Searching for Cost-Effectiveness Thresholds in NHS Scotland

Objectives: The objectives of this research were to identify the cost-effectiveness of health care services at the margin in the Scottish NHS; consider the extent to which the thresholds observed in Scottish NHS decision making are consistent with the threshold being used to make judgements about new health care technologies in the UK; and understand expenditure prioritisation decisions and the role that cost per QALY evidence plays in the decision making process. Methods: We used data collected by a committee of the Scottish Parliament on spending decisions at NHS Board level, in combination with telephone interviews with senior NHS finance managers to identify services at the margin(services where investment or disinvestment is planned to, or could, take place). We then performed literature searches for cost per QALY evidence to estimate the threshold. The interviews were also used to explore the factors driving (dis)investment decisions at a local level. Results : The estimated cost per QALY of services at the margin varies widely both between services and across different estimates of cost per QALY for the same service. However, cost per QALY evidence is rarely used as part of the decision-making process at territorial NHS Board level. We find that explicit disinvestments or service reductions are rare and that the majority of savings, when required, are made through increasing technical efficiency.Conclusions : The assumed maximand — QALYs — that is implied by the use of a cost per QALY threshold by the SMC and other HTA bodies appears not to be the maximand pursued by NHS Boards in Scotland. NHS Boards seek to achieve numerous objectives, including but not limited to health gain, simultaneously