Wednesday, 23 March 2016

And Finally.......

Letter from Pluto 

When I set out to paint a picture I never give it a title as I then immediately limit my scope - I must paint that image or scene. Rather I have a general idea in my mind and I let the brush take me where it might.

Similarly, when I have finished the work I never name it lest it confine the viewer to seeing what I have said I have painted OR look for it. Better the viewer decide what I have painted based on all she or he brings to the viewing, inspired by her or his own space and place and state of mind: that is part of the mission of the artist, to free, empower and enrich the viewer.

"The Kiss" by Caravaggio
Take Caravaggio’s ‘The Kiss’, which hangs in the National Gallery of Ireland, having been ‘lost’ for 200 years (it was in fact hanging in various places but thought to be a copy).

I would have called this ‘Illumination’ because although the artist needed the light coming from an unknown out of picture source on the left, it is the lamp holder who is in fact ‘illuminating’ the scene; a metaphor for the artist’s role and purpose, inviting light into dark places in order to help the viewer to see and perhaps understand the world from a different perspective. This is particularly so in this painting as Caravaggio painted his own face for St Peter holding the lamp; we do not see the artist’s face as St John, or Judas, or Jesus, or one of the soldiers but as the holder of the lamp, illuminating the scene.

To further my point, I do love the Dutch Masters, although I have some sympathy with van Gogh’s view that:

 “Those Dutchmen had hardly any imagination or fantasy, but their good taste and their scientific knowledge of composition were enormous.”

This pair of paintings by *Metsu are called ‘Man Writing a Letter’ and ‘Woman Reading a Letter’.
This leaves nothing at all to the imagination, but what technically superb works.
"Man Writing a Letter" by Metsu
"Woman Reading a Letter" by Metsu

And, another example is *Eva Gonzales's 'Brother and Sister at Grandcamps'. Could we not be left to imagine this, thereby transporting us to a place of our choosing with a person of our choice?
"Brother and Sister at Grandcamps" by Eva Gonzales

*Picasso on the other hand, in most of his work, empowered the viewer and although he did name his works it was an interesting journey for the viewer deciding what he or she saw before him or her and wondering about what the artist believed he was painting! And Picasso did not mind what we took away from his work.

So, where am I going with this? Perhaps to suggest that in all we do in our lives, including in our professions, we should not seek to compel or persuade those with whom we come into contact that there is only one way to approach what we do and what we see (my way?). 

With education I am inclined to the view of Doris Lessing:

"You are in the process of being indoctrinated. We have not yet evolved a system of education that is not a system of indoctrination. We are sorry, but it is the best we can do. What you are being taught here is an amalgam of current prejudice and the choices of this particular culture. The slightest look at history will show how impermanent these must be. You are being taught by people who have been able to accommodate themselves to a regime of thought laid down by their predecessors. It is a self-perpetuating system. Those of you who are more robust and individual than others will be encouraged to leave and find ways of educating yourself—educating your own judgements. Those that stay must remember, always, and all the time, that they are being moulded and patterned to fit into the narrow and particular needs of this particular society."

And I am reminded that in the teaching of surgery, which one would think is all about science, the trainee is constantly reminded that surgery is an art as well as a science.

Thomas Schlich writes:

‘The proponents (of surgery as science) claimed to manage the uncertainties of innovation through making surgery more scientific, drawing on the ideals of control, rationality, objectivity, and predictability. The critics (of surgery as science) mobilized another discursive pattern. They considered surgery an art and emphasized the individuality, contingency, and situatedness of medical practice’.

So what about what we do professionally, you and I? Is there room for personal interpretation, is there room for art in what we do, or is it all about being told what we see before us, is it all about ‘science’?

ISQua has embraced the patient as partner in all we do and in doing this we expect also to be working with the patient’s network; family, friends, colleagues. At ISQua we commence face to face Board meetings with a patient story, to ground us…to remind us why we strive for what we strive for. Each of us around the table takes something different out of this and applies it in our own way to our work and our lives – I like that, not much science there. And I know a leading surgeon (and you know or know of him too) who when asked by a patient when he has done his science, ‘Will you stay with me for a while?’ will always say ‘Yes’ bringing a special personal dimension to his work.

And referring back to Doris Lessing, I like the fact that our Education Programme is ‘learner led’, that it is flexible and relevant and that it values the contributions of the participants. And the popularity of the programme suggests our participants like this too. Add to this that the research of our Head of Education, Yulianna, has found that while forcing people to undertake professional development education (through legislation or other means) may result in more being done and done more regularly, critically and much more important is that mandating CPD reduces effectiveness; in other words if I decide to undertake CPD it will be much more effective than if somebody else decides that I must do it. I believe this means we are on the right track.

So there is much to be said for allowing ourselves and others the freedom to dream, to express ourselves and not to label our paintings.

This is my last BLOG as CEO and I have chosen LETTER FROM PLUTO as its title – here I go, ignoring my own advice and naming my BLOG. But you have to admit the name could mean anything. I will let you decide what it means for you but for me it reflects my willingness as CEO to embrace new ideas and ventures however ‘from left field’ they may seem and from whomever they might come. I have to admit many of the most outlandish ideas were mine and were often labelled by my staff as ‘coming from Pluto’. So what else was I to call my final BLOG!?

Peter Carter
Chief Executive Officer
March 25 2016

*Metsu and Gonzales died in their mid 30s, and Vermeer, who inspired Metsu, at around 40 – what precocious talent! Picasso on the other hand lived to see 91 and died happily at lunch in the South of France with his wife, family and friends! There has to be a message in that!

Monday, 8 February 2016

I have an Idea....

"I can't understand why people are frightened of new ideas. I'm frightened of the old ones."
John Cage

I have 52,768 items in my mail.

I also have a file with the title: ‘IDEAS’. When I click on ‘IDEAS’ the following message appears:
 ‘We didn’t find anything to show here’.

Now before you conclude that I have never had an idea in my life, sadly, many of my ideas are scattered amongst the 52,768 items in my mail; the remainder are orbiting Pluto just waiting to touch down. 

I hasten to add that my ideas that have touched down are in the SENT section, not the IN BOX, so they are my ideas. They reside in SENT because I have a habit of testing them on others before maturing them into a discussion paper or something a little less ephemeral than an email (or discarding them!).

I really must get organised, especially as I do not want my successor as CEO to discover how I ‘managed’ my mail!

 There are good ideas and bad ideas.

What is an ‘idea’?

John Locke said an idea is:  "that term which, I think, serves best to stand for whatsoever is the object of the understanding when a man thinks, I have used it to express whatever is meant by phantasm, notion, species, or whatever it is which the mind can be employed about in thinking; and I could not avoid frequently using it."  

There you go….now you know! 

‘’The capacity to create and understand the meaning of ideas is considered to be an essential and defining feature of human beings. In a popular sense, an idea arises in a reflexive, spontaneous manner, even without thinking or serious reflection, for example, when we talk about the idea of a person or a place.’’

In his book, 100 Mistakes that Changed History: Backfires and Blunders That Collapsed Empires, Crashed Economies, and Altered the Course of Our World  Bill Fawcett talks about bad ideas:
‘’From the Maginot Line to the Cuban Missile Crisis, history is filled with bad moves and not-so-bright ideas that snowballed into disasters and unintended consequences. 
Japan bombs Pearl Harbour. The Caliphs of Baghdad spend themselves into bankruptcy. The Aztecs greet the Conquistadors with open arms. Mexico invites the Americans to Texas - and the Americans never leave. ‘’

The Slinky: Inventor: Richard Jones, a naval engineer
Then there are the ideas that didn’t work but which succeeded as something else, including penicillin, the pacemaker, X-rays, post it notes, popsicles, potato chips, silly putty, the Slinky and Velcro.

Typically scientists, including those who deliver healthcare, share their ideas. That is what publishing in journals and presenting at conferences is all about. We stand on the shoulders of those who went before us in order to make progress. I remember well when CEO of the Royal Australasian College of Surgeons mounting a legal challenge to an attempt by a surgeon to patent a particular variation on a long standing surgical procedure…we won!

Festivals of Ideas
A Festival of Ideas is a space where an intelligent public can engage with some of the best thinkers across a wide range of intellectual endeavour. 

I like this idea (oops). We have music, book, flower, comedy and other Festivals so why not one for ideas. In fact there are scores of these Ideas Festivals held around the world and they come up with a whole heap of thought provoking stuff AND….they can lead to positive change.

Take the 2015 Battle of Ideas at the Barbican, London. It explored a range of issues in which we as healthcare professionals have a keen interest including a topic I have been writing and presenting on a lot lately and one which occupies the minds of the ISQua Innovations Group – Ageing.

Topics such as these were tossed around:

‘Can technology solve the ageing timebomb?

From scandals over the quality of elder care to predictions about the burden that greying baby-
boomers will place on future generations, it is easy to lose sight of the success story of individuals living longer and healthier lives. And amid the discussion of how we pay for an ageing society, there is much less debate over what that care looks like. Policy-makers stress the importance of preventative medicine to reduce the need for care, as increases in life expectancy provoke angst about the loss of autonomy as our bodies age. As Oliver Sacks has argued, however, there is a growing perception that ‘we have come to medicalise aging, frailty and death’, rather than focus on how to provide ‘a life with meaning, as rich and full as possible under the circumstances’.

Research in this field has tended to be high-tech, focusing on such things as designing robots to provide nursing care or ‘smart’ homes in which embedded technologies monitor people’s physiological state. Such advances offer significant opportunities for semi-independent care. In theory at least, technology also offers the prospect of more than just physical support, with experimental ‘robot seals’ providing emotional support for dementia-sufferers alongside a variety of tools that help retain mental agility and provide a connection to the outside world. But there are surely ethical questions about outsourcing compassionate care to gadgets. What kind of society is it that has neither the time nor the interest to provide care to its elderly? More prosaically, much of the care needed by older people with chronic degenerative illness is ‘high touch’ – of the kind provided by incontinence teams and district nurses – not ‘high tech’.

Do assisted-living technologies offer a radical transformation in quality of life for the elderly or merely a distraction from the unglamorous challenges of adequate care? Can such advancements challenge our pessimistic view of ageing in society? Will society – or the market - inevitably produce the right solutions to cater for an ageing population, or do we need a shift in cultural outlook? What should be the focus of assisted-living technology if we are to help the elderly to enjoy as full and active a life as possible for as long as possible?’


With the world's elderly population growing rapidly, scientists are suggesting that robots could take on some of the burden of providing care, support and - most surprisingly - companionship.
                Alex Hudson, BBC, 16 November 2013

With the proportion of over-65s on the increase, Britain is facing a crisis when it comes to care of the elderly. Is technology the answer?
Andrew Griffiths, Telegraph, 13 April 2013

Sensors installed in nursing homes and even individual residences are helping nurses monitor seniors' health, but questions remain about cost, and privacy.
Michael L Millenson, Atlantic, 11 January 2013

Soon there will be three pensioners for every child under 15. Now, Patrick Collinson reports, the Land of the Rising Sun is going back to the future …
Patrick Collinson, Guardian, 20 March 2010’

Then there are Commissions for the Future.

These have tended to be subject specific, such as one on the future of Hospice care in the UK, but Australia established a generic body in 1985 with a wide and open remit. It turns out this Commission did not have much of a future itself and it closed in 1998. The Aussie Commission of the Future attracted much criticism during its life but it published commentaries on the future of many things and one general text: 

Melbourne: Commission for the Future and Australian Bicentennial Authority 1989

Despite its critics, it did some good. The offices of the Commission were just around the corner from my offices in Melbourne and I used often take my lunch there and enjoy the company of these ‘futurists’. 

SO, do not fear to think outside the box, even if our ideas emerge because we are standing on the shoulders of those who went before us….we are where we are because those who went before us did that too!

Peter Carter
Chief Executive Officer
February 2016

Mistakes That Worked – May 1, 1994 by Charlotte Jones (Author), John OBrien (Illustrator)

Tuesday, 15 December 2015

Shifting Gears

Had I been on the beach that September morning as Paul was preparing to swim the Bay I would have reminded him of the storm the previous evening that had flushed the river together with its catchment debris into the Bay; I would have pointed to the grey Spring clouds overhead; I would have suggested he check with local fishermen whether schools of bait fish were running; I would have commented that the whales were migrating with their newly born calves; I would have asked whether he really needed to wear the wet suit that made him resemble a seal.

The culprit (7 News, Australia)
Had I been on the beach that morning and done all those things, I expect he still would have swum the Bay. I do not know which of those factors attracted the shark that took him, perhaps a combination of them. For his wife and friend waiting for him to walk up the beach at the end of his swim and join them for breakfast it did not matter what caused the shark to strike, for them Paul just never arrived.

We have come a long way in some countries in seeking to ensure patients know all the risks associated with treatment but this is still poorly developed in other countries, and wherever it is done, some healthcare workers do it better than others. The landmark Rogers and Whitaker case in Australia set the gold standard for ‘informed decision making’, still referred to as ‘informed consent’ in many places.

Arlene Macdonald comments that this case distinguishes between, on the one hand, the belief ‘that a medical practitioner is not negligent if he acts in accordance with a practice accepted at the time as proper by his peers, even though other medical practitioners adopt a different practice. In other words, the standard of care owed to a patient in all things is determined by medical judgement’ and, on the other hand, in the words of five of the six Judges in this case, there is a duty ‘to warn a patient of a material risk inherent in the proposed treatment; a risk is material if, in the circumstances of the particular case, a reasonable person in the patient's position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it’.

Had Paul that fateful morning asked me whether it was safe to swim and had I not mentioned the storm, the overcast conditions, the bait fish, the whale calves and the wetsuit I would have considered myself to be negligent….but the R and W judgement tells me I might have mentioned all those things and still been negligent had I not explored with him particular questions about the swim that had meaning specifically for him, for instance do these risks take on even greater significance for him because he has a young family to support; and that he would be swimming alone.

But I want to raise a question about this for your consideration. I have written before in my BLOG about a paralysis in the delivery of healthcare due to over prescribing, over ordering of tests and over informing of patients – medicine has become too ‘defensive’, too risk averse. Acting as agent provocateur I asked …. ‘Maybe there should be an agreed ‘likelihood percentage’ below which Docs are indemnified against not prescribing/ordering and against not mentioning possible complications (risks) in the course of providing ‘informed consent’.

The incidence of hospital acquired infection is around 6% to 10% in developed countries and docs will tell you when you go for surgery that it is a risk with a likelihood of about 10% (to be on the safe side). That is fair enough even though the surgeons I have worked with tell me no patient has decided not to go for surgery because of the risk of contracting an infection. So, could 10% be the threshold above which docs should warn of the risks, order the tests, prescribe the medication and below which they can’t be sued if the risk materialises?

The likelihood of sympathetic ophthalmia is 1 in 14,000, which is well below my suggested indemnification threshold, so in my scenario Dr Rogers would have been indemnified against legal action by Maree Whitaker, a case Mrs Whitaker won. So to go the way I have suggested will result in potentially successful actions being ruled out – in other words, there would be a price to pay.

Atul Gawande has had some interesting things to say recently about what the job of healthcare professionals is and what it is not:

“We think. . .[the job of healthcare professionals] is to ensure health and survival. But really. . .it is to enable well-being. And well-being is about the reasons one wishes to be alive.” Gawande examines the cracks in the system of health care to the aged (i.e. 97 percent of medical students take no course in geriatrics) and to the seriously ill who might have different needs and expectations than the ones family members predict. (One striking example: the terminally ill former professor who told his daughter that “quality of life” for him meant the ongoing ability to enjoy chocolate ice cream and watch football on TV. If medical treatments might remove those pleasures, well, then, he wasn’t sure he would submit to such treatments.) Doctors don’t listen, Gawande suggests—or, more accurately, they don’t know what to listen for. Besides, they’ve been trained to want to find cures, attack problems—to win. But victory doesn’t look the same to everyone, he asserts. Yes, “death is the enemy,” he writes. “But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee... someone who knows how to fight for territory that can be won and how to surrender it when it can’t.” In his compassionate, learned way, Gawande shows all of us—doctors included—how mortality must be faced, with both heart and mind. – Sara Nelson

The current healthcare ‘system(s)’ has an enormous number of virtues but it is fundamentally broken and broke. I say the SYSTEM is broken and broke – not those who populate it who are people for whom I have and have always had enormous respect and admiration. It is these people who can make it right if given the freedom to do so.

BUT, enough of all that!  It’s soon to be the Festive Season so to my reader (is there still just one of you?)

All the very best for this special time of year.

Peter Carter
Chief Executive Officer
December 2015

Bioethics Research Notes 5(3): September 1993 ROGERS V WHITAKER: DUTY OF DISCLOSURE By Arlene Macdonald
Being Mortal: Medicine and What Matters in the End. Hardcover – Deckle Edge, October 7, 2014 by Atul Gawande
Sara Nelson Amazon Editorial Review of Being Mortal.

Monday, 2 November 2015

La Liberté d’Imaginer: La Nécessité d’agir


I used to worry that what I write today might be at odds with what I wrote six or 12 months ago; now I worry that what I write today might not be at odds with what I wrote six or 12 months ago. The point being that the world moves on, and the world of healthcare quality and safety moves on with it…or even faster. I also think that we all have a prerogative, perhaps even a responsibility, to change our minds, to shift our positions. In politics, if it were not for the so called ‘’swinging voters’’ there would never be changes of government and we would all be the worse for that.

So, after I finish this BLOG I do not propose to check that my thoughts today align with my thoughts of yesterday.

Hence my theme.

China’s President recently visited Great Britain and much fuss was made of the visit. In his address to a joint sitting of the Commons and the Lords, President, Xi Jinping, quoted Shakespeare, specifically The Tempest Act II Scene 1 in which Antonio is trying to persuade Sebastien to kill his father the King so Sebastien can be crowned……. ‘What’s past is prologue’, he says to the impressionable Sebastien, his point being that what has gone before creates an inevitability about what we must now do………all that has gone before is just preparation for what must be a different future.

While we might not like what Antonio was up to, his rationale is ‘right on’ when it comes to healthcare and the future we face.

If we just ‘keep on keeping on’ in healthcare we will:
  • Run out of money
  • Age unhealthily
  • Have to make frightening choices as a society and as individuals about who we treat and who we do not. For instance, it may be that a child born today will only live past 70 if he/she remains well, we may choose to treat only the so called ‘productive members of society’ with our limited resources rather than those not creating wealth.
  • Fail to apply the latest treatments and technologies.
  • Miss the whole point of the patient journey and patient centered care.
  • Continue to try and make sick people, usually acutely sick people, well instead of stopping them getting sick in the first place.
Rather than go on, let me summarise the paradigm shift that is necessary if we are going to have any hope of making healthcare delivery possible in the future and of continuing to deliver safe, affordable quality care.

Frost & Sullivan

Or as Professor Angela Brand, Coordinator of the Public Health Genomics European Network (PHGEN) at the University of Maastricht and Director of the European Center for Public Health Genomics puts it, the basic building blocks of future medicine will be:

Predictive = predicting disease

Pre-emptive = preventing diseases

Personalised = highly precise personalised diagnosis and treatment

Participatory = patients play an active decision-making role in their health care.

I will reciprocate President, Xi Jinping quoting Shakespeare by quoting a Chinese proverb:
前人栽树,后人乘凉 “One generation plants the trees, another enjoys the shade”

Well, where healthcare delivery and healthcare quality and safety is concerned we had better start planting some forests because time is running out.

There are a number of reasons for us reaching this current position, where we are clearly heading for a fall, and soon.

One is the tyranny of the political cycle.

When did you last see a politician make a decision about anything that did not have a direct bearing on returning her/him to office in an election just months away? So it is not surprising that in the lead up to an election politicians focus on visible and popular themes like reducing waiting lists. Noble enough a quest, but the way they do this is by throwing money at half-baked schemes that might impact until after the next election then everything falls back in a heap. How do you really reduce waiting lists?………preventative medicine, stop people getting sick in the first place. BUT, that is not what the public, aka voters, want to hear because it will not impact for maybe two decades. BUT WHEN IT DOES IT WILL BE A CURE, PERMANENT, NOT A QUICK FIX OR BANDAID.

So how do we break this insidious cycle?

Is it possible to contemplate healthcare policy being formulated independently of politics? By a statutory body perhaps? But this usurps the proper political process, doesn’t it? Desperate times call for desperate measures and I am not overstating how desperate the future of healthcare delivery is if we do not take bold steps. If we do not remove healthcare policy from politicians we will need bipartisanship to achieve any serious long-term future planning and given the, by and large, schoolyard approach of politicians to any sense of bipartisanship, I wouldn’t be holding my breath on this one. The problem is, removing any major program from the political arena and placing it in the hands of an appointed rather than elected forum starts to erode the very tenets of democracy.

So, if the partisan politicians are incapable of taking a longer term approach to remodelling healthcare, if bipartisanship is highly unlikely, and if a statutory approach starts to look like dictatorial control, where does that leave us? Perhaps it is up to bodies like ISQua and the organisations to which you belong and to you and me to continue to fight the good fight and hope for a miracle.

Peter Carter
Chief Executive Officer
November 2015

Friday, 24 July 2015

"La liberté pour Rêver"

“Health is an eternal theme of humanity – and a strong, healthy and sustainable society is our common pursuit. So let us dream, but then let us return here to earth to do the work that is needed to attain health and harmony at home." Minister Chen Zhu, Minister of Health, China, 2013.” (2)

‘Opening a window to the future….
It is a warm Wednesday in January 2050 in Santiago. The newscaster is reporting the latest performance figures for the city, and Ana frowns as she hears that wellbeing and air quality have both dropped a few points. In the centenary year of the landmark Doll and Hill study on smoking and lung cancer this is not good for public relations! She makes a mental note to discuss this with the City Forum later in the day. For now she has to prepare for a visiting delegation from Tokyo, Lagos and Los Angeles who have come to finalise the protocol connecting the electronic data and remote sensing systems for maintaining population health across their megacities. Ana has kept in touch with them online in the peer to peer learning platform as they all connected years ago to the same cyber‐ engineer supporting their 3D vaccine printers. With Saito from Tokyo, Meng from Lagos and Raul from Los Angeles she had many long debates over the years on issues ranging from how to rebuild solidarity, to what the priorities should be for planetary health. She can’t wait to see them again!’ (2)

Opening a window to the present….
It is a warm Wednesday in ‘outback’ Australia, 2015.  A world away from Santiago 2050. The sheep are ‘full wool’ and need to be shorn. The air is pure and fresh and the skies are clear.

So what brings us from the bucolic ‘outback’ scene to the apparently inevitable and inexorable journey to the perils of 2050? Many things and they impact both directly and indirectly on healthcare.

Chief amongst them is the ageing of the population. This does not just burden healthcare and healthcare resources directly but indirectly as it places pressure on the environment – where in the future will water come from, what will we breathe if we have no forests and if the atmosphere we live in is dense with harmful chemicals?

We face a future characterised as follows:
  • ‘We will live longer lives, with greater possibilities for healthy ageing’ (but a danger of unhealthy ageing). ‘; 
  • We will be more urbanised and interact more with artificial intelligence;
  • Climate change and scarcities of energy, water, biodiversity and food will have a fundamental impact on health and survival;
  • Science and technology will advance rapidly, with linkages across information, robotic, health and bio- technologies, profoundly affecting public health and medicine’.
Amongst the ominous, good things are happening:
  • “In Bangladesh, continuous lifelong, portable, electronic health records are being developed based on unique biometric identifiers assigned at birth as part of universal vital events and health information systems”. Dr Tim Evans, James Grant School of Public Health, Bangladesh
  •  “In Shanghai they have community-based self-help groups organized with government input that help each other in terms of learning how to control their blood pressure and blood sugars, how to live a healthier life, group exercise etc. I think we need more innovative ways to deal with ageing.” Meeting delegate, January 2013 
  • “We need to put health not only in the hands of doctors, nurses, pharmacists or dentists- like many of us here, including me - but health must also be in the hand of the active citizen.” Suwit Wibulpolprasert, Ministry of Public Health Thailand, 2013 (2)
But progress is uneven and dependent on visionary individuals or teams.
  • ‘Large, centralized institutions with top-down, expert-driven thinking may not be the only, or best sites for the ideas, leadership and action for health futures’. (2)
So all this leads me to ISQua’s own humble attempts to shift world thinking about how to shape our healthcare future. In two months a group made up of the world’s big thinkers and clever thinkers will tackle this problem. The ISQua Innovations and Systems Change Working Group has invited these people to take part in a workshop at the ISQua Annual International Conference to talk about shaping the future of healthcare.

There will be around 30 in all brought together for a day to share information about how their various countries and people are understanding and planning for the inevitability that if we keep delivering healthcare the way we are currently delivering it the system will crumble under the weight of an ageing population with expensive comorbidities and a deteriorating environment. We will be faced with unpleasant and unthinkable choices such as who to treat and who to leave untreated. But the option of not thinking about these things is not open to us.

In addition to gathering information of how healthcare is delivered in different countries and innovative approaches to this, amongst the questions to be addressed are:

1. Does your government and do your healthcare authorities recognise an ageing population as posing a threat to future generations’ wellbeing?

2. Do you consider the ageing of the population to be a problem in your country? If so how will this manifest itself in your context? If not a problem why is it not so?

3. What are the consequences of the ageing of the population in your part of the world?

4. What if any steps are being taken by government and healthcare authorities in your country to address the problems of an ageing population?

5. Do you consider the steps being taken to be appropriate/adequate (if not, why not)? How might you approach this differently?

6. Is there any recognition in your country of ‘the patient journey’ as a means of improving healthcare quality and redistributing the cost burden?

7. Is it sustainable to continue to focus on hospital care as a means of addressing healthcare needs, especially in the light of the ageing population? What are the alternatives?

8. Would a shift to a primary care focus (or homecare focus) ameliorate the burden imposed on healthcare delivery as the population ages?

9. What do you see as possible solutions to the future challenges facing healthcare?

The future cannot be the same as the past.
We must start to address these issues now before we are so overburdened and overwhelmed by the immediacy of the problems that will surely come that we are powerless to deal with them.

The work we do now may ameliorate the problems for us but, importantly, may provide a better future for the people of 2050 such as those in Santiago we were introduced to at the beginning of this story.

前人栽树,后人乘凉 “One generation plants the trees, another enjoys the shade” Chinese proverb.

Peter Carter
Chief Executive Officer
July 2015

(1) "La liberté pour Rêver" and "La liberté pour parler" are essays written in French by French Nobel laureate J. M. G. Le Clézioand translated into English as "Freedom to Dream" and "Freedom to Speak" and published by World Literature Today .
(2) Dreaming the Future of Health for the Next 100 Years White paper from the Global Health Summit Beijing China, January 26-27 2013

Friday, 5 June 2015


Education must be not only a transmission of culture, but also a provider of alternative views of the world and a strengthener of the will to explore them.
Jerome Bruner

This is the view across the Dublin skyline from my office window. Dublin is a low-rise city.
Describe to me what you see.

I asked a number of my staff to do this and no two descriptions were the same…in fact no two descriptions were remotely alike. What we see when we look at a view is a product of many things including:

  • What we are doing at the time;
  • How much time we have to dwell on the view;
  • What’s on our mind;
  • How we woke up that morning;
  • Our upbringing;
  • Our education; and 
  • What we are looking for.

In the case of one of my staff it was a case of ‘What’s he on about now!?’ When I explained it was an exercise in preparing me for my BLOG all was forgiven (maybe not!).

In this view I see history; values; economics; political impulses; imperatives; restraints; constraints; hope and hopelessness. I also see beauty and ugliness.

The humble community housing in the foreground, named in honour of one of the heroines of the 1916 Easter Rising, Countess Markievicz, is overshadowed just a few blocks beyond by the glass edifices of the Ulster Bank HQ – a legacy of the Celtic Tiger years of excess. Just out of shot to the left is one of the world’s most prestigious universities, Trinity College and in the shadow of Trinity is the house in which Oscar Wilde was born. Just out of shot to the right is the Sean O’Casey Bridge over the River Liffey, which is a fitting tribute to the writer who had his own take on life:

I have found life an enjoyable, enchanting, active, and sometime terrifying experience, and I've enjoyed it completely. A lament in one ear, maybe, but always a song in the other.

And then, not such a fitting tribute to another great Irish writer is the building from which this photograph was taken, which houses the ISQua Offices, Joyce House, which would be an appropriate honour for the great man if the building had any prepossessing or redeeming features which, alas, it does not. Then Joyce himself had quite a different view on life:

“All Moanday, Tearday, Wailsday, Thumpsday, Frightday, Shatterday.” 

I could understand Joyce feeling this way if he ever had to live in Joyce House.

So, where is this all leading?
I think it is celebrating diversity. The Irish have become good at that in recent times having been not so good at in the past – witness a plebiscite on Gay Marriage a few weeks ago that was carried by a majority of over 62%. Yet, even when divorce and contraception was illegal in Ireland, not so long ago, Ireland, as always, was producing permissive writers such as the aforementioned Wilde, Casey and Joyce.

This BLOG is getting away from me a little and I am finding it difficult now to link it to what I want to talk to you about, being the new ISQua Vision, Mission and Values.

But, perhaps not.

Take the word ‘transformation’ in the Vision, and the Values of Transparency, Integrity and Ethical behaviour and……..wait for it……DIVERSITY.
These are nothing if not permissive values.

And why should not healthcare embody and encourage such important values. In fact, when one considers the challenges that are bearing down on healthcare now, and particularly those that will do so in the future, how can we continue to deliver high quality healthcare if we do not embody such values?

Now, what I really wanted to do with this BLOG was to issue an invitation to you. The ISQua Board needs to know what you think about the new Vision, Mission and Values before we lock them in as our guiding principles for the next three years.
I have reproduced them below in case you can’t read what is written on the staff kitchen white Board (or in case you mix them up with the Plant Watering Roster which is scribbled right next to them).

Be the leader of transformation in healthcare quality and safety globally.

To inspire and drive improvement in the quality and safety of healthcare worldwide through education and knowledge sharing, external evaluation, supporting health systems and connecting people through global networks.

TAG Line
Inspiring and driving improvement in the quality and safety of healthcare worldwide.

Priorities 2016 – 2018
External Evaluation, Events, Education & Knowledge Sharing, Person Centred Care, Innovation, Global Regions.

Transparency, Integrity, Diversity, Ethical, Excellence, Evidence Based

So please, be in touch to tell us whether you think your Society is on the right track

And the last word to Mr Wilde……
Questions are never indiscreet, answers sometimes are.

Peter Carter
June  2015

Tuesday, 7 April 2015

Message from the Cheap Seats

Margaret Thatcher did not leave us too many quotable quotes over which to marvel down the years but there is one that is particularly memorable.

When asked about being powerful, Baroness Thatcher said:
‘Being powerful is like being a lady; if you have to tell people you are, you’re not’.

It is the same for those who tell people they are ‘a visionary’, ‘a supermodel’, ‘a leader’, ‘a thinker’.

Believe me, if you are these things we (in the cheap seats) will know. If you feel a need to tell us you are something special, it is almost certain you are not.

The Beatles never described themselves as a ‘supergroup’, others did that. But when hit with a UK Supertax on their earnings George wryly observed, ‘since we have been told we must pay a supertax then maybe we are a supergroup!’ Then he went off to write arguably his best song, ‘Taxman’ which further cemented the Beatles supergroup status.

In a classic experiment conducted in the mid-eighties, 100 undergraduates, divided into same-sex pairs, participated in two unstructured conversations spaced one week apart. In the second session, one subject of the pair was asked to participate either as an ingratiator or as a self-promoter. After the second conversation, ingratiators were rated as more likable but no more competent, and self-promoters were rated as less likable but also no more competent than in first conversation. Naive target subjects clearly recognised presenters attempting to appear competent and reacted negatively to them.

Confirmation that self-promotion doesn’t work. And what’s worse, it’s even less effective than ingratiation, and everyone hates ingratiation!

From time to time I will have a staff member who has produced an elegant piece of work complain to me that a colleague or a superior has taken credit for it. My response is: ‘Those who matter know, and those who don’t know don’t matter’ (and if this doesn’t happen through ‘Karma’, then we make sure it happens through other means!). One cannot pass oneself off as something one is not for very long and get away with it, nor can one claim someone else’s work as one’s own and get away with it. We who have been around for a while, or even if we have just arrived on the scene, know what’s what and who’s who.

A frequent question from the mentees I attempt to help with their development is ‘how do I get on’. This often includes asking me how to promote themselves. My advice is, be measured. Present yourself honestly and openly through your genuine achievements and impress people with your energy and ambition and excitement in what you are doing and what you are hoping to achieve; get out there and build a network, learn from it and give back to it. We in the cheap seats can immediately see an overstated CV or bio for what it is – inflated; the self-promotion is blindingly obvious, and CVs and bios that are written that way are quickly consigned to the waste paper basket. Similarly on websites, in blogs, on Facebook, LinkedIn and wherever, those who are trying to make a silk purse out of a sow’s ear, or to portray achievements as more than they are stand out like the ribcage of a racing Greyhound.

Maggie Thatcher did not have to tell people she was powerful, we all got that as we get that the Beatles were a supergroup; her mere presence and their wonderful music did all the talking for them.

So, relax, do your good work, we in the cheap seats will notice you and we will promote you.

Peter Carter
March 2015

Self-promotion is not ingratiating.
Godfrey, Debra K.; Jones, Edward E.; Lord, Charles G.
Journal of Personality and Social Psychology, Vol 50(1), Jan 1986, 106-115.