very least, my noble friend will undertake to look at this and say that leaving out the word “only” might enable this amendment to the Bill to do what he wishes it to do.
My Lords, I thank the Minister for the government amendments in this group. I want to speak in particular to Amendments 2 and 3, but having just listened to the noble Lord, Lord Lansley, I can see that Amendment 11 has an awful lot to commend it.
At Second Reading, I expressed concern that proficiency in English was not a prerequisite for individuals to be treated as having UK qualifications. I was prepared to put down an amendment to that effect, but I readily acknowledge that this is a matter much better left to the regulators than put in the Bill. The addition of the words “any other specified condition” leaves this in the hands of the regulators. It is hoped that many of them will recognise the importance that anyone working in the UK should speak and understand English. It is important not only for professional but for social reasons. We are still, alas, a hopelessly monolingual country, and any overseas worker who can speak only their language will have a difficult time both with their fellow workers and with sorting out their everyday life, however brilliantly they are qualified and however much experience they have.
Clause 1 concerns qualifications and experience, but leaves it with the regulator to consider whether experience makes up for any lack of appropriate qualifications. These amendments put the onus exactly where it should be—on the regulator. We on these Benches support the amendments.
My Lords, I am delighted to speak to this group of amendments. My question for the Minister is why we need these amendments. I understand that he has brought them forward in part to satisfy concerns raised by the General Medical Council and those expressed in the report of the Delegated Powers Committee. My noble friend has had an opportunity to speak to other regulators—here I declare an interest as a non-practising member of the Faculty of Advocates—but what he is proposing in these amendments could appear to be micromanaging criteria that would best be left to the regulators.
Concern that has been expressed by the Bar Council for England and Wales that the Government are conflating two different aspects. The first is the right of the Government or the state to set out which person should have the right to enter and remain here. The second is what I believe is the right and the duty of the regulator, which is whether an individual has the right to practise a particular profession or to establish services in this country. In seeking to amend the Bill in the way the Government are doing, we are moving away from the mutual recognition basis which has served this country so well, and I do not agree with that premise. Perhaps I may repeat that I had the opportunity to practise in Brussels on European Community law on two separate occasions, so I think that the Bill before us and the regulations to which my noble friend has referred will make it much more difficult to achieve that in the future.
I refer also to a letter from my noble friend which he sent to the Delegated Powers Committee. He talks about a “generous agreement” that was sought with the European Union on professional qualifications. He goes on to state on page 12 in the third paragraph:
I confess to being slightly confused, because if we are moving away from mutual recognition of qualifications with the European Union, why are we seeking to establish them in international trade agreements? I look forward to my noble friend being able to clarify those concerns.
My Lords, I am grateful to the Minister for these amendments, as I have spoken at length about the problems that would have been created for the General Medical Council otherwise. I am also grateful that he had extensive consultation with his officials and the General Medical Council. As he said, the General Medical Council is grateful to him for bringing forward these amendments.
Having said that, I would like the Minister to confirm on the record that any determination made by a regulator on whether a professional is able to join a register can be based on an assessment of the individual’s knowledge, skills and experience rather than solely on qualifications. Can he further confirm that the regulator would be able to make such an assessment using whichever method they found appropriate, including existing tests of competence and any other test they might develop in the future when it is found necessary?
I also support the probing amendment from the noble Lord, Lord Lansley. When the General Medical Council considers qualifications and experience, it takes into account the experience that the individual may have gained in his or her own country, but it also has the power to look at the experience that the individual may have gained subsequently outside their country. The amendment sought by the noble Lord, Lord Lansley, seems appropriate and I would be interested in the Minister’s response, but, at this juncture, I thank him for his amendments, and I support them.
My Lords, I refer to my interest as a member of the GMC board for the sake of this group of amendments. Like the noble Lord, Lord Patel, I welcome the government amendments and thank the Minister for his discussions with the regulator. I listened with great interest to the comments and queries of the noble Baroness, Lady McIntosh, about the amendments. In a sense, they reflect the generic and skeletal nature of this Bill, which means that each clause has to relate to many different professions. Frankly, I think it argues for a more detailed Bill, which would meet her issues as well as mine.
The argument that the GMC and others have put is very simple. Clause 1 currently gives power to the appropriate national authority—in the case of health regulators, the Secretary of State for Health and Social Care—to draft regulations to introduce a process that will require them to assess whether someone has a particular overseas qualification that is substantially the same as a UK qualification. In the case of the GMC, a person so deemed would then be eligible to practise as a doctor in the UK. That is because the GMC does not require those with UK qualifications to do anything further to demonstrate that they have the necessary knowledge and skills for registration. This could give an automatic entitlement to practise, under the current provision of Clause 1, for international medical graduates on the same basis as UK graduates. Currently, GMC has a very rigorous process for assessing whether the international medical graduate is safe and fit to practise. Without these amendments, it would be almost impossible for the GMC to manage operationally, with 10,000 international medical graduates applying for registration each year. It would be virtually impossible to assess this number of qualifications from countries as diverse as India, Pakistan, Nigeria, UAE and many others, with hundreds of different medical schools. The concern was that the Bill as drafted could force health profession regulators to accept professionals into UK practice in a way that compromised patient safety.
The Minister was sympathetic, and I am very grateful to him. However, there remains the issue of the relationship of Clause 3 to Clause 1, which we will come on to debate. In relation to the amendment from the noble Lord, Lord Lansley, he clearly has a point. I hope the Minister might take this away and give it further thought.
My Lords, I declare that I am registered with the General Medical Council and I am president of the Chartered Society of Physiotherapy. Like others, I know that the GMC has welcomed these amendments from the Government. Indeed, they address many of the concerns that we raised at Second Reading. I have had some discussions too with the Health & Care Professions Council. It still has some concerns that I hope the Minister will be able to address.
Government Amendment 6 leaves in the phrase “substantially the same” at Clause 1(3)(b)(i), in respect of knowledge, experience and standards. Currently, the processes demand that registrants meet certain standards in order to practise. There is a concern that the phrase “substantially the same” in the legislation risks lowering this standard, potentially creating a two-tier system in which applicants from overseas would need to meet a lower standard than their UK counterparts.
It is, of course, most welcome that the Government have recognised that regulators currently make a holistic assessment: they look at education, training, commitment to CPD and, importantly, the level of experience of each applicant rather than just at something on paper from the institution from which they received a qualification at some time in the past. This focus on the situation of the individual, whether it is an overseas qualification or experience demonstrating an equivalent level of knowledge and skills, is crucial.
Our current workforce shortage is acute. We have a lot of vacancies across the UK and there seems no longer to be the incoming workforce that there used to be. We have people leaving as well, so the vacancy factor is becoming more acute with a workforce that is already feeling the strain and burnout following all the pressures of Covid. I hope that there will be a clear assurance from the Minister that there will be no dropping of standards in a rush to try to fill vacancies and that there will be a concerted effort to provide the education and training needed to make sure that we have the appropriate number of properly skilled people in our workforce.
The amendment proposed by the noble Lord, Lord Lansley, as discussed, seems to raise an important point. I think that the general tenor of the debate so far has been that we hope the Government will take their own amendment away and have another look at it, rather than expecting it to be put into the Bill today. It could come in on Report when it had been appropriately amended if necessary. It certainly would seem to need some more thought.
I am well aware from my own discipline of medicine that many drugs and conditions have remarkably similar names. It is extremely easy for people to become confused over which is which; that is how errors occur. Even if someone passes an English language test, it is actually their command of the language in the relevant discipline that becomes so important.
The other thing I want to ask the Minister before I sit down relates to those disciplines that are not yet on a professional register but will need to be. They include physician associates, anaesthesia associates and nursing associates in particular. I know that the General Medical Council will take on the registration of physician associates and anaesthesia associates, but I would welcome from the Minister confirmation that the same criteria will apply to them as will apply to those in professions that are already regulated by regulators to whom this Bill currently applies.
There is also a question about what will happen in future to some other groups that are not regulated, such as some of the psychological therapies that we discussed at length during the passage of previous pieces of legislation—for example, the Domestic Abuse Bill—when many Peers across the House expressed serious concerns about some of the standards of practice. We know that some of the schools of psychology have evolved in different countries around the world. It is important that we do not inadvertently create another problem by allowing people to come here and practise in an unregulated way.
That brings me to my last point, which is on cosmetic interventions. Currently, they are unregulated. I hope that we will see them regulated, but I request from the Minister confirmation that the same ability for a regulator to determine criteria will apply and that it will not be separate if it concerns a group coming into regulation that was not regulated previously. We know very well the number of damage cases that there are, particularly from inappropriate cosmetic procedures.
At this point, I seek those assurances from the Minister but reiterate that the government amendments are most welcome. They have demonstrated that they have listened to the representation, particularly from the General Medical Council but also from others.
My Lords, I will be brief. I support the Government’s amendments in this group and the amendment in the name of my noble friend Lord Lansley. Initially, I thought that his amendment was attached to the word “only”, which is often misused in the English language—most often as an inappropriate or misplaced modifier. Initially I thought my noble friend was going to say that it was a misplaced modifier. However, I listened to what he said, and he raised a very substantive concern about the drafting of the clause. Like other noble Lords, I hope that my noble friend the Minister will agree to take this away and look at it and, if necessary, bring an amendment back on Report to make proper sense of his new amendments.
Of course, there is a slight problem: once we have amended a Bill, we are not supposed to go back and amend it again at later stages. However, I think that if my noble friend were clear enough from the Dispatch Box today that he will look at this, it would not cause a problem.
My noble friend Lord Lansley may well have noted that, in our Conservative notes on the amendments that we are considering today, his Amendment 11 was described as an opposition amendment. I know that my noble friend has not always toed the party line—he is not alone in that—but I have never regarded him as the Opposition. I share this with the Committee in the hope that it will improve my noble friend’s street cred.
My Lords, I join noble Lords in congratulating the Minister on moving quickly on this. I also congratulate the GMC and the Nursing and Midwifery Council on moving quickly in terms of raising this issue with Her Majesty’s Government. Reflecting back on some of the things we heard in the debate on the first group of amendments, it seems that there are other professional groups in regulated professions that still have outstanding issues. I hope that the Minister can confirm that his door is just as widely open for them to bring their issues forward, albeit somewhat later, so that we can clear them up.
The Minister talked about whether we were assuaged and then stated that the Secretary of State for Health could bring forward statutory instruments concerning the health profession. We knew that. What we do not know, and what has not yet been answered, is how conditions set and laws made by this Bill that reflect on the consultation—as the noble Lord, Lord Purvis, set out frankly, this Bill and the DHSC consultation are travelling in highly contradictory directions—will affect the consultation and the health professions. It is that direction that we are more interested in, rather than the opposite.
I associate myself with the comments made by my noble friend Lady Garden of Frognal. These amendments are welcome. I note that, along with the noble Baroness, Lady Finlay of Llandaff, we expect to debate the word “substantially” later because we have some concerns around that. I also note her point about future regulators, so to speak. My assumption is that those regulators will be established by a different process somewhere else but, in order to add those additional regulators to this Bill, we will be seeing some more of the Minister’s statutory instruments in future. Perhaps the Minister can be clear about how future new regulators will be added to the terms of this Bill.
The noble Baroness, Lady Noakes, does not regard the noble Lord, Lord Lansley, as the Opposition, and I kind of do not, either. In this respect, I think the Minister would do well to listen to his very wise advice.
My Lords, as has been said, the changes made are welcome. However, we should reflect that there are still concerns over the powers. On
“to explain what such ‘additional requirements’ or ‘conditions’ might be” and—this is the important bit—had failed
“to explain why the amendment would leave it to Ministers to determine … whether there are to be any such conditions and, if so, what those conditions are to be.”
The committee also said that the Government had failed
“to explain why all such conditions should be a matter for secondary legislation” rather than primary legislation—a theme to which we will continue to return.
As the noble Lord, Lord Patel, said, the GMC welcomes the changes but has asked for a couple of things to be put on the record by the Minister today. For example, can the decision on whether a particular professional is able to join a register be based on an assessment of that individual’s knowledge, skills and experience, rather than on just their qualification? Also, will the regulators make that assessment? As the noble Lord said, the GMC has asked for that, but I must say, as a potential patient, that I too would like an absolute assurance that it will be the regulator who says that someone is fit to start cutting me open, or whatever else anyone would do.
On the little secret we heard about in the briefing from the other side of the House, perhaps the mistake next time could be calling my amendment a government amendment, because that way we might be able to get it through without anyone noticing. I live in hope.
The issue raised by the noble Lord, Lord Lansley, is a good one. I also wonder whether the Bill needs an “and/or”. That seems to go to the strength of putting this amendment to one side and putting it in on Report. The Minister should not think that there is any egg on his face or anything if we ask for a pause. As I am sure he will know, it is very normal for government amendments to be put in on Report; otherwise, they have to be brought back, slightly clunkily, at Third Reading, by which time we are normally rather tired and want to leave early. So if the noble Lord could not push his amendment today so that we can deal with it on Report, that might be the best way forward.
My Lords, I thank all noble Lords who have given their careful consideration to the amendments in this group. It was an unusual experience for me standing at the Dispatch Box almost to feel a warm glow as noble Lords welcomed my amendments. The lesson that I learn from that is that the quicker one can amend one’s own Bills, the better, probably, in your Lordships’ House.
As noble Lords will appreciate, the Government have not brought these amendments lightly. As we have heard, they have been informed rightly and properly by careful engagement with healthcare regulators. I thank a number of noble Lords; perhaps I can single out the noble Baroness, Lady Garden of Frognal, for her support and the noble Lord, Lord Fox, for his comments. Without reservation, of course, my door is open to other regulators who wish to speak to me as this Bill continues its passage.
We heard again from the noble Lord, Lord Fox, on his point about consultation with the HSC. I think that group 7, which is about consultation, will be a good place to return to that and I will try to address in detail the points the noble Lords, Lord Fox and Lord Purvis, have made.
My noble friend Lady McIntosh referred back to what, in her view, was clearly the golden age of mutual recognition with the European Union. As I said previously, we would have liked to have maintained that mutual recognition. The phrase I used at Second Reading was:
“We took the horse to water but it refused to drink.”—[Official Report, 25/5/21; col. 975.]
I hope that noble Lords will support my amendments. I believe that they protect the public interest, maintain standards and ensure that regulators have the necessary flexibility and autonomy to regulate appropriately. I thank the noble Lord, Lord Patel, for his comments, echoed by the noble Baroness, Lady Hayter, and I am happy to give a complete reassurance standing at the Dispatch Box on the important points that were made.
In relation to the points made by the noble Baroness, Lady Finlay of Llandaff, about the use of the word “substantially”, we have a later group which is almost entirely devoted to discussing that word. If I may, I will leave comments on that until we get there and, again, I hope to assuage noble Lords’ fears when we reach that point.
On what happens if other regulators pop up in this field, the way the Bill is drafted and, frankly, one of the reasons why we have not included a list of professions—I am sure we will come back to that later as well—is because it is a moving target. Of course, any new profession that ends up being regulated by law will automatically fall within the purview of the Bill by being so regulated, and if it falls within the purview of the Bill, the standards of the Bill and the methods that we have been discussing today in relation to my amendments will also apply to those new professions.
I come to Amendment 11 in the name my noble friend Lord Lansley, who made some interesting points during the discussion which were reinforced by my noble friend Lady Noakes. I always admire my noble friend Lord Lansley’s forensic attention to the detail of the legislation before our House. I think all Front-Bench spokesmen from this side always listen carefully to the points that he makes. I will look at this again, but I hope that he appreciates that the wording of Amendment 10 is intended to provide more flexibility about how regulators make their determination. We believe that they need this flexibility and will find it helpful.
Some regulators—and this is, of course, completely a decision for the regulators—may consider it appropriate to look solely at what is demonstrated by a qualification obtained overseas, others may require an applicant to pass a separate test of knowledge and skills, while others may choose to combine the two. Regulators should have this broad discretion available to them. I believe, and I am advised, that the proposed removal of the word “only” from Amendment 10 could cast doubt on whether the first of those options is available. I will have another look at this to make sure that that is the right reading. Meanwhile, I ask my noble friend not to move his amendment.
I commend Amendments 3, 6 and 10 to the Committee and beg to move Amendment 2.
My Lords, I am grateful to all noble Lords who have kindly approved of the argument made in Amendment 11 and to my noble friend for saying that he and colleagues will look at it again. I think that what they suggest is not the case. As it stands, Amendment 10 allows regulators to make a determination based on overseas qualifications and experience alone, but it runs the risk, which is a different risk, of preventing them combining that with other factors and assessments and bringing them together in the determination. That is the point. The removal of the word “only” would not, in my view, prevent a regulator making a determination based solely on overseas qualifications and experience.
I am grateful to the noble Baroness, Lady Hayter. If the Minister is willing not to move Amendment 10 today and to look at it again and bring it back on Report, I think that would be the best way to proceed. I think we all know what we want to achieve, which is to give the regulators flexibility. It is purely a drafting issue, and I am sure we will not need to be detained at length on Report if the draftsman, is, in the event, clear that the effect is as the Minister wishes it to be. He has not moved Amendment 10 yet, and I hope he will not move it when we reach it.
I think I have in fact moved Amendment 10. I commended amendments to the House and begged to move.
My Lords, I am grateful for that clarification. May I consider that point and come back to the House shortly on it?
If I make a slightly longer intervention than I planned, it might allow the Minister to consult the Whips in order to respond to the noble Lord, Lord Lansley, in a constructive manner. Certainly, these Benches would appreciate it if the Minister was able not to move his amendment at this stage. Like my noble friend Lady Garden, I do not think that there is a large area of difference. I cannot speak for the Cross Benches—I see the noble Baroness, Lady Finlay—I am giving the Whip plenty of time here, I hope.
The Whip should not indicate to my noble friend Lord Fox for me to carry on speaking, because normally that is quite the reverse of what my noble friend asks me to do, which is to shut up. However, that said, I hope that the Minister will reflect on it. If he is able to respond positively with a nod, I will defer my actual comment until later on in the Bill—he is nodding enthusiastically to try to do that.