OBJECTIVES: To compare the pharmaceutical STA guidance advice of Haute Autorité de santé (HAS) which appraises clinical efficacy/safety against the Scottish Medicines Consortium (SMC) in which appraisal includes both clinical and cost-effectiveness. METHODS: All English translated advice were downloaded from the HAS website resulting in 78 transparency committee opinions for between 2005 and 2009. These were matched with SMC advice, resulting in 39 matched drugs. A comparison between drug advice, the clinical evidence through identification of trials on the CENTRAL database of the Cochrane library and a statistical analysis was performed on improvement in medical benefit (ASMR) supplied by HAS and the cost-utility estimates (CQG) of the SMC. RESULTS: The HAS and SMC had the same advice in 14/39 (36%) of the drug comparisons. The average number of trials included were 2 trials in HAS advice and 1.8 trials in SMC advice with more comprehensive detail on the efficacy in HAS advice. Each matched comparison had at least one common trial and 30% of guidance included different additional trials. The correlation between the medical improvement provided by HAS and the SMC CQG were analysed and show that for those treatments considered cost saving by the SMC the ASMR was on average 4.6. The CQG for £0-£10,000 had an average ASMR; 3.6, £10,000-£20,000; 2.8, £20,000-£30,000; 3.1, and £30,000+; 3.4, showing little correlation between ASMR and CQG. CONCLUSIONS: The differences in guidance advice reflect the countries different HTA processes, interpretation of clinical efficacy and approaches to economics. HAS advice provided more detailed information on the clinical efficacy in comparison to SMC for these drugs. The SMC presented formal analysis of cost-effectiveness in comparison to France where economic issues are considered by the economic committee and not reported. The transparency committee implicitly uses economics as the choice of ASMR influences pricing decisions and the cost-effectiveness of treatments.