Aditya Chakrabortty writes:
For all the crowd noise and heavy-breathing match analysis, British democracy is a simple sport. We elect politicians to serve our interests. They direct the vital services that look after our families and communities, such as our healthcare and our schools. The entire political system rests on one basic premise: they work for us.
Believe that, as I do, and this week is one of vast democratic failure. Rather than working for us, Keir Starmer and his ministers are acting against us. They have rammed through parliament a sweeping law that will, independent experts agree, harm the public; and they have done so without even coming clean on the costs or the consequences. What’s worse, MPs and the press have failed to put this under scrutiny.
One way this has happened is through the use of eye-glazing jargon, to make everything look as dry as possible. So where I can, I shall try to avoid acronyms and technicalities.
In December, Starmer and Donald Trump struck a deal on medicine. Downing Street agreed it would spend more on branded drugs, in return for the White House not jacking up tariffs on British pharmaceutical exports to the US. As I wrote at the time, the treaty stank. One of the greatest achievements of British democracy, our NHS, set up to save lives, had been used to save face with Trump. The most rapacious president in American history now had his hands on our healthcare system.
Wes Streeting and his Department of Health and Social Care gave almost no detail about how much this would cost, or what that meant for patients. They created a black hole of information, then tried their damnedest to present defeat as victory. Look! ministers said: we get to buy these whizzy new drugs from America. Truth was, we always could, if we wanted to – except now the choice was no longer ours.
MPs never got to examine these vast changes. They had no chance to debate the great erosion of our independent system for providing medicine. No awkward backbenchers or querulous lords or scribbling hacks or public information for Starmer and Streeting. Using a statutory instrument, they smuggled the entire thing into law.
Only after the deal came into effect did the government publish even its headline facts and figures, sneaking them out just before the Easter bank holiday. Only this week did MPs finally get the chance to debate the changes, “long after the horse has bolted”, as Labour backbencher Rachael Maskell told me. And this morning we got the first detailed analysis of the cost for you, me and our NHS. The analysis has been conducted by three senior health researchers, including a former senior adviser to the National Institute for Health and Care Excellence (Nice), the body that sets how much we pay for our medicines. Published in the British Medical Journal, it suggests the public has been misled on an epic scale.
When discussing the deal with Trump, Streeting made voters three promises. First, in any negotiation, “the NHS is not on the table”. Second, “we’re not going to cut NHS services to fund the pharma deal”. And finally, over the next couple of years the agreement would cost “around £1bn” a year. All three of these pledges now look utterly false.
In the face of Trump’s bullying, the government will double how much it spends on drugs as a share of national income, going from 0.3% now to 0.6% in a decade. It also accepts that the money will come from the NHS budget. The BMJ analysis suggests that over the next couple of years the NHS will have to find almost three times the amount pledged by Streeting. By the end of the decade, the authors believe, the cost will be a total £44.7bn. For perspective, this week’s headlines have been dominated by a plan that will require the government to find an extra £15bn for defence. The NHS may have to find triple that just to pay for drugs, thanks to a deal fronted by its own health secretary.
That extra money will go from British taxpayers to shareholders in multinational drug companies. And working on the basis that it will come from the NHS budget, the study shows it will cause a massive loss of life. More money for branded pharmaceuticals means less for cancer scans or doctors and nurses, statins and diabetes drugs. Using many years of data on the links between NHS spending and patient health, the authors’ model forecasts that this will cause an extra 229,000 deaths by 2036. The academics describe this as a “conservative” estimate, but it is getting on for double the avoidable deaths Britain suffered during the Covid pandemic. You might call this a massacre made in Whitehall, at the behest of Trump’s White House, in order to buff up shareholder returns.
After the pandemic, Starmer and Streeting rightly led the charge in calling for lessons to be learned. The government was forced to launch an inquiry. Here is a trade deal that looks more lethal than Covid, yet which has been subject to almost zero democratic scrutiny. The Department of Health and Social Care told me it does not recognise these figures, but despite many requests from MPs and others, it has not published its own impact assessment. Indeed, the basics of parliamentary democracy have failed. No inquiry by the select committees working on health or trade or science. No Commons debate until this week, at which a junior minister was put up to catch the flak and was told by one MP that “everything [she] is saying is in the press release”. As for the media, there has been something close to silence. Over the past six months, according to the Guardian’s research and information department, the national newspapers published a grand total of eight stories on this deal that will change the face of our NHS; at the same time they did, however, find space for 274 stories on whether Wes Streeting would become the next Labour leader. One man’s career prospects deserve more airtime than the lives of our elderly, ill and poor people.
Soon, the UK will have a new prime minister, one who promised this week more democracy, more accountability, greater transparency. So here’s a test for Andy Burnham: is he really going to let this fatal deal, cooked up in private and shrouded in unforgivable secrecy, stand?
And Paul Knaggs writes:
Every protection racket works the same way. A man walks into your shop and admires it. Nice little business you have here, he says. Shame if anything happened to it. Then he names his price. On 1 December 2025, the British government paid the man. The UK-US pharmaceuticals deal was announced as a landmark agreement to safeguard medicines access and drive investment. Strip away the communiqué language and the transaction is simple. Washington threatened tariffs of up to 100% on British pharmaceutical exports. London agreed, in exchange for a three-year reprieve, to force the NHS to pay substantially more for branded medicines, most of them made by American multinationals, for the next decade. This week, we learned the price. Not the price in pounds, though that is staggering enough. The price in people.
TWO HUNDRED AND TWENTY-NINE THOUSAND
The analysis published in the British Medical Journal on 1 July, authored by Samuel Cross, Karl Claxton and Andrew Hill, is the document the government hoped would never be written. Ministers have refused to publish their own impact assessment, so three health economists did the work for them, using the government’s own methods. Their conclusion: diverting NHS funds to pay more for new drugs will cause roughly 229,000 excess deaths in England by 2036. Include the knock-on damage to adult social care and the figure rises to 291,000.
For comparison, the Covid-19 pandemic killed 137,000 people between March 2020 and June 2022. We shut the country down for that. We stood on doorsteps and clapped for the NHS. This deal will kill more people than the virus did, and it was signed with a handshake and a press release. These are not abstract deaths. The largest impacts fall on cardiovascular, respiratory and gastrointestinal disease and cancer. They fall hardest on the poorest areas, the places with the highest baseline mortality and the deepest deprivation. The Welsh Valleys. The North East. The former pit villages and mill towns that were promised levelling up and got a levy instead.
The mechanism is not mysterious. Health economists call it opportunity cost. The NHS budget is finite. Every pound handed to a pharmaceutical shareholder is a pound taken from a cardiac nurse, a screening programme, a GP appointment. The Department of Health’s own analysis shows the NHS frontline generates a year of healthy life for roughly every £15,000 spent. Under this deal, the NHS will pay up to £35,000 for the same benefit from new branded drugs. For every year of health the deal buys, it destroys more than two elsewhere. That is not a trade deal. That is a transfusion, running in one direction, from the sick of Britain to the shareholders of New Jersey.
THE MECHANICS OF SUBMISSION
The deal operates through three instruments, each one a ratchet. First, ministers took powers in March 2026 to instruct the National Institute for Health and Care Excellence to raise its cost-effectiveness thresholds. For over twenty years, NICE would approve a medicine if it delivered a year of quality life for £20,000 to £30,000. From April, the range is £25,000 to £35,000. The same pills, the same benefits, a higher price by decree. The Joint Committee on Statutory Instruments described this use of ministerial direction as an “unexpected and highly irregular use of the enabling power”. In plain English: the government bent the machinery of state to satisfy a foreign power, and bypassed Parliament to do it.
Second, the industry rebate scheme that claws back excess drug spending, known as VPAG, has been gutted. In 2025 the rebate rate stood at 23%. Under the new arrangement it falls to 14.5%, with anti-circumvention clauses that legally prohibit the NHS from recovering the money through any other route. Britain negotiated a treaty clause against its own health service.
Third, the government committed to doubling national spending on new medicines from 0.3% of GDP to at least 0.6% by 2036. The cumulative cost to the English NHS: £44.7bn. The annual cost by 2036: £8.8bn, or £170 million every week. Remember the bus? This is the bus in reverse, and this one is real. Science Minister Patrick Vallance has confirmed the money will come from the existing health budget. No Treasury top-up. The NHS eats the whole bill.
Ministers told the public the deal would cost around £1bn over the spending review period. The Office for Budget Responsibility puts the figure at £3.3bn by 2028-29 alone. The £44.7bn long-term cost appears in no ministerial statement. It had to be excavated by academics.
And when campaigners asked to see the government’s own impact assessment, they were refused. Global Justice Now and Just Treatment have been forced into legal action to discover what their government knew when it signed. Think about what that means. The state has calculated the cost of this deal in British lives, and it is keeping the number in a drawer.
THE EMPIRE SENDS ITS INVOICE
Now widen the lens, because this deal did not fall from the sky. It is one payment in a larger scheme of tribute. In May 2025, President Trump signed Executive Order 14297, accusing foreign nations of “freeriding” on American pharmaceutical innovation and directing his administration to force international prices up toward American levels. The enforcement mechanism was the threat: tariffs of up to 100% on medical exports from any country that maintained serious price controls. By the end of the year, sixteen of the world’s largest drug manufacturers had capitulated, pledging tens of billions in American factories. AstraZeneca alone committed $50bn to US manufacturing. Eli Lilly, $27bn. Novo Nordisk, $10bn. The capital, the jobs and the plants flow to America. The higher prices flow to everyone else.
This is how empire works in the twenty-first century. It does not send gunboats. It sends the Commerce Department. And Britain has seen this play before, because it is precisely the structure of the NATO arrangement: the ally as client, the client as customer, security sold on subscription with the premium rising every year. We are told to find 5% of GDP for defence because Washington demands it. We are told to find 0.6% of GDP for American drug prices because Washington demands it. The threat and the protection are issued by the same address. Meanwhile, our own political class conducts an anguished debate about warfare versus welfare, as though the only question is which British service to cut to pay the American invoice. It is the wrong debate. A country whose people die 229,000 deaths early has not been defended. It has been harvested.
And here a word must be said about sovereignty, because the people of the heartlands voted for it. Whatever one thought of Brexit, its core promise was self-government: our laws, our money, our decisions. Millions of working class voters did not wrench this country out of one bloc to watch it kneel before another. NICE’s thresholds, the pricing rules of our National Health Service, the allocation of our health budget: these are now set to specifications agreed with Washington, implemented by statutory instrument, hidden from Parliament and litigated out of campaigners. If Brussels had done this, it would be a constitutional scandal. Because Washington did it, it is called a landmark deal.
THE DEFENCE, SUCH AS IT IS
Fairness demands the government’s case be stated properly. Ministers argue the deal shields £5bn to £6.6bn of annual pharmaceutical exports from ruinous tariffs, protecting a life sciences sector that employs skilled workers across the country. They argue higher prices will attract investment, citing a £300 million AstraZeneca commitment in April. They argue patients will gain access to new medicines. And they can fairly say they negotiated under duress, facing an American administration willing to burn the global trading system for leverage. Each claim collapses on inspection.
The tariff shield defends against a threat that has largely evaporated. A US Supreme Court ruling cut the proposed tariffs from 100% to 10%, capping Britain’s realistic exposure at roughly £500 million a year. The deal’s costs will exceed the entire annual value of UK medical exports to America before 2031. We are paying £44.7bn to insure a £5bn export line against a £500 million risk. No underwriter in the City would write that policy sober.
The investment argument is weaker still. AstraZeneca’s £300 million is less than 1% of what the NHS surrenders, and the same company has pledged 130 times as much to American manufacturing. The UK represents under 3% of the global pharmaceutical market; the economic literature is clear that domestic prices in a market that size do not move global R&D decisions. Companies invest where the science, the talent and the tax breaks are, not where the procurement contracts are fattest.
And access? NICE already approves more than 90% of the medicines it evaluates. Its own modelling suggests the higher thresholds will admit two to five additional drugs a year. The overwhelming bulk of the new money will simply pay higher prices for medicines that were coming anyway. As the BMJ authors put it, the NHS has been reduced to “underwriting risk in global pharmaceutical markets”.
The duress point deserves the most respect, and it indicts the government most completely. Yes, Trump held a gun to the negotiation. But a government’s duty under coercion is to minimise the tribute and protect its people. This government maximised the tribute, concealed the cost, and dismantled its own price defences with anti-circumvention clauses that no coercer could have enforced without London’s signature. There is a difference between being robbed and helping the robber carry the furniture.
THE ROAD NOT TAKEN
There was an alternative. It was announced from a conference platform in Brighton in September 2019, and the people now in government helped bury it. Jeremy Corbyn’s medicines policy proposed a publicly owned generic drugs manufacturer to supply the NHS at cost. It proposed compulsory licensing to break the monopoly pricing of patented medicines. It proposed making public funding for research conditional on affordable prices, so that the system would, in his words, “serve public health, not private wealth”. It was denounced as extremism, Venezuela, the politics of the madhouse.
Set the two prospectuses side by side now. One offered public manufacture, lower prices and medicines security under democratic control. The other delivers £44.7bn to multinational shareholders, a health service legally barred from defending its own budget, and 229,000 graves. The first was called unelectable. The second was called landmark. The heartlands can do this arithmetic without assistance. They were told grown-up government meant abandoning fantasy economics. They are now governed by people who bought a £500 million insurance policy for £44.7bn and called it statecraft.
SECURITY COMES FROM WITHIN
Here is the argument this moment demands, and it is older than any of us. The security of a nation is not measured in the tonnage of its fleet or the tribute it pays to keep an ally’s temper. It is measured in whether its people are healthy, housed, paid and unafraid. Bevan understood this. The NHS was itself a security policy: the guarantee that no British family could be destroyed by illness, that the nation’s strength began in its own body.
A state that finds £170 million a week for American drug margins while its own citizens die of treatable heart disease has not misjudged a trade negotiation. It has forgotten what a state is for. Real security is a cardiology appointment that comes in time. Real sovereignty is a health service that answers to Parliament, not to the US Department of Commerce. Real defence is 229,000 people alive in 2036 who would otherwise be dead.
So the demands write themselves. Publish the impact assessment, in full, without redaction; a government that has priced its policy in lives has no right to keep the invoice secret. Put the deal before Parliament as primary legislation and let members vote with the death toll in front of them. Insulate NICE from trade negotiations by statute, so that no future minister can hand our medicine pricing to a foreign treasury. Fund any geopolitical premium from the Treasury’s trade budget, not from cancer wards. And revive, seriously and without embarrassment, the case for public pharmaceutical manufacture, because the events of the last year have proven its critics wrong on every count.
None of this requires revolution. It requires only that the British state value British lives above American dividends. That it apparently does not is the true scandal, and no tariff waiver can cover it. When the history of this deal is written, nobody will remember the communiqués. They will remember that a Labour government, custodian of the NHS, signed away more lives than the pandemic took, and hid the paperwork. They call it a trade deal. But when one side pays £44.7bn and 229,000 lives, and the other side waives a threat it invented, that is not trade. That is tribute. Britain is now a colony.
No comments:
Post a Comment