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The nature of policymaking often precludes a significant role for formal evidence-based practice. Management practice is also bereft of formal evidence and appears unlikely to change because of the methodological constraints on collecting good evidence. Despite this, policymakers and managers are keen to promote evidence-based clinical practice. This, in part, reflects rational management's desire to standardise the clinical process and develop the profession's accountability to the management hierarchy. To the extent that clinical practice is dependent on organisational settings, this push is inevitable. Widespread and persistent small-area variation in clinical practice, and concern over apparent high levels of avoidable error, make doctors vulnerable to these efforts to standardise clinical practice.

The Victorian casemix funding initiative has achieved initial success in implementing massive budget cuts while increasing hospital throughput and reducing waiting lists. For hospitals to survive, the relationship between casemix and resource use must be managed and this can only be achieved by the involvement of clinicians. With effective information systems and accommodating clinicians, games to maximise casemix, and hence revenue, will undoubtedly emerge. Side effects may include reduced access to "unprofitable" services, increasing pressure on "unprofitable" clinicians and the wooing of "profitable" ones, increasing difficulty in delivering continuity of care and the politicisation of the diagnosis-related groups pricing system. In the end, State governments will be left with a complex control system without resolving the fundamental dilemma inherent in being both the provider of hospital care and the payer.