INTRODUCTION: Program budgeting marginal analysis (PBMA) accommodates economic analysis, multi-stakeholder inputs, values, needs and perspectives within one framework in order to determine optimal use of available resources to deliver the highest 'health value'. Two pilot PBMA projects in two different services were conceived and completed in a Welsh Health Board (HB) as 'proof of concept' methodology for robust prioritization decisons and for improving quality of patient care, outcomes and

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... rience. The pilots were essential to enable development of a 'bespoke' PBMA process for the HB to implement. METHODS: The PBMA methods were based on methods and criteria for successful PBMAs reported in the literature. Project teams and stakeholder communities supported the PBMAs which were executed over a 12 -18 month period between 2013–15. Group decision support methods were used to facilitate meetings and decision making. Formal interviews with project team members and informal feedback informed development of the final PBMA framework. RESULTS: Identifying the costs and resources attributable to services and those that could be moved around services was challenging. Evidence of outcomes and 'health value' was more easily available. One PBMA pilot recommended that some modest service reorganization and quality improvement could be made within budget but no substantial improvement/decommissioning could be undertaken. The other pilot agreed a disinvestment decision on the basis of evidence and reallocated the resources to a higher value service. The HB commissioning team found the information from the PBMA 'journey' as useful as the recommendations. A PBMA framework for the HB was devised. CONCLUSIONS: A 'Prudent PBMA' framework trimmed back to the critical essentials enables success criteria to be met. PBMA is to be adopted as a 'way of working' to operationalize resource reallocation and disinvestment in the 'real world' of Welsh healthcare commissioning.