The 'Dispatched' Podcast - Series 5, Ep 23

The MS medicines controversy continues. Why wouldn’t the minister just deal with it and make it go away? It may not be that easy. Why any resolution will probably deal with symptoms rather than the cause. The realities of ministerial offices and the challenges they face that are not visible to outsiders. Another 'phrase of the week' is dissected to reveal its true meaning.

Transcript

Paul 0:08

Hello and welcome to the Dispatched Podcast. My name is Paul Cross, and I am delighted to be joined once again by my co-host, Felicity McNeil, PSM, to Better Access Australia.

Felicity 0:22

Hi, Felicity. Hi, Paul. Lovely cold week. I'm just sorry. I'm completely beguiled by Paul's bass just lying here snuggled on the floor and I'm waiting for one of them to snuggle onto my feet because they're cold.

Paul 0:36

Yes, they don't like the cold weather. They don't like the warm weather.

Felicity 0:40

They don't like weather.

Paul 0:41

They don't like weather.

Felicity 0:42

They don't like walking.

Paul 0:43

Yeah, they don't like walking. They like eating and sleeping.

Felicity 0:47

Yeah. Yes, it's a dog podcast. We're going into the happy spaces because, you know, I'm I'm devastated, Paul, that the Prime Minister turned us down for a podcast. But looking at what we're wearing, we were never gonna get it.

Paul 1:00

Um no. What a we'll get to that.

Felicity 1:04

We will.

Paul 1:05

Uh but let's start with the ongoing issue with multiple sclerosis medicines. We have spoken about it. I see Monica Ryan has just come out and suggested the minister sort it out. Um, Dr. Ryan says uh look, there is a a question here. The PBAC discussed it this week. We're led to believe the minister's been asked about it in a series of media conferences, he seems to be getting more and more annoyed by it.

unknown 1:39

Yeah.

Paul 1:39

Judging by his language. Uh well, that's that's the job, I suppose. I'm sure he accepts that. My my my confusion is why wouldn't you just make it go away? I mean, if I was advising him, I'd say, Minister, this outcome will be public in six weeks. Even if we sort it, we wait two or three weeks to sort it out, you're gonna be asked about it constantly. And it's not really sustainable politically to give the same answer every single time. Because of course, now the next time he does a media conference, the question will be, Well, Minister, you said the pharmaceutical benefits, blah blah blah, blah blah would meet and discuss it last week. What was the outcome of that? So is he really going to say, Well, I'm just awaiting to get the advice? And so if I was advising him, I'd say, Minister, just sort it out this weekend. Just sort it out. Make it go away. And if you actually do that, if you act and do it, you'll be a hero.

Felicity 2:43

Yeah, shamefully he will be.

Paul 2:46

But that's I'm just thinking about the politics of it. Uh but I but I wonder, because because the other thing I'd be advising him is that, Minister, how many times have we had to intervene in these issues? And is it becoming a more regular feature of our day-to-day work and what does that mean? Because MS is symptomatic of an issue. It's not the problem, it's a symptom of the problem. And my suggestion to him would be well, we're just gonna be back here in a few weeks on something else. So I think we have to have a bigger discussion here. And I I th I think he's almost publicly conceded that the problems run pretty deep at the moment.

Felicity 3:37

Look, it's been interesting to watch the narrative evolve, both from him and uh from the sector. I think we've started with a minister who, you know, barely a few months ago was saying my job is to get the best price, a better price. You know, can one down? The price is right.

Paul 3:56

Well, then he's right on that.

Felicity 3:58

Yes, he is. Legally that's legally that is what the PBAC is charged with, actually working out the price of a medicine. It's not actually got anything to do with patients. So Yeah. On the basis of that, all well and good. What we're starting to see is the the softening of the language. We should be grateful that the medicines that are in dispute are in the wheelhouse of patient groups who are significant in the community, who can clearly articulate what that means and can create a sense of this could be you, this could be your family. So when this happens on things that no one really cares about or understands, when they can't humanize it, it kind of goes through to the keeper because we've we've been having this issue, like you said, this this is not a new issue. It's an issue that is consistently being raised. We have seen that the as Natasha Robinson wrote about this week, the the agenda for PBAC, which is public, did not mention multiple sclerosis drugs or a number of other issues that we may be aware of are being considered. But it did mention pushbacks on risk share arrangements, it did mention pushbacks on recommendations to seek a further proposal to try and get the PVSE to change it mind. It included recommendations that have not been progressed. And I think she used the term swamped, and you've used the term unprecedented. Yeah, we're we're getting more pushback at the moment about we're the system's kind of hit a tipping point. Uh we've put procurement in front of patients, and we're starting to suffer as a consequence. So I think it's great that he started to soften his language. I think we have seen he is an interventionist minister, and you and I talked about it a few weeks ago. He does seem to have to intervene a little bit. He had to intervene to finally get the contraceptives properly listed on the PBS because procurement was before patients and the PBAC doubled down on pricing. He did have to intervene when the PBAC decided that there were too many submissions that month. And so they just put them on hold indefinitely and they'd get to them when they could, again, process before patients, and he had to get out up and say publicly, no, you'll meet. He did have to intervene in respect of this issue again. And it's an increasingly common occurrence. I'm actually surprised it took him to that long when you consider when you were reporting when he spoke on Neil Mitchell and admitted his the system he was in charge of, the system that gave him advice and that he was the sole decision maker on, if he wanted to be, was leading to avoidable deaths. So it's good that he's getting to that point. I'm with you that the greatest fear I have is that they do get together over the weekend and they solve this one. And everyone pats themselves on the back and says, Isn't this great? We've sold it, and these patients still have access, and this is wonderful. There's nothing to see here. The challenge for the industry, the challenge for all patients, including the MS patients who will probably get the the rest retained access that they want, is to keep fighting because you don't know what's next.

Paul 7:37

Yeah, and what the one certainty in this situation is that something is coming down the track at him. And we're going to talk about the realities of the day-to-day existence of a minister in their office. And we both have a lot of experience in that from different perspectives, but it's relevant to the conversation. But look, we're in a disruptive period, and I think we should embrace the disruption. It's a downhill and one ski situation, as Paul Keating once described, a political challenge that he had. But this is how change occurs. The safe, stagnant nature of PBS policy discussion for so many years has not got anyone anywhere. So this is going to be a disruptive period. Uh it's going to be uncomfortable. It's not going to be great for the advocates of change all the time. But it's a good thing. It's a good thing. And to to see the Minister's frustration at media conferences, I think, is a as much as anything going to drive change. So so the worst thing that could happen now is for an issue like the MS medicines to be sorted and the disruptive periods to come to an end. Giving the minister a platform to say, Oh, we've sorted it. But he must know now that he's in the middle of a situation, not at the end of it. So what did Churchill say about Um it's not the uh beginning of the end, it's the end of the beginning. I think that was after El Alamane, but that's that's how people should see it, that this is a platform to keep progressing. Because if you think about what Natasha has, and she's just continuing to do just a masterful job. And congratulations to you too, because I thought your quotes in her article this week were really, really spot on.

Felicity 9:36

Very kind, thanks. Hangry Pantzer.

Paul 9:40

But I think she's using old health department photo. Which is a wonderful irony.

Felicity 9:46

It it is. Uh m my children do laugh and say, We wonder which photo will appear.

Paul 9:50

Is that the coat of arms in the background in that one?

Felicity 9:52

I think it is, isn't it? No, it's not the coat of arms. That was that one, or am I thinking about last week's one? No, that one is uh from the emergency response room in the Office of Health Protection.

Paul 10:04

Which is just the TV room, everyone, but it's just got a bunch of TVs. But desks. Desks flashing red lights.

Felicity 10:13

Desktop laptops.

Paul 10:14

That's right, that's right. But no, I thought so. Kudos to you, I thought the quotes were really good. But the MS has been in the back end of this series. Yeah. But not early, so um people need to see this as just the next step along the path, and something else is going to appear.

Felicity 10:35

Well, it is, and I mean, if you look at the agenda from PBAC, if we if we focus on this issue that's front and centre now, there's a a challenging on the risk share arrangement for um cancer treatments. And obviously seeking to push that. There's a resubmission on the, you know, one of the most repeat offenders of trying to get a risk share change. And I don't mean that in a negative way, um, GPixant, with its listings and the the torture that has uh been extracted onto that listing over time and the constant pushing to say we are genuinely treating the patients that need treating. They're in there trying again to progress a listing that they've you know had multiple recommendations on but haven't proceeded with. You look at those things and say, what is going on? You look at the the three or four other ones which have a positive recommendation but are trying again, it's expensive to go back in.

SPEAKER_02 11:31

Yeah.

Felicity 11:32

It's very expensive to go back in. It's yeah. And that you also see that when companies choose not to progress and let the the recommendation lapse after three years, because the time and money that goes in to change the PBAC's mind on its procurement decision is just well, for that extra half a million dollars of work, you you could just give the patients the drug. And um I I think that's important. And I think, you know, this is also around the time that we've had the issue with uh Zolodex delisting. Sorry it is brand names, but that's what's being delisted from the PBS for breast cancer. And you know, reading the various articles on that, there's apparently a solution, an alternative medicine that AstraZeneca has available.

Paul 12:17

It's a high d it's a higher dose, yeah.

Felicity 12:19

But it's not on the agenda.

Paul 12:21

No, it's on the agenda for like it's it's going to be on the agenda for September.

Felicity 12:26

So it's a Tamara and it the the solution that is currently on the PBS expires on the first of November. And can I just tell you how many patients and clinicians are hoarding and bulk purchasing that it's not going to last until November? And why, if the department and the PBAC have known about this delisting for so long, why are they not why did they not consider this alternative when they agreed to the delisting in May? And why are they not considering it in July? Because it's going to take time.

Paul 12:56

But the systems, and you know this as well as as well as I do, I think maybe even better, but as an institution, it's just not responsive. Because it because it's self-preserving culturally. And so it is constantly going into a bunker and it's constantly just puts its hand up, talk to the hand. It's almost like Little Britain, you know, computer says no. That's that's what it's like.

Felicity 13:20

Yeah, it's not only procurement before patients, it's process before patience, too.

Paul 13:24

Yeah, but when it suits it, it hides behind process, but doesn't always hide behind process. Well, but but it when it when it suits it not to hide behind process, you know, is what is what I mean. I mean it if it suits it to hide behind process, it absolutely, it absolutely will, but other times it won't. And this is this goes to the I used the suggested this week that change advocates have to understand that you're you're always the away team in this stadium. But the home team aren't just the home team, they also write the rules and appoint the umpire, and so that that creates that that creates a problem. And and institutions in that situation, when they have that power of symmetry, inevitably end up going off piste. That's in it, it's inevitable. There's any number of academic uh uh perspectives on this issue that institutions are culturally tend to become cult culturally about self-pre preservation.

Felicity 14:29

Oh, absolutely.

Paul 14:30

Particularly when it involves power, particularly when it i they're dominated by the same people for such a long period of time.

unknown 14:35

Yes.

Paul 14:36

So there's a lot of there's a lot, there's a lot of aspects of this institution that rules us, our HTA overlords, that would be the subject of a fantastic study about problems. Uh Minister I work for confronted it, and as soon as he moved on, you know, they just went back to the way they were. And it and because this is the the characteristics of this institution, where we are now is inevitable always. Because it's uh its legal framework gives it so much authority and it uses that authority uh ruthlessly, I would say, to to meet its obsessions over price. And they're dogmatic and ideological.

Felicity 15:25

Yeah, I I think it's fair I think when I was speaking to people about this earlier this week I used to be in charge of this system and occasionally I made some fairly strident decisions and had introduced some fairly radical reforms. So I get that I am not without uh guilt or association with with some of the reforms. And you know what? Most of them I'm but no no, but that's you get your job. Let me stop for a minute. But most of it I'm pretty fine with. But most of it I'm actually quite fine with when you introduce price cuts, you know, on on anniversaries to a point, and then you you know you tighten up some of the the risk share so that it's not, you know, only 5% payback, and it's not just that you get to have an extra 50,000 patients when you only had 10,000 patients. Some of those things about redressing the balances or you know, the movements of things to to get to avoid price disclosure. There are things that the system moves, the industry moves, the system moves back. And so you're trying to constantly get that equilibrium and list the medicines. I think what you what what a lot of people didn't see during that time, and we have sort of talked about it when we talked about the history of the system, was when other parts of government were wanting to push and really slowly boil the frog, if not just actually chop the frog's head off and put forward all these other extreme ideas in pricing and the system at the institution of the PBS and the Department of Health push back. What I think that we've started to watch, and why why can we explain that why is it all happening now? And it's not just because the negotiations are coming up, and it's actually not just because Donald Trump's been talking about things. It's because we have slowly boiled the frog. Because every time we've put a new price framework in place, every time we've said we'll start the pricing a little bit lower, every time we've not funded the full number of patients, every time we've then hit the price again because it's a five-year rule, every time we've done an ad hoc price cut because we got some other company to agree to something, we've slowly boiled this frog. And I think that's what we're seeing now. And so when people say it's it's not on on their own, a lot of these reforms are sensible reforms. But each time you add a new reform, you have to kind of dial down some of the other ones to make sure you don't boil the frog. And so I guess that's what I'm encouraging patients and everyone to understand. We will get a solution, I expect, on MS. And we will all feel great about it. But it's only going to turn down the temperature on the frog from 100 degrees to about 95. That next notch on the dial is coming again. So we have to keep going. We have to have the grown-up conversation. And what terrifies me is that everyone is about to go in and have this negotiation between the purchaser and the provider, and the patient is nowhere. It is going to be effectively, it's a tender conversation, it's a contract negotiation, as opposed to what is the PBS about? It's about patience.

Paul 18:27

Yeah, and you know what drives me absolutely crazy is uh, and I ask this of the industry when has this ever worked for you? When has a negotiation that involves you going into a room with officials, locking the door, and having a secret of conversation? When has that ever worked for you? It's never worked for you. Part of the disruption is to get other people involved. And I don't care who it is, I don't care if it's doctor groups or but it's got to be patience. It's got to be patience. And yeah, that means you're gonna lose control of it a little bit, and that means other people are gonna stake a claim on any savings that are agreed. Okay, that's fine. That's gonna happen anyway. I just think you've got to embrace, to me, you've got to embrace disruption because the status quo, this stagnant body of water, as I described it this way, it's not working for you. It's not and it's not at you know what? And it's not working in the national interest. And how do we know that? Well, we know that because of the MS issue and all the other issues that have gone on in the last couple of years, and Mark Butler knows it better than anyone. And I I wanted to talk about, I thought it'd be helpful for our audience if we talked about the reality of a minister's office.

Felicity 19:36

Yeah, you've giggled a lot this week, haven't you? People have rang you going, what the?

Paul 19:40

Yeah, people people assume that these are high-functioning organizations. Okay, they're very small insular teams of people. And one minister's so so you've got to treat the ministry, and you know, the the cab, all the cabinet ministers in the outer ministry, you've got to sort of treat them all as separate entities. And they all have their own little internal cultures. And obviously, the minister of the day is an enormous influence over that culture, but we don't know, you can't know how the relationships operate. Now, they are dysfunctional a lot of the time because that is the nature of what they do. You are dealing the reason the reason we have ministers is because we have problems. Ministers aren't there to announce good news, they're there to manage problems, really. I mean, if we're thinking about it. A good day in a minister's office is one that's a little less bad than the others. It's it's a really tough grind. It's long hours, not a lot of money, you're under enormous pressure, you're dealing with any number of stakeholders. The toughest lobbyists are the bureauc bureaucrats. Okay, that's that's the toughest relationship because they lobby really, really hard for their causes. And they're trying to get the minister's attention. All the different advisors in the office are fighting for the minister's attention and realise how much of the minister's time is actually pre-committed in a given week to cabinet meetings and other you know, committee meetings and other obligations that the minister has. So there's not a lot of spare time. So, what's the role of someone like an advisor? You don't really have a lot of power. You've got no formal power, you've got positional power. But who knows? I I don't know how Mark Butler operates. Does are his policy advisors actual policy advisors? Or is that correspondence managers? Are they correspondence managers? Are they administrators? Like one of the ministers that I worked for, he did not he his advisors, including me, we just ran interference on stakeholders. I don't think I ever gave him advice on a specific policy issue that he actually. Because he already he already made up his mind. Is Mark Butler like that? I worked for another one who absolutely relied on advisors way too much. I thought, way too much. Didn't put in the work themselves. So we don't know how Butler's operates, but you can't know. And so when you think about this MS issue, and you can see, I'd advise people go and read the transcripts. They're all on the health department website, on the minister's website, and his comments on MS, and you see an escalating frustration. So rest assured, the minister is not sitting at his desk thinking about this issue for more than a few minutes a day, if that, because he's dealing with all sorts of other things. So he goes to the press conference, his media advisor says, You're probably going to be asked about this one. Okay, and so he thinks about it, he might speak to someone, he might call the secretary. I don't know. I don't know how he how he works. And he's certainly in the the press conference he did Wednesday, I think it was it Wednesday where he was just riffing. He was just making stuff up. Half the stuff was just wrong, but I don't think it's intentional. He's just not really that deep in the weeds on it. Okay, so he's relying on his department. I don't know, you know, and you've got to understand that in a minister's office, all the advisors are all competing for the minister's time. You know, you don't get half an hour to sit down with a minister. Usually, the best times that I had, I don't know how times have changed, it's probably even tougher now with all the social media obligations.

Felicity 23:36

But always time to do a dance.

Paul 23:39

Always good in the back of you know, great, great. You might get 15 minutes back of a car. That was good. I've I've always thought that was good. On the plane, bit hard to talk about issues on a plane, but just time.

Felicity 23:51

Chairman's lounge is always good for chat. Oh come on, you know it's true. Yes, yes, it's true.

Paul 23:58

That's right, that's right. That's why we need the chairman's lounge. But so you you don't you don't know. And so my thing about well, why isn't he just sorting it this week? I don't get it. Sort it and announce it on Sunday and Adelaide. Because he's got to turn his mind to it. Got to turn his mind to it. He's got a lot of new staff, right? Do they understand that the minister can just call the secretary and say, I want it resolved, or I want it resolved, I want it resolved now. I want advice on how I can fix this. Quickly put together what the PBAC has said, and I'm gonna sign off it. Bang, and it'll be done. But who knows? I I don't know. So it's really, it's it's it's really, really hard. It's just that when people in these ministers' offices have really impressive job titles, and I had a really impressive one. Great business card, you know, you have the blue pass, ball house, you get special privileges, got a car park underneath the ministerial wing, brilliant. Doesn't mean a thing. It doesn't mean a thing because you don't know what the personal relationship is like. You don't know if they're truth tellers. What sort of minister is Mike Butler? You know, when something goes wrong, do they talk about it or does he just go into his office and close the door and he stews on it? You know, are they truth tellers? I t I had to give a minister I would for bad news once. I actually advised them that you've got to apologise for something. And they didn't talk to me for three months. They're humans, they are humans. So, so when it comes to this multiple sclerosis issue and pricing, don't assume a rational political response. Because one, we don't know everything that's going on, we don't know the advice he's being given, we don't even know his own view besides that he wants them to stay on the PBS, we don't know how his office works on these things, so it's all of these challenges, and what's more. So if you think about this in isolation, this one pricing issue and the sort of challenge he's having with it, think about the the wider reforms that people want. Think about that. So, so it's hard enough dealing with a very specific issue on a particular day that's dragging on a little bit and causing you some problems. System level reform, that is a whole nother world of difficult, particularly if your department doesn't want it. Yeah, so that's just e imagine it that way. And I'm not I'm not saying that necessarily to say I have sympathies for him and his office um because that's that's the job. That's the job. But don't never assume that these are high functioning, high-performing organizations. They are under enormous pressure, and that's got a lot worse with social media, and it was bad enough when I was there, but it must be horrific now, and obviously they're losing their marbles because of the social media choices they're making.

Felicity 26:58

Yeah.

Paul 26:59

I wonder how long he spent making that dancing TikTok.

Felicity 27:04

At least I don't look as bad as the Prime Minister.

Paul 27:06

Well, we're gonna get to that. But when when someone, you know, this is why you need some grey hair in these offices. Minister, what we think? What you're gonna dance around and we're gonna magically have these signs appear. Someone needs to say, We're not doing that. We're not doing that. It's like the discussion in the Prime Minister's office when they said, Hey, there's this podcast, you know, and we think you should do it. It's called Bush Deep or something.

Felicity 27:27

Yes. The name really did give it all.

Paul 27:30

Yeah, yeah. I think we think you should do it at the lodge. And no one said, What hang on a minute. So, what's the style here? Like 730 report, is it you know, four corners, today show? What is it? Well, no, it's sort of light-hearted, you know. Well, what do you mean by light lighthearted? Oh, you know, it could be some innuendos, like they should have said, no, not doing it.

Felicity 27:51

Well, it's not like that podcast was run differently to the way that the host normally runs it.

Paul 27:57

Can't blame her. No, can't blame her. She did what she's always done. But it was beneath the prime minister to do to do that. And I'm I'm showing my age here, I'm kind of old-fashioned. And uh, you know, even doing it in the lodge was terrible. So I just think there's there's got to be a dignity to the office. The comments he made about Kylie Minogue, but also the Japanese Prime Minister, yeah. The innuendo involved in that, that's beneath him. He just a 60-year-old man, it came across as really creepy.

SPEAKER_02 28:32

Uh, yeah.

Paul 28:33

And I don't think he is. I just, you know, because he could see he was very uncomfortable with it. And what surprised me is that someone didn't step in and say, we're stopping this now. We're stopping it now. There's just no problem, there's no way you can you can do this. But I also know that bad news, you know, because politicians, they're like all of us, they've got big egos. And their egos tend to get, and you want them, you want them to be have big egos. You actually want them because we need people who are confident and self-assured, uh, and believe they can do the job, have that self-belief. You actually want those sorts of people in those in those roles. But so what does and this goes to the discussion before about the how these officers operate. So, do they have a bit of a investigation, a bit inquisition? Do they sort of review? I doubt it. I doubt it. A couple of quiet conversations, no apologies. In fact, I could even imagine a conversation with you saying, Oh, this has been hugely successful. Forget about all that. That's just old persons media. This it's been just it's just so relatable for millennials. They're gonna love it probably. So this is really good. This is how we, you know, this is you know, I'm not suggesting we do it again, of course, but don't think for a second that this has been negative for you. It's certainly not. The people who hate it aren't gonna vote for you anyway. I could see that being the conversation.

Felicity 29:52

Yeah, look, and I because I understand the politics, I'm gonna say, as a woman and as a woman of daughters, mother of daughters, it was it was icky.

Paul 30:02

Oh, it's horrify yeah, bad.

Felicity 30:04

It's also completely at odds with a parliament that has just spent the last three to four years explaining the importance of not having sexual harassment in a workplace. I mean, if you said that in the private sector, if you did that in the private sector, you would be fired. I it's simply not tolerable. You cannot have that conversation. If she had asked those questions, not about uh, was it Rhonda Birchman or Carly Monogan? Who is the third?

Paul 30:32

Um I can't remember.

Felicity 30:34

Yeah. If if it had been Senator Wong, Senator Gallagher, and Minister Wells, would he have been okay joking along, or would he have actually stood up for the women that actually work in his portfolio in his permit? And so, well, actually that's really inappropriate to do that. And what's more, why are not Labour women who are so quick to call out everything else not calling this out? I mean, I guess I saw the Prime Minister not call out the mean girls' issues either. And that concerns me. So which way is it? Is it that we're all fine with it? Or are ironically these incredibly strong empowered women who are regularly talking on Tic Tac about all the great things they do for women frightened of their male boss?

Paul 31:21

Well, it's situational ethics. Yeah, it is. It's if they do it, it's terrible. If we do it, we're gonna defend it. The defense uh has been poor. Um his one-line apology. It's it was yeah, I was disappointed by it because I don't think he I I don't I don't obviously have no clue. It doesn't really come across you could see that he was very uncomfortable with it. But the whole black t-shirt thing, too, it's like, come on, man.

Felicity 31:51

Well, that's what made you uncomfortable.

Paul 31:53

Black t-shirt, you're a 60 young man. You wear a black t-shirt to bed, basically. You don't, you don't you wear a shirt. You're the prime minister. Yes, he's trying to be the cool dude, and and again, I'm showing my age because you know I've I was going off on it this way, so I was going, Robert Menzies lived in that house. Yes. Have some respect. Have some respect. And I know that that is that is me showing my age, but it goes to the uh what what what's obviously this this government is not good at taking external criticism.

Felicity 32:26

I know I've I've seen that first hand, yeah.

Paul 32:28

Yeah, what's it like internally? What's it like internally? Uh because the you know, and I would encourage people to think about your own organizations that you work in and all the politics and the personal rivalries and the emities. A minister's offices is exactly the same is exactly the same. And and and in some cases, in my experience, it's a lot worse because you know, there's a tendency for people in those roles to become pretty self-important.

Felicity 32:56

Yeah.

Paul 32:56

Because situational power. Yeah, it's it it's power. So people run after you like you are the minister, and it's just crazy. And I would I would liken it to and when you leave, people people are constantly going back into those roles.

Felicity 33:11

Yeah.

Paul 33:12

But because they miss it's much better being the the the conductor than just the member of the orchestra.

Felicity 33:19

That's true. But I think you've raised you know, I know we're going to talk about, you know, word of the week. But situational power, situational ethics, it's a really big topic that I think whether you're an advocate or a policy developer or just someone living your life uh on a day-to-day basis in Australia at the moment, it's becoming very real. And it's the situational caveat that uh ministers or politicians put onto certain issues that creates the counter-response of immense distrust, uh looking for straight talkers, straight tutors. So we do need to really reflect on that. I know it's something that becomes quite important when you're in an advocate role where you've got to remember I'm either all in or I'm not. Like I I can't choose when I'm standing up for the PBS or standing up for newborn screening or standing up for opioid dependence. If I'm if I agree, if I support it, that's the job. And we don't have that luxury. And I think that the more politicians in particular try and use a situation to modify their ethics, their morals, their views, their power, is then when we see these real undercurrents of pushback in the community. And whether you're a supporter of One Nation or not, what do a lot of people like about One Nation, and in particular Senator Hansen, because she speaks clearly, she is consistent in her views, and you know where she stands all of the time. And that's an important thing to look forward as we all start to, you know, you see various uh lobbyists and advisors saying, How are we gonna handle this c and how are we gonna handle that going into the election? Remember to be really clear and true to your ethics and your power, and don't make it situational.

Paul 35:32

Yeah, and there's extreme versions of that in the US at the moment, particularly this week.

Felicity 35:37

Oh yes.

Paul 35:38

Uh it's terrifying. Yeah, yeah, it is, it is quite terrifying. How behaviour is acceptable if it's by your side of politics, and completely unacceptable if it's by the other. I don't think we really want to get into that sort of situation here, but the the the the Prime Minister's decision to do this, and you have to assume it was his, and the one-line apology, it kind of put all the pressure on his colleagues because all his colleagues have been asked about it all week. If he'd actually handled it properly at the start of the week, well, yeah, handled it probably starting or done it.

SPEAKER_02 36:21

I imagine.

Paul 36:22

But if he'd done it, handled it properly up front and just sort of given everyone the Peter Beattie, you know, the Queensland, the old Queensland Premier, he'll just give people he just gave people nowhere to go. If he'd made a mistake, he said, Yeah, I made a mistake. And so you give people nowhere to go. Yeah. And it's and and that to me is and it's a bit like uh it's an obtuse example, but the multiple sclerosis issue. I'd be saying to the minister, Minister, you don't want to be dealing with this every day for the next six weeks. Just get it done.

Felicity 36:52

Get it done and move on.

Paul 36:53

Get it done and move on.

Felicity 36:54

But rip the band-aid off.

Paul 36:56

Rip the band-aid off. But it also goes to the other point is that we we only see the tip of the iceberg. We don't know what's going on beneath the surface. We don't know what advice he's been given. We don't know if it's good advice, we don't know how strong his office is, we know how strong the department are, and they'll be giving all sorts of advice. It's quite possible because I said to someone this week and the PVAC rolled into town for their meeting this week and they had dinner the night before, so I assume they still do.

Felicity 37:29

Did they?

Paul 37:30

Yeah, yeah, you know, it's a bit of a social thing.

Felicity 37:32

Uh I remember Thursday night, don't I? I don't remember I missed out on Tuesday night, didn't you? You could just look crazy.

Paul 37:38

You just imagine there'd be some angry people around that table.

Felicity 37:42

Well, it's got the worst on the Wednesday.

Paul 37:44

Don't you reckon there'd be some angry people? And you know, because that's that's what happened. Because we're hu we're all human. It's all it's always somebody else's fault. And the PBAC are probably saying, why have we been put in this position? This is a pricing issue from the health department, and now we've got the minister basically playing semaphore with us via via the media, and every time the minister talks, he's just ramping up the pressure. So it looked off, maybe they'll double down, who knows?

Felicity 38:17

But yeah, and look, it's it's part of some of the broader issues that you and I have talked about with um the then administrative appeals tribunal and you know, testimony from advisory committees that you know no one would take the job if anyone knew what they actually thought or wrote. And and I think that's that's separable right there. The the transparency issue. So, you know, in a system that is pushing industry to release more and more of its information than to um agree to what's in public summary documents, the lack of transparency from these advisory committees, you can't have it both ways. You can't take the money and the kudos and all the branding that comes with it and the extra job opportunities. No, I completely actually stand up and say, you know, if you really think this is wrong, then say so.

SPEAKER_02 39:14

Yeah.

Felicity 39:15

You you actually, if you are giving advice, we know it's not independent, but if you are actually giving advice and you think that the department's gone too far, then you need to say so. Because that's your job.

Paul 39:28

Yeah, well, the the appearance of the AAT, as it used to be called. Now the ART. Now it's the ART, they changed the name basically. That was the big reform. Yeah. The and the the consequential legislation, they had to amend all these other acts just to change the name. Yep. But yes, I no, I I think that excuse was well no one will serve in the role if we actually know what they think. Well, hang on a minute. Hang on a minute. You that's a confession. That's a confession. So they that that should have been quite alarming for everyone as it was for us. But yeah, well, we'll see. We'll we'll see. Let's see if they stick to it. I as I say, I think if the minister's been really smart about it based on what I can see, and as I keep saying, I can't see everything. I'm announcing this in Adelaide on Sunday with a group of patients, yeah, and sorting it out and getting all the kudos from that intervention. Uh but I give it I give that a less than 50% chance.

Felicity 40:33

Yeah, and then you can still put a post tag on it. Oh, you know, but I'm doing this, but that doesn't mean I'm not still going for the best price, and you know, this can't be taken as anything.

Paul 40:40

Well, if he he acts on this, this is the sort of thing where people stop you in the throat as a minister and say, Minister, my mother or my you know, sister or whatever has MS and she was taking this medicine, I just want to thank you for what you did. It's that it's that sort of thing. It's that sort of thing. So and I'm not saying it's all about the politics, I'm just saying that that's that is definitely a consideration, and he's obviously very frustrated with it, and which I completely think is is fair enough because everyone in this process is asking, why am I in this position? Why am I in this situation? Let's phrase of the week. This is a this is actually I can't really say this. I really hate this one because I hate all of them. Opportunity cost.

Felicity 41:26

Yeah. Okay. So when whoever recommended this one, thanks very much.

Paul 41:33

So when we get the HTA outcomes from an advisory committee, and they say, well, we've got to, you know, it's very, you know, we've got to think about the opportunity cost. What really irritates me is that they never say what it is. It's just a it's just a word they use as an excuse. So they never say if we have to spend $100 million on this particular thing, it means that we can't put $100 million into whatever the discrete. There's no discrete choice. It's just a thought bubble about, well, it's opportunity cost. If we spend $100 million on this, that's going to be $100 million taken from somewhere else, which of course is not how it works at all. Uh and it just irritates me because it also it also um you know the phrase the phrase opportunity cost reflects the obsession with economic models that rule this system and it eschews sort of moral decision making and ethical, like the principle level decision making, is that we've got to think about this from a human perspective. And so it it pushes pushes that away. So that that phrase is one that really every time I see it, it irks me.

Felicity 42:46

Yeah, so it's got an interesting history. I've listened to former ministers get up at a Medicines Australia event and talk about an investment of $500 million in particular medicines and saying, you know, the opportunity cost for that was X hundred nurses. So I'm investing, but that's that's the cost I paid. I did I didn't do this, I funded here instead of there. And you know what? You can agree or disagree with that, but the minister has the right to do that because she is the one actually making the decision uh to invest money or not. What is wrong about an advisory committee who does not provide advice on any other aspects of the healthcare system, let alone fund any aspects of the healthcare system, is for them to put that moral pressure on a patient who is reading that they are not getting their drug recommended because there's an opportunity cost for something else. Well, no, the opportunity cost is mine, but it is not the PBAC's remit to decide what the opportunity cost of something is for the minister and the general government sector. The minister may choose to fund it. He may choose to fund that as well as something else in health. And as part of ERC, he may choose to fund something in roads as well and might take something from defense. I don't know, but that's their job, not your job. And I do agree with you that it is it is trying to guilt patience. It is literally a negative term to guilt patience to say, you realize that if I fund this, somebody else could miss out. Well, actually, no PBAC. Someone else doesn't have to miss out because government seems to fund everything else it wants to fund. Why do you obsess about this for medicines only? Why do you do it? You don't say to a GP, you know, certainly not with urgent care clinics, well, the opportunity cost of having GPs available is I won't fund something else. That doesn't happen. And so it would be fine for me if a minister explained in the budget that, you know, they had six medicines and they had six other, you know, grant opportunities and they decided to fund the medicines instead of the grants because they thought it would have a big bigger impact now. That's great. I understand. He made it or she made a decision on opportunity cost. But PBSC weaponizing it is bad. And like I said, I I have received advice uh in my earlier in my career in in health from the PBSC who noted they made a recommendation, they then quite separately said noting how much this may cost, there may be opportunity costs for you to consider. They didn't tell me they were, but they used to at least be respectful and say, we get that what we're recommending is gonna cost a lot of money. But this is now just stock standard to guilt everybody because heaven forbid you want access to a medicine.

Paul 45:46

Yeah, you make a very valid point. Very you made it very well that in this is why we have a cabinet.

SPEAKER_02 45:55

Yeah.

Paul 45:55

This is why we have a minister to decide, am I going to take this into the cabinet process? And the budget process. That's their job. And then they decide, well, if we do this, we can't buy drones, or if we we do this, we can't fix that road. If we do this, we can't do X, Y, and Z. That's their job. We elect governments to do that. We let governments and the fact that they just use it in such an off-handed way without describing the choice. They can't describe the choice because one doesn't exist.

Felicity 46:23

No.

Paul 46:24

It's just I mean they're basically saying, Oh, it seems like a lot of money, we don't really want to recommend it. So we're just going to use this fake term, opportunity cost. So it to me goes along with all of the others that we've talked about, you know, evidence-based decision making, you know, independence, expert committee, all that kind of stuff. And I described it, this is a lot of these phrases are used to shut down discussion.

Felicity 46:47

Yes. And it's grossly inconsistent, because let's stop and think about what do successive governments, all parties tell the PBAC and that area of the department. If you recommend something, we fund it. That is bipartisan support that says medicines are an integral part of our healthcare system, and they are so integral that if you recommend something, we're all in.

SPEAKER_02 47:13

Yeah.

Felicity 47:13

Because medicines, so often in the primary care centing, are the effective preventive for actually ending up in complex acute care. We've made it clear year upon year. As a former finance official, really bloody annoying. Because I just know you guys are done, fund it, whatever. So what can I do to actually try and get a better price? And what can I try to do to actually, you know, find the money to do that? That's okay. But they've made that policy decision. So stop whacking patience and making us feel bad. Because if you decide to fund my medicine for migraine or my medicine for endometriosis, I don't have to be made to feel bad because you might also have to find money to fund, you know, prostate cancer or a rare disease. That's the job.

Paul 48:00

It's the job. Can I can I just say that I thought you you made a point during the recording today that is worth repeating? And it's about the fact that we we don't know all the stuff in the in history, we don't know all the stuff the health department has defeated in terms of the PBS. We that's not visible. We we do know one thing they defeated, which was the National Commission of Audit.

Felicity 48:25

Thank you.

Paul 48:25

Yeah, so that was for people who don't know, this was an audit done, and we've talked about it before, that basically recommend a wholesale d deconstruction of the PBS as we know it. So and people should go back and read it. Actually, use our AI platform to search for it and it will provide it in detail.

Felicity 48:44

It was a jersey.

Paul 48:46

It was an absolute shocker, and it had to be defeated. And so we don't see that. That's not transparent to us. And I do wonder whether they s well whether they still fight things like they used to.

Felicity 48:58

Or whether they actually initiate the ideas themselves. Well, there is that like 50% reductions for very And look, you can there are times you do come under huge pressure and your savings, and let's be clear, that that side of the the health systems had a an absolute train wreck of our forecasting savings from brilliant measures and then implementing them shamefully and shambolically and it actually costing the government a lot of money. So that means when when you constantly fail on your savings targets, and you would know that from your time in government that you guys kept pro overpromising.

Paul 49:35

We succeeded constantly. That was success in our day.

Felicity 49:41

It was success to US Health, but in the broader government sector, when you keep promising you'll save a hundred million and you spend an extra 50 instead, um things start to happen and things start to change, and you you work hard to get your credibility. So when you are in health, you are desperately trying to show how accurate you are in forecasting, how accurate you are in spending, and how accurate you are in saving and how everything moves. You want the central agencies to trust your numbers because the moment they don't trust me, I'm in a world of pain, even more pain than I'm already in. And so if I looked at the what this the failed savings measures, and we talked about that in the history from 2017 and from 2020, and the failed message met savings on 60-day dispensing and the extra money that had to be paid for that, and the extra money that had to be paid in the previous pharmacy agreement as well, they don't have a great track record. So you can see them start to grab at things, going, This is a bonus saving I can show I've still I well, I would look at the biosimilar policies over the years as an example of that.

Paul 50:50

If health are going into a budget process proposing things on biosimilar, surely finance just roll their eyes and say we've been here before. So so we need absolute certainty on this.

Felicity 51:01

Yeah, you you do. And I I think it's also, you know, BAA's putting in its submission to the minister next week. That's when I'm finishing on the weekend. Um about what we want the minister, and we will send it, like I said, to all the industry groups, what we want you to think about when you go and lock us out of a room again and decide the future of our access. And the first thing we're saying is we don't want you to talk about savings.

SPEAKER_02 51:27

Yeah.

Felicity 51:27

We actually do not want you to talk about savings. We want you to talk about access and patience and what we need, which is therefore why you might want to let us in the room. But there are things going on there that people it's how we've ended up boiling the frog as well, too. They keep incrementally changing what they've already got, fearful of doing something bold and different.

Paul 51:52

Yes.

Felicity 51:53

And it's time for bold and different.

Paul 51:55

Well, yes, the environment certainly changed. Um all right. Hey, can I I've had a big win this way. Can I tell you about it?

SPEAKER_02 52:05

Sure.

Paul 52:06

When I bought my car, I bought the scratch and chip insurance, which everyone told me not to do.

Felicity 52:13

Oh, really?

Paul 52:14

Yeah. Oh, yeah, it's only for minor, it's only for minor scratches and stuff. It's one of those upsells they give you, and I, in a weak moment, said, Yeah, I'll do this. Uh paid off big time. Because, as you know, I'm not the greatest driver in the world, but I have uh smacked my wheels into the gutters a few times. So this grudges grudge purchase delivered majorly for me this week. I got my all my wheels fixed, and they did an amazing job.

Felicity 52:39

So, like you look brand spanking.

Paul 52:41

Absolutely brand spanking new. They come to you, they do it. It was really, really, really, really good.

Felicity 52:46

So you've had that win. Falton's won what, seven in a row? Eight in a row. Eight in a row, isn't it?

Paul 52:52

No, it's seven, and we're not talking about it because it's infuriated me.

Felicity 52:56

Oh, okay. Hey, you should try being a D supporter and having to watch the Hawthorne Melbourne.

Paul 53:02

Did you watch that Fremantle Sydney game last night? That was absolutely interesting. I didn't watch, but I saw the score. Oh, half time Fremantle hadn't kicked a goal. Yeah, and I think 15 goals was possible.

Felicity 53:12

But I think as I said, did you watch the D's in Melbourne game last year? Hawthorne. Yeah, they won.

Paul 53:18

Hawthorne became the first team in the 21st century to kick 12 straight goals and lose a game.

Felicity 53:22

Yes. After we'd kick 10 straight goals and almost lost the game.

Paul 53:27

Alright. Keep the feedback coming, keep the crazy phrases coming in, and uh we'll keep working away. Thank you. The numbers on the podcast are really, really good, starting to really build. And uh uh as I said, we will be making some changes about how we how we do it. Uh but uh we are really enjoying it and really enjoying the feedback. So thank you, everyone, and thank you, Felicity.

Felicity 53:49

Thanks, Paul.