A new pharmaceutical agreement between the UK and the US is bringing about a significant shift in the assessment, pricing and adoption of new medicines. Patients, doctors and researchers welcome faster access to innovative treatments, for example in cancer. Increased drug spending may increase the UK's attractiveness for clinical research and life sciences investment. Increasing NICE's cost-effectiveness thresholds will increase overall NHS spending on medicines. Without funding protections for the workforce, diagnostic services, primary care and other essential services, higher drug budgets can divert resources from already burdened areas. A more flexible pricing environment may weaken the UK's future negotiating leverage with industry. Maintaining NICE's independence is critical to maintaining the public interest. The overall effect of the agreement depends on how it is implemented.