OBJECTIVES: One of the key drivers behind the UK’s health service reforms has been to reduce regional and local variability of access to care and medicines. However, the devolved countries in the UK also have individual challenges- recently the Scottish Health Secretary, Alex Neil, said a  review of the Scottish Medicines Consortium (SMC) was launched in response to “concerns about variable access to medicines” raised by some clinicians, charities and patients. This study interviewed NHS leaders in Scotland to understand the reasons behind this variable uptake of SMC guidance. METHODS: Secondary research to understand NHS drivers & local decision-making processes followed by 1:1stakeholder interviews with  12 NHS Senior payers across Scotland.  RESULTS:   Scotland’s NHS is renowned as being at the forefront of new technologies and innovation. Uptake of guidance, like that of NICE is mandated, however, Health Boards (HBs) are facing many challenges to balance the national quality agenda with a need to make tough efficiency savings to ensure HBs continue to deliver for the local population. Whilst national groups such as NICE and SMC are seen as leaders within the HTA space, it would appear that a huge challenge within countries adopting these HTA recommendations and guidance will continue to be equitable implementation across the country, however this will now be greatly influenced by local decisions on affordability, similar to the decentralized picture in Italy and Spain. CONCLUSIONS:   The implementation of SMC guidance was seen as a national driver by Scottish Health Boards (HBs). Implementation decisions are taken at a HB level and a key driver influencing implementation is now local affordability and infrastructure capacity, of interest for many payers is the challenge of medicines optimization