Antimicrobial resistance, where microbes that cause disease develop resistance to the medicines meant to treat them, is a growing problem worldwide. 

Experts agree that we must reduce our use of antimicrobials globally to slow down antimicrobial resistance; but if we buy less, pharmaceutical companies will have less revenue to develop new antimicrobials when old ones stop working.  

The Antimicrobial Products Subscription Model is a new way for the NHS to purchase newly developed antibiotics to treat infections caused by drug-resistant bacteria. The payment model aims to encourage pharmaceutical companies to develop new antibiotic medicines and to prevent their overuse.  

Why do we need a new way to pay for antimicrobials? 

Antimicrobial medicines like antibiotics and antivirals are used to treat infections and limit the spread of disease. However, the more they are used, the more likely it is for microorganisms like bacteria and viruses to develop resistance to their effects. Drug-resistant microorganisms are sometimes called “superbugs” because they have developed the ability to survive treatment with antimicrobials. 

Making new antimicrobial medicines requires significant investment and many years of research. Companies historically funded their research through the sales of their products, with high sales as the incentive for investing in new products. However, the need to limit the use of these medicines to avert antimicrobial resistance creates an incentive problem for the pharmaceutical industry: they cannot rely on sales volumes to recoup their investment.  

This incentive problem has been linked to the lack of new potential antimicrobials. A report from the World Health Organization, which monitors the development of new antimicrobials, said that the supply of new antimicrobials was “still insufficient” to address the problem of antimicrobial resistance. It highlighted the need for financial and non-financial incentives to support the development of new antimicrobials.  

How does the Antimicrobial Products Subscription Model work? 

The Antimicrobial Products Subscription Model has been called “Netflix” for antimicrobials. Under the model, NHS England will pay a fixed annual subscription fee to a pharmaceutical company for access to new antibiotics. The pharmaceutical company receives a guaranteed return for access to its products, and there should be no incentive to overuse (or over sell) these medicines. 

Antibiotics will be eligible for the scheme if they can be used to treat infections caused by bacteria on the World Health Organization’s priority list of drug-resistant bacteria, which are responsible for high levels of disease and death.  

The National Institute for Health and Care Excellence, which assesses the clinical and cost effectiveness of treatments, will assess each medicine’s eligibility for the scheme and its value to the NHS. This assessment will be used to place medicines in one of four bands, attracting subscription fees of between £5 million and £20 million per year for England. Under the scheme, access can also be extended to Scotland, Wales and/or Northern Ireland for an additional fee.  

The model fulfils a commitment in the UK’s five-year plan (2024 to 2029) to address antimicrobial resistance: to implement subscription models to purchase antimicrobials, and to advocate for the use of these payment models in other countries.  

The UK’s five-year plan also commits to environmentally friendly antimicrobial manufacturing standards. Under the new subscription model, pharmaceutical companies bidding for contracts need the BSI (British Standards Institution) Kitemark for Minimized Risk of Antimicrobial Resistance Certification to show that they have responsibly disposed of waste with active pharmaceutical ingredients. This is designed to minimise the risk of antibiotic waste escaping into the environment (for example, through wastewater), as this can lead to the development of antimicrobial resistance.  

The subscription model has been welcomed by industry bodies. The Association of the British Pharmaceutical Industry called the scheme “an example for the world to follow”.  

Has the NHS subscribed to any new antibiotics?  

As part of a pilot for the model, two subscription-based contracts for antibiotics that can be used to treat severe infections caused by very drug-resistant Gram-negative bacteria were awarded to the pharmaceutical companies Pfizer and Shionogi. 

Both new antibiotics are included in the UK Antimicrobial Registry, a research study that will assess how they are used, how well they work and their safety.  

On 12 August 2024, the NHS tendered contracts with an estimated value of almost £1.9 billion over 16 years for new antimicrobial medicines. Pharmaceutical companies are invited to apply to provide new antimicrobial medicines in England, Scotland, Wales and Northern Ireland, with contracts beginning on 1 April 2026.  

Are other countries adopting a similar approach? 

The NHS Antimicrobial Products Subscription Model is the first subscription payment model for antimicrobial medicines in the world. However, other countries are considering introducing new approaches to encourage the development of new antimicrobial medicines: 

  • In the USA, the PASTEUR Act is currently being considered by the Senate. This legislation would allow the US Government to set up a subscription model for antimicrobials, similar to the NHS model.  
  • In Sweden, pilot payment models have offered pharmaceutical companies subscription fees to avoid shortages of key antibiotics and ensure access to new ones. The Swedish Public Health Agency will make recommendations on these schemes to the Swedish Government in January 2025. 
  • The Council of the European Union has recommended the development of EU-wide “pull incentives” to encourage pharmaceutical companies to produce new antimicrobials and ensure access to these medicines in the EU. These might include payment models that have “revenue guarantees” for pharmaceutical companies, similar to those offered by subscription payment models. The EU’s Health Emergency Preparedness and Response Authority is developing a pilot scheme (PDF) to test different incentive models.  

Further reading 

The Library briefing Antimicrobial resistance provides more information on the causes and implications of antimicrobial resistance, and UK and international action to prevent it. 

About the author: Claire Duddy is a medical and health specialist at the House of Commons Library.

Photo by: Andrew Norris via Adobe Stock

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