The quid pro quo for a public system is that claims on such systems will always outstrip the resources we have available to put into them. Here, the main principles behind an economic approach to managing such scarcity are outlined, along with some short case studies of using these in practice. Some important policy distractions also require addressing. For example, does having national-level health technology assessment (HTA) agencies really address the issue of scarcity? How do we know HTA agencies have made our health care systems more efficient? The idea, here, is that we need to get further into localities in combination with national-level HTA. There are also many management frameworks, such as lean thinking and balanced scorecards, that take on the appearance of solving issues of resource scarcity, but without facing up the real choices that have to be made. We have to avoid health and social care managers constantly succumbing to such gimmicks; but part of this involves making the health economics frameworks work for them.