The 'Dispatched' Week in Review Podcast - 8 May 2026

In this week's episode, the focus is on the latest example of no progress on reform, the mindset and intransigence it reveals, the repeated pattern, and the early evidence that it would always end this way. Can it be an opportunity? Next week's Budget is upon us, and the discussion focuses on what to look for, that just because it is not in there, does not mean it is not in there, and why gaining any cut-through will be a real challenge.

Transcript

Paul 0:08

Hello and welcome to the Dispatched Podcast week in review. It is Friday, 8th of May. It's the eve of budget week.

Felicity 0:19

Yeah, we're about to lose our hometown for a couple of weeks. Well, that's really only one week everyone flies in to be part of the circus and you know go to 17 different events to hear the same thing to realize they still didn't get funded no matter how many PowerPoints are written in the case.

Paul 0:35

I'm thinking my name's Paul Cross, by the way. I'm delighted to be joined by Mark Coose, Felicity McNeil, PSM. But yes, I would like to own a venue for that week. For the budget week. Just that just those five days. If I could just have a steak just for those five days.

Felicity 0:52

I should put my place on Airbnb.

Paul 0:55

I tell you, I tell you, it's not crazy when you look at what the hotels charge. You can even put on a Pauline Hansen should be using that new Cirrus G7 to fly people in and out and charge people for it.

Felicity 1:10

People could even actually bring a swag and slip in the plane and save themselves some money. It's like one of those experienced Airbnbs. Stay in the plane.

Paul 1:18

That's right. What if anyone stays at the zoo? You know that was an amazing zoo where you can that would be so non-compliant with any corporation.

Felicity 1:26

But maybe they do because then they go, you've actually been in a human zoo, which has been quite offensive to watch, and then you actually get to watch the you know the respectful animals, the lions, the tigers, and the bears oh my behaving much more popularly.

Paul 1:39

Why do you why do you come to camera? You know what you know it's on TV.

Felicity 1:43

You know it's because everyone likes to be seen. And are we going to count how many posts on LinkedIn? First thing the minister I was delighted to be at.

Paul 1:53

Don't don't don't The Minister gives the same speech three times. And I don't understand it because I I do understand it, but the documents are online as soon as they're tabled, which is like 731 basically.

Felicity 2:08

Well, BP's one to six, but the you know, for for your health. That takes longer, you're not allowed to actually release the portfolio budget statements until the appropriation bill has been entered.

Paul 2:21

Yeah, but the critical information, the top line is in the But it it's not even that.

Felicity 2:29

It's like it's a bit late.

Paul 2:32

It's a bit late, yeah.

Felicity 2:34

I mean, sure if you're actually going to go and meet with a few um opposition senators and members to try and encourage them to uh stand up against some measures that you were concerned about. But I mean I I a dear friend sent me a um some parodies this this morning on uh Jim Charmer's presentation to the press club on you know, like I I need more money from the boomers uh to uh to fund certain things. So I I think it's gonna be an interesting time and you know the the government's gonna have so many fires going on, and they're that you know, well done them on being so successful in getting people to believe this, you know, intergenerational equity argument as a reason to take the money from uh working parents who've spent you know 10-15 years saving trying to provide for their own retirement and their children, and actually, you know, most people who own uh investment properties in Australia are what they like to call the mum and dad investors. In fact, you know, if you read the Defence Housing Australia annual reports, they particularly target mostly mum and dad investors to encourage people to recognise that that's how sometimes people save for their own retirement, for their own costs, to put you know, help fund their children through university, etc. But we are facing a uh an Australia where people who have done that for five, ten, fifteen, maybe thirty years are now being told, well, thanks for that. Now we will take that money again, which has already been taxed six times, and we'll decide where it goes. And uh, you know, shout out to Nick Coatsworth, who's been posting a few things on Oh, I have seen those, yeah.

Paul 4:22

It's been great.

Felicity 4:23

It's like I hear you, Nick. It's like, yes, we we've spent all our lives trying to self-fund. Uh, you know, there are many generations who've actually grown up with nothing and are the first generation to have actually been able to save some money and and provide for their family. But uh no, it's it's I really trust people who've only ever worked in government and been paid by the government to tell me how best my children should spend my money.

Paul 4:48

Yeah, I yeah. You know my views on it.

Felicity 4:55

Yeah. It's pretty impressive. And I I liked the uh the conversations this morning on we will now tax people, sorry, we will have a levy on your electricity bills to fund people installing their EV charges. So if you're a person that doesn't drive an EV, you're going to pay more for it.

Paul 5:13

Who in government used to talk about spending less money?

Felicity 5:16

Yeah.

Paul 5:16

Because because the it all presupposes, and I don't want to go too far down this rabbit hole, but it all presupposes that government is better at spending money. And we all know that it's not. There's no historic example of where taxing more leads to better outcomes. I'm sorry, there's there's just not. There's just not. And it disturbs me. Things like negative gearing, which I think people just don't understand the principle of. The principle is that if you realize a loss on an asset, you get to offset that loss against your income. Yes. What's wrong with that? Because you can negative gear everything. So a margin lending on the stock market, you can negative gear that effectively because it's debt.

SPEAKER_02 5:56

Yes.

Paul 5:57

So, and it's a loss. So I wonder what principle I I'm looking forward to this being explained, but obviously they're just using this as an opportunity to push forward all their ideas about how they're better at spending money than we are.

Felicity 6:08

Yeah, and look, I know.

Paul 6:09

This is Nick Coatesworth said in that post. You're taking all their money, but you're not giving it back.

Felicity 6:16

No. No, it's not, you're not giving me an alternative way to say that, you know, if if your principle behind it really is that we tax the wages too much and we're providing the opportunities for um lower levels of tax in, you know, non-hardworking earning money, then why aren't you actually giving us proper tax relief to actually allow us to then realise the benefits of the fact that you're taxing somewhere else? But it's, you know, people have been running a lot of the media this week about, oh, these are broken promises. You know, that the Prime Minister called out black and blue that there would be no changes to negative gearing, that they wouldn't target CGT. And when people are in shock and horror, I'd just like you to remind you, I got a rolled gold promise of an expanded world-leading AT plus diseases newborn blood spot screening program in 2022 holding babies. And I ain't got nothing. So, you know, why should we be surprised?

Paul 7:11

Well, yeah, I'd I will he be punished over that? I doubt. I don't know. But I think the punishment should come with a bad idea. And I think punishing people who've worked hard. I mean, well, someone who's been in the workforce for 40 years has more than someone who's been in it for 10 years. Well, shock horror.

Felicity 7:27

Yeah.

Paul 7:27

Shock horror. The reason the housing market is so poor is because government's made it difficult to build housing.

Felicity 7:33

Yes.

Paul 7:34

So, so, so government's created the problem. I don't know how they're going to solve it. And we all know, I mean, I say this facetiously, but ever since we created a federal health department, your health hasn't really got better. It's like it's like skills departments, there's going to be less skills. It's like the Centre for Disease Control, it's probably going to be more disease because government just don't they don't really impact our lives uh unless they choose to. And and this strikes me as an assault on this so-called sort of attempt to address intergenerational equity. I think it's just this weird uh sort of ill-considered assault on people who've worked very hard all their lives and are now being positioned as some some kind of, you know, they're the problem. I mean, if people are worried about their kids, here's an idea. If you're worried about the ability of your children to buy a house, why don't you sell them yours at a low price? I mean, people act very rationally when it comes to money. And as I always say, it finds the fastest path downhill like water. And so if you start to punish investment and wealth accumulation, people will do less of it. It's like, you know, in the 70s in Great Britain where they had the tax system was based on earned and unearned income. So unearned income under Harold Wilson was taxed at 98 cents in the dollar.

Felicity 9:00

Aspirational goals for the treasury.

Paul 9:02

And it was unearned because it was off investments or property. But I had to earn it in the first place. And so what did what what was the rational reaction of people back then? Is they moved to France.

Felicity 9:13

Yes.

Paul 9:13

So all those great rock and roll albums from the Rolling Stones and all that, they were all recorded in the south of France because they became tax exiles. People left James Bond left, Roger Moore left the country. So to me, it's just these are decisions are being made by people who aren't going to have to live with the consequences of it because they've all got defined benefit superannuation programs.

Felicity 9:33

Yeah, and you know, the the the people that they think they're targeting, the the one to two percent of you know those who have, you know, expansive share portfolios or investment portfolios, you've failed on multiple occasions to try and actually target those areas that you you you consider are appropriate, or you know, and I'll I'll leave that to the broader community to judge. But yeah, you're doing all of this and I've got some breaking news. Oh, okay.

Paul 10:00

Uh breaking news that is going to affect people who travel in and out of Canberra. Update from Qantas.

SPEAKER_02 10:06

Uh-oh.

Paul 10:10

From 14 June, we'll be temporarily closing the Canberra Domestic Business Lounge.

Felicity 10:16

Oh no.

Paul 10:17

We do undertake essential maintenance. During this time, we'd like you to invite you to use the Qantas Club Lounge.

Felicity 10:23

Oh, not the chairman's?

Paul 10:25

No, no, no, no, no, no. So that's that's a that's a big issue. And I think I think I actually prefer the location of that one because you get to look at uh the plates. The blend, the blend. But I thought that would be that's important. But let's let's move on.

Felicity 10:40

Although thankfully that is after the budget.

Paul 10:41

That's after the budget, and I'm sure that I'm sure that's a complete coincidence that they're doing it during the winter recess.

Felicity 10:47

Yeah, what with your coincidence. So winky dink.

Paul 10:50

I want to read you something from November 2021, something that we wrote a few weeks after the HTA review was initially announced.

SPEAKER_02 10:59

Okay.

Paul 11:01

Arguably, I used the AI tool to find this, so it's it's very good. I encourage people to use it, and the queries are going up, which is great. Arguably, the greatest challenge is to frame the HTA review as something other than just the reconsideration of technical submission guidelines. The terms of reference are yet to be announced, but the agreement says it will focus on the selection of comparators, the methods for evaluating treatments for rare diseases and new technologies, the use of real-world evidence, and managing uncertainty. Well, that's pretty much where we're at. The government's current agreement, the previous agreement with Medicines Australia, included a significant breakthrough on the issue of comparative pricing erosion. However, officials simply refuse to implement their ministers' commitment and the association agreed to scrap the clause two years before the expiry of its agreement. What does it say about the prospect of change? Why will the officials who have refused to implement their ministers' existing commitments accede to anything new? The issue is compounded by the fact the new agreement says the review's report will be considered by the PBOC. It is hard to understand why the report will be filtered through the PBOC if it is intended to be more than a guidelines review. The PBAC is a technical advisory committee. The policy framework under which it operates is a matter for the government. The industry's real challenge, and this is a challenge that applies to all change advocates, is to foster a wider debate on the merits of HTA and how it is applied in decision making. It is not a science, but at times can be mistaken for a religion. In the end, it is just economic modelling. In Australia, the decision-making process simply subordinates the guesswork of companies to that of the PBSC and its evaluators. In reality, the system treats health technology assessment and its modelling as a negotiating process. So we're four and a half years on from that.

Felicity 12:56

Yeah.

Paul 12:57

And I'm not I'm not reading that to say that I told you so, although I am tempted.

Felicity 13:07

Tell me I told you I told you so without telling me I told you I told you so.

Paul 13:11

The point was made that the way that review was the review was framed and the way it was worded in the agreement, it was always going to end where it is now.

Felicity 13:21

I'm just going to call you Confucius.

Paul 13:23

That's right, Nostradamus.

Felicity 13:25

Nostradamus.

Paul 13:26

But that's it's it's more a case of just knowing, understanding the inherent intransigence of this institution. That once it they agreed up front that they weren't going to alter the fundamental framework and that the PBSC would get the final say, well, the current process where the PBSC is basically restarting the review five years on, four and a half years on, was always inevitable.

Felicity 13:50

Yeah, it's a I I know you have a lot of people in this sector who are newer or work in different parts of the sector where they don't see whether rubber hits the road with respect to these reviews, so it's not something they've had to focus on, the policy, the stakeholders, where it happens. And I think it's an important lesson because I know you often express concern that people think that you're saying the same thing over and over because you are.

Paul 14:20

It doesn't make it wrong.

Felicity 14:21

Because the system is, because this is the learning and the capacity of the system to um, you know, slowly crush. It's like, you know, in in Superman, remember when he falls into the the car crusher, the metal crusher, and it's slowly crumbing in on him? That's what it's been like for 15 years now. Um, you know, and I'll I'll talk about that. That's some of that started during my time, which is a system that started to move in and to do things slightly differently. But without the stewardship in there, without the pushback, every time the new base is start is the status quo and it goes further down. And I think that's a real concern, which is this was obvious to everybody at the time of the signing of that agreement, just like the price cuts, the catch-up price cuts, were obvious to those that looked at as to what it really meant for the system. And it's time for people to understand history. We we were talking about it in respective boards. So, you know, you have an audit and risk committee, and you often like to separate that because audit is looking at the past to understand how it informs your risks in the future. And what you've articulated was the audit, which is this is what is being done here already. So when people are trying to understand why you're calling for um, let's everybody contribute to these news new definitions, let's challenge the system, let's let's break it in respect of what it's intending to do. It's because audit-wise, you've learnt what the system does unless you actually mitigate that risk. And the last chance that the community and the industry has to really stand up at the moment and say, this is not acceptable. We won't, you know, if you're going to do this, let us tell you how it's wrong. This is that moment. Because what happens is that when you are articulating, as you did in November, and I know you did at your conference afterwards, and you you did actually talk about the themes and the lack of consumer engagement or patient engagement.

Paul 16:24

The dangers, you know, danger process. Yeah.

Felicity 16:28

People still get no, no, she'll be right, she'll be right, she'll be right, or she wasn't, or they, if they identified as they were not. So it's a really important reminder that right now history is repeating itself, but on steroids.

Paul 16:44

Yes. Uh and I I think there is a way to approach this Delphi survey, and I've suggested overwhelm it. A company did call me yesterday and they said, How many people do you think we should uh get to fill it out? And I said, How many sales reps do you have? And they said, 300? Well, that's a good start. I said, You've got to treat this Delphi survey with the respect it deserves. Okay, it's obviously been rigged. Obviously. But let's take a step back here. Because I know the industry is now in a conversation about, well, how can we engage with this process? Let's coordinate it. You've got to understand that everything you're doing risks legitimizing this process. And it's going to be used against you. So in 18 months, when you rightly complain about the outcome, I can see the department being at Senate estimates saying, Well, Senator, I don't know why they were involved at every step of the process. They were part of the review. They actually had representation on the review. They supported the outcomes and the recommendations. Uh, this was a consensus process. More than 50% of the people who contributed to it were industry. And it's a consensus document. Of course, we had to consult more broadly than that, but we've got a we've reached an agreement. So this is their outcome. And that's the end of the conversation. And they're going to say that for the next five to ten years. But I do think there is a way you can manage it. I just think you now have to go into this process, and for once, just for just please, just for once, understand, understand that the it's a preordained outcome and that you can't change it now. You cannot change it. It's done. So the worst thing you can do now is legitimize it. Hence, I propose blow it up. The other, the other alternative, another alternative, is to say, well, yeah, we're going to participate in this, but we're writing to put on the public record, and in writing to the minister and the secretary and whoever else, just because we agree to participate does not mean we agree to the outcome. We're saying that now. We are we are leaving the door open to opposing this situation or whatever you come up with. We do not agree to consensus until we see it. Put that on the record, get as many stakeholders to sign up and endorse that position. Because what do we know about this institution? It's incredibly intransigent. It is it is unique in the Commonwealth for its willingness to completely disregard and ignore stakeholder opinion. So there's two things here. One is how many times will you allow the institution to throw sand in your face before you stand up for yourself? That's that's a simple question. Maybe it's just a case of ducking or weaving. But this is happening over and over and over and over again. This is how little respect they have for you. Because they think they can get away with it. They think they can get away with it.

Felicity 19:56

They don't think. They know.

Paul 19:57

Yes. Well, yes, they know. A way to look at this, so you've got to stand up for yourself. Don't do anything now that legitimizes this process. Because you can't change the outcome. As we wrote in 2021, the fact that they decided, and I said this at the time, evidence of they were gonna put it through the PBAC. That was it. Every time the PBAC has been involved in this review, they've said yeah, but starting with remember the discount rate?

Felicity 20:28

Yep. We can do this, but we'll just change.

Paul 20:30

We'll just change everything else so that it has no net effect. And then the outcome to the actual final report, and now they're doing this. Guys, this report's dead. It's dead on arrival. The review is dead on arrival. However, I think there's an opportunity, and I sort of when we were talking earlier, I used the metaphor as like imagine this is like it's the old chemotherapy, you know, where it all, you know, it almost kills you before it saves you. That's that's what I think the opportunity here is is to go to politicians, to go to the minister, to go broadly within government and say, you've got these people who've been in this system for 25 years who are just completely ignoring what stakeholders say. They are completely ignoring it. They are completely intransigent on it. And I don't think there I don't think, I don't think they maintain legitimacy because of that. You've got to start challenging the legitimacy of the institution, and this is evidence of that.

Felicity 21:30

Yeah, and I guess I'd remind your readers, in particular those who issue ready pr press releases or go to photo ops to celebrate a listing that's finally taken however many years. Three years. You've got to actually you've got to walk the walk walk the talk. You've you've actually really got to do it 'cause I I've got to say as a a patient, as a patient advocate and a system uh challenger I get really tired of being at a function and having a company talk to me about how terrible it is and how tough it is and everything that they're doing. Um, all those who work in the industry more broadly, and then I read your articles or I read things and stuff where something's been listed and there's the quote welcoming and this is a really great thing. And I'm like, you can't have it both ways. You you you actually have to have a backbone the way we as patients have to have one, and say, you know, nothing, or it's disappointing it took us this long, at least it's here. Like it's really quite, you know, and there are a couple of companies that have done it over the last 18 months and even put out statements saying we cannot progress any further. And I'm very grateful to them because they're taking the hit while everyone else is just grateful that something happened. And if you actually want us to have a chance in all of this, you know, the the thing that terrifies ministers most of all is bad publicity. It really does. It's like they're they're more frightened of a delisting than they are of something never coming here because the publicity that comes from that is poor. And the moment everyone comes together to welcome something and do the photo op, the moment all the patient groups and you know come together and say, Isn't this great? The lack of accountability, holding the minister to account and saying, What took you so damn long? This is what happened while you waited. Yeah, you can do better. So, you know, we've we've you you've reported on the the CAR T therapy that's now gradually being made available. Um a therapy that the minister admitted the delays in access were leading to deaths. And where is that? Where is that in the conversation? No, all I've heard this week is isn't it great? It's awesome. Oh, and we're starting it out here and then it'll eventually appear in a couple of other states once they've worked out what they're going to do and how they can do it. Can why why is nobody leading with the fact how many people died waiting?

Paul 24:14

There's a lack of coherence in the industry's position here.

Felicity 24:17

And it's it's problematic because what it means is that intelligent bureaucrats and intelligent political uh strategists can push all the way through because all we have to do is point, and you know, I used to do it in estimates for every time someone's raising a concern about me, I could point to three different things where the system was being told by the industry that this was good, that they'd welcomed it. And you you cannot give a bureaucrat and a minister and a strategist those free tools to position you.

Paul 24:54

Well, actions speak louder than words. And if you if you're going if you're going to participate in these Delphi surveys without supporting actions that undermine them and at least create a plausible defense in 12 months' time when the outcome is inevitably terrible, then that's what's going to happen at estimates this time next year. Well, I don't know what they're complaining about, Senator. They were part of the process.

Felicity 25:23

I mean, is it XYZ? I mean, I already saw I already saw it in uh an online thing this week that, you know, they've already put out there that, you know, with all this taxing though, but it includes six billion in new investment in the PBS over the coming four years. I mean, well, it's six billion in new investment in the PBS that's already been announced, and by the time we do rebates and special pricing arrangements, how much money was really spent on the PBS that's going to be announced in the budget?

Paul 25:49

What a budget measure, though, that the government gets to claim all that money and it's gets most of it back.

SPEAKER_02 25:55

Yeah.

Paul 25:56

It gets to claim it as a spend. But again, people need to understand. Like, you know, I was talking to someone this morning and they said, What do you what do you think the most important thing in achieving change is like get the basics right? Just get the basics right. And and that means understanding budgets. So when a treasurer comes out and says that the week before a budget, they're managing you.

unknown 26:17

Yeah.

Paul 26:18

They're anticipating what you're going to say. So you're going to be out there saying, We need to implement the HCA review, the system is terrible, we're not listing drugs, and then they're going to be saying, Yeah, but we're putting billions of extra dollars into the PBS.

Felicity 26:29

We announced six billion in new listings alone between my EFO and this budget.

Paul 26:33

Yeah, so that's that's that to me is getting the basics right, is understanding. And you don't, I don't think people should need to get too ambitious. I I I mean, it change is incredibly hard in this system. There is really no history of any Australian government agreeing to change on a program like the PBS that it didn't want. And they will fight tooth and nail. The reason they agreed to the F1F2 split, yes, it benefited companies, not all companies, but it benefited companies, but it benefited the government a lot more because it freed up the off-pattern sector for price reductions. The only time they've agreed to be dragged kicking and screaming to some minor process changes was when the US government said you've got to do something here. And that's the only time. There's otherwise no history of it, no history of it. So this is why I think time is to pivot. Time is to pivot, and you've got to pivot towards challenging the legitimacy of the institution, which has become increasingly intransigent. That PBAC update they issued yesterday, like they type that angry. So passive aggressive. Get over yourselves. It's like, or we don't like being attacked criticized. Like, well, bad, don't do the job then. Like if you take the money, accept that the good and the bad. You're given this incredibly privileged position. I'm sorry. If you're gonna deny access to medicines and vaccines and whatever else, don't be surprised when you get criticized. Do you just get people like do you expect people to thank you for it?

Felicity 28:22

I'm so grateful that my child got my ninja coggle band. I thank you.

Paul 28:26

People are so polite to these people. They they they think they they seem to think there's like a like a you know, style on a show troll, like it's denunciations. They get away with all sorts of stuff.

Felicity 28:37

It's almost the um I hate to get it.

Paul 28:40

You're like a spoiled child though.

Felicity 28:41

Maybe, but but it's also got a bit like the the old days that you know certainly m my parents or my grandparents grew up on word with you know the deferential approach to a doctor. You know, whatever the doctor says good, you know what doctor says, you know, doctor says, and it's kind of become this it is, you know, it's like Moses and the Ten Commandments, they're coming down from you know the hill of the PVAC and thou shalt not question. So it it does, I think also they had when when the system was more flexible, when the system was more generous in the way that it dealt with patients and access, just because you allow people to put in more consumer comments doesn't mean that you're actually making things better for patients. Like I said, if I I wish PBOC and MSAC and everything relating to those programs, I say it every budget, every year, every election, these should be sub subject to ART, you know, re review because until you have to actually have that independently reviewed as into what did you take into account and why can't a patient have a a process of challenging the decisions made by someone who literally determines life or death or even just access to chronic disease medications, which is you know increasingly the the harder area. If if you want to, like you said, do that and you've been doing it for decades, that's the job.

Paul 30:19

It's the job. It's it's I'm sorry, and you get it's not like you're doing it for free.

Felicity 30:22

No.

Paul 30:23

If you don't like the criticism, maybe here's a crazy idea. Look, I don't know, this is one is out of the box. Maybe maybe some of the criticism is deserved.

unknown 30:32

Yeah.

Paul 30:33

Maybe you should listen to it. Maybe you should actually hear it and respond accordingly. But the passive aggressive stuff about the policy and legislative framework. Like, well, well, and the transparency bit is what annoyed me, is whether, oh, we support transparency. Oh, the PBAC executive has been working on this guy. It's like what how give me a break off six years or something now. It's but it's to me, to me, I I was just I I sort of laughed at it when I read it. But it but it's it's not a pleasant document. It's not a and but again, what it reveals is this institutional intransigence. It's that we're above criticism. Why are you criticizing us? So no, you're not above criticism, I'm sorry. And if you don't like it, leave. I mean, frankly, or change it. You know, a short a short tenure on the on these HTA advisory committees now is like just over a decade. It's like the adwardium period is like you know, it it's it's if you've only been on there for 10 years, you're just learning your job. You know, that old public service thing, you know, you're not really part of APS and you've unless you've been in it for 25 years. Oh, really? It's like, but it's like, you know, but you know, it's it's it's like that attitude is that time is somehow good in this one space. And I I just to me, this is why I think the pivot is an opportunity to start saying, I'm sorry, no other part of Commonwealth policy are you so allowed to systematically disregard the views of stakeholders.

Felicity 32:00

Yes, and I again I it it's basic governance, which is you shouldn't be allowed to be on advisory committees or in appointments longer than it it's standard practice, two terms. You know, like I said, the ACT government is really clear about it. Two terms, that's it, unless it's an extraordinary exception. In uh the private sector, it's two terms. Sometimes it's uh just depending on on something, you know, if there's important issues, but the duration and the of appointment to the same positions and in the same committees is is beyond I'd like to say that even my primary school where I was on the the board of the school as a parent, I wasn't allowed to serve that many terms either. Like it was literally three terms and only for two years, there's no more.

Paul 32:54

The implications are real. The tenure limits have a purpose.

Felicity 33:00

They do.

Paul 33:01

Uh because people become completely institutionalized. And there is no better example of the health technology than the health technology assessment institution, where I think people have been in there for so long that they're incapable of seeing a world outside. And and I also believe that often that FAS role that you are in is very unusual for that to be promoted from within. It's generally historically people have come from outside. Yes. Uh, because there was an understanding that things can get a bit wild in that part of the health department, and so so it's it's it's and often often I think the challenge has been historically that the officials who serve it believe that's what they serve. They forget that they served the government, i.e., big G government and the minister and the broader community, that they serve the institution, and that's not correct. It's this this is a this is a critical point. So again, I think I said it last week, I'll say it again this week. That people make the mistake of thinking that HTA, this HTA institution is a technical framework, it's not as an ideological one. So when you're negotiating with it, you're not negotiating objectively, you're negotiating with an ideology. So you imagine like trying to get the Iatola to do something. I mean, if you think about it, right? So that that country is now basically on the precipice of total collapse, and that's fine. That's fine for those people who run that country because they're willing to burn the house down to save it. And I think even on issues like most favored nation, I think it's the same. I think I think they're so ideological about it. If burning the house down and by that means patient suffering and death, if that's the price we have to pay to save the house, they'll do it. They'll do it because it's ideological, because they've been in it for far too long. And so there needs to be change, and that means new people, but I also think it needs broader change. And this was the the flaw with this entire review. We are this was inevitable. I mean, this was a level of cynicism even I didn't even expect. But this was inevitable because the institution always prioritizes its own interests over everyone else. That's that's how it responds, and this was the danger of the review that I was highlighting five years ago is that they they are actually going to use this to strengthen the institution, which is why you have to attack it. The irony is that the more they strengthen it or act to strengthen it, the more detached they come, they become from the community, and the greater risk there is for them. And you get the New Zealand Pharmac situation where they spent years defending the indefensible.

Felicity 35:48

Yeah, and look, as someone I I think when uh Minister Butler was first appointed, and given that he was supposed to implement my newborn bloodspot screening, I say it's mine, but it was BAAs and it was the communities and that that big change. I thought, well, here we go. New new new life, new energy. Unfortunately, we had all the ministers come down and tell the departments how fabulous they were. Oh. You know, removed all that that tension point. And you saw a government very quickly take the existing status quo advice from departments on how things should be done. So I don't have newborn blood spot screening nationally expanded. I certainly don't have an achievement of actually getting Pompeii even recommended for consideration compared to that because the minister accepts the HTA system and what it does above all else. I'm really grateful that he intervened to get off-patent contraceptives available for for women and improving in endometriosis. That's fantastic. I hoped that when he said on radio that people were dying because of the MSAC system, that he would take action. What we've seen, however, is the capacity to just ride on through. And now I we have a minister who is also responsible for the NDIS. And that is the biggest game in town for him. And so if anything was going to actually have changed, if any momentum could have been achieved when the minister intervened in a couple of circumstances, you know, I was very grateful when he intervened and pushed back on PBSE, telling them, you know, which ones they would not consider because they were just too busy. There were moments where I had such great hope and faith in this minister, and then I've watched what he's let happen with newborn screening, I've watched what he's let happen with this three-year listing delay, and I now respect that the man's too busy dealing with what he's going to do in the NDIS. And the PBS and the HTA review are just a side issue that is completely irrelevant to him, and the only thing I think we've really got to hope for is a new health minister.

Paul 38:07

Well Yeah, and that's pro unlikely.

Felicity 38:10

Exactly.

Paul 38:11

Uh he's obviously going to have to see this NDIS thing through to the end, which puts him in that portfolio at least to the next term of government, assuming they win. Uh well, someone's telling him No one's telling him that he's in trouble on the HDA review, besides people like you and I.

Felicity 38:27

No. And he's so used to me complaining about everything. But um sorry if you can hear that. It's an angry bass. Maggie is playing with my feet because I might be playing with the Bassett's. Um They are cute. But yeah, I I and I I don't say it to be, you know, the man's got a very complicated portfolio. He's done some really great things which we always write and say thank you for.

Paul 38:54

But unless Well he doesn't feel any pressure under any pressure on the ICR review.

Felicity 38:58

Which is my point.

Paul 38:59

Unless someone makes this an issue, it is just I suspect the evidence is actually that the pressure is coming from the other side, i.e., from the glass finance department, the beautiful finance that that's where the pressure is coming from.

Felicity 39:13

Yeah, probably.

Paul 39:14

That's yeah, yeah. So he's feeling more pressure internally than he is externally. The fact that he went to the Farm Oz last year and says I'm announcing a review of a review. The fact that he was at the AFR Healthcare Summit, and I have to tell people again, he he alluded to these Delphi studies six weeks ago. He knew about it in March.

Felicity 39:30

At least.

Paul 39:30

He knew about it in March. And did anyone hear from the minister or his office about what they had planned? No, because he obviously knew, and his office obviously knew it was not going to be received well. If it was going to be received well, they would have called and told them.

Felicity 39:44

Would have written letters. He would have written, hey, this is what we're doing.

Paul 39:47

But they knew it's like, oh, we're just extending it. You know, people say to me, oh yeah, but he wouldn't have got his head around it. Guys, don't judge a minister by your own standards on detail.

Felicity 39:56

He's a brilliant man.

Paul 39:57

He is he's a very smart guy, he's got a league legal training, he reads things five or six times. When you see the uh briefings that have been released under FOI, and they are worth going to look at because you see how he engages with the advice.

SPEAKER_02 40:13

Correct.

Paul 40:13

It's structured very interestingly uh with a series of options that he ticks and he signs and then he goes through and writes all over it. And uh that goes to his style. He understands everything.

Felicity 40:25

Yep.

Paul 40:26

And so when he knew, when he spoke at the AFR Healthcare Summit and said what he said, he knew. He knew, but he was just buying some time. He was buying some time.

Felicity 40:35

And also banked on the fact that based on the the history of the way the sector engages on this, there'll be an initial like, but then everyone just rolls over.

Paul 40:45

Everyone's gonna roll over on this on this Delphi survey, and that that that would be a big mistake because it's gonna come back at you. They're gonna weaponize this against you, and they're gonna use it to shut down dissent post hoc. And that's well, it's clear as day. That's that's what's uh that's what's gonna happen. So we've got the budget next week. You going to any events?

Felicity 41:16

Um look, unfortunately, I hadn't realized it was budget week, so I'd made a whole heap of plans to um do other things with people who were not related to the budget.

Paul 41:27

So can I just say something? No, no, no, no. I I have some invitations and I'll accept some of you, but you know I won't go to the National Press Club anymore. But uh but um Yeah I just want to say the point about getting the basics right. So let's just go back 12 months, almost 12 months, almost 12 months, incoming government brief from the health department to the minister. What did it say? Statutory price reduction framework PBS is going to expire in mid-2027. Uh as you know, Minister, we've been in discussions with the Department of Finance on capturing these savings going forward, and we'll be reporting back on those just conversations at the end of the year. Anything, any insight on that? Anyone asking questions about that? Because what that is a euphemism for is uh we're working on a statutory price framework, a new one. So as the industry prepares for a negotiation, understand that the health department are going to go into that very well prepared. The other thing is that when the PBS forecast next week likely shows decline over the Ford estimates, it'll be flat or declining or very little growth. It does not mean the government is not investing in the PBS. The reason it shows flat or declining growth is that it doesn't include the impact of significant new listings. And we obviously mock the top-line figures they use, but they're still investing the PBS, it's still like net$500 million a year or something. It generally includes, although who knows what it's going to include beyond the expiry of the framework in terms of SPRs, but it includes the impact of statutory price reductions, but it does not include the impact of significant new listings. So it will show a decline. So please, no press releases expressing disappointment about not investing in the PBS. Okay, we can criticize the government for not investing in the PBS, but judge the 2728 and 2829 forecast in two years' time.

Felicity 43:36

Yeah, it'd be better to focus on the delays to listing. Yes. And calling up what the six billion is, because yeah, it just it makes it too easy. So you have to always look at what is the information, the the the um adversarial arsenal that your opponent has to diminish the value and the strength of your argument. You never have to be perfect, you know, if I say to people and they're getting ready for budget night, this doesn't have to be, you know, an a a complete, you know, HTA review process that has, you know, ABS statistics and AHW with triple verified source codes and everything to make sure that, you know, this is absolutely accurate. The concept is there. But there are certain concepts that you lead with which not enough in the PBS, you then have to remember that there are some programs in health that are getting no new funding at all. And so when you actually say there's you know there's no new funding, there is new funding. And whilst it might not be the right amount of money, it's getting something when so many other areas aren't. The critical thing that matters to patients because in the end if something happens is how long it takes. You know, you you are actually there on that one. You know, we've been talking about it since 2020, you know, whatever numbers you want to use. Back then it was 920 days on a 10 year average. So what are you doing? You know even even the department says yeah it's about 660 days um in the the arguments they said it was longer than the industry it was in 460s and the department said it was 660. So it knows everyone's moved out again now which is good. But which I think was really quite smart on their on their behalf to actually put that out there because then it you know it says well you know what else can you trust? These guys got that wrong we're being transparent what's the deal so really think about what it means for the patients who are still waiting um you know you've seen some of those articles over the the last few weeks but you have to make it about all diseases not just some and you you have to be a bit smarter about it to say that the haves and the have nots the equity in the system is a real issue and that's what you need to be going on.

Paul 45:58

Yeah get your arguments really spot on so that they're hard to defeat that's what I that's what I I talk about the basics and I don't mean that as being critical but the the the thing is the problem is not comparators, discount rates and all that kind of stuff. The problem is the basic architecture. The architecture of the system is bad.

Felicity 46:17

Yeah.

Paul 46:17

And so when the review started on the premise of the basic architecture is not going to change oh and the PBSC are going to get the final say it was inevitable that it was always going to land where it has as a guideline review where the PBSC which is opposed obviously opposed the process all the way along and I want people to imagine this this is an institutional body that historically does not like scrutiny does not like accountability and does not like people questioning what it does. You know we talked about the PVPA last week and I can remember after the 2001 election I went with the new minister and we met with the chairs they were considered the chairs of those bodies and there was the PBAC MPS medicine wise uh APAC one other I can't remember and they all talked to the minister about we need to get rid of the PvPA we need to abolish the PvPA and I pulled her apart aside afterwards and I said them arguing for the abolition of the PvPA is why you shouldn't do it because it's the way we keep them accountable.

Felicity 47:16

So two listeners will get off this podcast and Paul will get I told you you shouldn't have reduced that was a part of the very important red tape reduction. If you're only going to note something then get out of my way I guess so you know you asked me last week what I thought was going to be in the budget. We've had a fair bit what else do you think's in the budget next week Paul?

Paul 47:40

Oh there'll be a lot on the NDS NDIS there'll be listings announced since November there will be a couple on top of that I suspect because why not you get you get great political bang for your buck from those announcements because the industry is so helpful in helping you make them such and such welcomes the listing will there be decisions taken but not yet announced but if they do that they can't include it in the forecast can they not that anyone would really notice only nerds like you and I would sort of look for that. Might be a 2015 situation a little footnote No I don't think there'd be a footnote for a decision taking because the negotiation isn't starting until July it wouldn't surprise me because historically these negotiations have generally been prefaced by governments making decisions about savings. You did it two or three times. No 2013? It wasn't a negotiation policy measure yeah but you know but you know what I but but decisions taken but not yet announced is not a historical for this program. It's generally standard.

Felicity 48:59

But that's my point it is standard it's just what is not standard is a footnote. That footnote was different that that was because something was all sorted and there were games going on but what do you think?

Paul 49:10

Do you think I already mentioned myself last year but yeah I I if you're the health department you had what was said in the IGB last year where they had to go back I think it was I I can't remember the exact wording but my my understanding was the minister had to go back to cabinet with it. You know people will say oh yeah but the office said there's nothing in it that's because they're not legally allowed to tell you that there is they have they're legally obligated to lie to you about it. So don't take any notice of what they say on that yeah I think I think yeah I think there's a strong chance there is but I just I just don't I don't because the gut the the department is going to go into a negotiation with the outcome already framed. I mean to the idea I mean surely no one now thinks that oh no the department's just going to turn up and we're going to get a blank piece of paper and that's where we're going to start. The IGB says that's not going to happen.

Felicity 50:13

Well that's why we never show up with the blank piece of paper.

Paul 50:15

No but that's what so so we just don't always tell you so the industry has probably already been sorry the department probably already has a savings target in mind. It may have had a savings target set and it probably almost certainly has ideas to make that happen. So and who knows it may well be back there somewhere in in the contingency reserve who knows but I I I where do I sit on this I'd almost be surprised if it wasn't but we won't know. No. Unless official repeats the mistake of admitting it oh that was that was funny. Because they they they want to go into a negotiation with maximum leverage.

Felicity 50:57

Yeah but also you you need permission from the cabinet to go into a negotiation. Yes. So when you know that you actually have to do it twelve months out it's not like you go well I I won't talk to you. Of course you have to go and get the permission. That's the whole idea of good planning.

Paul 51:10

So and part of that is the cabinet saying well we're going to give you permission however well they give you an envelope about what you are and aren't allowed to parameters you shouldn't ask for.

Felicity 51:20

So that's that that's a no-brainer and whether it's a contingency reserve target in there or whether it's something else in there, you know it it it's almost irrelevant. It's it's there and it's coming. But I I think the the broader challenge the Australian community is going to have not just this sector is there is going to be so much in this budget that again the noise is going to be deafening and picking up on specific issues is going to be really difficult. So unless you've got really good working relationships in a particular sector or with a particular you know area of interest for some journalists who understand that this is going to be hard. The NDIS is already up and running with the whole you know everybody counts. Well it's like yeah they do um they've already started that they are going gangbusters the whole CGT and the the negative gearing the EV you know removing the EV incentives uh the the cost of living the the fuel excise the tobacco there is so much going to be in this budget let alone the rephasing of and cancellation of some infrastructure investments in trains, trams and buses etc defence so much going on that's the other challenge for this industry and this bit particular part of the health sector you're going to get dwarfed in health dwarfed in social services and dwarfed in a massive budget. So are you ready?

Paul 52:48

Well what was the figure that they said they're going to take out of the NDIS crazy it was 34 billion or something of growth. Of growth yeah yeah but that's because the minister announced that it's 13 billion higher than it was than when they last looked at it looked at it and those actuaries might they'll be earning their money. That's the um it's like the Scarface mansion the NDIS you know they've just got all like bags of cash to put it but well yeah I I think it's it's it is you that is a really well made point that this is going to be a very busy document and a lot of discussion. The government this is a very smart government technically so there's going to be some surprises on the night and I suspect that's around tax and they might be good surprises obviously not for everyone but they're smart so they're they're sort of clearing the decks by getting all the bad news out there now in the hope of shifting the narrative next week makes perfect sense and look I I just think PBS and all that sort of stuff like you know I've written about the Delphi survey five times this week and I'll probably write about it again next week. But I'm as guilty as anyone of getting dragged into the vortex of this technical nonsense and I don't like it. I don't like that what I wrote 2021 in 2021 has come has been turned out to be correct but please I'm just urging everyone to understand that you're not dealing with a technical framework. You're dealing with an ideological one and until you understand that until you imagine that it's you've got to you've got to imagine it like you're you're negotiating with the Ayotolla they will burn down the house to save their ideological framework. They will burn it down and so if the upfront preface of any process is we're not going to change anything meaningful then don't you would have been better not embarking on the process and I said to this to people at the time the best outcome you can hope for is status quo if that remains the case and you'd be better off not doing it. And people got really angry with me because they remember how excited they were about this yeah what why are you can we say why are you excited? It's the first review in 30 years. No it's not once in a generation it's the yes once in a generally once in a generation it's taken a generation but anyway look I hope the people coming to camera next week have a good time I know there's lots of events and all sorts of things going on. Hope you have fun at them too I'll go to a couple which I think are valuable. You know what's going to happen now is that you'll say that and people look at which ones they went to and didn't went wow yeah there are some there's some interesting things there's some things that I find the slightest bit interesting but no it's it's it's obviously an important week for the government it's an important week for the opposition. No just task no because it's six hours and there's nothing in it. You know you and I know these documents incredibly well so we can sort of read them in about five minutes really as it pertains to pharmaceuticals right and then because we know where to look yeah so it's and I don't say that to both that's just experience. We know where to look so no I haven't been to the lockup for many many years because it's not a good use of your time because you know you sort of you get there early afternoon and then certainly from the perspective of my readership it's sort of over in 15 minutes. Even in 2015 there was nothing in it.

Felicity 56:56

There's a footnote that you kept going on about in today's podcast.

Paul 56:59

It was very important I was stuck in that goddamn changes to the you know Monash model for all I got a little secret too you know you're not you're not allowed to be connected but you can still access the APH Wi-Fi well after listening everyone just lost that it's so crazy. It's very much a trust system. Yes it's very much and people do respect it because you want to get invited back but it's uh yeah they don't cater it oh here we go it's all about the catering and to those of you who don't think that's true before I started this podcast with Paul he did sit and talk to me about his catering choices for your wonderful conference okay yes that is coming up and we are starting on that day I haven't published the programme yet because I always publish it late because you've got to leave some gaps because things like Delphi studies come up but we are starting we've been working with Patients Australia on this and they've been absolutely brilliant and they're going to present some surveys survey work which is really interesting about human engagement with the health system we've got a couple of patients coming and their stories are harrowing and kudos to them their willingness to share it it's very courageous and I know it's not easy and their willingness to do that it's very great it's gonna be privileged for everyone to to hear that so I'm really I'm really looking forward to that excellent alrighty any F1 on this weekend?

Felicity 58:26

No it's another three week wait it's just like yeah don't don't even start me just no no start no and now I'm looking at the end of the year and saying you know if they don't don't sort out this whole thing over in the Middle East there's more races planned for the end of the year. I just this is not good planning and some of us just really need our F1 more than like you know three weeks and five week gap and then another three week gap and yeah sorry I it's the only thing that keeps me going particularly when the football's not so great.

Paul 58:57

We're not talking about the football.

unknown 58:59

Yep.

Paul 59:00

Moving straight on from that well thank you Felicity uh thanks everyone for listening we like your feedback got a really good feedback about the second special podcast we did because I think it was really helping to explain to people why that Delphi survey is such an outrageous idea. So really appreciate the feedback on that keep it coming and we hope everyone has a long and well it's not a long weekend is it's just a normal weekend. Yep. Unless you're working from home on Monday nope oh no everyone's gonna be coming to camera okay okay thanks everyone