OBJECTIVES: Following a review into access to new medicines in NHS Scotland, SMC was directed to improve transparency and increase access to new medicines used at the end of life and for rare conditions.This paper outlines the experience with introducing these changes in the first year. METHODS: SMC advises NHS Scotland on the clinical and cost-effectiveness of all new medicines. In January 2014, we began to implement a number of recommendations to improve public transparency and increase access to new medicines used at the end of life and for rare conditions.  Changes introduced include: holding all SMC meetings in public to increase understanding of how the committee works; introducing a more flexible approach to the assessment of medicines used at the end of life and for patients with rare conditions; introducing a new framework for assessing ultra-orphan medicines; and involving pharmaceutical company representatives in the discussion of their submission. RESULTS: All SMC meetings have been held in public since May 2014 with full capacity attendance and positive feedback.  Private sessions to discuss commercial in confidence information have been kept to a minimum. Twenty end of life /orphan medicines have been assessed with input from the new Patient and Clinician Engagement (PACE) process since August 2014, with fifteen accepted for use and five not recommended. These include four medicines assessed using the ultra-orphan framework.  Company representatives have been in attendance at meetings since November 2014 to help address outstanding questions from the Committee and clarify issues if required. CONCLUSIONS: SMC has worked closely with key stakeholders including clinicians, patient groups and the pharmaceutical industry to introduce these changes. Early experience suggests that these are meeting the desired objectives of increasing transparency, giving patient groups and clinicians a stronger voice in decision making and are leading to an increased acceptance rate for medicines used at the end of life and rare conditions.