The 'Dispatched' Podcast - 20 March

How Australia’s health system is failing patients by prioritising process and cost control over timely access to treatment, forcing more to rely on compassionate access programs. HTA processes are slow, often dehumanising, and used by the government as a delay tactic. Meaningful reform requires shifting away from process-driven decision-making toward real patient needs. The opportunity articulated this week by one leader is to pursue a more strategic approach to policy. The episode also highlights the growing role of pharmacy, which is increasingly based on trust and confidence, especially post-COVID, in contrast to struggling GPs.

Transcript

Paul 0:08

Hello and welcome to the Dispatched Podcast. My name is Paul Cross. I'm delighted to be joined by Mark Who's Felicity McNeil, PSM, Chair of Better Access Australia. Hi Felicity.

Felicity 0:19

Hi, Paul. Didn't recognise you when you weren't in high viz.

Paul 0:28

Okay, so that's a cheeky reference because last week it was the Rare Cancers Australia Coszy Challenge at Threadbow, and I was asked to be a marshal. And I agreed, because I've done it many times before. And I thought the role of a marshal was effectively going to be you know like those guys on the aircraft carriers that you know just point.

Felicity 0:54

You thought you were handing out the the red cancer's caps, let's be honest.

Paul 0:59

But but it turns out as it turns out, the role of Marshall was defined as guide. So I was like Tenzin Norgay and and uh had to lead what was described as it was described as the first wave, which had sort of D-Day landing vibes.

Felicity 1:20

I know I I saw you more as Julie Andrews climb every mountain, forge every stream.

Paul 1:25

The problem was I was I wasn't very confident, as you know, because you're a witness to the fact that I lost a couple of people in the first five minutes. They may still be wandering around the mountain, but I'll deny any direct responsibility. But it was actually a really good weekend.

Felicity 1:42

Yeah, it was um it was lovely to as I've said to you, many of these things are not actually about the fundraising themselves, it's the bringing together of the community to remind them that they are not alone, that there is I mean, as humans, we we need to be together. We need to to to have a shared experience at times to whether you are the person who was living with the cancer or you're the person who was caring for the cancer or you're associated with someone, it's that shared experience and doing something positive in a time when things are hard because there is so much uh stress and negativity in all of our lives, and in particular when you're going through uh cancer treatment or any other long-term chronic disease treatment, it's that coming together. It's it's like when you went to the cystic fibrosis events the other week. People come together because it brings them hope, and in this case, hope is a strategy because it empowers and it gives people strength. I think the thing that really struck me is that that people can can attend these events and it's actually about other people, and you know, all selfless, selfishly we all feel a bit better from it. Like, you know, if you're part of something good, you you feel good, but it is a reminder about why many people in the sector do what they do, or many people who even aren't in the sector do what they do, and I'm always privileged because all I do is most of the time is work with patients, and it's humbling and it keeps you really focused on what matters because in the end, process means nothing if someone is denied access. And I think that's a reminder from all of those stories. I think the thing that worried me most of all, and I know you've written about it, is the lack of compassion in the system where a patient is sitting there saying, Thank you so much. And am I am I allowed to say the pharmaceutical company? Thank you, Bayer, for funding me access to a treatment that keeps me alive to be in my son's life and my husband's life. And there is no sense of whenever that might change.

Paul 4:00

These were heartbreaking and heartwarming stories. So that was Sarah, who's a teacher from Canberra, who's had a cancer for 30 years, cycled through treatment. Her whole family, well, her husband is her carer. I've I've I've heard her describe her experience several times, and it's very courageous to do that. And we have to thank them for a willingness to share their story because it can't be easy. And to do it in front of what must have been five or six hundred people. And I was just appalled by the fact that this woman is alive because of a compassionate access program, which is charity, and the system basically just turns the other turns the other way. And I I've been on this scene for quite a while now is the complete lack of humanity and compassion, the lack of human compassion in our decision making, and unfortunately that is the way it's designed.

Felicity 4:57

Yeah, it's it's an interesting time as someone who used to write the letters when or sign the letters when patients would write in seeking access to a treatment that wasn't currently funded on the PBS. It was a little bit different back then.

Paul 5:10

Um it's got a lot worse.

Felicity 5:12

Yeah, I was gonna say things were actually being listed uh on a more regular basis. And it used to be that this is a thing, and we would talk about we we can't do something unless they've first got a positive recommendation and the timing of the schedule, and then by the way, you may be able to contact the the company in the intervening period. Uh now part of that's an obligation as a as a public servant. I have to give you all options. Your doctors, you know, you can get it in the hospital system. It's really important. I have to tell you everywhere you may be able to get treatment to something that you want or you need, but we can't currently fund for whatever reason. What concerns me with the number of uh recommendations that, you know, we moved from the five-year review of recommendations to two years because we didn't want Minister Hunt embarrassed by how many recommendations weren't proceeding, we which is now a benefit for all ministers. The need for compassionate access and the continuation of compassionate access, it's a get-out-of-jail free card for government, and I think it has to stop. And I'm not saying take it away from patients who are currently getting there, but the system relies on it and the system relies on the goodwill, and so the system doesn't hit that tipping point very often. Uh, you see the the tipping point on uh chronic disease medicines because they don't give compassionate access for very long. They they do it temporarily for a listing process, and we've seen that with migraine treatment. Uh, the amount of money that patients who need a particular migraine treatment are paying every month. So, where where are we heading with all of this? Where why is government getting away with this?

Paul 6:54

Well, it's not it's it's it's got a lot worse because officials now promote it. So if they're asked about these issues at a Senate estimates hearing, they openly suggest patients contact the company for charity. I find that utterly offensive. And I'm curious about the conversation or the meeting held within these bureaucracies that ends with that being a good idea.

Felicity 7:18

Yeah, but it it it it becomes the it's the default. Like I think the the lack of accountability for it. So I used to, as um head of Hepatitis Australia, explain to many patients that the medicine they were getting was actually charity too, because of the rebates and the number of patients that were being funded each year. That once you were in the first X thousands of patients, the government paid for your medicine. Thereafter, it was a free handout from the pharmaceutical company. So our risk shares do that as well.

Paul 7:50

Yeah, I d I just don't I don't understand why why it goes to show how far off pieced the discussion has come that that is considered an acceptable response to a patient being denied government funding, which is a euphemism for human compassion. But I don't I don't understand I don't understand why Well I do understand how we got here because the system explicitly removes human considerations from its decision making. I mean it does it formally. It's a dehumanizing system, it's designed to dehumanize. That's the whole point of it. And so discomfort is not something the system can cope can cope with. Remember when the PBAC started having consumer hearings?

SPEAKER_02 8:45

Yes.

Paul 8:46

And they lasted no I presume because they found it incredibly uncomfortable.

Felicity 8:52

Maybe. I don't know. I mean, as someone who sat in on those those hearings, yes, sometimes they were good learning lessons to to humanise the situation, but also as a bureaucrat the system was quite human for me because you meet with patients all the time. I think it's that process itself that allows us to disaggregate. And it's one of the things that worries me about I hate to mention it because you know it's my least favourite thing, the HTA review. But what is going to be coming out of that in the budget and the recommendations is not going to change the need for a patient to be on can compassionate access to many medicines for a long time to go. It is going to solve it for one or two things. It's going to be held up as this. Look at this, we've got this new process. And yet, if you look at the reforms that we've made to the guidelines and the PBSE processes over the last 15 years, it hasn't improved.

Paul 9:53

It's slowed it. The HTA, the government is already setting up its excuses not to fund new policy proposals in the budget. It's going to blame the Iranian situation. You can already see it.

Felicity 10:08

Oh yeah. I walked here today, by the way.

Paul 10:14

It's and the government's response to people filling their tanks.

Felicity 10:20

It's un Australian.

Paul 10:21

It's idiotic that response.

Felicity 10:23

It's not an Australian to go and fill your tank up.

Paul 10:25

Yeah, so it was I I just and much as I dread talking about the HTR review. Well, let's let's talk about it in a different way. I interviewed I want and I want to come back to these advisory committees. I interviewed Owen Smith from Bristol MySquib this week. And I was so impressed with the conversation. It was one of the most enjoyable I've had in all the time in the 14 years I've been doing this. In that 45 minutes, he refused to go down into the weeds of comparators and discount rates. The only thing that he said was, look, they're symptomatic of the problem, but they're not the problem. He talked in very strategic terms. And I think this is an argument that the industry can win, but it requires a lot of patience. And because it's not about an explicit reduction in a technical input or a change in the wording, a lot of people who are intrinsically tactical and and market access is a is a tactical thing. They struggle with it conceptually. But but it's a very easy argument for the gut for the industry to win, which is that, well, Australia, do you want a thriving life sciences sector? Well, yes, of course. Well, the that what are the factors for a thriving life sciences sector? We need a good workforce, good infrastructure, we need a good economy, we need economic policies or government policies that support the sector. What's an example of that? Well, obviously, if we're not commercially viable, we're not going to invest in Australia. Well, that makes perfect sense. Well, well, what what's your commercial market? Well, in Australia, for the pharmaceutical industry, that's mostly the PBS. You get around to it that way in describing it as being in the government's interest. But because it's not immediate right in front of your face, and it's a multi-year conversation, people tend not to have the patience for it. But I was very impressed with Owen. I mean, he's an ex-politician and an ex-senior politician, so no one should be surprised that he's very articulate. But I was I really enjoyed the conversation, and I can say that I rarely end a conversation with someone in that sort of position going, I can see a path forward here. Normally it is seriously. You think comparators is the problem? So I was I was I I hope, and I had to I hope people read the interview. I hope people have read my follow-up today, which is saying this is the path forward. If you if you insist on having conversations about technical aspects of health technology assessment, the government is gonna love it. Because they win those conversations every single day.

Felicity 13:22

Process is government strengths. That's that's their home turf.

Paul 13:26

And we've seen that with the HTA review. They're like a pig in the proverbial, they just absolutely love it. They're gonna have that conversation all day, every day, and they're gonna win it. And the fact that it's in year five, which is almost unbelievable. But it's not. You and I but you and I both know that they're squeezing their life out of it. And I can already read the minister's press release. So he'll announce something incredibly making it sound incredibly exciting, but he'll also say that because of the prevailing budget circumstances, we've had to moderate the outcome and our ambitions around this. But we're not we're not forgetting we're going to come back and look at it in next year's. I mean, you could see you could write it writes itself. You and I have both written those things.

Felicity 14:12

I you know, I can't respond because in life and say it writes itself. Yeah, we do know the game. Yeah. And we do know that one July on the negotiations and the money, what do you want? How much are you gonna pay for? So here it comes. Yeah. Um and you know, I I think the the sector's also going to get caught in the game playing that's going to go on with, like you said, the the oil situation, and so everything's gonna cost more, so we're gonna have worry about medicine shortages, which won't really be real, but um we'll we'll use that as an example to to start worrying and you know, adjusting everything, and we'll see the wholesalers coming and saying, Oh, you're definitely gonna have to give us some more money to you know help you manage that stock, even though they're getting a massive bump up on 1 July. You can see the way the supply chain will move. Um, I have read your articles and um listened to you talk so positively about your interview. How long is he here for?

Paul 15:14

Well, that's that is the issue. Um uh but setting that reality aside, it's he's supporting St. Kilda, by the way. That's all you're doing.

Felicity 15:32

Right, okay. But well, if you support St Kilda, a lot of other things look good.

Paul 15:37

Yes, that's right. But but oh they'll I I could see them getting on a roll this year. But but the it's the the argument. So I went to the Danish life sciences event in Parliament House this week with King Frederick and Queen Mary, and it was a really, really good event. Uh the CEO of Noble Noble spoke at the National Press Club, and you know I will not go to that venue because they have a habit of being anti-Semitism. Jew hating bigots. Uh but the event itself was really, really good, and there was a senior official from the health department there talking about how critical the life sciences sector is to Australia and how important commercialising their discoveries is. So that's the first step. Everyone needs to understand you've got to get them to agree to that premise, and then everything else follows from that. If you leave with your chin around technical inputs, that's you can't win that. There's no there is no I've and I constantly put it out there, there is no example of in the four decade, four-decade old history of this system of a positive change based on that interaction. And as and I'll say again, when I heard Mark Butler say at the GBMA summit, which was another good event, and there have been a sequence of really good events recently. When I heard Mark Butler say, I've asked the department to revisit the definitions of high-added therapeutic value and high unmet medical need, I just went, whoa. New wording means less flexibility. It is not beyond I said at the start of the HTA review that the most positive outcome is the status quo. That you get to keep what you've got. But I'm increasingly of the view that those examples we've had recently, particularly with cystic fibrosis therapies where the system has shown great flexibility, that all of this new rev revised wording is going to just give these HTA advisory committees who are ideological.

Felicity 17:44

Except when they want their own money.

Paul 17:46

Yes, I yes, ideological, it's going to give them the ability to be to show less flexibility. Which is ultimately, I suspect, what they want.

Felicity 17:55

Well, they like an excuse to double down, and like I said, we like one odd thing that says, here, look, we did this great thing, but everything else can wait. But you know, the cystic fibrosis drugs was also a tribute to the pharmaceutical company itself.

Paul 18:08

Yeah, Vertex stood their ground, yeah.

Felicity 18:10

They they play ball. They go in, they are very clear, they understand the value of their product, they understand how the system works, and they do not compromise. They say what they mean and they mean what they say. And that's where you see uh an organization that has said, okay, we'll play by your rules, but we will play by your rules. Um and unfortunately, we don't now part of that is let's be honest, it's a revolutionary treatment, it's transformed lives, and so therefore the system really wants it, and it's got a huge strong uh patient group pressure there. There's nothing like dealing with young children. The reality is the system yields more to that awareness. So, yes, there's a there's a coming together of a confluence of events, the perfect storm that allows it, but they are one of the few companies I have ever seen stick to the system, play by the system's rules, and hold the system to account. And they are proof that when you do, it bends. So it's you know, you report On the right product. Yes, on the right product. And so, you know, the the the flip side we've got of that is we now have um the the broad indication of a listing, and I realise it's um in the same company we've been talking about again today, BMS. But that's taken them years. That's taken years despite the desperation, the need, and everything like that, because the system there's so much going on as well. So when you're competing with other companies, when you are working on different indications and different products, the ability to stand firm on one issue becomes very difficult. And because when you've got other competing interests and the system is very smart and says, Well, I know well I'm well you're trying to hold your ground, I've got this going on over here. And so that's why our system only works really well in the area that we've seen such cystic fibrosis when all those perfect situations come to come to fruition. So in the meantime, everything else that's being negotiated for this outcomes of what it may be in the HTA review. Patience will continue to be an afterthought. I I don't want to be, oh, I'm now making sure that there's an extra consultation process with you in a HTA process. I I want patients front and centre. I want the system redesigned. It needs to genuinely patient-centric doesn't mean that you ask us after the fact or midway through an evaluation process. Patient-centric is actually we're here to actually treat patients.

Paul 20:50

Well, I don't even know what the term I mean the term patient-centric is one of those invented constructs that I absolutely revile. Really? Because because why do we have to argue for patient-centricity? Isn't it a given that that the system is constructed around the people whom it is designed to serve?

Felicity 21:12

Well, I think, you know, if you're in the hospital setting or you're in the primary care setting, yes, because the patient, the individual is in front of you. What happens when we have a disaggregated process that's four steps away from the patient? Is that I don't think patient centricity is there. What why did Mark Butler have to intervene on ocular injections? Because a system and a process that's so far removed from the patients, even though there were consumers in those groups, lost sight of what it means to be at the receiving end of that health care system. So a GP can see me and a pharmacist can see me, and they see patient centricity every day because the patient is in front of them and it's personalized care based on what the system will or won't allow them to do. But once we Enter into these processes where we pull some people are clinicians and some people are experts and some people are economists and some people are data managers and then we say now let's look at this at the population level. Oh, and now we've got you know 400 responses from consumers which we disaggregate into a one-page summary. This is how patients feel about it.

Paul 22:21

We saw that with the GLP1 advice. Yeah. Just a grab bag of nonsense.

Felicity 22:25

And so when you do that, I I think patient centricity is something that our health, our federal health system needs to contemplate, particularly the area of health financing.

Paul 22:37

But I think we need to change the the wording. I don't think we should have a review to change the wording. I don't think we should buy into these false constructs, these, these, these terms that are that are sort of, you know, it's like the sausage machine, it sort of squeezes out these new terms all the time and this phraseology. And I I I repudiate it because I think, well, well, patient centricity. I I don't well patient centricity. Well, what about patient rights? If I go into a hospital, the first thing you see are my rights on the wall. If I go to an aged care facility, it's constantly reminding you of of your rights.

Felicity 23:13

Yep. Um we've been asking for a a bill of uh a charter of rights for patients in the HTA system.

Paul 23:21

Well, it's the the ocular injections is the perfect example. What were these people thinking? I mean, I'd like to have a look at the conflict of interest statements of the of the people who participated in that. But what what were they thinking? I mean, obviously, what did they say 13,000 people were going to be denied essentially funding, private funding for ocular injections in in days day as day pa day patients, in day hospitals? It's just nuts. Like who thought this would be a good idea? And why is the government messing around in this nonsense anyway? I'm still gusting. I don't I don't get it so much, but my husband. How many times is he having to intervene in these systems before he goes? I think we might have a problem.

Felicity 24:09

Well, I wish he would realise there's a problem because I think that's the opportunity, and I appreciate I know he's got a lot on with the NDIS and aged care and sport, and um I'm surprised he's not running the fuel crisis now as well, too. The man does everything. But the problem when you are I know anything else? I'm sure we'll fix the GST this afternoon.

Paul 24:30

They have a lot of trustees, obviously has a lot of trust inside the cabinet.

Felicity 24:35

Yeah, and that's great. But at the moment, the guy is smart politically and can see when he has to intervene and stop something happening, what is going to continue to be the wasted opportunity is when will we get a health minister that will strategically tackle what is going on in the health financing system. You know, so right now we're focusing on whether, you know, private health, you know, it's great. So we're we're focusing on will I know how much my specialist is going to charge me. I do find that when you ring up, they do tell have to tell you what the costs are. So we're worried about that website and we're worried about sending private hospital funding into IPA. Like terrifying. That's our solution.

Paul 25:15

Oh, that's crazy. I know, but that that's not.

Felicity 25:18

But my issue is we're tinkering over there. So this is this is the party of Medicare, supposedly. We're tinkering over there with with private health insurance and how we how things are priced there, and not even allowing me to access the same technology that I can actually get in a public hospital system. But there is a fundamental flaw in our health financing units. Yeah, but we're not tackling that, we're doing it on a piecemeal basis.

Paul 25:44

Because it's ideological. It's like you know, you these health financing ideologues and when he's saying the government should just spend willy-nilly, but that's but it's it's it's it's the opposite. There's almost a triumph in spending as little as possible. That's the that's the goal. And having no absolutely no generosity, having a system characterised by absolute parsimony, that's that's that's the ideology here. And so when you when a minister takes it on, it's a bit like the Terminator 2, you know, the guy who got shot and his body would he was just made out of that weird metal that would just reform. That's what it's like. I mean, I won't when Michael sacked the entire PBAC and it just sort of reformed because because it's an i it's an ideology. If you're gonna defeat it, you've got to drive a stake through its heart and bury it six feet under the ground. You've got to absolutely kill it off and start again.

SPEAKER_02 26:38

Yes.

Paul 26:38

And and the problem is they're constantly it's convenient for ministers, and the GLP1 advice that was published this week is the perfect example. Yeah, they've just vomited on a page a hundred different reasons why the government shouldn't fund GLP Ones.

Felicity 26:56

Yeah. Under the PBS.

Paul 26:58

Under the PBS. It is just a grab bag of excuses.

Felicity 27:01

And another thing.

Paul 27:02

Yeah, and and the and the classic one that I cited was well, we don't want to do this too soon because better products will be coming in the future and we might have to pay high prices. So we don't want to base the price now. What are you talking about? If there's something this system is good at, it's getting prices down over a period of time. It's just an excuse. So the minister can go, well, I've got 50 reasons here why I don't I shouldn't fund GOP ones now. So I've got one a week for the next 12 months, basically. And it's just an appalling piece of advice. And that brings us to that subject which has irritated me for years. Stay out of policy.

SPEAKER_02 27:44

Yeah.

Paul 27:44

Why are we constantly ministers do it all the time and it never used to happen? PBSC was a sort of you know, be seen and not heard kind of thing. Go and sit in the corner and do your job and stay in your lane. But now ministers have worked out that, well, hang on, if I get them to give me policy advice, it gives me an excuse not to do something. And we all we we both know that the GLP one request from Mark Butler twelve months ago. I mean, it took 12 months to formulate this advice. I mean, give me a break.

Felicity 28:12

It's a delaying tactic.

Paul 28:13

It's a delaying tactic.

Felicity 28:15

Following on from the delaying tactic of the diabetes inquiry in 2023, which was based on having to try and dodge the GLP ones in the first place. So we remember it was about obesity and diabetes. So that that actually had a primary focus on, you know, Australia's too fat. Let's ri talk about all the reasons that you guys are are lazy and you're doing this, and it's your own fault for getting type 2 diabetes. That was about delaying GLP ones.

SPEAKER_02 28:40

Yeah.

Felicity 28:40

And of course, brought up all the other things like insulin pumps and CGM and research and diagnosis and the usual things. And of course, two years on, we still don't have a response to that because what did it recommend? We need GLP1s and we need CGM and we need better insulin pumps and we need better research and we need better Medicare numbers. And so here we are today. So what did the the health minister do? PBAC. Now you need to tell me now that the now that they're parliament tell me what to do about the PBS. Oh, and by the way, MSA, can you tell me what to do about CGM?

Paul 29:10

Yeah, tell me what to do. And it's it's well, the point I made this week is that if you want to do this, you shouldn't. And as individual men, because these committees have no particular expertise, it's just a bunch of people, basically. There's m probably more expertise outside the these committees in the community there is on them that they just have positional power. Now understand you know you're crossing the street basically. So when you are on the street of technical advice based on clinical and economic considerations, you're kind of immune from the political process. The policy process is intrinsically political. So if you're gonna start doing this, if you're gonna continue doing it, then I'm sorry, you don't you don't get to hide behind things anymore. You're subject to you need to be subject to more criticism, you need to be more externally accountable, particularly now that the PBAC chair is commenting on research infrastructure investment.

Felicity 30:07

Yeah.

Paul 30:10

Then I'm sorry, you're gonna have to start making regular appearances at Senate Estimates hearings.

Felicity 30:14

At a minimum. And if you're going to keep allowing that committee or those committees to provide you policy advice, again, because you're not subject to the AAT slash ART, there is no way to challenge that.

Paul 30:29

Well they pollute they pollute all of those policy processes.

Felicity 30:34

But we all know it's an excuse. We all know that I'm taking a well-instituted process that everybody respects and loves, you know. And I put something through there and everyone accepts the delay. Oh, it's because it's got to go to PBAC. And it's very cleverly done because always a loose reference to to be able to ask PBAC advice, it has to be related to their areas of um legal remit. So it has to be about the PBS. So what is always, well, we think you can, but we don't think you should put it on the PBS. That's how we get the excuse through, which is um Am I looking at this or am I not? So I I I it just frustrates me because everyone plays ball with it. Everyone, you know, why aren't all of those submissions made public?

Paul 31:24

You know, because Well, we got their curated presentation of patient import.

Felicity 31:30

Exactly. But again, because we went through PBS and the PBAC, which is where PBAC remember, it only it summarizes in the public summary document. Only the I think the sponsors get the the broader information from the community. And I'm not sure if they get it verbatim or whether they just get a summary from individuals. But anymore, I I can't remember where it's up to. But if you had done that in a normal policy process, then those should have been actually made public. So, you know, it's a bit like when we did the National Medicines Policy Review and the that area of the department refused to release all of our submissions. So, you know, we started publishing them until the the department relented and made it public. Why can't we know what everybody said?

Paul 32:14

Why can't we because we know that of the 540 submissions, 539 would have said you need to fund those for a broader patient population.

Felicity 32:21

Yeah, and then there would have been the one submission from that group that says we're worried about the environmental impact. And then there would have been one submission from some of the HTA providers uh to the system that says, Oh, definitely you can't make these cost effective. So, you know, this is outrageous spending of money.

Paul 32:37

And it gives the minister now the ability to say we're acting in a policy perspective to prioritize certain groups. And people need to go back and read the responses of the PBAC and MSAC chairs to the HTA review's final report, where they said almost I mean, they obviously coordinated these responses where they said we understand that people want faster funded access, but we shouldn't compromise our decision making or spend any more money. I'm sorry, that's nothing to do with you. But that will be used in the government's response to the HTO review.

Felicity 33:24

Yeah, and it really peeps me off because if I go and read the diabetes malitus inquiry, I can read the 432 submissions.

SPEAKER_02 33:33

Yeah.

Felicity 33:34

I could look at them, so sure some are redacted, one or two are personal, not a problem. But why can't I on this? Because we're using the fake PBAC process to curate and moderate the information that's going out to the community. And like you said, you know, I don't I'll be writing to a minister saying, you need to publish those 500. Yeah. You need to make it available so we as a community can understand what your committee picked and chose from those to actually tell you information because, Minister, did you get to know exactly what was in there or just what they told you?

Paul 34:08

We got the 14-page curated response. The first page is the is the title page, the second page is the copyright, the third page is is the acknowledgement of oh why are they doing an acknowledgement of country in a document? Well please, can you please explain that to me? I mean, it's bad enough that it's in email. I mean, there's so much stuff in people's email signature blocks these days.

Felicity 34:34

You can't find their name.

Paul 34:36

You can't find their name because you've got their country acknowledgement, you've got the the pronouns, and it's just people.

SPEAKER_02 34:45

Like I just want to stop. I just want to call you.

Paul 34:47

I just want your phone number and your email, like your name. I don't need all the political statements going with it. But it's it's crazy. And so in the end, you get this curated presentation of these perspectives. And and this goes all the way back. And I said this at the time in the Medicines Australia 2022 agreement, the HTA review, we will do it, and it will go through the PBAC cheat PBAC first. Like, why did you accept that? Yeah. Why do you accept it? I don't I don't know why you would sign a document that says because we we know at the time that that was that was the way you can spoil the outcome. Even if the industry, it was their insurance, because the inclusion of that requirement was a confession. It was the government saying, even if you manage to get stuff in this report that we don't want, we're just going to stick it through this advisory committee and get all of that filtered out. And that's exactly what has happened. And so now we've got the once-in-a-generation, which it wasn't, of course. The once-in-a-generation opportunity opportunity for meaningful reform.

Felicity 35:53

I told you not to use that term.

Paul 35:55

And we we get I know that's like bingo. We should have shots every time someone uses that. We'd be fall down drunk ten times a day. But but but what we get, and now we've got nomenclature changes. We've got wording changes. This is this is this is where it's ended. And of course, this is where it was always going to end. But I I I think we've got to challenge. We've got to push back on these committees being used as a front. I mean, they're like the Hezbollah of of policy processes, right? I mean, they're like the proxies.

Felicity 36:28

Where's my shadow?

Paul 36:32

They're just like throwing bombs. And it needs they need to it needs to stop. But people have to put back on it, push back on it, which is why like bring it back to where we started. The Owen Smith discussion was so good. Because it's disarming, it's changing the conversation. You can have a conversation with government about the issues that Owen raised without talking to the health department. And this is what I used to always do when I was lobbying on that great uh acid reflux stroke.

Felicity 37:05

That's got you that watch you're wearing.

Paul 37:08

Yes. But you you know who I didn't speak to for 12 months?

Felicity 37:13

I know the health department.

Paul 37:14

The health department. Why would I speak to them? They're not gonna ever agree to this. And and after we got the$200 million turnaround, you know who called me? The health department. Oh, Paul, you really should have spoken to us about this because obviously we are very concerned about manufacturing investment in Australia. And I burst out laughing. It disarms them. It's uncomfortable, and it's and it's the right the right workaround. They're more than happy having a conversation with you about, and you by you I mean the industry, about market access issues because they win that. They're like the Harlem Globe Trotters.

Felicity 37:47

They they can't control strategic policy in industry and investment. And so I did see that the report that um Mr. Owen Smith was talking about does say that it's a once in a generation opportunity.

Paul 38:01

I think that that's that's just Please. It's a once in a generation. Well, what's well I suppose the the listing, the broad listing for the uh PDO1s, that was literally once in a generation because it took a basic It took a generation to get that done.

Felicity 38:17

Speaking of generational change and um some crazy conversations that have gone on this week. Uh Mark Butler announcing at APP that he was going to separately fund the co-payment effectively for concessional women who are accessing contraceptives.

Paul 38:36

The crazy response from the doctors.

Felicity 38:39

So uh yeah, like talk about losing your mind and you know the whole TGA said you should never do this, as you and I had previously discussed. Well, actually, no, they just said it shouldn't be downscheduled for a medicine that's already available, you know, on a script for 12 months. That's a very different conversation. But one of the things I found really uh distasteful was uh certain people writing in the the sector about how much money the guild gives or gave to the gov to the now government in the the most recent election and therefore implying that Mark Butler had been bought. Um I I think everyone forgets that this was actually an election commitment under the women's health program. So it wasn't just Mark Butler, it was the entire government who said that we should actually be finding a way to make these medicines affordable because organizations such as BAA had been saying, look, it's great that pharmacists can now prescribe, so I'm saving the money here in my seeing a pharmacist because the state government pays for that, but I'm still out of pocket for my medicines, and that's whether I'm a woman or a man. So whether you're getting uh contraceptive, a UTI, eczema, basic cardiovascular support. Men and women, we're missing out, they're still um paying for those medicines out of pocket and it's not counting towards their safety net. And as you and I have discussed over the years, the changes in the safety net, particularly for concessional patients, has become really important. That is actually what's made medicines affordable, not the the current$25. But the hysteria on it is is extraordinary. And this whole doctor's group saying, well, you know, we're protecting women. Well, no, you're not. You you're not talking to women. What why are women using these services? Because they can't get to their GP, because they can't get timely access to something that they need, because the system, you know, my my GP is only open from, you know, 8 till 5.30, and I'm working and I'm picking up my kids from childcare and my pharmacist is open till later. So primary care is about where I need it, not about how you want to control it. Um, so I think it's great that you know we're see seeking to tackle this cost of the medicines, but I'm still going to come out harder and tougher on it, which is if I'm a non-concessional woman, which most women between the ages of 18 and 55 who are accessing the contraceptive will be. Um, this doesn't provide me any additional support. It doesn't provide it for me under the PBS. And I know this is one of those really big things we're tackling right now. The system is terrified of a pharmacist being able to prescribe and dispense. But is our PBS about access to medicines, or is it not? Or are we going to continually just make up these little different pockets of programmes, which is a bit like the GLP ones? Are we are we trying to just set up separate separate buckets so we don't have to address how the PBS operates?

Paul 41:40

Well the response of some people to that was just so puerile.

Felicity 41:47

Yeah.

Paul 41:49

To make the assertions they did that it was somehow linked. And some of the people who were doing this were actually serious people who know better.

Felicity 41:58

Well, it's a very serious corruption allegation.

Paul 42:01

Yeah, which I did ho I did ask someone, well, if you're gonna say it's corruption, just say it. Have the courage to say it. But it was ridiculous. The fact is that, as you say, it was an election promise. It actually makes a lot of sense. Pharmacists who qualify for this do a lot more training on these issues than GPs do.

Felicity 42:18

A hundred percent.

Paul 42:19

In order to be able to do it. In fact, we know someone who had to do it a couple of times.

Felicity 42:23

And was proud of that because that individual said it shows that I really have to study hard. So when I prescribe, I have really learnt how to prescribe safely.

Paul 42:33

I just I think the GPs are taking the wrong lesson from this. I would have thought the lesson is the government in expanding pharmacy scope of practice, and this applies to nurses as well, that reflects their trust in that relationship. So when they do this, they are very confident that the pharmacists are gonna do it really well. Now, at the same time, general practice is being slowly nationalized through these urgent care clinics. There's gonna be hundreds and hundreds and hundreds of those things. Obviously, the government sees them as a massive political plus, even though I think the merit, the policy merit, is highly questionable. But GPs, they have so little trust in you. They have so little trust in the relationship and your ability to deliver a policy outcome that they're establishing an entirely separate network of GP uh government-owned GP clinics.

Felicity 43:37

But also they completely devalue you, so they don't think you're worth that much money. So they do actually think a pharmacy is a pharmacist is worth a certain amount of money. And they think that you're not. So we've talked about, you know, the the horrific variation between what an urgent care clinic GP will be being paid. Paid versus what a private clinic will be getting for a bulk billing item. I mean the disparity is appalling and is creating these incredible tensions in the space. It's also taking away choice. So it's it's taking away my right to go to my GP, who my GP is brilliant. Not only is she a GP, she's also a fully trained pharmacist. Like I've hit the windfall with her. It's one of the few GPs I go to who will completely understand everything about medicines. Um it's extraordinary. But if I want urgent care, I can't go to her. I have to go to one of these these clinics, supposedly now, and of course, in we're in the SAT, so only 53% of anything is bolt-wheeled anyway. But I also I also still, I guess philosophically have an issue, which is I think GPs, primary care is worth more. And I think the signal that we send on this is wrong. I think there should be some contribution, irrespective of like I said, I don't believe the I've said it over and over again. I don't think people earning over a certain amount of money should be being bulk-billed for a GP session. I think the value of my GP is greater, and I think that I'm happy to pay a contribution so that then when the person sitting next to me who is being bulk-billed is bulk-billed at a higher rate to genuinely reflect the value of that service. And I think this is, like you said, where the doctor groups could learn a lot from pharmacy who understand the value of the service they provide, who have worked also with states and territories. And I think that's where we see a marked difference, is that on that federated level, the the pharmacy guild and pharmacists PSA as well work with the state governments to say what is the intrinsic problem in your healthcare system? What do you need? Because in the end, state government is at the front-end front line of acute care setting. So they're always looking at the longer term as opposed to in the federal.

Paul 46:11

Let's be frank, general practice is very poorly represented.

Felicity 46:15

Yes.

Paul 46:16

I mean the fact is the argument that was made last week that the TGA rejected this is complete nonsense.

Felicity 46:22

Correct. Yeah. From Schedule 4 to Schedule 3.

Paul 46:27

Yeah, this is a completely different decision. So in order to qualify for this, pharmacists have to undergo specific training, be certified, have private consultation rooms and certain equipment on hand. It's a medical consult, which is entirely different to a down scheduling decision.

Felicity 46:45

Yes.

Paul 46:45

So I assume they did that deliberately, knowing the truth.

Felicity 46:50

Yeah.

Paul 46:50

But understand that the government have done this because they know that when they do this deal with pharmacy, pharmacy will do this systematically. And a lot of women, and we can argue the rights and wrongs of establishing this outside of the PBS, the fact that the spend won't count towards a safety net. Uh it'll be interesting to get the modeling on that to see what the total impact on the safety net qualification is. But a lot of women are going to access particularly, I mean if you are of childbearing age and have a concession card, you are a low-income earner.

Felicity 47:31

Very low.

Paul 47:32

Yeah, so this is really going to change things for women and make something that may not have been so accessible far more accessible. I think we've got to welcome that. And you said, well, when you go into a pharmacist, you walk into your local pharmacy, and I've got one 200 metres from my front door, maybe 300 metres from my front door, my dogs can just about make it on the walk. I can speak to Rob within 30 seconds pretty much of walking into that pharmacy. It's a very welcoming environment. I go to a GP, you know, they've got the signs up saying, don't come in if you're sick. There's door, there's seats outside the front door with people sitting there with face masks. There's you've got the the receptionists who oftentimes are angry with their situation in the world. Everything is in a it's completely inaccessible. They need to completely reimagine that model, I suppose is what I'm saying. It's just not welcoming. And then I have to pay certainly$120,$130, which I don't begrudge. And if I I now, if I was a woman of childbearing age, and I I can go through that process to get an oral contract there, or I can go and walk into my pharmacist and have a consult. I know the one I'm going to be choosing.

Felicity 48:54

Yeah, and and Mark Butler made the same comments at uh APP, and this is where uh prescribers, you know, that general practice and the AMA really missed the boat. And it's it's expanding on what you talked about, which is during COVID, the only people that actually cared enough to actually stay open and see patients face to face were pharmacy, you know, and and I think that the story I was telling you was I had a cough, I'm an asthmatic, I was not allowed in to see my GP. I go into the pharmacist sick as a dog, they get the stesoscope out and things, and they go, We can hear that you've got pneumonia, but no one will see me. No one will let me in. They said no one's gonna let you go and get an X-ray, like that welcome to the world that shuts down. So I'm really sick, but no one will help me. Who helped me? The pharmacist. The pharmacist rang a GP, told them the thing, got me a script, filled it then and there, but I got diagnosed with pneumonia by a pharmacist, not because a GP would not let me in because I had a cough. And I think the system hasn't understood how much tr transfer of trust went into that space because when we were at our most vulnerable, it was pharmacists that actually stood up and cared for us. It was pharmacists when we had that complete debacle of the roll-out of the COVID vaccines and you know, and how you could get in and who you could see, and a GP wanted you to walk, you know, 400 kilometres away from them to do it. It was pharmacy that said, give it to us, we'll get it out there.

Paul 50:32

Yeah, and the bias that was in the institutional health system bureaucracy against pharmacy was nuts.

Felicity 50:39

They accepted a lower fee to do it because they said, Well, roll it out and then we'll keep arguing.

Paul 50:44

But you're right. That that this is where people misunderstand the power of pharmacy in terms of advocacy. It's not it's not simple, it's a complex web of factors, one of which is that there is high trust. Is that when you ask pharmacy to do something, they do it systematically. And they will do this program on all contraceptives, they will do it or as they will on UTIs, systematically. And and I I would be very surprised if it wasn't incredibly successful. And are they gonna get paid for it? Yeah, they are gonna get paid, but it's it's it's from a policy perspective. There's a lot of bang for your buck in in that from a government perspective, where the GPs, and I I'm not criticizing individual GPs, I'm not doing that. They work hard and I think they're incredibly underpaid.

SPEAKER_02 51:33

Yes.

Paul 51:34

But they're underpaid because they're poorly represented. And this poor representation goes back to the 1980s and 1990s with this obsession with with bulk billing and everyone getting bulk billed. It's absolute lunacy.

Felicity 51:48

That wasn't even the plan of the policy. But we've we've retrofitted it to to become something new and something different. And it just I I think it's an interesting time. And and like you said, as soon as anything happens with uh policy rollouts within pharmacy, then everyone goes to the whole, you know, the big bad wolf. The reality is, like I said, COVID happened and it was a changing moment in healthcare for this country, and because that organization is so strategic and forward-looking, like I said, you know, vaccines are now standard. They were advocating to me and explaining to me about that in 2010 a long-term strategy to be part of a health system and understand how they could contribute to it and be better recognized as clinicians, yeah, not um shopfronts.

Paul 52:36

And they've done it, they've invested in the infrastructure. You you go into a pharmacy ten years ago and you go into a pharmacy today, and it is a very different experience.

Felicity 52:46

Absolutely. And so there I was reading criticisms of you know, but there's no, you know, just getting a script as a woman and you know, where's your privacy? I might you do realise to be able to be a prescribing pharmacist, you have to have a separate space consultation room that is private. Like perhaps read the rules, guys, before you denigrate and just it was like under so undergraduate.

Paul 53:05

It was unhinged. I when I saw it and I sure I showed it and I said, This is absolute, it is unhinged. The political donation thing. I mean, really, if you're going to get a multi, multi, big, big, you know, several hundred million dollar big deal on the basis of a few tens of thousands of dollars of political donations. Well, governments are selling these things too cheaply. It's just ridiculous.

Felicity 53:26

But it was just, but it was also like, you know, then I went, Well, do you want to go through every other company and organization that's done that?

Paul 53:31

So, you know, as if the GPs aren't making donations?

Felicity 53:35

Well, they I don't know if they were specifically, but I I looked at things and went, well, there's a whole heap of pharmaceutical companies that have donated. So are we now saying that because the ministers announced like funding of their particular medicines or expansions to that, are you saying that that was linked to it?

Paul 53:49

Well, in the last 10 years, pharmaceutical industry contributions to the political process in Australia have increased because they it used to be that the donations have turned into subscriptions, and that's a bit of a workaround for global rules that generally ban companies from making donations. But though the the participation in the political process, if we call it that, by the industry has gone up significantly. Yeah, but I'll Would anyone say that's led to positive outcomes?

Felicity 54:15

Yeah, and I guess there's all sorts of other things that I looked at. So you you know, because they wanted to get they went and looked at the um, you know, the AEC and the the transparent listing of donations. So we looked at all the other things and said, are you going to call out everything in non-health as well? Because, you know, in the education sector, in the infrastructure sector, I mean interesting ones, and defence. Like, do you do you want to do that?

Paul 54:38

You look at the universities.

Felicity 54:39

Oh yeah.

Paul 54:40

So I I found it quite I've always been of the view that that participation in the political process like that generally has the counter effect. It actually makes it hard. It makes it makes it hard. And and most ministers, particularly at the federal level, they attend those things because they tend begrudgingly. And I you've been I've been there. Like I I can remember going to ministers with those things, and you just sit there and you cycle through these meetings or you attend dinners, which the and the dinners can be quite alright. You can actually learn some things, and that's interesting. I learnt at a dinner with Prime Minister John Howard that he actually did select the Prime Minister's 11 cricket team. That was my question. I said, Do you actually select that? And he got really offended. He said, Of course I do. I went, okay. Man actually knew knows his cricket, but but it was a ridiculous, ridiculous response.

Felicity 55:30

I I do, and I think it's um like I said, I I I've looked at it across the broader system, and I think to actually make that accusation against the minister was stupid.

Paul 55:40

He would have been f I I I wonder if he was angry or just laughed. Maybe a bit of both.

Felicity 55:45

Yeah, maybe, but I just think that's it's a really low blow. And for you know, basically it was an accusation made by a former senior public servant to to make that kind of accusation and to think that that's appropriate.

Paul 56:01

But it it also reflects a complete lack of understanding of how the political process works.

Felicity 56:06

It's again from a senior public former senior public servant who should know how the process works.

Paul 56:11

Yeah, but it's it's just it's just that cla it's you know, one thing that characterizes doctor groups and senior ex former senior health officials often is resentment resentment and jealousy about the ability of pharmacy to secure positive outcomes. The thing is, what's the Medicare spend? 30, 35 billion a year. What's the spend on pharmacy? Five billion. The thing is, if I spend$100 million on pharmacy, I get a billion dollars of value. That's the reality. That's the reality. If I spend$8 billion on a new bulk billing incentive, I get a couple of additional uh uh uh percentage points on the bulk billing rate. I mean, so it just stands to reason. You you get great bang for your buck by partnering with pharmacy, and when you ask them to do something, they deliver unbelievably well because they're businesses. They go, if I do this, I get five dollars per in game. Okay, we can do 20 of these a day. That's a hundred dollars a day, that's a hundred dollars a day, we're open six days a week, six hundred dollars. That's that pays for my pharmacy, you know, pharmacy assistant for a couple of days. So to me, it's it's just GPs, if they were more systematic, like so how many GPs do you go to are promoting so if they see someone who's our age, how often do they say to them systematically, have you had a Hubinkoff vaccine Resolve? So it's it's a different cultural thing, but anyway, it's it was a it was a crazy response. And speaking of crazy things, yeah, I want to finish on the UN Commission on the Status of Women. So I I got my I got the notification today from the Prime Minister and Cabinet, issued information from a meeting of the UN Commission on the Status of Women. And as is always the case with anything to do with the UN, and you did send me that very funny video about the UN. I decided to go and have a look at so who's on the board of the Commission on the Status of Women? There's some fairly risable African regimes. I think Saudi Arabia are on it.

Felicity 58:20

Well, looking better than Iran, yeah.

Paul 58:23

Better than Iran. So it's just why do we keep involving ourselves in these organ these organisations? Like the I think Iran are until they might still be on the executive board of the human rights, you and human rights commission.

Felicity 58:39

But uh isn't it that thing where we say, oh, if we bring you to the table to hear how we all are wonderful, maybe that will actually indoctrinate and and change your views. Okay.

Paul 58:50

Yeah, you wonder when there's the the end of the end of World War II and uh those great thinkers in the American administration said, Well, I think we what we should do is the League of Nations was a complete disaster. Let's set up United Nations. And it's yes, yes. And I wonder they envisaged what it would turn into.

Felicity 59:16

Yeah, it's a cute.

Paul 59:17

The absolute laughing stock uh that that it's become.

Felicity 59:21

It's it's a very interesting um with everything that's going on globally at the moment, the where we put our efforts and what do we think will drive change.

Paul 59:32

Well, you don't even bother what they have to say these days. It's it's if you've ever been to the UN headquarters, it's a very impressive building, but it's like a time capsule.

SPEAKER_02 59:41

Okay.

Paul 59:41

Because it was sort of built in the 1960s, I think. And it's unchanged. Unchanged. It's perfectly maintained. But the chairs, the tables, the building itself, it's all it's like a time capsule.

Felicity 59:59

Oh, is it like the um flats on Northbourne Avenue where we said there's these horrific flats from the 1960s are an a cultural icon, so we have to retain them.

Paul 1:00:09

Yeah, yeah, it's exactly it's exactly the same.

Felicity 1:00:13

We shall not change.

Paul 1:00:14

Yes, it's exactly the same. But yes, it's good to be back.

Felicity 1:00:18

Yeah.

Paul 1:00:18

It's great to be back.

Felicity 1:00:20

Your new site's going well?

Paul 1:00:23

It is. We've got to keep training it. Uh, I'm really excited, you know, I'm all in. Uh the language is still, we're still it's still beta format. It will be for a couple of weeks. People are gonna access it without a subscription at the moment. That's not gonna be the case for much longer. Uh, but it is a great way to collate the history of the publication and all of the policy issues and issues that we've written about. You know, some people are just using it to say, just summarise what he's written today. Other people are saying, can you give me the history on this? What about this? And that that's where it's really, that's where it's really, really, really good. Even stuff like hey, when did the PBSC recommend this? It's it's really good. As long as we've reported on it, it's very, it's it's very good. But uh people keep using it and uh I'm sending the feedback. Yeah, sending the feedback, love to know. Felicity, thank you so much.

SPEAKER_02 1:01:17

Thank you.

Paul 1:01:17

It's good to be back. I hope everyone has a wonderful weekend. And uh go and check out the website for the uh UN Commission on Status Women. The status of women go the Congo. Uh thanks, Felicity. Thanks, Paul.