News of a recently brokered pharmaceutical deal between the United States and the United Kingdom has raised new concerns about access to medicines and the future of public healthcare. People’s Health Dispatch spoke with Diarmaid McDonald from the UK-based organization Just Treatment to unpack the content of the deal, its implications for the National Health Service (NHS) and its patients, and its wider significance for governments and movements in the region.

People’s Health Dispatch: Can you talk us through what’s included in this new UK–US pharma deal and why you believe it matters so much for people in Britain?

Diarmaid McDonald: Really simply put: this deal is the result of months, if not years, of pressure from the pharmaceutical industry for the NHS to spend more money on medicines. And they’ve been massively boosted in that effort by President Trump. The deal, from what we’ve seen of it – because it’s not published, and it’s not even clear if there is a full text – can be pieced together from the UK statement, the US statement, and the pharmaceutical industry’s response. From that, we understand that it includes several commitments.

First, the UK has agreed to increase the cost-effectiveness thresholds that the National Institute for Health and Care Excellence (NICE) uses to determine whether a medicine should be made available in the NHS. Those thresholds are going to increase by around 25%. Second, there’s a commitment to adjust the overall price cap under the VPAS scheme. That cap works by limiting the growth of spending on branded medicines at an agreed rate. When spending exceeds that amount, the industry pays a rebate back to the government. That rebate rate is being reduced from roughly 26% down to 15%. Third, the UK has committed to double the amount of money spent on medicines as a percentage of GDP within ten years.

Now, what that translates to in terms of impact on the NHS budget depends on who you listen to and how you calculate it. One thing we know for certain is that the government has said this money needs to come from within the existing health budget, so within the existing NHS budget. And that’s particularly concerning, because it means money will be taken from other areas of health spending and redirected into the pockets of the pharmaceutical industry to boost their profits.

That’s problematic because even at current prices, we were already spending more on innovative or patented medicines for worse health outcomes than if that money were spent elsewhere. There’s very clear evidence that other healthcare interventions are far more cost-effective than innovative medicines.

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We’ve also been working with health economists on the potential impact of these commitments. Their calculations suggest it could cost the NHS up to £3 billion (around USD 4 billion) per year, which would translate into 15,000 or more excess deaths annually. If you project that over ten years, and then factor in the commitment to double spending on medicines, we’re literally talking about hundreds of thousands of people who will die essentially to please the pharmaceutical industry, boost their profits, and please Donald Trump.

There are also huge gaps in what we know about the deal. As I said, there’s no text available. You hear different interpretations from different sources. Journalists are being told about additional elements, but there’s no transparency, and the agreement is apparently still not finalized. It’s an agreement in principle, with more work to be done. But even what we do know is really damaging, really dangerous, and will cost lives.

And maybe the final thing to say is: why has the UK done this? What are we getting in return? There is one clear commitment from the US: a 0% tariff on pharmaceutical exports from the UK to the US. There are already question marks about how that would work under WTO rules applying to the sector. And, furthermore, it’s only in place for three years. So in exchange for permanently eroding the price-control mechanisms that protect the NHS and patients, we’re getting a temporary waiver of fairly theoretical tariffs.

A lot of this also happened in a context where the pharmaceutical industry was pressuring the UK government around investment in the economy. But this deal has not resulted in any commitments from the industry to invest in Britain. To most objective observers, the UK has been screwed over really badly. And patients are going to be paying for it – with their lives – for years to come.

PHD**:** Beyond excess deaths, what other implications do you foresee for patients and for NHS services under this deal?

DM: One calculation is that there are going to be 15,000 or more excess deaths a year if some of the numbers being quoted in the press are reflected in reality. And there are concerns that this is an underestimate of the total cost. The government’s statements don’t line up with the actual content of the deal. They’ve talked about it costing £1 billion (USD 1.3 billion) in the near term, but we know that even the adjustment in the VPAS rebate rate is, by our calculations, going to cost more than £1 billion a year. And then you have to add the other concessions they’ve made around the NICE thresholds and the long-term commitment to increased spending. So the government’s numbers just don’t add up, meaning the estimates of excess deaths are likely an underestimate.

Beyond that, there are also likely to be non-lethal impacts, things like the number of quality-adjusted life years that will be lost. That number is in the hundreds of thousands per year. Even if people don’t die as a consequence of this, their health will be severely negatively affected.

That’s one set of impacts. But we also know there are a lot of competing demands on NHS spending right now. We’ve got a staffing crisis. We’ve got ongoing industrial action led by doctors seeking the restoration of pay levels from 20 years ago. And while pay restoration would cost a few billion pounds a year, we’re seeing the government choose to say they don’t have money for healthcare workers, who are absolutely vital to the system, while saying they do have money to bolster the profits of drug companies for no tangible health benefit. In fact, the evidence suggests the deal will be detrimental to health in the UK.

We’re also going to see questions about how the NHS can actually manage the financial implications of what the government has agreed to. We’ve seen, in the past, situations where expensive medicines were recommended but then rationed within the health service to minimize their total budget impact. We saw that with hepatitis C treatments. We worked with patients who were essentially told to go away and come back when their cirrhosis had worsened. That’s a very recent example of the NHS being forced to deal with overpriced medicines by not being able to follow purely clinical or regulatory evidence, but instead having to prescribe based on budgetary constraints.

It seems pretty likely to us that this will once again become a feature of how the NHS tries to balance the books with no additional resources, while the government has signed this deal that forces them to spend more money.

PHD: And are there wider political implications you think people should be aware of?

DM: I’d say there are really serious political and democratic implications. As I said, the text has not been made public. Much of what we know comes from sources other than the UK government. Members of Parliament have not been briefed. There has been no scrutiny of the terms, no statement to Parliament. In fact, we know more from statements made by the US Trade Representative and by the pharmaceutical industry than we do from the UK government. That’s unacceptable. It’s a basic failure of democratic accountability.

We also know the industry will learn from this, and other industries will too. They will see how they were able to pressure the UK government into meeting their demands to boost profits, and how willing the government was to acquiesce to bullying, coercive tactics. We’ve seen industry try to exert this pressure for decades, trying to attack and weaken price-control mechanisms in the NHS. There’s no reason to think they’ll stop now. This coordinated effort has worked: it will drive profits in the UK, and they will do it again because they have an insatiable appetite for revenue growth.

We’ve also already seen industry figures shift their messaging. Previously, they said the real barrier to investment in the UK was the government’s failure to properly value medicines and increase spending. But immediately after the announcement, they moved the goalposts and said this was “an important first step.” There is no evidence they intend to reverse their position on investment in the UK economy. I think the government has been played for fools. And every industry will be watching this closely and learning from it, which has really serious implications for the future of the country.

PHD: When we look at all of this, how does it actually fit within this government’s health policy and overall behavior? Because, from the outside, it doesn’t really make sense. How do they explain it to themselves?

DM: I think part of how they’ve been able to explain it to themselves is that some of the most senior people in government who were negotiating this agreement, who were pushing for it, are former senior pharmaceutical company executives. So we have a revolving door that is deeply prejudicing and biasing discourse and policymaking at the highest levels. And that’s really dangerous. That’s a real failure of the democratic process. We don’t have objective, informed decision-making happening, because you’ve got people who owe their past careers – and likely their future careers – to the pharmaceutical industry.

We’ve also got, as I said, an industry that has been pushing for these changes for decades. And there are a couple of factors that came together this time that gave them the power to get away with it in such a shameless and overt way. The current UK government has two primary electoral strategies as it tries to get re-elected at the next general election. One is to “fix the NHS,” and the other is to fuel economic growth. Those are the two things they’re hanging their hat on. And for both, they’ve chosen policy agendas that make them completely reliant on the pharmaceutical industry.

On the health side, the government’s 10-year plan for the NHS is full of techno-utopian idealism about what new medical products, technology, AI, and data-driven tech can deliver in terms of efficiency and effectiveness. To make that agenda work, they need the pharmaceutical industry as a very close partner. That gives the industry an outsized amount of power over health policy in the UK right now.

The second element is their economic growth strategy, which is incredibly reductive and, I would say, economically illiterate. It relies almost entirely on rolling over and doing whatever large multinational companies want, whether in AI regulation, health policy, or any other sector, in exchange for inward investment. That has left them massively exposed. So when the pharmaceutical industry coordinated to announce a series of cancellations or pauses in their R&D or manufacturing investments in the UK, it hit a very painful pressure point, especially for this government.

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Those two things gave the industry enormous leverage. And then you add Donald Trump in the White House, with a very aggressive international trade policy and a very reductive understanding of how failures in US drug pricing and access can be fixed. He also has a willingness to be seen to “make deals.” He’s actually done a bunch of deals with the pharmaceutical industry that, according to US experts we’ve spoken to, are not going to drive significant price reductions or more sustainable pricing practices. They’re voluntary, partial, non-transparent, and non-binding agreements.

In exchange for these deals, the pharmaceutical companies have won the full support of the White House and the muscle of its trade department to push around countries like the UK. So domestically, Trump’s deals don’t damage industry profitability, and internationally they massively bolster it, starting with the UK. And we know for sure it’s not going to stop here: Europe is next.

PHD: I did want to talk a bit about the arguments that the deal is going to drive innovation and growth and so on. What do you make of those claims, and what evidence – or lack thereof – have you seen?

DM: I think one important thing to note is that, although the UK government’s announcement includes references to “accelerated access to new treatments” for patients, that is a highly contestable claim. The efficacy and value of those new treatments for patients is very questionable. And even setting that aside, you won’t find strong evidence in government communications that this deal provides meaningful health benefits. They’re not really trying to make that argument – beyond rhetorical claims about speeding up access to new medicines. There is nothing in this agreement that demonstrates a broad health benefit for patients or for the NHS.

It’s also interesting that NICE, the health technology assessment body in the UK, made a pointed statement in response. They explicitly said this is a government decision aimed at influencing business investment and wider economic growth. Even NICE is not trying to claim there is any health benefit here, because they know there isn’t.

So the bulk of the government’s justification lies in the supposed economic benefits: avoiding tariffs and encouraging investment. But, as I said, the tariffs were highly dubious to begin with. And the investments that were paused or cancelled by industry have not suddenly come rushing back. Nothing in the deal obliges companies to resume those investments. There is simply no evidence that this will happen.

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We’ve also seen no economic impact assessment. No assessment on the NHS. No analysis of the broader economy. The government is essentially making a vibes-based announcement. There is nothing in what they’ve said that evidences their claims that this deal will fuel innovation or drive economic growth. It’s an empty rhetorical device. In fact, health economists we’ve worked with think the economic costs of the deal will end up outweighing any hypothetical benefits.

To my mind, this doesn’t solve any actual problems facing the NHS. It won’t improve health outcomes in the UK. It won’t fix the economy or fuel growth in any meaningful way. It is likely to be detrimental. The only “problem” it solves is a perception issue: it gives the UK government and Donald Trump something to wave around publicly, something they can claim is evidence of action, something they hope will bolster the UK’s position in negotiations with the US. But the only people walking away with anything tangible or valuable are the pharmaceutical companies. And even they aren’t satisfied. They want more.

PHD: In this situation, what reactions are you seeing from the movement, unions, and civil society, and what space is there to develop that further?

DM: I’d say this has been one of the most frustrating issues to work on in a long time. We have repeatedly tried to advance a more critical assessment of what the government was doing and how the industry was behaving, and it has been very difficult to make progress.

We basically believe the pharmaceutical industry has been breaking competition law, acting as a cartel, in the way they coordinated their announcements around investment in the UK. We made a complaint to the Competition and Markets Authority. But that institution has been gutted by the current government. They removed effective leadership and installed, for example, former Amazon executives, which, to use a well-known phrase, is putting a poacher in charge of the gamekeeper role. There is no appetite there to take this on. From what we hear, there is a lot of anxiety inside the CMA about doing anything that might upset the government or be seen as undermining its economic growth agenda – even when that agenda is economically illiterate.

We’ve also struggled to get parliamentarians to pay adequate attention. But we’re trying. A letter went to the Prime Minister today signed by over 200 academics and health experts, demanding full transparency and publication of impact assessments so we can hold the government accountable. We’re working with a number of parliamentarians who are interested, and we’ll be briefing them properly on the nature of the agreement in the new year. We’re pushing for the Health Select Committee to scrutinize the deal. There is some political opposition – Liberal Democrats, the Scottish National Party – because even though the immediate impact is felt most in England, the implications extend across all parts of the UK.

We’re also trying to build public understanding through the media and social media, and coordinating closely with US allies, who can see the damaging effects of their domestic politics on other countries. We’re exploring ways to secure congressional scrutiny of these approaches. And with the immediate pivot from the UK to Europe, we’re starting to coordinate with allies across Europe to respond collectively to this renewed threat from industry.

One very troubling element is that, even in the government’s public announcement of the deal, we saw charities, supposedly acting in the interests of patients, championing it. That is deeply worrying. Even if the deal results in a small number of additional drug approvals, it comes at the cost of thousands of lives. And I found it pretty telling that all three organizations quoted in the government’s press release take funding from the pharmaceutical industry. That speaks to a wider democratic deficit in how this decision has unfolded.

Our task now is to push for accountability and to get commitments from political parties to revisit and reverse this agreement. And when that scrutiny happens, it needs to be holistic. We must consider the alternatives, because the government has refused to. They have not considered other approaches to economic growth, to health equity, to innovation in medicines, or to improving access. Only once you ignore all the far more coherent options does it start to seem even remotely logical to do what the government has chosen to do. That kind of wrongheaded thinking needs to be challenged when political leaders reassess what the UK has signed itself up for.

PHD: As this deal moves forward, what do you think the public and parliamentarians most need to understand?

DM: I guess the last thing I would say is that politicians in the UK need to ask themselves whether it is a price worth paying to have 15,000 people a year – and, over ten years, many times that number – die in order to sustain a really broken and extractive business model. We know the alternatives could be far better for the UK economy, far better for UK science and research, far better for the NHS, and far better for NHS patients.

They need to ask themselves whether they can sleep easy at night knowing that what the government has signed up for is going to translate into so many avoidable, excess deaths. And if they don’t feel easy about that, then it’s really important that they reach out, inform themselves about the details of this deal, and start to generate political pressure on the government to justify these decisions.

And for parliamentarians across Europe and in other parts of the world who have not yet caved to this strategy and these tactics: you still have time. It is crucial that your commitment to your own populations – your commitment to the right to health – takes precedence over the industry’s demand for ever-greater profits. It’s really important that you hold firm and do not follow the very bad precedent the UK government has set.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch*. For more articles and subscription to People’s Health Dispatch, click* here.

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