The 'Dispatched' Podcast
BioPharmaDispatch - discussing the issues impacting the Australian biopharmaceutical and life sciences sectors with Paul Cross and Felicity McNeill.
The 'Dispatched' Podcast
The Dispatched 'Week in Review' - 3 October
We open by marking Yom Kippur and a frank discussion before pivoting to the US 'MFN' drug-pricing moves, what they could mean for Australia’s PBS, and why institutional rigidity in HTA persists and is worsening. Medical research funding rhetoric versus slow progress in PBS and health technology access, hospital funding and NDIS pressures, and the expansion of pharmacist prescribing, as well as the need for subsidised pharmacy services.
Hello and welcome to the Dispatched Podcast Week in Review. It's Friday the 3rd of October. My name's Paul Cross. I'm delighted delighted to be joined by my cohous, Felicity McNeil, PSM. Hi Felicity.
SPEAKER_00:Hi, Paul. Lovely sunny day with lots of wind and no flying and long weekends.
SPEAKER_03:I know it's not a great day for general aviation because it's not been a great month. It's been so windy that it hasn't been a great time to get the little Piper Warrior up and about. The fancy new avionics. So close, so close to getting that. But but it's been an interesting week. It's Yom Kippur this week. Yeah. Which for those of you who don't know is the holy day of the Jewish calendar. It's the Day of Atonement.
SPEAKER_00:Yes, and people have decided to use that very important day in your Jewish calendar to once again show that we have a big fight against anti-Semitism both here and globally, and I'm really sorry.
SPEAKER_03:Yeah, uh the events in Manchester is just heartbreaking. I d I don't want to spend too much time on it, but uh can I just say that this did not start on October 7, 2023. There have been armed guards at synagogues and Jewish schools for as long as I've been alive in countries like Australia. Uh if you walk past a synagogue now, there are armed guards. There's just more of them than there used to be. Let's not accept the idea that this anti-Semitism is in response to events of the last two years, which by the way were triggered by the mass slaughter of Jews, including hundreds of people at a dance festival.
SPEAKER_00:Yeah, I think um I mean sitting opposite to you in a podcast now for two years uh since October 7th happened. And one of the things I have struggled to come to terms with is that from the outset you said people have always hated us. There's always been anti-Semitism, and I had not understood that because obviously I'm not anti-Semitic. A lot of my good friends are Jews. But I'm making light of something but I'm really serious about it, which is it never occurred to me that it was so prevalent in the community that it was just bubbling below the surface. I didn't understand for you and your community, and whether that's here in Canberra or those of our friends in in Melbourne and Sydney, how just below the surface it really was, and how naive I was to that. And it seems that October 7th has set free the people's right to express that as opposed to shout it down. And I'm really sorry because people like me should be doing more and should have done more and should have listened more to the fact that this was something that you were dealing with on a daily basis, but we just couldn't see it.
SPEAKER_03:And and Jewish people have, well, in Australia but in other countries, have managed this, particularly and and and unless the the show uh in in World War II uh was just the latest example of anti-Semitism dating back two and a half thousand years. We've been repeatedly colonized and recolonized in our ancestral homeland by virtually everyone. By virtually everyone. So this is not a new experience, it's not a new experience at all. In Great Britain, it's been particularly bad. I mean, remember when Jerry McCorbyn was leading the Labour Party, he is an absolutely disgusting anti-Semite. A lot of what we see now is a manifestation of the sort of language he used, and unfortunately, some Australian politicians use some of the same language. And none of these people have been to Israel, none of them understand that it's the only democracy in the Middle East that Arabs can vote, that Christians can vote, that they have all the same rights. In fact, in many ways, people don't understand this. If you're a Jew in Israel, you are required by law to serve in the IDF if you get conscripted. Arabs have the option. Now, a lot of them choose to do it. If you go to the brigades now fighting in Gaza, they'll include Arabs and Christians.
SPEAKER_01:Yeah.
SPEAKER_03:People don't understand it. I'm not saying everything is perfect in Israel, in the same way I would criticize Australia, I would criticize Israel. The absolute nimrods in countries like Australia who wear these terror rags that they buy off Timu, and the sort of language they use, it's just I it's like they're affected in some way. This hatred that they espouse is not because of the last two years. This is a hatred they've always embraced.
SPEAKER_00:It's just now they have a platform. Well, well an acceptable platform, it seems, to be able to demonstrate this.
SPEAKER_03:Well, the Nazis that are Hamas, and they are Nazis, let's just be clear about it. They they share all the same ideology. They are a product of the Muslim Brotherhood and effectively an offshoot of the PLO. Okay, and who did the PLO back in World War II? It was the Mufti of Jerusalem who spent World War II in Berlin. We are fighting for our existence as a people, and we have been doing that for two and a half thousand years. So you think a couple of demonstrations in Sydney and Melbourne and London are going to distract us from that? We're in this for the long haul, people, and that's probably going to disappoint you, but we're not going anywhere. We are not going anywhere. We are an incredibly resilient people. You need to get your head around that, that we are here. And we are not going anywhere. And if you don't like that, I literally don't care what you think. Because we fought everyone throughout our history. Because we've had to. This is the oldest prejudice in human existence. And sorry, I'm getting emotional because it's been a very difficult 24 hours.
SPEAKER_01:It has.
SPEAKER_03:And it's going to be a very difficult weekend because these idiots who are going to demonstrate. And none of them are going to say, geez, I wish Hamas would sign that agreement that's on the table. Because all the language, you know, and even if they do sign it, you know they're not going to adhere to it. And so they won't be calling for Hamas to surrender and stop the suffering. They want the suffering to continue because of these idiots who get these terror rags and wrap them around their heads. And you know, there's nothing worse, honestly, when you see some 65-year-old white woman walking the street with one of these terror rags. And you know me, I say things to them.
SPEAKER_00:Yes, you do.
SPEAKER_03:I'm not very I'm not very polite. Because I'm just I'm just fed up with it, and I'm not I'm not frightened. I'm not I'm not going to be frightened, but sorry, that's a lot of time uh talking about something, and I always get abusive emails after I do this, and you know what? Bring it on.
SPEAKER_00:Yeah, and bring it on. Well, people shouldn't be giving you abusive emails, and that is part of the problem here, which is if you want free speech, people, then you've got to allow it to to be said. But more importantly, you shouldn't have you shouldn't have to be continuing to defend this and the the lack of respect for the lost lives on October 7th and the blind focus of individuals and groups to focus on to support something else as opposed to that is a day of incredible suffering. And again, to attack a community on their most holy day. I mean, if you were Christian and someone did this to you on Christmas Day or Good Friday, you would be mortified, you would be horrified, and we would be shouting from the rooftops that this is unacceptable and things need to change. But we don't have that moral leadership in anywhere at the moment, really, that provides a safe space for everybody to practice their religion, practice and protect their own people.
SPEAKER_03:Look, it's terrible what's happening in Gaza.
SPEAKER_00:It is.
SPEAKER_03:Absolutely terrible. It's it's heartbreaking, which is why Hamas should surrender. Surrender and it stops tomorrow. If they gave up the hostages, if they gave up the hostages on October 8, there's no way the US would have allowed Israel to go into Gaza. So you know, I don't know why Bibi apologised for the attack in Qatar. Because I think that the that's that's been a you know a wake-up moment for the Qatari leadership to say, uh, you know, because that is a that's a that's a state that sponsors terrorism. So you have these Hamas leaders and their Nepo babies living in these six-star hotels just pocketing all these billions of dollars in Doha while the Gazans suffer.
SPEAKER_02:Yeah.
SPEAKER_03:And so okay, that's 10 minutes of that. But I also do want to say that I also get a lot of very nice feedback from people. I got some very nice text messages this morning from people who knew how affected my very small community. Like you know, 15 million people globally.
SPEAKER_02:Like, who are we a threat to? Honestly. There's a hundred thousand maybe in Australia? Maybe who are we a threat to?
SPEAKER_00:Uh onto something much lighter. MFM.
SPEAKER_03:Yeah, well that isn't that interesting. Um I thought the agreement with Pfizer between Pfizer and the Trump administration was interesting because it it sort of put a a a fence around it indicated what the administration was willing to accept. And on the surface, from what we know, there's not a lot of detail. Most of it's confidential, but what has been reported based on what has been announced and briefed, is that the MFN price, designated price, is for Medicaid programs in the US, which are government programs, which are jointly sort of funded funded by uh the US government and the States, and that's about 20% of the population. So And in return, Pfizer gets access, priority access to that super fast FDA approval process, which I which I think is that that's probably good news for countries like Australia and New Zealand, I suspect. It just depends. Well, as my most things with the Trump administration, there's the stated ambition and the what actually happens, and that there can be a they use the stated ambition as a negotiating tactic, and then the actual outcome is a is a little less than that.
SPEAKER_00:So So you're saying that the Australian government gets to just sit back and go, nothing to see here, guys, let's keep the PBS as it is?
SPEAKER_03:Uh yeah, potentially, yeah.
SPEAKER_00:So that would be a loss for patience, actually. So we've just been sold down the river.
SPEAKER_03:Well, I d I don't know. Because I we we don't know what how they're going to use this MFN price. There has been the Wall Street Journal reported a list of countries, but the language was very strange. Australia wasn't in this quite small list, but the paragraph was to the effect the MF MFN price is going to be established based on a basket of countries, including, and they're all European countries, I think. Maybe Japan was in there, but it including could is one of those words that can be defined.
SPEAKER_00:Including, but not limited to yes, yes.
SPEAKER_03:We've got seen that one on. So but I think it's start I think it's starting to take shape. Now how it impacts Australia, I don't know ultimately. I don't know. I I like you actually see it as an opportunity. Uh of course, whilst we live in denial of the relationship between price and access, time to access, which we have we we are in this very little strange little world where we deny the relationship. Uh that if we actually were willing to pay more, we would get access much more quickly.
SPEAKER_00:And to things that don't even come here now. But look, um it it does it will be sad for the patient community if Australia isn't on that list, because nothing is going to change in the PBS other than a what is it, a HTA guidelines update.
SPEAKER_03:We'll get to that.
SPEAKER_00:The nothing will change because, you know, as you've been writing about this week, it is an entirely captured, insular-looking, talk to the same people system. And unless something extraordinary like MFN demands Australia, like I hope every company representative here in Australia is talking to their US counterpart saying, please, please, please insist that Australia is put on to that list, because it's only when we're on that list that we are finally going to be able to tackle the genuine issue of lack of timely and lack of affordable access to medicines in Australia via the PBS.
SPEAKER_03:It's a point well made. I I did report this week that companies are submitting higher prices. Now, what we don't know is that are they claiming cost effective or you know, is it the price they want, or is an SPA we're willing to then rebate that? We don't know. And and speaking to people in industry this week, I think there's not a single approach. Obviously, companies can't sit around the table and say this is how we're going to handle pricing. There's some legal issues there. Of course, the government could ask them to do it.
SPEAKER_01:Yes.
SPEAKER_03:Uh, and then they'd be protected. And that may not be a bad idea, but companies can't proactively agree amongst each other how they're going to submit on pricing. So that that is a bit of a challenge because all the companies are going to approach it differently. And I suspect for some MFN is going to be a much bigger issue than it is for others. So we'll we'll wait, we'll wait and see. But uh you know, it it in a way it's anything that that has the potential to change, alter the direction of the conversation in Australia. I mean I've written this week extensively about institutional rigidities uh based on a French sociologist, Michelle Crozier, who wrote a book in the 1960s, which essentially posited that the institution instinctively seeks to progress its own interests.
SPEAKER_01:Yes.
SPEAKER_03:And it's it particularly in bureaucracies, its own interests is its own interests. It's not necessarily the people it serves. So in our health technology assessment institution, if you break it down into insiders, and I'd call them the gatekeepers who struggle to see beyond the gate, and all the outsiders who act in different ways. Uh the institution, something like the HTA review, uh, which was an example of the institution review in itself, and and it decided that it was world class, they they see it as a legitimized legitimizing their processes and what they do. So they tend to add layers of complexity. And I use the example of the submission pathways work over four years that was designed to streamline the listing process, but it sort of double cost recovery fees and listings now take longer than they did. And I argue that well, yeah, because as Crozier said or argued these processes, these big bang review processes tend to add complexity. And it and whilst they're ostensibly presented in really rigid terms, that this is the process you have to go through, because in an institutional framework those inside the institution have the all the power, it gives them to discretion, gives them the discretion to to work within zones of uncertainty. And HTA is really, really a great example of that, where uh layers upon layers upon layers of new process create enlarged zones of uncertainty and give more power to the institution. So my argument is that, and as Crozier said, unless you're changing the the institution big bang review processes or reform processes are only going to make it worse. They make they make the problem they they are intended to fix much worse.
SPEAKER_00:Yeah, it's uh I mean you and I've talked about it. We've been in the system and outside of the system, and I think one of the the gifts of stepping away is that you can see, and you can see at times when you captured you were captured yourself, and there are times that you can see when you were steering. And I think that it's why I'm very concerned about the MFN fizzing out, is because without that great moment of disruption, the system will just continue to command and control the stakeholders within it. And and I watch all the postings and I watch all the materials and I listen to people talk, you know, that I get the same as you. They tell you privately what they really apparently think, and then they walk into a room and do something completely different because you know they want to stay at that table and they want to stay part of it. The system makes being part of the system the goal, not actually the access to the the medicines.
SPEAKER_03:Well, I described it as like a loyalty programme, it's like a frequent flyer program.
SPEAKER_00:Yes.
SPEAKER_03:You know, you get rewarded for exhibiting loyalty, and it it's a horrible cultural characteristic where you know, and I I I you know you saw this at at Farm Oz when Mark Butler announced the review of the review. Now he would have been told by the institution, they're gonna welcome this. They're absolutely gonna welcome it. I mean, but but clear as day, updating the wording on comparators and the discount rate's gonna make it worse, not better.
SPEAKER_01:Oh, yeah.
SPEAKER_03:Because it's just gonna add complexity. But but because that's the point of the process, is to add complexity. And not no at no point in the history of this program has there ever been one of these processes that has ever simplified and made it easier. It's always added complexity, and it's never looked at the power structures within the framework, and that's really what we've got to go to. But when Mark Butler announced that, the institution, because that's who he talks to, they would have said, Oh, this is you know, this is what they asked for, Minister. This is great. And so what you had that night, you had some people clapping because, well, they're part of the institution, so it's good for them. Yeah, you had others clapping because, you know, it's that sort of North Korean, if I if I don't clap here, I'm gonna get taken out of the back.
SPEAKER_00:So someone will see what I'm saying.
SPEAKER_03:So I I have to be seen to be clapping. And then you had, you know, me burst out laughing, but then you had genuine dismay amongst patients. I mean, they were genuinely upset. I spoke to them there. They were confused. Though it was they ranged from absolute confusion to dismay and defeat and disillusion. Because they've been gaslit.
SPEAKER_00:They have, and I I I've experienced also in the lead up to Parliament next week a number of patient groups who are telling other organizations, oh, just just be nice to the government. No, we we we don't we don't brief against them, we don't talk to the opposition. Everyone's got to play nice. We know we we never do that. That that's you shouldn't you shouldn't encourage them to challenge.
SPEAKER_03:Like, we're we're gonna effectively lobby by not lobbying.
SPEAKER_00:I was gonna say, have have you met me? Have you have you heard my rights? But um it it's also the the irony of this is I want to read you a post. Okay, and then you can guess who it's written by. Medical treatments with potential to help millions of people have missed out on critical research funding, as funds allocated to the Medical Research Future Fund are not being spent. Hundreds of medical research proposals have gone unfunded at Monash University, including proposals for developing optimal intravenous treatments for children with asthma, best practice care for traumatic brain injuries, or prevention of post-surgical infections. So many people could be helped by unlocking this funding. World class research makes all our lives better, longer and healthier, if it actually leads to funding. Health and medical breakthroughs are many years and often decades in the making because of the rigor and complexity of science, and to ensure that treatments are safe and effective. Underfunding research now would mean we miss out on critical treatments in the future, and our communities will suffer needlessly as a result. This is an easy fix. Let's release funds already available in the MRFF to our world-class researchers so they can get on with their important work. Who do you think wrote that?
SPEAKER_03:I know there's been some members of Parliament who've been talking about the what I what I think is a very sensible move to to cap disbursements under the MRFF for a limited period of time to protect the capital base.
SPEAKER_00:That's just sensible, is that so this is so that we can in many years and decades live a longer, healthier life, right?
SPEAKER_03:Makes sense.
SPEAKER_00:It would require accessing money to actually purchase those products once developed, correct?
SPEAKER_03:Well, far more important because none of those none of those things are going to become commercialised products because they're MRFF. It's going to be because of invest shareholders in pharmaceutical medical technology companies.
SPEAKER_00:So this post got uh 221 likes and lots of comments. And do you know why? Because it's by the chair of the PBAC.
SPEAKER_03:You're shitting me.
SPEAKER_00:No. So the chair of the PBAC is seriously concerned about the future of access to health to live better, longer, and healthier for care for children with asthma and best practice for prevention of post-surgical infections. So could we just talk about the delays in releasing money under the PBS? Cognitive dissonance flipped. On the delays in actually accessing medicines that actually improves lives. That's a remarkable post. It's like left brain, right brain? I I don't know. You know, when when people do that um thing where they pretend for you know that too much, too little, and they they flip around to be one side versus another. I'm sorry, you can't make that post. You cannot make that post in all seriousness and good conscience, whilst you are part of the problem that it continually delays access to medicines. So apparently it's going to show that they're safe and effective. Well, I'd like to remind the chair of the PBAC that she is looking at medicines every three months that are safe and effective, and she still says no. Well, every month, really. Maybe she should just research.
SPEAKER_03:Well, this is this is interesting. I think it's interesting that sorry to make it personal, but it is personal.
SPEAKER_00:If you put that out there, we have to have this conversation.
SPEAKER_03:It's a very it's a very political post.
SPEAKER_00:Mm-hmm.
SPEAKER_03:It's a very political post. I wonder how the minister feels about it. I think the cap on disbursement disbursements was a sale through the parliament, is my understanding. Yeah. Because it was based on advice that we just need for three or four years, I think it's just for four years, isn't it? It's not permanent. We're going to cap the annual disbursements at I think 650 million or something to build the capital base of the MRFF. So it's only temporary.
SPEAKER_00:Well, it's not when we did it with a future fund. We've hit a point.
SPEAKER_03:Like, let's not just spend everything like just this is like it's not free money, Pete. That is being run effectively like the future fund, is my understanding, as an investment vehicle. So I actually think it's very sensible to get the base going. I mean, look at the future fund. I mean, that's it was just a brilliant policy. And I think the MRFF will be remembered as a really, really good policy, but I I I've I I think that's a really interesting line for the PBAC chair to cross.
SPEAKER_00:Yeah. Big time. Uh now And I I'd like to, you know, instead of that, you know, for for research, if if we've got one of the problems I do have with the MRFF is that we took money from the healthcare system to establish that.
SPEAKER_03:Well all of it. It was taken from public hospitals.
SPEAKER_00:Yep. And the PBS. So my my question is is that perhaps you know the PBS could now have um a separate bucket and we could assign that you know$200,$300 million a year from the MRFF is going to fund, you know, the breakthrough molecules.
SPEAKER_03:Well, clinical trials, which is what MRF is funding a lot of, is not access because it's inequitable. Not everyone gets access, some people get placebos. It's it's not it's not access. These are investigative therapies, most of which won't progress. Okay, because because I'm sorry to have to tell everyone that the reality of developing healthcare innovation is based on the commercial opportunity. Not one health technology, the MRF, funds, will progress as in into a into sort of any kind of uh approved therapy in the absence of a shareholder or investors going, we think there's a commercial opportunity here. And that is entirely 100% based on the opportunity in the US market.
SPEAKER_00:Yeah, and I I think it's also quite funny because this is also saying politically and publicly that research into molecules and to healthcare can take decades. And yet that is something that the PBAC and the PBS sets aside and goes, no, no, no, you know, you just you're just rich companies and you just this you're gonna make a fortune out of this, so stop trying to to cream it from us all. So I guess for me is that I I read the comments and all the likes.
SPEAKER_03:Oh, yes. I've got something before the PBRC, I better like this. There would have been a bit of that.
SPEAKER_00:Um but my issue is there's no comment in there, and and I've held off saying it, which is if you could apply that same focus to your evaluation of medicine-seeking listing on the PBS or diagnostics and technologies through MSAC, we would have a much healthier Australia. So but not one person's called it out and said, could could you see that the same way in in your day your your second full-time job, the the the PBAC? And I I think that question needs to be asked. There is a cognitive dissonance there. It's just do as I say, not as I do. I'm I'm sorry, I I I don't normally identify something specifically about an individual, but this goes to our institution and how it is being administered. And if the chair of the PBAC really feels that way about the MRFF, then I expect to see a different approach to the way the PBAC operates. Because if you believe all that, then the way that you're running the PBAC is not consistent with your value proposition. So which value proposition is the correct one?
SPEAKER_03:Well, and let's let's be blunt. If you applied anything like health technology assessment to what the MRFF invests in, you'd shut down you would shut it down tomorrow. Please. Yes. Yeah, you would like you would say Well, virtually none of this is going to progress. Okay, because and the only reason it will progress is because someone sees a commercial opportunity, takes it, and then you know, takes it to the US.
SPEAKER_00:Because what do they do? That go, oh, prevention of post-surgical infection. Haven't we done like 4,000 different research projects already on, you know, antimicrobials and infection?
SPEAKER_03:Let's look at this. There is a lot of industrial and health policy in Australia that supports basic research. MRFF is one, NHN MRC is another. Uh the RD tax incentive. Now let's talk about a company called TLX.
SPEAKER_01:Yeah.
SPEAKER_03:Who are a great radio ligand therapy company. I mean, they are, I don't know what their market cap is now, but this is one of Australia's great emerging companies. Uh and they have emerged in nuclear medicine. I presume that at some point they would have claimed the RD tax incentive. They may have even got some initial funding for the research. And they've commercialized this product globally. It's in the US, it's in Europe. And what did MSAC do on nuclear medicine? Started recommending knockoffs cooked up in hospital basements.
SPEAKER_00:And who was the chair of MSAC at the time?
SPEAKER_03:Right, so as one might describe this as policy incoherence, but it's not a it's not a slush fund for medical research or it shouldn't be seen as that. No. Is is that if you want to if you if we want to have some kind of neutrality in how we assess this spending, you know me, I'm a complete heretic when it comes to health technology assessment. I think it's absolutely voodoo most of the time. But let's apply it to the MRFF funding. And maybe we should do like a productivity commission review of the MRFF and see how long see how long it lasts. I think it was a very noble but political creation based on the coalition government saying we want to take back some money from these public health programs, but we need a political justification for it. So then let's let's shift it into into these other health-related areas of medical research. It's very, very admirable, and hopefully the MRF actually does manage to come up with something commercial, but in the end, anything that it invests in early that ends up being commercialized will be because of investors see the commercial opportunity. So it's it's really it's really as simple as that. And the commercial opportunity will be assessed based on the US market.
SPEAKER_00:Yeah, and what's the other the entrepreneurial one? Is it that through industry that they also pretend and they compete against other like seed investment funds?
SPEAKER_03:Isn't there a lot of there's lot there's lots of them. Yeah, there's lots of them.
SPEAKER_00:That actually go from research to compete.
SPEAKER_03:There's a there's a lot well, yes, yes. I I don't know why, yes, I do know what you this the National Reconstruction Fund.
SPEAKER_00:That's the one, yeah.
SPEAKER_03:The government set up basically a government-funded uh venture capital firm to compete with private investors. It's interesting, but it doesn't make a lot of sense that the government would actually compete with private investor money. I d I don't I don't really understand that.
SPEAKER_00:Well the irony is it it it's like they've almost tried to borrow um the Israel model where they provide seed funding for innovation and then it then it is is is repaid based on you know paying it forward. So it's like they've they've taken that idea. Because I remember governments were looking at that ten years ago, which is that that very innovative model in Israel to actually support new thinking, genuine technical innovation.
SPEAKER_03:The innovation coming out of Israel is absolutely remarkable, purely on pages. Very innovative.
SPEAKER_00:Oh, I walked into that one, didn't I? But uh yeah, look, I I I did just want to raise up because the your um work this week has been very thought-provoking, I hope, for it makes perfect sense to me. I think you and I talk about it all the time, but trying to encourage your readership and your listeners to go back to union like you used to and read the basis of why something is happening.
SPEAKER_03:Yeah.
SPEAKER_00:And to understand the theories behind what happens. It's what it's why we always try to understand history, because to know where someone is going to go, to know how something is going to go in a negotiation, you need to understand the historical patterns of behaviour, the motivations, the way an organization or an institution moves and how it responds to things. If you aren't constantly trying to understand those motivations, um, you know, sometimes you just want to call it game theory. But if you don't want to know that, then you'll continually and perpetually ignorance is bliss, but people are dying.
SPEAKER_03:And I I'm not really interested in criticizing those within the institution. I think they're victims of it. Because they operate with within a very rigid institutional framework. And and it the the inst game theory is a nice way to describe it, but they it's a highly predictable thing, is that any institution always seeks to protect itself.
SPEAKER_01:Yeah.
SPEAKER_03:Instinctively. So when you have a review, well, who are we going to get to review us? We'll get people within the institution, those loyal to us, to review us. We'll do that. That's I mean that sort of thing.
SPEAKER_00:Yes.
SPEAKER_03:So that's so what I would encourage, particularly patients who I think have been real real victims in this process, because they could promise something. And I think the promise was well intentioned. But we were saying four years ago, why are you so excited? We were effectively arguing this four years ago, is that these review processes are not about reforming the process, they're about giving the impression of reform and getting you to agree to something that they want.
SPEAKER_01:Yes.
SPEAKER_03:It's about adding complexity and layers of complexity, which is why the submission pathway reform is such a great example. It is. And it's just the latest, by the way. So I would say that if they're not going to reform the power networks, and I use the example of common law as a quite an obtuse thing, I mean, because it's so old. You know, King Henry II established it, and what a what a character he was. And he had all those dreadful children who, you know, put his wife in jail, jail, a lot of aquitas, and she spent like the last 20 years of her life in prison. I mean, prison for her was like in this nice castle, but you know, King Richard I, like Richard the Lionheart, one of the most famous kings, King John, one of the worst kings. Um but he established the common law. And that's that's a 900-year-old principle that we still live with today. And I talked about neutrality, is that when you appear before a court, your interlocutor, and you know, it could be the prosecutor, it could be the defence, take your pick. They're also not sitting in judgment of the case. The judge is neutral. And if you have the right, you have the right to appeal that, and all sorts of legal processes and principles. And you look at what happened with Tony Mockbell today, obviously, he's a dreadful human being, but his conviction is gonna have to be overturned because it breached a long-standing principle, which is that your barrister can't be informing on you. So that's that that's that's really important. So we have faith in that system, and it's endured for such a long time because we trust it. It doesn't always deliver great results, but we we have rights.
SPEAKER_00:Yes.
SPEAKER_03:And in our system of HTO, we have no rights.
SPEAKER_00:No, as you know, that's why we at BAA have been calling for forever for the PBS decision making and the MBS decision making to be subject to administrative tribunal appeal.
SPEAKER_03:Yeah.
SPEAKER_00:But it's exempted and it shouldn't be.
SPEAKER_03:No, and you don't have the right. So so if you resubmit, the same people review it. Which just makes no sense, really, if you think about it. They uh th the same people evaluate it and and reassess it. And you have no uh real right of review, you can you can trigger the independent review under the FDA, but the PBAC just ignore that. Which is why no one does it anymore. But there's also a fear of a punitive response of standing up for your rights. And if you if you fear a punitive response to you exercising your right, then you have no rights.
SPEAKER_00:Correct. But it's even broader for me, which is as a patient, I have no right of appeal. So I am literally living or dying by the decisions of the PBSC and MSAC. And so if I'm like an R.K. Crosby who sits there calling for a Royal Commission, because she literally does not get access to her medicines because the PBAC says no. So she has to self-fund no matter what happens in that system. She has no right of appeal.
SPEAKER_03:And she's got debilitating conditions which impact her ability to work.
SPEAKER_00:Yes. And she's got nowhere to go. So she can write to a minister who ignores her, she can write to a parliament that ignores you. There is no legal recourse for her or for me. You know, in the medicines I want access to for my family, there is nothing. And yet, I say this all the time, if I was looking for something with respect to the NDIS, if I'm looking at something with respect to social security, if I'm looking to migrate or be a refugee in this country, I get to go to an administrative appeal process. But you don't get to do it for your health care. And when are we going to wake up and say that is simply not good enough?
SPEAKER_03:If you're a convicted murder murderer, you can appeal to a different court.
SPEAKER_00:So so But if you sentence me to death because you won't run my medicine, I have no right of appeal.
SPEAKER_03:And that's where the focus needs to shift is to the power frameworks, which is so one-sided, so asymmetrical, and so leading to really unfair outcomes. Now the the institution's defense of itself well claim that it's world class, it's just so detached from reality, that betrays the that betrays the truth. You know, because that they they almost defend too much.
SPEAKER_00:You know, it's the lady doth protest.
SPEAKER_03:Yeah, it's it's almost it's almost too much. No, no, well let's let's even this up a little bit. If this system is so good, if HTA is so good and so powerful, then let's equalize the powers here. And this is what Crozier argued is that you've got to have constant review, not big, big bang reform processes, constant modes of feedback, equalise power, give people more power in the system. Take power away from the PBOC, create a second body that you can appeal to. There's all sorts of things you can do. Change the legal framework for the way they assess medicines, which now is so price-obsessed. There's a lot of things you can do, and that's where the argument needs to shift. Because they love an argument about comparatives because it's so easy to defeat. And they've defeated it already.
SPEAKER_00:Yeah.
SPEAKER_03:And it's you know if you look at if you look at the wording they're going to include, it basically says they actually lock in lowest cost comparator because it effectively says, because now it's quite vaguely worded. But what they're proposing to say is that we're always going to choose the lowest cost comparator, but we'll tell you when we're not going to. The evidence that you're going. So guys, can't this is an this is an example. They are creating more zones of uncertainty.
SPEAKER_00:Yes.
SPEAKER_03:To give that give them room to move. So they're presenting it to you as rigid, but they're giving themselves more room to move. And that's that's the argument you have. Make the intellectual case against the system. That it it this sits outside, this is a quasi-legal process. It has all the characteristics of a legal process. So it's got you know rules, it's got regulations, you know, it presides, you know, all it's got all the appearance of a court in a legal process. So let's treat it as such. But let's apply some common law principles. And if it was good enough for the Plantagenets. By the way, you know they didn't even speak English. They speak French. I do know that. I love it, you know, when you go to Westminster and there's got that magnificent Victor, you know, I think the Victorians built it, that statue of Richard the Lionheart.
SPEAKER_00:Oh, yeah.
SPEAKER_03:Who didn't speak English and only spent six months in England, but he's one of the great English heroes. He didn't even like it. He tried to sell it, he tried to sell London.
SPEAKER_00:He'd have trouble selling it now.
SPEAKER_03:He's one of the great English heroes, didn't even speak English.
SPEAKER_00:See, we welcome all.
SPEAKER_03:Let's finish on Mark Well, it's having a hard time at the States. Now, I I was like renegotiating the public hospital agreement, the National Health Reform Agreement, euphemistically named. I just love the way who gives these the National Health Reform Agreements. Who gives them it's like you know the PBS access and sustainability package that you're responsible for? It's like nowadays you go into AI and say, I'm gonna and they put something really negative in the budget, but I need a positive wording for it. Can you help me with this? Let's keep the PBS real, folks, Bill 19. You know, we're supposed to they just make this crap up.
SPEAKER_00:With opportunity comes responsibility, call that was our branding.
SPEAKER_03:But but the states have gone into meltdown because of course I've I was involved in one of those like 20, and it's always the same. The states just want more money, and I think Rudd was the only one who basically just gave them everything they wanted. And that you know, and that you can't get them happy, it's never enough. So now I realised this week that now I feel sorry for Mark Bellard because he's got the added added complexity of the NDIS. So he thought he'd locked in the NDIS reforms, but it was pre-election they gave it away that there was a problem on public hospitals. Because remember they extended it for 12%.
SPEAKER_00:They did, and they whacked in a huge amount of several billion dollars to do that.
SPEAKER_03:Yeah, it's just like just give us six months' peeps. Yeah, this is like this is this is not looking good. And so now the states are saying we're gonna blow up the NDIS reform unless you give us more money on public hospitals. So they're directly linking the two now, and they can.
SPEAKER_01:Yes.
SPEAKER_03:In the one negotiation. So I just I thought this is gonna be brutal.
SPEAKER_00:Well, but you know, I do have some sympathy for the states, which I know people will find a bit of a shock given that they're still not implementing newborn screening. But I still remember reading the Tasmanian budget before they then had to have another election. But they were quite clear that the federal government was short seven to eight percent of the percentage of funding for the hospital costs in Tasmania. And so the state was having to find it. Now the thing is, if you've actually got an agreement that says you're going to make a percentage of the funding, and then you don't pay that, like contractually, you you do have a problem. And the Tasmanian budget was saying, look, the the Commonwealth's committed to sort of try and sort that out and actually get to the amount that they're supposed to be paying within sort of, you know, five to ten years. Meanwhile, in a an island state like Tasmania with very limited revenue, I mean it makes New Zealand look lush in in respect of revenue opportunities. But they have to find that money.
SPEAKER_01:Yeah.
SPEAKER_00:And so we have kind of got to this point of if you're not going to do proper primary care prevention and you're not going to facilitate different ways of getting into the uh primary care system with different, you know, we've got a workforce problem, we've got this problem, we've got access problem, we're not giving you the medicines, we're not giving you the technologies. The the acute system becomes the default. And urgent Medicare clinics in limited places does not solve the problem of a hospital set setting that is dealing with chronic disease. I mean, New South Wales has estimated that, you know, over 50% of the community by 2032 will be dealing with more than two chronic diseases. So that by itself lends to these problems. So we we have a a health issue in the primary care setting that we see manifest at the acute care setting. And until we actually tackle that issue more broadly, which, you know, like you said, we got rid of all the um public health stuff to put it in an MRF, we have an acute care setting that that can't cope. And it's not just you can't just keep building hospitals and you can't just keep ramping people at ambulance bays. It it is a really difficult issue. And they're quite right. If you look at the money that has gone into the NDIS and the way it's been allowed to grow, unfettered, and yet the money that's been limited to the PBS, the MBS, PBS in particular, um, and the health reform agreements, the reality is that you can't turn people away. If someone shows up at your emergency department, they have to be cared for.
SPEAKER_03:And and the tough thing about these negotiations, it's all bets are off with political loyalties. So ostensibly, a Labour federal government might look and say, Well, we're only dealing with two coalition governments. You know, we've got one well, I don't I don't think it is coalition in Tasmania. It's a Liberal government in Tasmania and uh and a and an L MP government in Queensland. The rest of Labour, so we're sweet. No. No, my experience of this was that it's your own side that's worse.
SPEAKER_00:Oh yeah. It's like when you go home for the family again.
SPEAKER_03:You're all at work's much nicer to you than when you get one of the. It's much tougher.
SPEAKER_00:You owe me.
SPEAKER_03:Yeah, yeah. And I it's and I think this is I don't think this is a first time for Mike Butler. I mean, he would have negotiated with the States all the time, but in HRA, I think this is his first. I think so. Yeah, that's that's that's hard. That is gonna that's gonna keep him busy between now and the next budget.
SPEAKER_00:That's already looked great on the photo shoot at the AFR, so you know, all bad.
SPEAKER_03:Uh the green medicine. Alex picked up the big green Medik in the background. Like, oh god, so come on, man. Uh okay. Well that yeah, so that's that's gonna be something for everyone to watch because the NHRO is input because there's a lot in there these days. There's an orphan cell therapies, gene therapy, all sorts of stuff.
SPEAKER_00:It is, remember, that's the that's the pathway. It's it makes newborn screening look like it's actually going somewhere.
SPEAKER_03:Now, in very exciting news, something's just popped into my inbox.
SPEAKER_00:Okay.
SPEAKER_03:It's the invitation to the pharmacy guild annual parliamentary dinner.
SPEAKER_00:Oh, you're special.
SPEAKER_03:Yeah, yeah. I always get seated right in the back of the room. Uh that's weird. It's actually a pretty good dinner. I've it I it's I remember the food, surely.
SPEAKER_00:No, no, it's parliamentary.
SPEAKER_03:Okay, it's just deplorable. Uh I remember when this was held in the middle of 60 days?
SPEAKER_00:Yes, I do.
SPEAKER_03:And it was like a lot of empty seats. Yes. It's gonna be such a love in this year.
SPEAKER_00:Oh, and it was it was pretty lovely last year, too, to be fair, because they'd kind of like broken bread together. So I know I I'm like you, I I moved from because obviously BAA was very staunchly in support of uh pharmacies. So we were right up the front of the table for when the fight was on, and then as soon as that fight was sorted up, you go down the back there.
SPEAKER_03:See if we can stand up on something again that we might actually care about. The upside is that easy to leave early.
SPEAKER_01:Oh yeah.
SPEAKER_03:Easy to leave early. Because I, you know, you gotta stay for the speeches. But it's just gonna be such a massive love in this year. Massive love in. So it's just the turnaround in that relationship. It's because now they're riding the way of scope of practice.
SPEAKER_00:Oh yeah. It's coming bigger. That's gonna be a similar.
SPEAKER_03:They still haven't worked it out. That the the health system is really changing.
SPEAKER_00:Very, very quickly.
SPEAKER_03:Very quickly. You know, if these trials, the UTI and the what was the other one they're doing? They're allowed to prescribe?
SPEAKER_00:Well, they're allowed to prescribe 23.
SPEAKER_03:Yeah, so if that if that goes really, really well, and I guarantee you, pharmacy will make sure it goes really, really well, because that is where they're really good at ensuring the the the right patients get the treatment. They'll be s they'll be s because they'll be thinking strategically.
SPEAKER_00:Well, the biggest issue is the the hidden um part of that, which we have talked about, which is making those medicines PBS subsidized, because at the moment they're not.
SPEAKER_03:Yes, well, that's the same.
SPEAKER_00:And the moment that's being looked at and they're trialling that. I wonder if the MRFF's funding that. Um But sorry. But that's a that is a game changer and it should. And so at Better Access, we had been talking about the fact that we fully support um prescribing by pharmacy, but it must be PBS subsidised because it's still leading to a pricing inequality. Yeah and it shouldn't just be for concessional patients. So at the moment the trial I think is to the states meet some of the uh attendance fee for for actually the the clinical service that the the pharmacist provides, and then the the patient is meeting the out-of-pocket cost. Um so we we will see how that goes. But once once it's giving them access to the PBS, then the transformation is here, and the fact that GPs can now, you know, currently, you know, you can ring up and it's just a repeat prescription where you pay your$25 and they'll issue the script that will change.
SPEAKER_03:It's gonna be it's gonna be a good one, but that dinner I I I I skipped it last year, but I won't be skipping it this year.
SPEAKER_00:No, d do you reckon that the I I I'm hoping that when the guild asks for PBS prescribing, it's for 60 day script. We'll do 60 days.
SPEAKER_03:Oh, sweet unit policies that aren't working.
SPEAKER_00:We'll man we every script we write will be for 60 days.
SPEAKER_03:Yeah. Um listening. Sorry for my bit at the start, it's just been a very difficult 24 hours.
SPEAKER_00:Well shouldn't apologize. I actually encouraged you to talk about it.
SPEAKER_03:Yeah, yeah, you did.
SPEAKER_00:If you don't talk about it.
SPEAKER_03:Yeah. Uh anyway, I think it's gonna be horrible the weekend, but I'm just gonna disconnect, I think, as best I can. As which is, you know. You know. You got F1 this week, yeah. On a light of night, haven't you?
SPEAKER_00:I do, I have that, and we have uh daylight savings, so one less hour to have to endure old Cod swallop.
SPEAKER_03:All right, thank you, Felicity, and thanks everyone. Speak to you next week.
SPEAKER_00:Bye