The Relevant Perspective of Economic Evaluations Informing Local Decision Makers: An Exploration in Weight Loss Services


Since 2013, obesity services in the UK National Health Service (NHS) have focused on a tiered structure, with tiers 3 (specialist weight management services) and 4 (primarily bariatric surgery) commissioned by Clinical Commissioning Groups (CCGs) and widely reported as cost effective and recommended by national guidelines. However, CCGs have been reluctant to fully conform to the guidance. We explore how the different evaluative perspective of those generating evidence from local decision makers has contributed to this failure of the CCGs to provide services considered cost effective. We explore four elements where the conventional economic evaluation framework, as applied by the National Institute for Health and Care Excellence (NICE), differ from the reality faced by local decision makers: the cost-effectiveness threshold, the implications of decision uncertainty and budgetary excess, the valuation of future costs and outcomes, and the scope of included costs. We argue that the failure of the conventional framework to reflect the reality faced by local decision makers is rendering much of the existing literature and guidance inappropriate to the key commissioners. Our analysis demonstrates that it is not reasonable to assume that the framework of economic evaluation used to inform national guidance applies to local decision makers, such as in the commissioning of weight loss services. This failure is likely to apply to the majority of cases where evidence is generated to inform national decision makers but commissioning is at a local level.

This is a preview of subscription content, access via your institution.


  1. 1.

    NHS Commissioning Board. Clinical commissioning policy: complex and specialised obesity surgery. London: NHS England; 2013.

    Google Scholar 

  2. 2.

    NHSE and PHE Working Group. Report of the working group into: joined up clinical pathways for obesity. London: NHS England; 2014.

    Google Scholar 

  3. 3.

    Royal College of Physicians. Action on obesity: comprehensive care for all. Report of a working party. London: Royal College of Physicians; 2013.

    Google Scholar 

  4. 4.

    England NHS. Commissioning guidance to support devolution to CCGs of adult obesity surgical services in 2016/17. London: NHS England; 2016.

    Google Scholar 

  5. 5.

    Digital NHS. Health survey for England 2017. London: NHS Digital; 2018.

    Google Scholar 

  6. 6.

    Diabetes UK. Us, diabetes and a lot of facts and statistics. London: Diabetes UK; 2019.

    Google Scholar 

  7. 7.

    Digital NHS. Statistics on obesity, physical activity and diet. London: NHS Digital; 2018.

    Google Scholar 

  8. 8.

    National Health Executive. NHS England authorises controversial CCG plans to delay surgery for obese patients; 2016. Accessed 21 May 2019.

  9. 9.

    Royal College of Surgeons. Patient access to bariatric surgery. Royal College of Surgeons (RCS) and the British Obesity and Metabolic Surgery Society (BOMSS) Report. Royal College of Surgeons; 2017.

  10. 10.

    LighterLife. We reveal how the NHS is abandoning the obese. Available at: Accessed 21 May 2019.

  11. 11.

    Local Government Association. Weight management survey: research report. London: Local Government Association; 2018.

    Google Scholar 

  12. 12.

    Kneale D, et al. The use of evidence in English local public health decision-making: a systematic scoping review. Implement Sci. 2017;12(1):53.

    Article  Google Scholar 

  13. 13.

    Turner S, et al. Evidence use in decision-making on introducing innovations: a systematic scoping review with stakeholder feedback. Implement Sci. 2017;12(1):145.

    Article  Google Scholar 

  14. 14.

    Clancy C, Cronin K. Evidence-based decision making: global evidence, local decisions. Health Aff (Millwood). 2005;24(1):151–62.

    Article  Google Scholar 

  15. 15.

    Fenwick E, Claxton K, Sculpher M. The value of implementation and the value of information: combined and uneven development. Med Decis Making. 2008;28(1):21–32.

    Article  Google Scholar 

  16. 16.

    Gulliford MC, et al. Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records. Southampton: Health Services and Delivery Research, NIHR; 2016.

    Google Scholar 

  17. 17.

    Avenell A, et al. Bariatric surgery, lifestyle interventions, and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation. Health Technol Assess. 2018;22(68):1–246.

    Article  Google Scholar 

  18. 18.

    NICE. Obesity: identification, assessment and management. CG189. London: NICE; 2014.

    Google Scholar 

  19. 19.

    NICE. Obesity prevention. CG43. London: NICE; 2015.

    Google Scholar 

  20. 20.

    Brown TJ, et al. Exploring the evidence base for Tier 3 weight management interventions for adults: a systematic review. Clin Obes. 2017;7(5):260–72.

    CAS  Article  Google Scholar 

  21. 21.

    Alkharaiji M, et al. Tier 3 specialist weight management service and pre-bariatric multicomponent weight management programmes for adults with obesity living in the UK: a systematic review. Endocrinol Diabetes Metab. 2019;2(1):e00042.

    Article  Google Scholar 

  22. 22.

    Hughes CA. The rewards and challenges of setting up a tier 3 adult weight management service in primary care. Br J Obes. 2015;1(1):1–40.

    Google Scholar 

  23. 23.

    Mahawar KK, Small PK. Medical weight management before bariatric surgery: is it an evidence-based intervention or a rationing tool? Clin Obes. 2016;6(6):359–60.

    CAS  Article  Google Scholar 

  24. 24.

    Drummond MF, et al. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2015.

    Google Scholar 

  25. 25.

    NICE. Guide to the methods of technology appraisal 2013. London: NICE; 2013.

    Google Scholar 

  26. 26.

    Claxton K, et al. Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold. Health Technol Assess. 2015;19(14):1–503, v–vi.

  27. 27.

    Lomas J, et al. Resolving the “cost-effective but unaffordable” paradox: estimating the health opportunity costs of nonmarginal budget impacts. Value Health. 2018;21(3):266–75.

    Article  Google Scholar 

  28. 28.

    Pearson SD. The ICER value framework: integrating cost effectiveness and affordability in the assessment of health care value. Value Health. 2018;21(3):258–65.

    Article  Google Scholar 

  29. 29.

    NICE. Sofosbuvir for treating chronic hepatitis C. TA330. London: NICE; 2015.

    Google Scholar 

  30. 30.

    Woods B, Faria R, Griffin SJP. Assessing the value of new treatments for hepatitis C: are international decision makers getting this right? Pharmacoeconomics. 2016;34(5):427–33.

    Article  Google Scholar 

  31. 31.

    Booseley S. Hepatitis C drug delayed by NHS due to high cost; 2015. Accessed 21 May 2019.

  32. 32.

    Claxton K, et al. Discounting and decision making in the economic evaluation of health-care technologies. Health Econ. 2011;20(1):2–15.

    Article  Google Scholar 

  33. 33.

    Attema AE, Brouwer WBF, Claxton KJP. Discounting in economic evaluations. Pharmacoeconomics. 2018;36(7):745–58.

    Article  Google Scholar 

  34. 34.

    Wright A, et al. Towards an effective NHS payment system: eight principles. London: The Health Foundation; 2017.

    Google Scholar 

  35. 35.

    Martin A, et al. Delivery and impact of the NHS Health Check in the first 8 years: a systematic review. Br J Gen Pract. 2018;68(672):e449–59.

    Article  Google Scholar 

  36. 36.

    The Lancet Public Health. Addressing weight stigma. Lancet Public Health. 2019;4(4):e168.

    CAS  Article  Google Scholar 

Download references

Author information




SH, LB and GR conceived the idea for the manuscript, and LH provided input regarding the accuracy of the descriptions of the CCG and other local decision-maker processes. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sebastian Hinde.

Ethics declarations


This research was co-funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRC) and Applied Research Collaboration (ARC) Yorkshire and Humber. The views expressed are those of the authors, and not necessarily those of the NIHR or the Department of Health and Social Care.

Conflict of interest

Sebastian Hinde, Louise Horsfield, Laura Bojke and Gerry Richardson have no conflicts to declare.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hinde, S., Horsfield, L., Bojke, L. et al. The Relevant Perspective of Economic Evaluations Informing Local Decision Makers: An Exploration in Weight Loss Services. Appl Health Econ Health Policy 18, 351–356 (2020).

Download citation