LONDON – In the government’s telling, the pharmaceutical trade deal Britain signed with the United States last December opened a door for NHS patients: new medicines, previously too expensive or unavailable on the health service, finally within reach. Samuel Cross read the same deal differently. The University of Liverpool researcher and his colleagues spent months calculating what the NHS budget looks like when it commits to doubling its spending on American pharmaceuticals by 2036, and what that commitment costs the patients who depend on everything else the health service provides.
The answer, published Thursday in the British Medical Journal, is 229,000 excess deaths.
The BMJ study is the first peer-reviewed analysis to quantify the mortality cost of the December 2025 UK-US pharmaceutical deal. Under the terms of that agreement, Britain committed to raising NHS spending on American medicines from 0.3 percent to 0.6 percent of GDP by 2036, a cumulative commitment of £44.7 billion. The government did not specify where that additional spending would come from. Cross and his co-authors modelled where it would have to come from, drawing on NHS expenditure data to estimate which treatment categories would bear the greatest funding pressure.
The mechanism is straightforward even if the numbers are vast. The NHS budget is finite. When it commits to purchasing additional American medicines, it must redirect money from existing treatments. The study found that cardiovascular care, respiratory procedures, cancer treatment, and gastrointestinal services are the four areas projected to face the deepest cuts under a realistic NHS budget scenario, and those are also the four highest-volume, highest-impact treatment categories in a health system already operating close to capacity.
“The agreement benefits pharmaceutical companies and comes at a cost to NHS patients,” Cross said. “There’s really no way to sugar-coat that. The numbers speak for themselves.” He was precise about what the study claims: it does not argue that the new American medicines lack clinical value. It argues that finite money spent on one treatment cannot be spent on another, and that the NHS has no slack to absorb a £44.7 billion additional commitment without consequences for patients who are not being prescribed American drugs.
The study’s projections arrive in steps. By 2028, the deal requires an additional £1.3 billion in annual NHS pharmaceutical spending. By 2036, that rises to £8.8 billion per year, pushing medicine spending from roughly 10 to 12 percent of the total NHS budget. Those figures capture the deal’s direct pharmaceutical commitments. If adult social care is included in the modelling, which competes with NHS acute budgets for government funding, the projected death toll rises to 291,000. Al Jazeera reported the study’s findings on Thursday.
The government’s response has been to emphasise what the deal provides rather than what it costs. Patrick Vallance, the Science Minister, has described the new medicines as “life-changing” and said they represent options that NHS patients “previously would have been denied.” His office has not issued a response that addresses the mortality projections directly or provides a counter-methodology for estimating the clinical benefit to patients who gain access to American drugs under the deal.
The British Medical Journal is the United Kingdom’s pre-eminent peer-reviewed clinical publication, and a study in the BMJ carries institutional authority that places the 229,000 figure in a different category from political commentary. The government will face pressure to respond with specific rebuttals backed by comparable analysis. What the study does not resolve is which framework is correct for evaluating the deal: the government’s case rests on the clinical value of expanded medicine access; the BMJ’s case rests on the opportunity cost of diverting NHS resources from proven treatments. Both framings carry real lives in the balance. The study establishes the mortality mathematics of one. The other remains, for now, a political assertion.
Pharmaceuticals have become one of the central battlegrounds in UK-US economic relations. The December agreement was a bilateral deal negotiated independently of the European Union. The Turnberry Agreement ratified last week between the EU and Washington caps US tariffs on European goods including pharmaceuticals at 15 percent, under a parallel but structurally different framework that adjusts tariff terms rather than committing to specific NHS spending levels. Britain’s deal went further, tying NHS purchasing directly to expanded American medicine consumption.
The BMJ study arrives as the NHS faces structural budget pressure from multiple directions. A separate investigation last month found that private equity-backed companies collected £24.4 billion from UK public contracting in a single year, including NHS-adjacent service provision, with limited government oversight of value delivered in return. The pharmaceutical deal and private equity’s NHS footprint represent two distinct mechanisms by which private capital extracts value from a health system whose budget is determined by democratic spending decisions. The BMJ study is the first to quantify the mortality consequence of one of them.
What the study cannot establish, and what no one has yet commissioned anyone to establish, is whether the patients who gain access to new American medicines will live longer than the patients who lose access to existing NHS treatments. That comparison would require the government to publish its own modelling of the clinical benefits it expects from expanded pharmaceutical access, with the same methodological rigour the BMJ applied to the costs. As of Thursday, it had not. The 229,000 figure stands without a rebuttal that carries equivalent peer-reviewed authority.
