Towards the equitably efficient and transparently decidable use of public funds in the deep blue millennium

Health economists concerned about the efficiency and equity of health care provision have focused their attention and evaluations on programmes and interventions at a population or group level. Clinicians, including those seeking to improve the quality of care by making it more evidence‐based, see their task as using their clinical judgment to make the best use of the resources available to them as a result of policy decisions. The existence of significant incoherence between the two (or more) levels is increasingly recognized, but clinical guidelines, the only current response, are analytically inadequate to the task of reducing it. ‘Clinical Guidance Trees’, on the other hand, not only have the potential to bridge the policy–clinical gap but also provide the means by which public funds can be allocated to individual patients on the basis of a societally determined willingness to pay per incremental unit of benefit. This paper aims to stimulate debate about a system in which all public funds are allocated on the basis of patient specific cost‐effectiveness analyses, conducted on the basis of sociopolitically determined parameters (including equity weightings), but individualized ‘quality of life’ measures. The system, seeking to maximize ‘equificiency’, would do away with the increasingly unsustainable division between public and private sector provision and remove many expensive layers of health care decision making. While it would have many problems (including strategic behaviour various by parties), these need to be considered in the light of the problems of all alternative systems, including those of the status quo. © 1998 John Wiley & Sons, Ltd.