OBJECTIVES: To illustrate how decision-making in England and Wales is influenced by cost effectiveness and other factors, with particular emphasis on decisions for end-of-life treatments.  METHODS: An analysis of all technology appraisals published by the National Institute for Health and Clinical Excellence (NICE) from 1st March 2000 to 31st May 2012  was conducted, with recommendations categorised as ‘recommended’, ‘optimised, ‘not recommended’, ‘only in research’ and ‘non-submission’, by therapeutic area and by technology process (multiple technology appraisal or single technology appraisal). These categories were then mapped against the most plausible cost per QALY estimate and the recommendations were contextualised with the factors used in decision-making.    RESULTS: Since March 2000, NICE has published 256 appraisals containing 482 individual recommendations on the use of technologies in England and Wales. The majority (78%) of these decisions recommended the use of a technology either in line with its licensed indication (‘recommended’) or under specific conditions (‘optimised’). ‘Only in research’ and ‘not recommended’ decisions represented 5% and 14% of all recommendations respectively. Of the 135 recommendations in technology appraisals which considered the use of oncology treatments, 61% were ’recommended’ or ‘optimised’. Since January 2009, 15 end-of-life technologies have been considered of which 9 were recommended because the additional weight that needed to be assigned to the QALY benefits was acceptable to justify these as an appropriate use of NHS resources. Examples from other therapeutic areas show how factors other than cost effectiveness have affected the recommendations, such as equality considerations, or the impact of health-related benefits not captured in the QALY.   CONCLUSIONS: NICE has provided guidance on a wide range of new and established technologies, with the majority recommended for use. The starting point for the decisions is the ICER in line with NICE’s commitment to support the cost-effective use of NHS resources, but other factors regularly influence decision-making.