The 'Dispatched' Week in Review'- 14 June

Why long-term thinking and planning are the key to success. What is the ten-year goal, and how does a new agreement progress that? Plan for policy and government engagement like it's a product launch. Also, is the problem with the HTA Review the process or the expectation? How a different starting point would have made this outcome positive.

Transcript

Paul 0:08

Hello and welcome to the Dispatched Podcast. I'm Paul Cross and I'm delighted to be joined by Marco Hoos, Felicity McNeil, PSM, Chair of Better Access Australia, amongst other things. Hi Felicity.

SPEAKER_01 0:21

Hi Paul. How's how's it all going?

Paul 0:24

Pretty good. Pretty pretty good. It's very cold. We're doing this. I must warn the listeners that we're doing this remotely today, and that always challenges my technical capabilities.

SPEAKER_01 0:34

I have Yeah, how long did it take us to start?

Paul 0:37

Extensively consulted YouTube. YouTube is like GPS. How do we ever live without it?

SPEAKER_02 0:43

Yeah.

Paul 0:44

I don't do anything there without consulting YouTube. There's so many people who have so much useful advice to provide.

SPEAKER_01 0:51

Yeah, they are true. People who've gone through the pain first.

Paul 0:54

Yes, yeah, and it's really, really helpful. You know, it's even fixing stuff around the house.

SPEAKER_01 0:58

Perhaps YouTube could actually fix the HTA system.

Paul 1:01

Well, that's right. That's right. A system where people spend a lot of time licking themselves. And licking each other, quite frankly.

SPEAKER_01 1:11

Okay. There's a visual I didn't need.

Paul 1:14

Oh just yeah, anyway. I probably speak too bluntly about this. I did uh I was interviewed by a journalist who's doing a series on PBS decision making. I may have spoken bluntly uh about it, probably a little bit too bluntly, time will tell. Uh but someone's got to speak bluntly about it. But we did a episode last week about the history of agreements, and I I thought it would be useful is sort of do another part of that where we talked about where we could talk about well going into the the next negotiation for agreements based on our experience and understanding of what's gone previously, what would be our approach? Because I get that a lot from people. So if you're so smart, why don't you what would you do? I never claim to be smart, by the way, but I have been around a bit. And I I do I do have some thoughts. So, what do you think about talking about that?

SPEAKER_01 2:21

Yeah, it'll fine. I think given that I did most of the talking last week, you can do most of the talking this week, and I can ask you questions for a change.

Paul 2:30

We've got really good listenership on that episode. So I think the history is really relevant because I I I you know you sort of can get very short-termish in this system, and I'm actually writing about that tomorrow. We are recording this on Sunday. I'm writing about that tomorrow, about how you've got to think long term the guild's strength, and I go back to Trent Toomey, the national president of the guild, when he spoke at our annual conference in 2024, and they were just about to sign the eighth CPA, and he said, Well, I'm not you know let's talk a little bit about that, but I really want to talk about the ninth CPA and how we're planning for preparing for that. Yeah, they're very, very long term, so everything's a continuum for them, and obviously the their strategy for a long time has been around broadening scope of practice, and general practice has finally woken up to that. Still haven't quite focused on probably the real danger, which is the nationalisation of their profession, but I I I think that's the the critical component of their strength, that they plan multiple agreements ahead, and they have organizational resilience based on its durability and consistent consistency. So the people who negotiated the eighth agreement or were part of that negotiation. So, Trent, for example, uh, an agreement. It was the national president for an agreement negotiated in 2024, but he negotiated the actual agreement in 2015.

SPEAKER_01 4:07

He was part of the team. He wasn't negotiated. They do a cyclical thing, which is you build the ranks and you take on the different positions. But I think the thing that is might counterfactual to that is that the guild doesn't focus on the agreements. The guild focuses on the policy and practice outcomes they want and how the agreements align with that. So where do we want to be in 10 years? What wants we not stuff up in five? And I think that to me is the difference because if you think about 2010 when, you know, the the fifth CPA, and it was a lot of BAU with um responding to price disclosure and other bits and pieces, they were working outside of their agreements in respect of uh vaccination access in the states and starting to move state-based vaccination into the national immunisation program and breaking down that shibboleth, which of course is now standard of care across Australia, getting your NIP vaccines in the pharmacy setting, not just the GP setting. And so to me, that is the difference when you know most of the sector, whether it's the AMA, RSEGP, Medicines Australia, GBMA, they think about their agreement or what's coming next in our agreement. And that is their critical failure, because it therefore becomes about what's in there, what we might what might we like to tinker with next, as opposed to seeing an agreement as a tool to the broader policy and practice objectives that uh pharmacy is seeking to achieve for patient, practitioner, and practice. And that to me is the ballgame. And that's the way ideally good policy, strategic policy and operational policy in government should work. And analogy doesn't these days, they've also got into a bit of the habit of let's deal with the agreements. And I'm not just talking about in health, there's many other parts of the sector. But that to me, until you change that mindset, we are going to walk through these eternal uh swiveling rounded doors that you know to the RACV club where you walk back in and walk back out and walk back in and walk back out and don't realise whether you're inside or outside.

Paul 6:20

Quite nice RACV club in often. Uh it's one person at a time. Uh it's very strict. The it's a really it's a really well-made point. So we have these long-term objectives, and how's this negotiation going to progress those?

SPEAKER_02 6:39

Mm-hmm.

Paul 6:40

And I think that the beauty of the organizational strength the guild has. And and people say, well, it's because they're large political footprint with a presence in virtually Australian, every Australian suburb. Well, the GPs have the same. In fact, they've got a much larger physical footprint than pharmacy, really. Uh, or at least at least as large, probably larger in terms of numbers, but they're not anywhere near as effective.

SPEAKER_02 7:07

Yeah.

Paul 7:08

So it's not it's not fair just to say the guild is is successful because they have this on-the-ground political presence. No, they're actually organizationally very focused on progressing, progressing and disciplined uh uh as an organization in progressing their policy goals, and that that to me is what makes them very effective. So if I speak to Trent or Anthony, uh they would be able to recount discussions from five or ten years ago about particular topics, and and I think that that's a real strength. That's that's a that's a real strength. And I and I think they're also very honest. How did we do well? How did we succeed? Where do we go a bit a bit wrong? So they would have looked at the 60-day issue very objectively, uh post hoc, I suspect, and said, where did we succeed and where did we fail? And that that's that's a great organizational strength. But but if we think about the actual the industry associations, Medicines Australia and the GBMA, you know, I I I, as I wrote on Friday, I can see a path where I can see a path where they actually say, look, we we will agree to some moderate savings, but we don't want to pay we don't want to pay for HTA reform as it's currently progressing. Uh, we don't really want any other processes or reviews. We're happy just for status quo for five years, just leave us alone for five years and we'll give you some savings for that. I could see that as a viable path forward because I don't think anyone could argue that the agreements as they now currently exist, certainly the last couple of iterations, which have been just full of reviews and processes, they haven't delivered at all. You know, they were meant to streamline processes, but they've become more complex and things have slowed down. And I think that was a point that that I've got a lot of feedback on that you made really well in last week's podcast where you talked about the process used to be much faster, and that put a lot of pressure on, but it was quick, much quicker than it is now, and that's that's the beauty of history. I could so I could see I could see an outcome where they just go, hmm, no, we just we want to be liberated, and these agreements actually are very restricting because we're only allowed to work on these things. We we can't really talk to you about anything else because you use this restrictive approach to exclude other discussions. So we don't want to we don't want to do that anymore. So we we basically want to operate outside that to progress our objectives. I could see that as a scenario.

SPEAKER_01 9:51

Yeah, and you know, that's a fair scenario as a patient advocate and representative. What are your other objectives? I I have no idea what the long-term policy trajectory of the medicine sector is, what is their real goals? I'm starting to see it with respect to um the GBMA and what their policy goal is. But for the the innovative sector, I am bamboozled as to what I could say that other than wanting to talk about discount rates, comparators, and um you know price cuts, what their actual policy goal is. Same as I I would say for RACGP. I mean, they're so busy arguing against the guild, and and I saw that in the Australian this weekend. You know, we we can't mount an argument, so we'll get our insurer to mount an argument. Yes, absolutely. Um and the the pharmacy for pharmacy uh insurer comes out going, well, dudes, you know, perhaps sticking your own stick in your own business because we actually know what's going on here. Um, and and laughing about the oh, you know, it's about training. Well, yeah, everyone's doing training and three poorly diagnosed UTIs is not symptomatic of anything when I consider how many poorly diagnosed UTIs and many other diseases in uh primary care anyway. So I I felt that was again leading me to chin. But like I said, your your suggestion is sound. Um and you know, run forth and do it. And you know, personally, I would I would appreciate the the sector not making medicine listings even longer, which has been the outcome of their agreements for the past 10 years. But also, if you're saying you want to go and progress something more profound and of a policy and reform area, then please tell me what it is because I I genuinely have no idea. And as someone who spends a lot of time in the sector and a lot of time with patients, I actually don't know what you stand for, other than perhaps now maybe MFN.

Paul 11:54

Yeah, so this is the strategic and the tactical. And the strategy, I suppose, is the path you choose, and the tactic, tactics are the steps that you take along the path. And it seems to me that the strategy has been these agreements. The problem is that the reason you can't discern anything outside the process and these technical inputs is that's what these agreements that that's the pathway that's been chosen. And it's not a great pathway. I mean, it's sort of it's a it's a it's it's like that first part of the Mount Kosyosko challenge. That it's like that horse track.

SPEAKER_02 12:33

Yeah.

Paul 12:34

Uh but but and I and I don't think that's that was never the intention. I think people were genuine in their belief that this process would deliver. You and I both knew that was never going to happen because that's not the nature of the institution, but I think it was well intentioned, but it goes to the need for the broader strategic consideration of where does this sit in the continuum? So if no, I now I can't see any chance of an organization like Medicines Australia or even the GBMA saying, we don't want any anything in this agreement. We're just happy with we're happy to pay to just be left alone for four or five years. I can't see either of them doing that. Uh as we discussed last week, the GBMA is in the fortunate strategic position where if it gets what it wants, the government gets what it wants to. So that makes it a little bit easier. But but I can't see either of them doing that. So my question to them would be well, where does what you're about to embark on sit in terms of achieving your goals, long-term goals? And when I say long-term, I mean sort of 2036, 2037 would be my take on that. So, where where is the conversation you're about to have sitting in that continuum and how is it going to progress? But as you point out, that requires everyone to be really clear about what that objective is that they want to achieve in 2036. And beyond some HTA reform, it's not discernible like it is with pharmacy, where if you were to ask Anthony or Trent or anyone in the pharmacy guild, what are you trying to do? It's a it's a rhetorical question because we we already know. Agreement processes have sort of just wedged the industry into this corner where and they can't get out that to me, they need to try and get out of it and liberate themselves. That's kind of where I was so to me it's it's it's the continuum. As you said earlier, the pick it up here. So as you said, the agreement negotiation is about finalising something that's already been in discussion for quite a while. Now that that may well be what the pen, I mean, obviously it's pretty clear what the government is thinking. They've made it clear, it's very convenient. They've said there's going to be biosimilar reform. They've said there's a savings issue in the budget, and we already knew there was interagency discussion, and that HTA reform will be part of the negotiation. Now, I think it's eminently possible that I mean everyone's been very surprised by the well, I don't think they're surprised now, but I think people wouldn't have expected in 2021 that the implementation of HTA reform would be delayed until 2027. But I think it's eminently possible that the government at the time knew exactly that's what they were going to do. That they were going to give them the review as part of this agreement, and then the implementation will be part of the next one.

SPEAKER_01 15:40

Yeah, and and like I said, it's a it's a it's a viable option. It's whether it's an industry that has the strengths and courage to do it. And it's again, what is your plan? Now it's hard to correlate that with the latest report on access denied, uh, and that the public statements that the industry is making in respect of where they seem to be signalling to patients and to the government about what they're planning to do and what they're planning to ask for.

Paul 16:13

So Well, I've got some information on that.

SPEAKER_01 16:17

Okay.

Paul 16:18

So the general managers are currently completing a survey about what they want to achieve in the next strategic agreement. Now that might be an engagement tool. It's quite possible it's a tool of engaging to engage people and make them feel like they're part of the process. If it is a genuine survey to determine the objectives, then they're in much bigger trouble than they realise. Because one, that survey should have been done four or five years ago. Uh it's a very tactical thing to do. It's why I believe it's probably an engagement tool. As I said before, the government's well prepared. They've already done a lot of work. The industry can't be starting the work now. It's too late if that's the case. This next negotiation has already been framed. It's been framed about savings, biosimilar policy, probably shortages in there as well, and HTA reform implementation. That's what the government is going to frame this. Well, they already have. That's the overturn window. So I suspect the general managers will come back with what we expect. My my issue with that is it's it's not strategic, and there is no example in the history of this program and this institution of these processes delivering meaningful reform around HTO. I, in the article I published on Friday, talked about one successful process, which was the post-PBAC process, which a current PBAC member actually worked on in the early 2000s. That actually did help because there was a lot of post-PBA. People think it's bad now. It was much worse 20, 25 years ago. And so they they worked. I think this was when Tony Abbott was health minister. They worked, there was a deputy secretary, it was the industry leadership, I think it was it was board members, maybe even the chair of Medicines Australia at the time, worked on constructing a process, which then was subsequently conceded uh in another negotiation.

SPEAKER_01 18:29

So yeah, in the 2017 negotiation, they literally gave it all away. Yes. Again, under the false premise that everyone who's in there thinks my medicine would definitely be category A.

Paul 18:39

Yes, yeah. And that and that's the challenge. So what I encourage the commercial, and because they're all commercial leaders in the industry, I encourage them to think about these processes like they think about launching a product. So they they start a product launching preparation years in advance. They go through very detailed and expensive internal processes. They build capability within their organization, they understand the market, they understand what their competitors are doing. They picket the plan, they picket the plan, they picket the plan to constantly test it and make it better. They constantly revise it. Obviously, there's long-term strategic objectives, but tactical changes have to be made in response to market considerations. But they go through a lot of planning and detail. They're very strategic in how they do that. Well, policy and government engagement are exactly the same. That's exactly what the guild does. And that's exactly what really effective organizations do when it comes to government. So I would characterize that the guild has historically, and I don't think the government is as good as this as they used to be, but the government has planned its approach to policy in the same way the government does. And and that's that's kind of the reason it's it's successful. I mean, I think people genuinely thought with the HCA review that it would be implemented in, you know, the review would quickly be done and then it would be implemented a couple of years down the track. That was never going to happen.

SPEAKER_01 19:58

No, we did fall on about that.

Paul 20:00

Yeah, we did. We did. And and I and that to me is the opportunity is that for the general managers out there who are being asked to input on something that that fairly, they're not really policy and government engagement is not what they're not their specialty. So they have people advising them on that, but but but it's it's tough because you've been asked, well, what do you want to get out of this agreement? Well, they're naturally what they're gonna say is, well, what's my okay? So what have we got in our pipeline? Well, okay, so we want this, this, this, this. It's a completely fair thing to contemplate. Now which is why I don't think the question should be asked in the first place. Because I think this is where uh corporate memory is a real issue, the lack of, and understanding that you've got to the best way to construct your approach to government and policy is to think about it like you are a bureaucrat. And that will that will enable realistic expectations and objectives, less disappointment, probably, and you'll be able to liberate yourselves from these processes, which are designed to live it deliver nothing, but but but it'll also enable you to look at a negotiation in 2026 in terms of how does it follow what's happened before and how is it going to contribute to us making meaningful gains in the middle to the end of next decade. Now that's gonna frustrate a lot of people. But impatience is something that governments can very easily weaponize.

SPEAKER_01 21:37

Yeah, yeah, they can. And like I said, I think you're you're making a a siege point, which is if if you're doing that consultation now, that terrifies me. It actually really does.

Paul 21:49

Yeah, yeah, yeah. So I think it's not real. I I think it's actually to engage them, but anyway, sorry.

SPEAKER_01 21:55

Okay, but then I'm still at all Why do you need that to engage? Like what have you not been doing for the last three years, two years, one year? Um and I I think that is the difference too, which is there are, you know, 5,800 pharmacies around the country. And gosh, we're gonna feel like we're paid advertisements for the guild who do not, which we are not.

Paul 22:22

But if they want to pay, that's fine.

SPEAKER_01 22:24

But they have a significant longevity in their their staff and in their support and their secretariat, and they cultivate that. So when anybody, if you engage with in this negotiation processes, whether it's about their agreements, which like I said, are a tool, not the outcome. But on the broader policy that they engage on, there is considerable history, ownership, sharing of information. They they are the preeminent succession planners. And so they have a continuity within their organization that then allows them to take the information and feed it in a constant two-way stream with their membership. And so nothing that they might bring to the table as part of an agreement negotiation or as part of broader contribution to policy discussions is anything new to them or to their membership. Yet again, what you're articulating is going on right now is that why? You are making it sound like it's new. I get that general managers change, and that's a different culture in the medicines, particularly the innovative sector, that you're cycling through your senior leadership a little more than you would say in a pharmacy owner. But that does not change the fact that your business has been in this country for 25, 30 years, had the information, had the space. Like you said, the people who spoke on your commercial panel at your conference showed what an industry and a company is capable of when they actually focus appropriately as they do. And you've spoken about this many a time over the years, which is if you approached Australia market and policies the way you do an individual product launch, you would be fine.

unknown 24:16

Yeah, yeah.

SPEAKER_01 24:17

Like you don't.

Paul 24:18

Yeah, this is the irony, is that these are incredibly strategic companies and they work over very long timelines. I mean, products have 20 years of patent life plus five most of the time. And I just think government engagement is exactly the same. You've got to you've got to apply the same discipline. There is I think there's too much decision making based on hunches and conversations and it becomes very reactive. And that that's not a criticism of the of the individuals because people have been asked to make decisions who aren't necessarily qualified to make them. And there's an element of you don't know what you don't know. And that's it's it to me, to me, it's like this, right? So if I went and started working for a pharmaceutical company tomorrow, would they make me a commercial director? I hope not. I mean, I run a business, but I wouldn't have the first clue how to plan for a product launch like a pharmaceutical. I wouldn't know who to speak to. I wouldn't know how to speak to internally, I wouldn't know how to plan, I wouldn't know how I wouldn't even have the first thing to do. Probably bring together the different functions in a team. Because the people in those roles who are leading those decisions have worked towards those roles, they've built up a lot of experience. And they know what to do the first day they're on the job because they've been part of it for a very long time, generally. So it's a it's a it's a learned skill. I just think government is exactly the same, is that people are being told and being given responsibility and processes for which they have almost no experience. And so inevitably that leads to to less optimal outcomes, in some cases, bad outcomes, because if you don't know what you don't know, you don't know the questions to ask. When you're told something, you don't know to say that doesn't sound right to me. And and the classic way decisions are made sometimes is well, I was speaking to advisor X, I was speaking to the minister at a dinner, and they said this. And therefore you revised your entire plan over that conversation. I mean, that that's just no way to make a decision. And which is why, and we're not the lesson to learn from the pharmacy guild is their long-term thinking, and they're organ that that they're the strongest thing about that organization is is their organizational building, the capability they build. So when you've got the leaders, the people, the people who led who will lead the next negotiation or the negotiation of the ninth CPA were part of the negotiation for the eighth. And in some cases the seventh. So you have this you have this continuity and that and that that that is a great strength. So they think, well, you know, we when we're in that negotiation in 2015, this is what they did. And this is what was said, and now they're doing this. So this is what's changed. The industry doesn't have that so much.

SPEAKER_01 27:28

Yeah, and and when they do, and and look, look also to be fair, I'm I am aware that they're they contact in various people who've been in those different agreement negotiations thinking that that solves the problem. But I still think that the reason they they they stumble at the first hurdle every single time is that they don't have a long-term policy objective and strategy. So I can read the strategic agreement that says, you know, bringing innovative medicines and you know, making sure they're available to patients. But so what is it that you expect the PBS to look like in 10 years' time? You know, it's look it's like the complete train wreck that was cell therapies. I mean, we've got a HTR review saying, you know, let's recommend that PBSC should be able to decide, you know, you know, we'll go through a single portal, then we'll decide where it should go. And that is a knee-jerk response to the fact that the cell therapies like uh in 2019 and 2018 got sent to MSAC because of the the legal framework under which PBAC can make give advice and it can't. Now, instead of preparing for that for years and saying this is where we need to change the legislation, you know, assuming you want it to be in PBAC and not MSAC, um, and putting those kind of things in, that was something that was coming for a while. We we knew that for a while, so that something could have been planned for. But now what happened is that we went in, struggled with it, even watched some cell therapies go one part to MSAC, one part to PBSC, depending on where they're readministered. And the thing we tried to do now is say, well, what we need to do is move that to PBSC. And that's the key recommendation from this HTR review. Okay, so we're reacting to what happened, yet you should have been planning for that in 2013. So, you know, that was being first raised in 2011, and it was incrementally coming there. But that was the time for starting the policy shift 2013, 14, 15. So by the time you get to 2018 when those cell therapies arrive, the system's legislated to move, it's understood what it's doing, it's had the broader policy discussion about, you know, how many years have we been talking about personalized therapies? Like it wasn't new. And yet that's where things are at. So today I still look and go, well, what is your plan for that, other than these two recommendations that say, I want a single portal, and ideally we'd like PBSC to have more say over more things. I mean, goodness gracious me, that's pretty scary. That's that's not the solution. Yeah, it goes to the symptom symptom of there is no longer-term genuine policy thinking. They have got captured themselves into the idea that our strategic thinking is when we have another agreement and what we put into an agreement. Again, they see the agreement as the outcome, not the tool.

Paul 30:15

Yes, yeah, so so I'll give you I'll give you two scenarios. The the the first scenario is the actual around the HTO review. And the HTA review has suffered from unrealistic expectations about what it would deliver. If uh there'd been more realistic expectation about the process and what it was likely to deliver and people, dare I say, there were some people saying predicting the outcome, then this could actually be seen as a success. If if expectations weren't so high, if if the original expectation was this is the next step in the process towards meaningful reform in this system, meaningful reform in this system means changing the relevant section of the act, putting more obligations on the PBAC, because at the moment all I care about is price. And as the you consistently say, Mark Butler says my job is to get a good price, which is true. That's his legal job, and that's the PBAC's role to help him do that, to help the minister do that. If people had started this process by saying, we know that this is not a cure all, it's not the panacea, it's probably more red pill than white pill. And and but it might we might be able to make some progress, it might be a step in a longer term plan to deliver meaningful change, it might even provide evidence of the problem the intransigence, the lack of willingness to consider reform, the institutional um what's what's what's the rigor mortis? So in that case, it'll be successful if it shows that. Now the latter, I think not only is it realistic, but if it was this is the next step, then what we've got now, which is so dissatisfying to everyone and so infuriated people, would have been considered successful, but expectations were set too high, and expectations were set high because of lack of understanding of history, lack of corporate memory, lack of understanding how government thinks and how it actually operates, how government does not does not create processes to deliver what stakeholders want. It del it creates processes to get you to agree to what they want, but also to limit to limit the outcome and to control the outcome, to restrict you. If all of that had been the starting point, then what we see now would have been a success because they could say, This is what we told, we told you so. We told you that this process was not going to deliver the sort of reform that people expect. We told you that stakeholders were going to be disappointed. We told you that unless we get meaningful reform, change in the basic architecture, which was ruled out on day one of this review, remember that's what the terms of reference said. No change to the basic architecture.

SPEAKER_02 33:26

Yeah.

Paul 33:27

Then then I could see how this would have been successful.

SPEAKER_01 33:31

Yeah, maybe. And but I guess also I'll still come back to my point, which is if you actually really had an idea and a vision and a 10-year plan on what policy and process is needed for the future of access to uh medicines and uh vaccines and et cetera, in Australia, you would not have agreed to this review. And that's the problem. Because if you are actually aligning something and you do have a 10-year plan about where you're seeking to do something, you know when something is going to benefit the longer-term goals that you have for policy and process reform or where it's going to potentially impinge on it. And you've heard me say it many a time, which is that when you're in government, certainly when I'm in government, I'm looking at the 20 years. Yep. And then I'm understanding the 10. And so therefore I know what I can do is change the five right now, and I've got to make sure what I'm doing in the next two does not do damage and prevent what I'm trying to do in the five, 10, and 20. And if it does, where does it actually move those lines? And if you do not have that constant vision, then you end up with what you're getting. So the irony of an industry that is bleating about comparators and what that means for them, agreeing to 36% price catch-ups, price cut catch ups in these things, and then turning around and studies, but now we've got a problem with comparator erosion. An industry that gave up the previous protective mechanism against that. That's what happens when you don't have a 10, 20 year plan and understand your systems and understand what you're agreeing to. Agreeing to something in the next two could stuff up, doesn't it?

Paul 35:13

Yeah, well, there's there's got to be is that rules-based decision making as I describe it.

SPEAKER_01 35:18

And so, yes. Your idea about take the and but like I said, the rules-based decision making also helps if you understand what it is you're trying to achieve. So longer term where it's going. So, you know, your idea, you know, has has value and merits. It um can disempower the the government and the system in respect of what you may or may want to do. But you know, if you're going to do that, then please take the time over the next three years to actually work out what it is that you think our health system should be for patients.

Paul 35:52

Yeah.

SPEAKER_01 35:54

And go away and actually build that 10-year plan. And that's, I think, where with the imperative, isn't it? And like I said, I'm I'm watching from a patient perspective right now. So HTA review has been everything. Then we get up, we we we accept this, welcome the six billion dollars worth of new listings, which of course aren't really six billion, they're probably about two and a half. And then we then say, 'Thino, that's not good.' And then we come out with the new access denied. And I'm like, so where are you? What is it that you actually want? And what is it that you stand for that actually helps benefit me as a patient on a day-to-day basis? And I've got to say that's not clear. And so great that you're consulting your EGMs and all those right now to say, well, what do you want out of this agreement? But think about it. Like what messages are you sending and and what are you going to achieve if you if you let that go? Where would you move on? And I'd be quite happy for them to let go and and move on and let perhaps some other people design the system.

Paul 36:56

Well, try something, try something new. And one of one of my I was working on something last week and I never quite, I couldn't quite land it, but it was about storytelling. And a lot of people talk about the industry's narrative, it doesn't have a narrative. I think the industry absolutely does have a narrative. It's its narrative is about HTA reform. I think that the challenge it has is storytelling. I think Armin Smith from BMS went close to it at our conference a few weeks ago, but I think there needs to be a story. It doesn't tell a story. And when I say story, I mean national interest. This to me is really, really important around the national interest. We we need whether whether people like it or not, we need a successful life sciences sector in this country. Uh, it offers good jobs, highly skilled jobs, often highly paid or well remunerated. The employers are pretty good generally. Uh, these are the sorts of uh careers that you'd want your kids to go into, basically. But the industry doesn't tell a story about itself, it doesn't tell a story about its products, the importance of those products to people. It uses a narrative based on terms that I really struggle to understand. And I want to introduce a new segment on our podcast, which is stupid word games. And I think the most offensive phrase that's ever been constructed in this crazy world is patient centricity. Because one, centricity is not really a word. And what does it mean? Exactly exactly. I mean, no one can sort of explain we we we want to put the patient at the centre of what we do. Yeah, but we don't. Okay, we don't in our system the price is at the centre of what we do, and the patient sort of circles around it. Now we know this because in the patient appendix to the the consumer engagement report or the HTA review final report, HTA was at the centre of what we do, and patients circled it. I I think we need to be obsessive about patients. I think we need to be absolutely obsessive about them. And and that means doing absolutely everything we can to make their lives better. And unfortunately, in the system, and I've used this analogy, and it makes people really uncomfortable, and I don't particularly care, but our system essentially walks past sick people like someone does a homeless person. Now, our human reaction to seeing a homeless person is sadness. Why? Because we care about people in our community. Our system of HTA doesn't just walk past a patient and often disregards their need. It actually says, not only are we not going to provide the funding for the healthcare that you need, it's actually in your interest that we don't do it. And that to me is offensive in ways that I can't even begin to describe. But that is how our system works. And I'm sorry, I have a real problem with that. And the system gets away with it because of processes that industry agrees to in these agreements.

SPEAKER_01 40:07

Yeah, look, um, I do understand patient centricity, and it comes from um citizen centricity, which is, and you see it quite work quite well in New South Wales and the way they redesign the way their bureaucratic systems for licensing and all these kind of things actually say stop having to do it 19 times, one person, everyone links in. That's that's the concept behind it, and it can work quite well. What the the problem here, and in particular this part of the health system. So, you know, if you if you go into the pharmaceuticist to get your um script filled, it's patient-centric. You're there, you're in front of them, they're looking at this, got a problem, they're ringing up to find, you know, if they can get your medicine across for you. They are focusing on you as the individual patient. They are patient-centric and their goals align. If the patient gets what they need, pharmacy as a practice succeeds really well. So it's a it's a nice goal. What happens when you come into the PBS now and MBS as well is that we deliberately do not make it patient-centric. We talk about population level, which allows the dehumanization and the methodological construct of an idea and a model as opposed to the person sitting in front of you who needs treatment. And as I've always said, you know, you know, if you go to a specialist and so this one, they'll say, well, just one minute, I appreciate what your symptoms are, but let me look at this from a population level and see where, you know, you might fit in. That is the problem with allowing the adoption of patient centricity in the HTA system because it is specifically designed not to do that. It aggregates everything to make those decisions possible. And so I support you on, I don't have a problem with patient centricity because I see it worked very well in the acute care setting and many other parts of the system. But it will never succeed in the HTA system because HTA's primary objective is to not see an individual, but to see a population level effect.

Paul 42:06

Yeah, and that's that's that's well put. I think maybe my hatred of it is the way it's used and weaponised.

SPEAKER_01 42:11

Yes.

Paul 42:12

And see, I I think the story opportunity is for people to say, we are absolutely obsessive about patients. It's not everything that we do is about patients, but we obsess about serving their interests. And you make the point about going into a pharmacy. They are by and large obsessive about meeting your needs as a customer, and as a customer, you're a patient because otherwise you really wouldn't be in the pharmacy. So I I take your point on that. I just think these terms, all these terms are bastardized in in these processes, and it becomes almost ironic. And I just I just don't accept that. I mean, when I was speaking to someone this week, I said, this is like this, I don't even know why they have consumer representatives on the PBOC. Because they're not legally mandated to take and take these views into account, which is why when the current uh composition of the PBOC was legislated in the 1980s, it didn't include any patients. It didn't actually legally require any patients to be on it until late 1990s. And and I and I can tell you, we only put that in the legislation to keep some of the other crazies off the committee. And and that that to me, I think, is is is a real problem. There's no legal obligation on the committee to consider uh the the input of patients, and we don't even know how they do it because the stuff will not be released under FOI. And then we get these utterly offensive Delphi surveys, these these self-lecking exercises about HTA. And it's just, I'm sorry. This this is what you get when you don't have a story, and it and it and it makes me it it makes me angry because it legit just all it's contributing to is further legitimizing a deeply flawed, a deeply flawed system.

SPEAKER_01 43:59

Yeah. Look, um it it's a a valid point, which is and it's almost a concerning point. I I find that, you know, when you're in the acute care setting and I spend a bit of time there with my mum, a doctor and a nurse and the whole team on there don't need a reminder about what it is that the patient might need. But we're saying in our HTA system, we have to keep reminding them that there's a patient at the end of this, whether they're sitting in the room or whether we have a you know facilitated workshop to talk about something or whether we have, you know, a new Venn diagram. I think that's the thing that we need to crack open because patients are treated like a source, source of window dressing, or something we bring in at the last minute because they're having a bit of trouble with the PBSC. So, you know, can can you talk to the media for us? You know, can you do this? So we'll support you because it's aligned with us. Patients are an afterthought, and that's not necessarily because individual companies don't have patients at the center of what they do. I mean, that's both their combined success. Patients are well, the company succeeds. But what I do think is that when they go into the HTA process, they go from being these people who are running these great familiarization programs, I know you don't like them, but you know, supporting patients, having access, running trials, trying to get something done. But the moment they move into HTA, they move back into that thing where it's, you know, it's a consumer, not a patient. And, you know, as Bless Nicole Cooper used to always say, You think I want to take medicines like this and have stage four bowel cancer? Yeah, well they treat it like I don't want to be here.

Paul 45:29

They treat it like buying a car.

SPEAKER_01 45:31

Yeah. And so I guess, you know, it's a very important point that, you know, I guess when it's finishing one, but there is something really toxic about HTA when you have to put patients in front of everybody working in the system to remind them that that's actually your priority. And like I said, you don't need to do it in the GP clinic, you don't need to do it at the pathology clinic, you don't need to do it at the pharmacy, you don't need to do it at the specialist, you don't need to do it in the hospital. But apparently, and I don't need to do it on the clinical trial, and I don't need to do it on the familiarization program, but the moment I hit HDA, a patient is window dressing that everyone has to occasionally pull out and say, Look, remember someone at the end of this.

Paul 46:14

Well, because they're an afterthought.

SPEAKER_01 46:17

Yes.

Paul 46:17

Legally, they're an afterthought.

SPEAKER_01 46:20

Yes.

Paul 46:20

The legal framework.

SPEAKER_01 46:21

And I it in the PBS, not in the MBS, but yes.

Paul 46:24

Yeah, in the PS, they're an afterthought. And they're treated like that because the legal framework requires it. It doesn't prioritize them. That's why, you know, should HTA play a part in decision making? Well, yeah, it can. My view is that it just shouldn't play the part it does. And that's that's the conversation that we need to have, is that we're all reversed into these economic models. And this is the story point. You think about all the great political leaders, all the great entrepreneurs in the world, they tell a story. Think about the entrepreneurs, you know, they tell a story to their investors and they get money thrown at them basically because they can tell a great story. And that that's what that's what's missing here. There's no story to be told about comparators and discount rates and processes and streamlined. I mean, let I tell you. If we talk more about these these PBS processes have had the absolute shit streamlined out of them for two decades, they've been more streamlined than a fighter jet.

SPEAKER_01 47:19

They say streamlined they're longer.

Paul 47:21

Yeah, but but but the more streamlined they get, the lot, the longer they take. It drives it drives me absolutely crazy. But so I I think, as I said, scenario one and scenario two, there is a scenario under which the HTA review outcomes could have actually been positive in terms of telling the story, helping to tell the story. And unfortunately, expectations were raised too too far. I think there is a possibility that the industry should say, we'll give you some moderate savings. We're not paying for those outcomes. Or we are, and then we don't want any more processes for four or five years. We want to be free to go out and advocate for the things that we want to advocate for, and we don't believe we can do it within the strictures that you impose on us. So we're gonna do that. So we get we need to get out of the step back from this institution a little bit and see how that goes. And then think about it in terms of how are we going to get to where we really want to be in 10 years' time. And that that have have that conversation. That conversation should have should have been had. Maybe it it has been had. I I I don't know. But think about it in those terms and think about decision making in policy and government engagement in exactly the same way you think about preparing to launch a product. The same discipline, the same focus, pick at it, pick at it, pick at it. You know, I was at an event in Canberra recently, and someone in the health department said, Well, you know, our job is that when you present an idea, our job is to pick at it. Pick at it and pick at it and find all of the flaws. And I thought, I hope everyone in that room heard that. Because I thought it was a yeah, I thought it was a there was only about three people in the room, but I thought that was a really, really good description of of what they do. And it's what they should do. That's that's that's their job. That's what everybody should do. Yes, and and that's what companies do for products, and it's what industry should do. But there we go. Felicity, thank you.

SPEAKER_02 49:18

Thanks, Paul.

Paul 49:20

Thank you for putting up with my technology failures.

SPEAKER_01 49:24

Thank you for putting up for my lost in translation.

Paul 49:27

I'm having such a good football weekend this weekend, and you know why?

SPEAKER_01 49:31

Because you're not playing.

Paul 49:33

My team's got the buy. And that means as a fan, I also have the weekend off. Thank goodness.

SPEAKER_01 49:38

Yeah, I know. I'd just like to point out to your to your listeners that you know, for the last four weeks, what you've been winning and you're still complaining. I'm probably complaining more now.

Paul 49:47

Yeah, because it's gonna make us hard. You know, all this win, it's gonna put us up the ladder, it's gonna make us under the new draft rules, it's gonna make us harder, make it harder for us to get Cody Walker in the in the draft. He's gonna be one or two in the draft. So there's always, you know, me, I'm very negative football.

SPEAKER_01 50:04

Didn't win by enough, didn't win this. Oh no, we still play badly. Oh, it's probably yeah, I've just got to say he listens. Yeah, I'm looking forward to Carlton starting to lose again because at least that be back to normal. No, well, the complaints will be rational. Enjoy the win.

Paul 50:20

Sorry, sorry. Uh thanks, Felicity, and thanks everyone for the feedback from last one. Obviously, really enjoy talking about our perspective on the history. This is why we wanted to come in today and talk about well, what what are the opportunities now? And there are there are some opportunities, just need to think about it maybe a little bit differently. Thanks, Felicity.

SPEAKER_01 50:38

Thanks, go.