BMJ paper examines projected impact of UK–US pharmaceuticals agreement

A new analysis published in the BMJ estimates that the UK–US pharmaceuticals agreement could substantially increase NHS spending on new medicines over the next decade. The authors argue that, without additional funding, the resulting opportunity costs could affect healthcare delivery, while the government disputes the projected financial impact.

The Baseline

• A BMJ analysis estimates the UK–US pharmaceuticals agreement could increase NHS spending on new medicines by £44.7 billion by 2036.
• Researchers argue the resulting opportunity costs could affect healthcare delivery and population health if additional funding is not provided.
• The findings contribute to wider discussions around medicines pricing, HTA reform, and broader approaches to assessing value within the NHS.

A new analysis published in the BMJ has examined the potential long-term consequences of the UK–US pharmaceuticals agreement, concluding that higher NHS spending on new medicines could come at the expense of other healthcare services if additional funding is not provided.

The publication follows a series of policy reforms reshaping medicines assessment and pricing in England. The UK–US pharmaceuticals agreement announced in December 2025 was accompanied by the first increase to NICE's cost-effectiveness thresholds in more than two decades, alongside changes to the Voluntary Scheme for Branded Medicines Pricing, Access and Growth (VPAG). Coinciding with publication of the BMJ analysis, the government also announced a series of NHS medicines pilots designed to explore how these reforms could be implemented, including pilots examining productivity benefits, broader measures of value, earlier patient access, and new approaches to implementing NICE recommendations.

The paper, authored by Karl Claxton (University of York), Andrew Hill (University of Liverpool), and Samuel Cross (Christchurch Hospital), examines the cumulative impact of the reforms introduced through the agreement. These include higher NICE cost-effectiveness thresholds, adoption of a new EQ-5D-5L value set that increases estimated quality-adjusted life year (QALY) gains for the same health benefit, a reduction in VPAG rebate rates from 23% to 14.5%, and the government's commitment to increase expenditure on newly launched branded medicines from 0.3% to at least 0.6% of GDP by 2036. According to the authors, these changes will increase NHS medicines expenditure without a corresponding increase in overall NHS resources. They estimate annual NHS spending on new medicines would rise by approximately £1.3 billion in 2028 and £8.8 billion by 2036, resulting in cumulative additional expenditure of £44.7 billion over the life of the agreement.

Rather than evaluating the clinical value of individual medicines, the authors examine the wider health opportunity costs of the agreement, estimating the health outcomes that could be displaced elsewhere in the NHS if additional medicines spending is funded from existing resources. Using previously published evidence linking NHS expenditure to mortality and health outcomes, they project that reduced spending elsewhere in the health system could contribute to approximately 229,000 excess deaths in England by 2036. When indirect effects on publicly funded adult social care are incorporated, that estimate increases to 291,000.

The researchers argue that the greatest impacts would likely occur across cardiovascular disease, respiratory disease, gastrointestinal disease, and cancer, while existing health inequalities could widen because reductions in NHS spending disproportionately affect more deprived communities. They also question whether the agreement will substantially improve patient access, noting that NICE already recommends more than 90% of the medicines it evaluates and estimates that increasing the cost-effectiveness thresholds may result in only two to five additional medicines being approved each year. "The agreement is more likely to increase the prices paid for medicines already entering the NHS rather than substantially expanding access," the authors write.

The analysis also examines broader assumptions underpinning the reforms. While ministers have argued that higher medicine prices will support pharmaceutical innovation and inward investment, the authors describe the supporting evidence as uncertain, arguing that the UK represents a relatively small share of the global pharmaceutical market and that domestic pricing decisions are unlikely to materially influence global research and development investment. They also note that the economic benefits of securing tariff-free pharmaceutical exports to the US should be considered alongside the potential health and economic consequences of diverting NHS resources.

The publication has prompted differing responses across the sector. The Department of Health and Social Care disputed the projected £44.7 billion cost, stating that the estimate is "not recognized by the department" and maintaining that the agreement will improve patient access to innovative medicines while being funded within existing spending plans.

Campaign group Global Justice Now also criticized the reforms. Responding to the publication, campaigner Tim Bierley said: "This latest research adds to the overwhelming evidence that the Trump medicines deal risks taking a wrecking ball to our health and our economy. Billions that could be spent on recruiting more NHS staff, cutting GP waiting times, or improving our hospital care are set to be siphoned off by corporate giants in the pharma industry."

Beyond the financial projections, the authors call for publication of the Department of Health and Social Care's impact assessment, arguing that greater transparency would enable more informed parliamentary scrutiny of the reforms and their long-term implications.