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'- 17 October
We discuss what could be a significant policy shift in PBS decision-making, with clinical judgement backed by what is a 'common sense' outcome. It could be a new precedent, but only if all stakeholders demand clarity on the criteria so that it can be applied more broadly. We also reflect on patient advocacy in New Zealand, where access has become a political issue and the focus of a significant discussion at this week's Valuing Life Summit in Wellington.
Hello and welcome to the Dispatched Podcast Week in Review. It's Friday, 17 October. My name is Paul Cross. I'm delighted to be joined by my co-host. She's going to introduce herself using her honorific. No, no, she's not, according to that stare. Felicity McNeil. PSM. Hi, Felicity.
SPEAKER_02:Hi, Paul.
SPEAKER_00:Well, you can't blame me for trying.
SPEAKER_02:Yeah.
SPEAKER_00:Let's get into it. We're going to talk about a couple of issues this way. One is the September recommendation secured by Bristol Myers Squib, which will sort of streamline. Well, I suppose that's definitely what it is. It's going to streamline the listing of their two immunotherapies, Uvoy and Opdevo. Which is interesting. I'm very cynical about these things. Generally, there's a bit of a gap between the announcement and the truth. But I think there is quite a bit of positive in this. I spoke to the the company. Uh at length had a really good conversation about their interpretation of it. I asked them, is this a product outcome or a policy outcome? And I don't want to mischaracterise what they said. I think they said it was a product outcome with the potential for it to be a policy outcome, and I think I believe that's reflected in the in the wording of the PBAC outcome where they talk about an emerging framework. The opportunity now is to for everyone, the patients, clinicians in the industry, to get some clarity around what this outcome is, the criteria that's used, and how how it will be applied going forward, because I don't know why we would limit it to a particular group of patients.
SPEAKER_02:Well, I think first of all, before I comment on that, you should perhaps explain to your listenership what exactly the recommendation is.
SPEAKER_00:So this has been going since 2017. In lots of iterations. Greg Hunt asked the PBOC to consider a pan-tumor listing for the PDL1 immunotherapies. There's quite a few of them now. That sort of went off into a strange process about lung cancer and gave the appearance of a fairly selective tender. It didn't really go anywhere. A couple of companies, Bristol MySQL and MSD, resubmitted in recent years, and that initiated a process that would enable the use of therapy in a way that reflected a trust of clinicians. I think it would be fair to say. So what's what's what's happened over the last two decades in this system is that we've developed a process of highly complex prescribing restrictions. And that's been a way to limit utilization and the financial cost. The problem with that is when products like the PDL ones, which have a lot of indications, not all of them are going to be PBS-able, but also some of the clinical use of these therapies is going to be outside of what would be TGA approvable just because the companies aren't running the clinical trials, the patient groups aren't large enough. So the outcome here is, and I'm going to characterize it in my own language based on my conversations with the company. We have a lot of experience as an advisory committee with this product, with these products and with the class of medicines, and that gives us confidence that they can be treated cost-effectively, they can be used cost-effectively, even where we have not determined that a particular use is explicitly cost-effective under our legislative framework, which is them saying we trust that the use will be consistent with the evidence, product information, I suppose, the clinical trial use and clinical expertise, clinical judgment. And we trust that that will be cost effective. So as new indications come along, uh they will be automatically added. But even if they are not TGA proved, clinicians will be free to prescribe them via the PBS based on their own experience. They've also removed the lifetime single-use rule, which I think is a is a good removal, and I expect the other PDL ones will follow, whether they're successful or not. I don't know. So it is it is whilst it's limited to these particular products at this point in time, it is an interesting shift. Done outside the HTA review framework, by the way. I don't think any I think it's probably more a reflection of the House of Reps inquiry recommendations than the HTA review. But I do think we need to take a step back and say, well, okay, let's get some transparency around the criteria that's been applied here. Let's publish that that that that criteria and that framework so that other patients and other clinicians and other companies might be able to take advantage of it.
SPEAKER_02:So it's a fairly interesting point of time for this to be happening, but is it radical? Not necessarily. So if we reflect back on the post-market review that was undertaken of a suite of medications that are in F2 that had specific indications, and the PBAC noted that many of these listings are now used in many other circumstances and are actually significantly cheaper. Many of them are part of the 100 million scripts that people completely pay for for themselves. And that the obligation to and the artificial construct of indication-specific listings as opposed to general listings, not to be confused with a section 85 general listing, but a general listing which says paracetamol. I know we don't call it that anymore, but paracetamol. See paracetamol can just be on the PBS. Okay, and you can use it for whatever way you want to use it. And you can put a statin on and you can just say statin, and it can be used in whatever way, shape, or form a clinician wants to use it, and that post-market review specifically noted that many of these indications would not be on the ARTG. But let's just go with the vibe and they said we're pretty happy to do it, especially considering they're a lot cheaper these days, and that we should continue to come forward for it. What is innovative about this is that something that we've only seen talked about in F2 is being contemplated in F1. And lucky cancer patients that your chair is an oncologist who can say with all comfort and clarity that for the first time ever, doctors who treat cancer can be trusted to prescribe a medicine even if it's not ARTG registered, and by their own knowledge of that medicine, it will automatically be deemed to be cost effective. I mean, I wish we could have done that for the BDMAs, which we are still sitting there with these incredibly complex issues.
SPEAKER_00:So maybe we need a rheumatologist this year.
SPEAKER_02:But on a genuine level, if you're saying that you're happy for any treating cancer physician in the country to prescribe those in any circumstances, so it should now just say, here's the two drugs, and that's it. That's all it should say, and it and that you can be used in more than than c more than once. Then my I do turn to my head is which well, you know, the the minister says 5,000 patients a year are expected to benefit. So is that the new threshold in the risk share arrangement? Um are all uses of the drug treated equally? I mean, we've spent 15 years now where we've say it's more efficacious in this cancer versus that cancer. I am completely comfortable with this as a construct to a point. But my question is why these, other than the fact that fantastic, I know Mark Butler's been really pushing on getting some outcomes for the rare cancer communities and the general community of you know life and death treatment. But how how are we actually going to do this? This isn't anything new, it's just new in F1.
SPEAKER_00:Yeah, there's an element of common sense. I mean, I I I am going to guess that these medicines are being prescribed this way anyway, at the moment.
SPEAKER_02:And they're just lying?
SPEAKER_00:Yes, yeah, yeah.
SPEAKER_02:Well, not sorry, sorry, they're confusing which item code number they write down.
SPEAKER_00:Well, there are so many item numbers here. I mean, the the the clinicians have every right to be confused. Uh, and given the prices are all different, it must be hell for the company too. But but i there's an element of common sense. Now, that's good to see because our HTA system, and you know, I've described I've described it in New Zealand this week. It's like people treat it like swearing on the bones of saints, that medieval practice, and it's not. This is common sense, and it's really good on Robin Ward and the department and everyone for applying common sense. They've got a risk share, so there's absolutely no exposure to the Commonwealth. So I they've no doubt they've negotiated an absolute knockdown price, and that's great, and the company's appears willing to sign up to it. So, well done. And if the minister put his foot on the system whilst he was also putting his foot on the system about women's health, then good. Well done. Absolutely, congratulations. The system works at its best. And I did speak to Owen Smith, the managing director of Bristol Myers Crib this morning, who is an ex-politician, very senior politician in the UK, and he gets it. We elect governments for a reason. And I think based on the discussion in New Zealand, they finally worked that out with Farmac as well. But I like to I like to see the common sense. Now, here's the reality. This is where we get some truth bombs. Uh the advice to the minister on this from the department, I'm going to guess, is you're going to be highly caveated. The risks. There's going to be some risks, which is that Minister Everyone's going to expect this now. So they're going to go and do put up the fence mode around this outcome to try and limit it, its applicate. I don't know why, and maybe I'm being too cynical on this, and I could and I could be wrong, but 25 years, almost 30 years of experience provides some valuable, valuable insight into how officials tend to respond to these exceptional outcomes. And I think that's the risk. So the challenge now for everyone is to say, well, we we don't want this limited. If this is the position, we don't want this limited to this outcome. We actually think this provides a really sensible framework to widen access to more medicines in a quicker and faster way. We can trust clinicians and enable this in a way that provides virtually no financial exposure to the Commonwealth because you've got these risk shares. So let's supply this common sense more broadly. And in this case, common sense means positive outcomes for patients. I mean, the company says three and a half thousand people will benefit from this. Mark Butler says five thousand. Whatever it is, it's a lot of people, and that's great news. That's that that's that's really great news. But I don't think we should limit it to those lucky few. I think it should be applied more broadly. So if I'm a company, if I'm a patient group, if I'm an industry association, I'm writing to the minister and saying, right, well, let's have a conversation about how we're going to codify this. So we're going to apply it more broadly, because we don't think it's equitable to apply it to one group of patients. As fantastic as this outcome is, it should be more reasonably applied. Now, is the criteria the fact that advisory committee has a lot of experience with these products? Which is true. There's probably, I mean, I don't know how many BD MART submissions there have been over the years, but the PDL ones would be rapidly catching up if they haven't already passed. Every meeting has at least one. So there's a lot, dozens and dozens, probably well over a hundred. So they've got a lot of experience. There's a lot of clinician experience. They know how to use these therapies. That's that's great. It's a it's not a huge patient population. And they do provide incredibly good outcomes for many, many patients. So if that's the criteria, if you want to put that criteria down, put it down and and and put it on a website so we can all find out and we can have an argument over that criteria and whether it's broad enough, whether it's too narrow, or what it should be. But I do think it needs to be transparent. I think that's fair and reasonable, and it's what we should all be demanding now. Because the risk is that this is very uh distinctly applied in this one case, and then in two years' time no one's talking about it. Which is exactly what happened on happened on Hercepton 25 years ago.
SPEAKER_02:Took the words out of my mouth.
SPEAKER_00:Yeah. We funded that therapy outside the PBS, and then we went into siege mode. And then we put up, we put we filled the mode, put up the walls, and every company that came and said, Well, why can't we have that? Why can't we have that? We said no, no, no, no, no, no. And then eventually the companies give up asking.
SPEAKER_02:Yeah, well, PBAC has made this decision. Um, you know, as the bureaucracy and the ministers, I cannot do something unless it's a specifically recommended by the PBAC. Well, they've done it. And that is now the precedent, and that should now be the minimum standard. If you're saying it's because we have to wait till something's been listed for ten years, I mean a partial component of this, these medicines individually have been listed for even longer than that. Uh as a combination, it's been slightly shorter. But yeah, it's it's like I said, it's what the PBAC has been saying they should be doing in F2, and we're gonna end up with this huge gap still. Um and this recommendation space can't just be for small patient populations because again, cancer is more readily quantifiable, so it has to be flowing through them. I I I get very concerned about this. I look at the biologics and what's still happening in that space, and they're not in the dirt cheap medicines like the statins, and they're not in F1 for the most part anymore, like these treatments, but they're considered expensive because uh there'll always be several hundred dollars a month in in exposure to the the Commonwealth. So, how can we actually take this new um gospel according to the PBAC and make it equitable access to it, and also not be reliant on copious submissions from individual pharmaceutical companies? It should be the automatic standard if you apply for this then X, Y, and Z, or if this is here we need a retrospective review of that. Um I mean I've noticed in that same meeting that the PBAC is kind of happy with their agenda list for their post-market review schedule and not too too keen on a few things that um have come out of like the ADHD medicines, and they said it shouldn't be a post-market review, it should be a research project in respect of uh broader access to those medicines. So you you're quite right, it's a it's a very important threshold moment. The challenge is the the system actually cultivating that and turning it into this is our new way forward. And I'd be really happy if the industry could just completely forget about the HTA review and just focus on this. Well, because this is actually part of the solution that you needed. Um you really did.
SPEAKER_00:I wonder what recommendation the HTA review would deliver this outcome. The HTA review hasn't been implemented yet, so there you go. I I think the BD Mards is a really good point. They they they uh have been around for a very long time, over two decades. Uh a quarter of a century, really. They uh there is a lot of clinician experience and there is a lot of HTA experience with these therapies, so why can't we trust those clinicians?
SPEAKER_02:Exactly, why can't we? And you know, it it's a it's good because I mean it shows the the evolution of time and that the sad part is our system is really struggling and people are increasingly missing out, and it's creating that tipping point and that pressure point, hence we've got access to contraceptives after after 30 years, and now we'll have access to to this kind of approach after 10 years. But you and I have talked on many a time, BDMAs, we've seen measures to curb behaviour, we've seen the letdown on once they're off patent, we should you know improve the access because they'll be cheaper. And it's been a real double down, and again, it becomes about I don't want it to become this, I don't want it to become cancer versus chronic, acute versus chronic, and we have to, while everyone is celebrating this moment, we have to make sure it reaches through to all areas of health care, not just that, which is something that was obviously reset valuing Health New Zealand. If you don't attack chronic disease when you're still in the primary care setting, it's very expensive at the acute care.
SPEAKER_00:One one last point on this this one is you know the government and its officials have traditionally been very, very effective at transacting policy change through submissions.
SPEAKER_02:Yes.
SPEAKER_00:Through product. So it's the industry secures something in an agreement, officials don't like it, so they just get rid of it via product submissions by getting companies to agree to it. It's very rare that the potential is the other way. So kudos to the companies for doing these submissions because they pressured the system. These are very effective medicines, the patient experience is good, the evidence base is good, and there's a sort of a common sense good idea proposal, all of those things. So take a step back, look at the drivers of this outcome and see if it can be replicated for other patients, because I think from an equity equity perspective, because we always hear about equity in this system, I mean, as you know, I'm convinced that the people who use that word generally don't give a lot of consideration to what it actually means, or they have a very narrow understanding of what it means, but from an equity perspective, if one group of patients are gaining access to medicines via this policy change. Which it looks like a policy change to me, that then then I think rightly we should think about it more broadly than that. And that goes beyond cancer.
SPEAKER_02:I agree, and like I said, the the postmarket review from a couple of years ago was very clear that they were very happy to they they changed that principle that it should be a general listing for those that are cheap medicines on F2, and they looked at particular groups of drugs and said we should continue to review and evolve this, which again puts the the impost on others. So that this is nice to see it happening in F1. I think the other important thing to remember about this is that, you know, like you said, full kidos to the companies who have continued on this space because this is an argument and an idea they have been putting forward since 2018. So I know it was called for in 2017, but they first started making it. It was a thought bubble in 2017. Yeah, but that they've first started trying to come up with this solution since 2018 and 2019, and importantly, they have re referenced other countries who have had this type of policy and this approach to these medicines. Uh our system was a little more conservative saying we need more time, we need more time. I don't want the criteria to be 10 years listing and then we'll consider. I I I'm hoping that what they've actually learnt about this, what it means to be familiar uh with the treatment to engender trust in a clinician to prescribe appropriately, is not a we wait ten years and then we see.
SPEAKER_00:Yeah, yeah, it was a it's the genesis of this was very is quite amusing. Because it was at 2017 Rare Cancers Australia CAN Forum event. Uh Greg Hunt needed an announceable because he was the king of announcables. And I can remember I I don't think this is breaking any confidences, but Andrew Wilson came up to me and said, I just got a call from the minister, he's gonna announce something, he wants me to do this thing about.
SPEAKER_02:I thought it was that you that told him that you'd been somewhere while he was on the way to Parliament and you warned him that the minister.
SPEAKER_00:Oh, it could have been it could have been either of that. So it's the longer that's it. It was you telling him there's there's an announceable coming. Yeah, that could be just announced it. Yeah, you're gonna be able to do that. Oh, that's right. That could be you're doing this. I went, oh really? Uh like you know, the implementation advisory group considering AI. Uh hey, let's talk about the Value in Life uh Medicines New Zealand event in Wellington this week. Uh first we have to talk about the flight back to Australia, which which there were quite a few uh colleagues, industry people on that flight, and we got to know each other over about eight hours because a three-hour flight that left at 6 a.m. in the morning relevant time, which is 4 a.m. We ended up doing orbits east of Sydney for about an hour because of fog. Then we got directed, diverted to Brisbane to refuel.
SPEAKER_03:Because we had a better chance of like going for the refuel rather than those who'd flown in from the US and the UK who were running out.
SPEAKER_00:They were they were a bit uh on fumes. Uh refuel flew back to Sydney, and I think we got back about 12 30, so it's like an eight-hour flight. Yeah, yeah, about an eight-hour flight. And then then then I know you you stayed in Sydney, but but but I had to get on that Qantas transfer from the international to the domestic terminal, which it's just a horrific experience. I I I I I do not enjoy that at all. And yes, I can be a a little bit of a a princess.
SPEAKER_02:Hey, don't don't appropriate names that those who are called a princess are fine with.
SPEAKER_00:But but but that that was that was quite funny. And did you get the the sorry email from Quantas? Did you get that one?
SPEAKER_02:No, no, I didn't. I didn't get that.
SPEAKER_00:I just Well it wasn't really a sorry, it was a we understand your flight, da da da. You'll appreciate no thank you for your pa. It was all of that. No, I never said I was patient and I never said I appreciate it, but anyway.
SPEAKER_02:No, I think the funniest thing with some of the people we were on those of us who were on that very early flight had been laughed and mocked at by those that were on the later flight.
SPEAKER_03:And there were some people on our flight texting and going, yeah, that plane that you were already sitting waiting for, we're still circling personals.
SPEAKER_00:That's I'd had to fly back to Wellington to collect everyone else. Uh anyway, look, it was a great event. Congratulations uh to Malcolm Mulholland and Rachel Smooley and Graham Jarvis and the team at Medicines New Zealand. They put together a great event. Uh, as always, the it was patient clinician driven, primarily. Some of the uh experiences they shared. Fiona shared uh you know her ongoing experience, uh, which was great. She's got spinal muscular atrophy and has uh came to Australia so she could uh actually relocate her family to Australia to access treatment. And look, it was really good. Some of the some of the messaging I found a little bit worrying. Uh not from the patients, but more from oh well, you know, that the Treasury presentation was a real highlight.
SPEAKER_02:Um for for basically anyone from Australia, it was basically like this.
SPEAKER_00:It's the IGR. If we do what what it was a fantastic exercise in framing where the Treasury official did their job, no criticism of them. They did their job. They basically got up and said, if we do what you would like us to do, the world's gonna end. We're gonna descend into a vortex of Hades. And and and so that that would there was a lot of that. There was a lot of that. David Seymour, who's the Farmac Minister and the Deputy Prime Minister, spoke and said, Well, you know, the bare bones of Farmac are pretty good, we just need to trim the sails. And my response to that, well, if by trim your sales, you trim the sails, you mean put an excess missile into the side of it, that would be that would be interesting. I was fortunate enough to be on a on a platform uh about most favoured nation pricing, which was which was interesting, but uh but but I thought the the the two-day event I thought it was pretty good for Licidie.
SPEAKER_02:Look, it's a it's a it's a community that's finally been led into the building. Yes. And they're exploring that and having some open conversations. Like you, I and you mentioned this at the conference. We we need to learn from the constant pressure and the push that they did. They pushed the system over, they pushed the wall over and went through it, and the system has started to change, and it's actually become a political conversation as it should be. And you had four politicians up there talking about how it's going to be discussed at the next election. And you and I have been saying that Australian patients need to understand that constant push, push, push and demanding better, make the system move. What I started to see a little bit of, which worried me, was because New Zealand's on a low base, they kind of look to Australia like it's this great saving sun. And the language of, you know, we just need HTA uh to sort of really get in and fix this, and we just need to fix our laws, and we actually just need money. But it was also the let's adopt processes. We we just need more process and that will help us get somewhere. I liked some of um the the conversations from people who were really clear about what it's like when you go to an international conference and New Zealand sits on the table with Rwanda with respect to access. That was jarring.
SPEAKER_00:That was jarring. He was fantastic, too.
SPEAKER_02:And you have another uh uh clin uh consumer group that talks about sitting on the table with Romania and in in their area of of health care. And so you could still hear the the grating concern and the fear, and it's like sometimes you you've got New Zealand has to be careful that they didn't just let enough air out of the tyre that the community will keep rolling on. And I think that was some of the thing that I heard, which is an open and questioning mind, which is really good, like you know, let's try and work together. But if you really don't see further concrete change in the next six to nine months, you have to take your election opportunity as the chance to hold your governments to account again, to have that difficult conversation. Um Tim was talking about that, you know. Well, we borrow money for everything and we're paying it back on a certain period of time. No one ever asks us if we want to borrow money for the medicines. And I thought it was a really good point. You're happy for me to borrow money and to take out debt to purchase my medicines, but you're not happy as a government. So I thought there were still those ebbs and flows of, you know, let's question, but it is it is that hard balance when you're finally being led into the room and having a conversation, it's really good. You've got to make sure that you're not actually being captured by it and being fed through a process that becomes the objective of process itself to say that see, here we did something. And yeah, I I mean I had to keep saying to people, you think we have it really good in Australia, but we actually really don't. And we look like whinging Australians because I I appreciate that it's a lot better in many circumstances that are in New Zealand, but equally that's not my I don't like it when my government uses that as an excuse. And I think, as you said, they should aim higher and we should be very careful about everyone over there selling you just need more HTA like we have in Australia. And you'll be sorted. Because in the end it's about the money and the prioritization of the health system.
SPEAKER_00:Yeah, so my I yeah I agree. I think we made the point you've got to aim higher than an aspiration to match Australia. That you might see HTA as an enabler in Australia compared to what happens in New Zealand. You might be right about that, but HTA can be whatever you want it to be.
SPEAKER_02:Correct.
SPEAKER_00:It can be an enabler, a gatekeeper, an excuse, it can be anything. And and unless you introduce HTA in an institutional framework that gives patients and clinicians and others some reasonable say, some power symmetry, then to me the risk is that you just end up like Australia, just starting from a much lower base. So that's that to me is not a great idea. So don't be too enthusiastic about HTA. Yes, Australia looks great from New Zealand, but it's not so great if you're living it.
unknown:No.
SPEAKER_00:And and I think we we need, and that's oh you know, that's obviously what I said. You know, don't don't get too close to that HTA sun.
SPEAKER_02:Yeah, you're listening. I think he's probably selling it a little bit short as to how well he explained.
SPEAKER_00:I think I may have said it something like, you know, Berlin in 1946 was better than Berlin in 1945, but only because the bombs had stopped dropping.
SPEAKER_03:Yeah, yeah, that's that's really bad.
SPEAKER_00:I mean it's it's it's I think they need to aim higher, and and the only thing that concerned me in all of that was this idea that well, we're part of the conversation now.
SPEAKER_02:Yeah, that's my point.
SPEAKER_00:And yes, you pushed hard, you had the funding injection next year, and now you're inside the tent. Just be clear-eyed about how they're going to use that against you and be prepared to keep pushing from outside the tent. And I believe they are, I believe they are, but having been let inside the tent and treated with some degree of respect for the first time in a long time, we have to recognise we have to recognise that as progress. And the people who have have been let inside the tent are fierce critics of FARMAC who are leading public demonstrations, who, if it was in Australia, would never be allowed inside the PBS tent. They'd be allowed access to the consultation hub.
SPEAKER_02:Yeah, and it's uh also something the industry needs to reflect on about how exhausting advocacy is for patient groups. And in particular, like in New Zealand, where they're not paid. There's no money that comes from the pharmaceutical companies, there's no money that comes from the government. Every patient there that is advocating it is is basically doing it off their own funds. Certainly there are some uh areas of healthcare where donations are much higher because it relates to cancer and people are are very keen to to fund and support that in those areas. But that was something that also when you talked about the need to keep going and the the fight and the advocacy, the hardest part for the panel, which it's not only you, uh Liz DeSomer from Medicines Australia and Graham from Medicines New Zealand, was that you turned to that group in that room and said the advocacy has to come from you. And to watch the watch the shoulders slump and the exhaustion levels of people say I still have to keep going. And it's like, yeah, it it's really, really hard. And I I hope that the industry people in that room saw the shoulders slump of those patients because they aren't paid. They are still trying to get their health care often substandard health care, and this is as much true in Australia as it is in New Zealand. And yet they're expected to free of charge be doing all this hard work and this heavy lifting. So someone on a TalMac nicely came up to me this afternoon and said, I would like to understand how we can actually support patient groups better rather than the traditional process. Because that was the hardest thing for me to watch is people going, seriously, more work to do here if we don't. And it's tough, like I said, patients it'sn't for most of them, most of us, it's not our nine to five job. We're doing this out of the goodness of our heart somewhere else. And that's often what allows the system to to defeat in some areas of healthcare because people simply do not have the energy or the physical ability to I did say F-I-S-C-A-L ability to keep going after something for everybody and not just themselves.
SPEAKER_00:Well that well, that's that's the that's the particular cruelty of these institutions. Yes, it is. Is they take advantage of that by running the clock. Now I did say it to that audience, I mean I you know I said to that audience, and I tried to lighten it up a little bit, but uh the New Zealanders love love nothing more than Australians telling them what to do. So the all I said to them was just learn the correct lessons from Australia, and the wholesale adoption of HTA, the way we use it in Australia, is not a lesson you should learn. You need to look elsewhere. Uh I I think I conversely, there is a lot that we in Australia can learn about the precursors to change in New Zealand. Absolutely, and it is worth studying that. You have these unbelievably skillful advocates and energetic people like Malcolm and Rachel and Fiona, and we have those people in Australia. The precursor in New Zealand was industry getting out of the way and allowing patients and clinicians to clearly articulate their experience and their anger. So there's no gaslighting, there was no telling them that that that bad was good and good was bad. There was no lowering of expectations. Patients took took control, and that is that is a soup that might be hard to replicate. I don't I don't know. Our institutional framework. The institutional arrangements between Australia and New Zealand are very very different. Very different. We have very different cultural attitudes to institutions. In New Zealand, they have no written constitution, they have no states and territories, and they have no upper house of parliament. So that that makes the soup, it's got fewer ingredients. And I don't mean that in a negative way, but it means that when when a government is elected, change really occurs. And you see that with with the current coalition government in New Zealand, where when they are elected, a lot changed. I mean, they abolished, they abolished the federal, the National Health Department, Health Agency. I mean, so it was it was they can do that. Now that stuff is much harder in Australia because the complexity of our government and our institutional frameworks are far more rigid and less open to change. But that doesn't mean we can't replicate some of those things. And the real lessons for me, uh, and we saw it again this way, was the leadership of patients and clinicians. Incredibly articulate patients and clinicians, either describing their personal experience, their anger, using all the right words, because I did say on the panel, the thing about HCO is it's it's an area of academic endeavour that's responsible for the invention of more words than any other. These are just invented terms. Let's just get back to what it is. And so that that to me was very impressive, and and I'm glad that there are quite a few Australians there, a lot of companies were represented. Bring back those lessons and how we can replicate those things here to get some energy. And yes, unfortunately, unfortunately, it requires ongoing effort, and I'm sure that's the message in a way that many didn't want to hear, but but they're in the process now of being the risk is institutionalization, which which I I don't I don't believe would be would would would be great. It sort of brings it after all of that exceptionalism in the last couple of years. I think you know if that's what you want to do, and if that's what you see as the benefit and the goal, that's great. Just be clear right about what it means. But yeah, it was great. Wellington, it's Wendy Wellington, it's got that name for a reason.
SPEAKER_01:Yeah.
SPEAKER_00:Okay, thanks everyone. Congratulations again uh for Kristom Ice Grib and all the companies, but MSD included, have been pushing this new outcome. Uh, we have to say that, well, it's potentially very positive as long as we can transition that into a policy change. And congratulations to uh the people who put together the Value in Life uh event in New Zealand this week. It was fantastic, it was twice as big as it was last year, twice as long, and every bit as energetic. And I thought it was great.
SPEAKER_02:Thanks, Felicity. Thanks, Paul.