A Festshrift gives us the opportunity to look both backwards and forwards. Ken Donald?s career stretches back to his intern days in 1963 and has encompassed clinical and population health, academe, clinical settings and the bureaucracy, and playing sport at state and national levels. There has been considerable change in the health care system over the period of Ken?s involvement in the sector with more change to come ? where have those changes left us? This paper discusses these changes in relation to performance criteria.