title: Local health care expenditure plans and their opportunity costs.
abstract: BACKGROUND
  In the UK, approval decisions by Health Technology Assessment bodies are made using a cost per quality-adjusted life year (QALY) threshold, the value of which is based on little empirical evidence. We test the feasibility of estimating the "true" value of the threshold in NHS Scotland using information on marginal services (those planned to receive significant (dis)investment). We also explore how the NHS makes spending decisions and the role of cost per QALY evidence in this process.
  
  
  METHODS
  We identify marginal services using NHS Board-level responses to the 2012/13 Budget Scrutiny issued by the Scottish Government, supplemented with information on prioritisation processes derived from interviews with Finance Directors. We search the literature for cost-effectiveness evidence relating to marginal services.
  
  
  RESULTS
  The cost-effectiveness estimates of marginal services vary hugely and thus it was not possible to obtain a reliable estimate of the threshold. This is unsurprising given the finding that cost-effectiveness evidence is rarely used to justify expenditure plans, which are driven by a range of other factors.
  
  
  CONCLUSIONS
  Our results highlight the differences in objectives between HTA bodies and local health service decision makers. We also demonstrate that, even if it were desirable, the use of cost-effectiveness evidence at local level would be highly challenging without extensive investment in health economics resources.
authors.affiliation: Office of Health Economics, 105 Victoria Street, London, SW1E 6QT, United Kingdom. Electronic address: sschaffer@ohe.org.
authors.forename: Sarah
authors.initials: S
authors.lastname: Karlsberg Schaffer
authors.affiliation: Office of Health Economics, 105 Victoria Street, London, SW1E 6QT, United Kingdom.
authors.forename: Jon
authors.initials: J
authors.lastname: Sussex
authors.affiliation: Office of Health Economics, 105 Victoria Street, London, SW1E 6QT, United Kingdom.
authors.forename: Nancy
authors.initials: N
authors.lastname: Devlin
authors.affiliation: Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, G12 8QQ, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Walker
mesh_terms: D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data; D003659:Decision Making, Organizational; D017048:Health Care Costs / Q000706:statistics & numerical data*; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006285:Health Planning / Q000191:economics / Q000379:methods*; D006801:Humans; D007407:Interviews as Topic; D019057:Quality-Adjusted Life Years; D013222:State Medicine / Q000191:economics / Q000458:organization & administration; D006113:United Kingdom
keywords: Cost-effectiveness thresholds; Decision-making; National Health Service; Scotland; Scottish Medicines Consortium