Considerable emphasis is currently being placed on the pursuit of efficiency in health service provision. This paper reports the results of a survey of the use of economic appraisal to assist decision makers in choosing efficient courses of action. The survey group comprised National Health Service staff who had undertaken a correspondence course in health economics. The respondents were asked to identify issues arising locally where economic appraisal could have been applied but was not, and to suggest reasons why economic appraisal had not been used. They were then asked to give local examples of attempts to use economic appraisal and to indicate whether they were successful or what problems had been encountered. The results suggest that there is greater use of economic appraisal than is apparent from published sources but there is still not very much. The paper also summarises comments from the respondents on the decision making process in the National Health Service.