So without further ado, I will introduce our evening lecturer is Neil Ferguson.
He currently works at the international level with a number of health technology assessment
agencies really with a remit to try and align process and mechanism across those agencies.
He is the chair of the HDI International Patient and Citizen Involvement Group,
so he has a strong working relationship with patients and involving patients in health technology assessment processes.
And he's also on the board member of patient focussed medicines development.
And that's really trying to better promote how evidence can be generated for all different stakeholders views in a decision making process.
So without further ado, I will hand you over to Neil. Thank you very much.
Thank you, Stuart, and thank you for having me here and thank you for being here.
So what I really want to take you through today is, you know, I've seen that,
you know, the kinds of information those of you that run on on the MSE course,
the kinds of information you've been looking at and you've been going into sort of health economics,
really understanding some of the mechanisms behind what I want to do tonight is took it a bit of a higher level about how bodies work with each other,
how they learn from each other and how sometimes they can't learn from each other and they can't
work with each other because I think that's really important to understand where the barriers are.
And in the second half, one of the areas where we're seeing a lot of alignment in HK is around patient involvement in the process.
I want to take a deep dive into patient involvement in how to see the perspective I'm bringing.
This just builds on what Stuart has said.
But really, I work with chapatis and regulators, with patient groups, with industry, with academic researchers,
all with the aim of getting people to play nicely together for a change and learn from one
another and really understanding the different perspectives and the different limits.
Different stakeholders have so often what I hear from the industry or from patient groups is they often say to me, why can't he change?
And he often finds it really difficult to change because of the rules behind which they're being set up.
There's a lot of reasons why it's quite hard to change processes like to,
and we have to understand what those limits are and why it's hard to change HCA before we can convince them to at least try to change sometimes.
So I work with HCA International. So for those of you that don't know, that's the International Scientific Society for Health Technology Assessment,
Stewart and I, that's how we got to know each other on Paradigm, which was an international collaboration and in particular,
the area that I was looking at was how patients can be involved in early dialogues with bodies and those
early dialogues that first time that a company that's developing a medicine can go to a party and say,
Can you give me a bit of advice here? What kind of evidence would you be looking for?
And we worked with about 15 bodies to develop that piece of work and with patient focussed medicines development,
I just wanted to flag up a new and emerging discipline of evidence, which is called patient experience data.
And it's new is coming along. And one of the things we're trying to do a patient focussed medicines development is say,
let's not make this one of these situations where the regulators have one set of evidence that they look at and bodies have another set of evidence.
So from the very start, we're trying to pull everybody together to say,
let's make sure this new class of evidence is usable, both for regulatory and to purposes.
So what I'm going to take you through today, I'm going to talk a little bit about the context,
the context within which to sets and what is the impact of that context for international alignment.
Then we'll take a deeper dive into patient involvement, and I'll go through a couple of case studies.
So when we think about the context, you've probably seen this, but this is the 2020 definition of.
And I want to just flag there's two elements that you can see in bold that this is a multi-disciplinary process.
So not no. One stakeholder is able to do on their own.
They need the other stakeholders to come together in order to make that process and informs decision making.
And I've. Really want to focus on that inform, because there is some myths that people have about.
I'm sure you don't have them because you've been studying this, but the Mid-South bodies decide which medicines or similar technologies we have
access to or that determining access to medicine becomes purely evidence based.
And I know that's how a lot of people think about it. But in fact, if the politicians who ultimately decide, OK, this is from a report,
it's done by the World Health Organisation and the European Union, and they look at this interface between state and health policy.
And they say H.J. provides evidence based input.
So again, this input informing it promotes evidence informed policymaking.
So it just promotes it. He doesn't make it happen, and they say it offers a bridge between the research and the policy community.
So you can already see that state lives in this very unsafe world.
On one side, you've got all these people creating evidence and on the other side, you've got all the policy makers.
And it's to that sort of sits between those two and tries to make sense of it.
So policymakers decide within each country the overall resources available to health care.
They decide what is more spent on schools and less on health care or vice versa,
for example, within health care, they will decide where the priorities should be.
So in one country, they might say we have a real problem with long term conditions like diabetes and heart disease,
so we want to put more money into treating diabetes and heart disease.
Another country could say, we think that's OK, but we think we have a real problem with rare diseases.
So we want to put more money into understanding and treating rare diseases that policy decisions, they're not decisions.
Importantly, it's also the policymakers and the governments that decide how much resources a body has,
how many people can work in that body, how much money do they have?
And that has a massive impact on the methods that that body can use.
They can't do anything too complicated if they only have a few people in order to do all those things.
And finally, it's the policymakers that decides what kind of happens in their country.
So what's the focus of that is only going to look at the clinical evidence?
Or is it also going to look at the health economic evidence? Is it going to look societal evidence?
Some of them do that to all of those are political decisions that are told to the FDA.
This is how we want you to operate. And so I think it's really important to keep that in mind.
And I want to show you one example to show how much politics determines access to medicines.
So it's a U.K. example I've picked because we're here. But in the early 2010s, there was a real problem in the U.K. of accessing cancer medicines.
So new cancer medicines would come out. They would be assessed by the Health Technology Agency called Nice.
Here in the U.K., a nice would say usually we will not recommend this for reimbursement within the National Health Service.
And yet people in France had access to the medicine, and people in Germany had access to the medicine.
So this suddenly became a lot of political pressure.
Why do we in the UK not have access to the same cancer medicines as people in other countries?
And there were three strategies the government could have tried here.
The first thing they could have tried is to say, we're going to do nothing because we believe in our process.
And if the medicines don't bring value, then we shouldn't pay for them, so we should carry on with the system as it stands.
The second thing they could do is to say, we think this shows as a problem with how to is conducted in the UK.
So we want to change the methods of stay in the UK so that we get more access to cancer medicines.
So they could have said the third thing,
which is we will just throw money at this problem and we will sidestep the process using separate pots of money.
And of course, they went for the Option C, so they created something called the Cancer Drugs Fund.
And you can see this is a quote from The Lancet at that time, saying this is a triumph of political expediency over rationality.
So instead of solving the. The original problem, they just threw a lot of money at the problem to hope it went, it goes away.
But it didn't go away. So this is just a few years later.
You know, the government at the time having to inject another 400 million pounds into that fund just to keep it going.
And you can see from the headline that this is seen as a party. Political movement is not seen as a movement.
So you can see how politics can determine the access to medicines regardless of what a body says.
And this creates a challenge when we're thinking about aligning systems, because if systems are not purely they're evidence based systems,
but if they sit within political context, then it becomes much harder for alignment to happen.
So let's talk about that. When I think of alignment, I think of it in two ways.
On the left hand side, I call informal alignment and on the right hand side, the more formal kinds of alignment.
So on the left hand side, you share best practises. A body might speak to another body and say, We tried this, it was really good.
You should try it too.
They partner on projects together doesn't mean they're going to change their system, but at least they partner and projects together.
And in terms of discussions with regulators. Yet they can have discussions with regulators.
They can hear what each side is doing. Does it mean that they have to change anything on this side, though?
On the right hand side, you have more formal networks that have been created.
A lot of these actually in Europe, because that's where a lot of the challenges first happened, where we saw the divergence of parties.
So you had formal networks created like you netter really charged with coming up with a common model for how you do,
which would hopefully then filter out to all the countries. So alignment would happen.
That didn't work at all. And so they said, OK, let's come up with some legislation.
Let's make laws at the EU level that force people to align the way that they do.
And I'll talk about that later, and you can see that that's not really going to happen either.
And then what is successful is what happens in a country so often.
The really good alignment you see is at the national level between different parts of the health care system, including how to.
So it tends to work very well with other parts of the health care system locally.
They just find it really hard to make decisions that change the way they work at the national level.
So when we look at this informal side, you know, different ways that this can happen,
it can happen through organisations like, I think to a lot of best practise sharing.
It can happen through consortium that have multiple parties involved working on a project together,
and it can happen through just discussions that naturally happen between different bodies,
you know, and just as an example, I pull together some things from I, you know, they run a global policy forum twice a year.
They invite bodies from around the world to that forum, as well as people from the industry and others.
And they look at these bigger issues that they don't quite know how to solve yet.
How are we really going to deal with managed entry agreements in the future?
How will they evolve? How do we get better at disinvesting from old technology or inefficient technology?
And how do we deal with manage value based decision making?
What does good look like there? They also have a lot of specialist groups that look at one particular area of HCA.
So there's a group looking just at real world evidence trying to understand how real world evidence is used by HCA bodies,
and they're thinking about the future as well.
How this artificial intelligence and machine learning lead to better real world evidence that creates better information for.
And of course, they have an annual meeting, an annual conference,
and that is probably the place where most alignment happens four days in one place, everyone together.
That's where the magic happens. But the right hand side of that circle, I'm sorry to say, is really, really hard.
You know, this idea that this can change the way they work just by sharing ideas.
It doesn't really work.
So as I've said before, UNITA was charged with creating a sort of common model for how to that would then sort of be taken up by the various.
National bodies. And actually, it always hits up against this wall of in my country,
I think we're doing better than that model, so we want to stick with what we've got.
You know, so it's not invented here syndrome, you know,
we've developed the best that that reflects our societal values and we don't want to change that.
I'll talk about the second one in a moment that the EU legislation, but I believe it's my opinion that it's been watered down too much.
I honestly don't see how it's going to work, but and then we see positive things happening at the national level.
But let's talk about that EU thing. The challenge is still that health care budgets are set and managed by national governments.
They're not managed collectively across multiple nations.
And so the danger is, or the fear is that if you have an international process that could force governments to spend money that
they were not planning to spend or to make different investment decisions than they were planning to make.
And so there was a lot of pushback about how much of a limit would this a system have.
And the second thing is the thing I was alluding to a few minutes ago that they are really focussed on.
We have the best model for how to see if you're going to create a European wide to which model do you choose,
whichever one you choose, a lot of people are going to be unhappy, you know?
So what they did was they said, OK, we will take the least controversial part of a and only make that Europe wide.
So the very first, if you like the main analysis of who is looking at the clinical effectiveness relative to what's available today,
so relative clinical effectiveness, that assessment is due to happen jointly.
So it can happen in one place and everyone will accept that report and say, OK, at least we don't have to do that at the national level.
But the economic and pricing in all of those other things that lead to a yes or no that stays at the national level.
So it still means you're going to have very divergent decisions from country to country.
And actually, even the first thing I said is not true because there was a lot of pushback about certain countries saying,
but we think our system is better than what you're planning to do.
So we don't want to take this Europe wide reports.
We don't want to use it. We want to do our own. So they've made it.
So it's not mandatory for countries to use this, this new EU wide report.
And so we've left with a system that's even more fragmented and nobody knows who's
going to take those reports up or not when it actually starts going forward.
I sent them my last slide for this section is really, you know,
I think the fragmentation is part of the nature of having national health care budgets.
I find it difficult to see a future where you're going to have common decisions made that impact the way that governments spend money nationally,
you know, supranational level and you're always going to have for societal reasons and economic reasons.
Different focuses to your to you're going to have to that look.
Some of them will say, actually,
we just all we care about is the clinical outcomes we will pay for the clinical outcomes and we're not paying for anything more.
And you'll have others that say, Yeah, but we think the patient impacts also need to be part of the value.
So we want to look at that as well.
And then you'll have others that say, we believe those two things, but we think we should also be thinking about the societal impacts.
You know, in some Scandinavian so sweet and in some of in some of the results, they go that far along there.
And you're still going to have arguments about what evidence they accept.
You know, some will say, we don't agree with your model. We don't agree with the the surrogate end you've used.
We think you should have looked for actual hard outcomes,
and some will love patient relevant evidence like patient reported outcome measures and some hates it.
And I think we're still in this fragmented world.
But for those of you that are interested in, that's what makes it so interesting.
I mean, if everybody did exactly the same, there would be nothing to learn.
And there would be nothing to compare. So I love the fact that this is still quite difficult to navigate because.
Each of those difficulties, each of those hurdles is an opportunity to learn what works best and what doesn't.
Moving on to part two patient involvement, it's related, actually,
because I see patient involvement and a really good example of where the agencies have aligned and learn from each other and move this forward.
OK, so this idea that alignment doesn't happen. Patient involvement, I think, is an exception to that rule.
So 1970s, would you believe that was really invented by America in the 1970s?
It was mainly. The Office of Technology Assessment was a federal office founded in the early seventies.
I think it ran until about 1992, and in 76 they produced some guidance of how to do health technology assessment.
And they said it's impossible to do it without thinking about patients, families and society as well as everything else.
OK? And yet when the port is in Europe and Canada and Australia and elsewhere started to form in the 90s and 2000s,
they just forgot that advice and they didn't bother involving patients.
And yet, by the time you get to 2017, this man here, Brian O'Rourke, he was the head of Catalyst, which is the Canadian health technology assessor.
And he said quite clearly, if you're not involving patients, you're not doing.
So there was a massive change that happened between the 2000s and by the time we get to 2017,
OK, and today what we see is we see patients being involved in multiple parts of the process.
Yes, they input into the assessment process, but they also get active in the early dialogue's years before an assessment,
their input and increasingly into managed entry agreements, especially to make sure that they're manageable for patients.
The first managed entry agreements included a lot of monitoring trips and extra
visits for patients in order to prove that their medicine was still working.
And if they missed some of those visits, they were taken off the treatment. You know, so, so so patients need to be involved in these.
They're increasingly providing their own data into HCA processes, helping HCA bodies understand what it's like to live with this disease.
They advise on the impact of the healthcare system.
The drug companies often say to bodies on medicine is so fantastic that it's going to change the way that this this disease is treated.
Patients will not be treated in the old way.
Once we have this treatment, and that's great because you need to check if the health care system needs to change,
what's the impact on that change on patients?
And finally, when you have a team that's covering a disease area that they've not looked at for a long time or they've never looked at before,
they often do scoping meetings to understand from a patient what it's like to live
with that disease so they can think about that before they get into the HCA thesis.
This changes all the time, this map, by the way,
so I wouldn't focus too much on how this all details out because next year it will be different again.
But you have a lot of countries have something called patient group submissions,
so that's where they invite patient groups, not individual patient patient groups, to submit evidence into a HCA.
Others have consultations, so public consultations where the whole public they could be nurses,
doctors, patients, family members, whoever they can input into a process.
Usually it's like a website where you can you can sort of look at your your comments and we so we are seeing Germany is a bit of an outlier,
but a really interesting patient involvement process. They do it on two levels.
They say our assessment will only consider evidence that we think is patient relevant.
So there's always this argument with drug companies and the GBA in Germany about what is patient relevant, you know,
but they also have a really interesting mechanism for involving patients where
they they really basically give money to full patient associations and say,
with this money, you make sure we have patients in our process.
And it's a way of ensuring that the patients in the process have not received any funding from the industry.
OK, so they do it. So why do parties involve patients?
Well, as I've said before, if? First, they said, we don't want to do this, we don't want to do this.
So they said, OK, you know what? This is dead easy. We're clever people.
OK, so the industry provides us with the evidence and we can look at the evidence.
We can start reviewing it. We can bring in clinicians to the table and we can bring in health economists to the table.
And together we can debate the evidence and then we can make a decision, you know, should we reimburse you recommend that this is reimbursed.
And if so, to whom? And how do we reimburse it?
OK, dead easy. Except it's not because the clinical evidence never tells the whole story, especially when it's a new product.
The clinical studies only provide part of the story they need to be extrapolated to match the health care population in that country.
So the clinical trial population is usually very tightly defined. And so there's this big question how would the results from this clinical trial
really going to be reflected in real people on the ground in our country?
The second thing is that clinical trials, because the regulators are getting faster and faster,
approving medicines, clinical trials and shorter and shorter in length, you can almost see it on a graph.
Yeah, and it means that there's virtually no evidence about the duration of response from a medicine at launch.
So we know it might be expensive and we know it works at first or within the first 24 or 48 weeks, but we don't know much more than that.
So if you cannot pay this much for it, can we at least start to think about whether it's going to work in the longer term?
How many years is it going to work for that sort of thing?
Quality of life and patient reported outcome measures are really hard to interpret, especially for a tag.
There's often really big challenges, with missing data in patient.
Reported outcomes is often not talked about, but there's always a lot of missing data in patient reported outcomes and how that's
dealt with statistically can completely change the shape of that evidence point.
There's also been a move over the last five 10 years to really build new patient reported outcome tools that are specific to
each particular disease for good reason because you want to know as much detail about what it's like to live with that disease.
But when you have so many different patient reports that controls, how can a body keep on top of them all?
How can it compare the results of one tool that was used by one company compared to the results of a different tool used by a different company?
So it becomes really, really complicated. And then there's this old chestnut here.
This is this is the one that always brings down the is is what did you use as your comparator in your clinical studies?
You know, and so you often have really credible questions to ask, why did you pick that comparison?
We don't use that. We don't use that drug in our country. So actually, your data means nothing to us.
We can't really understand what is telling us. And as I mentioned before, when you have a lot of innovation and in particular disease area,
the clinical trials never reflect the most recent innovation.
So if you let me give you an example, you've got a new treatment that comes out for skin cancer.
But just two years ago, there was a great new treatment that came up for skin cancer that changed the landscape of skin cancer.
But your clinical trial never measured that because that treatment wasn't there then.
You know, so as a stay, that creates a massive problem. Now, how does this latest innovation compare to a recent innovation?
And we have to have the answer. So we have all these uncertainties.
And so the approach breaks down, and you start to ask in the committee meeting these kinds of questions.
You know, I can see your data, but I'm really starting to question what is the most meaningful part of your data.
I should be focussing on what outcomes are important.
You mentioned all of these different populations that we could potentially be reimbursing,
but do we understand the particular needs of those populations?
Is there a particular patient population that is really underserved as much higher needs?
For example, in many diseases, skin diseases are a good example.
So dermatology, skin diseases, you often have disease scores, you know,
numbers attached to have severe there's this disease is and it's sometimes really hard to
link what those disease scores mean and improvement of one point in that disease score.
What does that really mean for a patient?
If you're saying you're going to change the way that this whole disease is treated, have we thought about how that impacts the people who are treated?
Ultimately, we're trying to answer this question quite clearly. Who will?
Benefit most, and let's focus on them and obviously, what is the real value of the treatment?
So in the round, based on what we know, what do we think the value is?
And I argue that patients are the missing link in these deliberations.
They really could, explaining how a disease affects day-to-day life, what they can do, what they can't do.
They can translate the endpoints being measured. The patient reported outcomes as well into specific impacts that they experience every day.
They can highlight if there's any change in these scores. What does that mean?
A two point scale? Oh my god, that's transformative. I could do so much more if I improve by two points.
And they can clearly articulate how current ways of managing their disease is not good for them is not meeting their needs.
And you can see here I've highlighted specific twice here, and it's probably the words if I'm if you were a patient patient group,
people here, I've probably set up at least 50 times already now because I cannot emphasise enough.
The emotion does not help. So if a patient group comes into a stay and says, Oh my God,
this disease is so difficult to live with my life is how so many other patient groups with different diseases come in and say those things.
It doesn't help the body understand why is your life?
How? Why is it so bad to live with this disease?
So what I always say to patient groups is, be specific, say exactly because if this symptom,
I can't do this every day and the second symptom stops me from doing this other thing.
And then it's quite easy then for the body to say, I hope with this new treatment actually deals with those symptoms really well.
So it helps them link impact to the, you know, the treatment in front of them.
Oh my God, time's rushing on. OK, I'm going to be a bit quick enough.
So they add patients into the mix and patients provide that context to them.
We looked at this guy. We did a Big Delfi study internationally, multiple stakeholders, and we asked why should patients be involved in HK?
And the list is here, but I really want to focus on this relevance on the first one.
Patients have information and knowledge and experiences that no other stakeholder has.
So the doctors cannot answer the same questions they can answer. The economist can't answer those questions, either.
And it's understanding that missing piece of knowledge that improves the quality of what people used to think that if we invited patients,
patients would just be demanding. We want access to everything. It turns out they don't.
You know what they say is we want new drugs, but we don't want any drug and not any price.
We want drugs that are transformative. We want drugs that are really going to change the way we experience disease.
And they can be as critical, if not more critical of the industry when they think that the evidence that they've collected has not been good enough.
You know, and I've heard lots of very difficult discussions between patient groups in the industry of why did you choose that as your comparator?
Why did you when you run the trial for 24 weeks, why did you have this stupid exclusion criteria that doesn't match reality?
You know, they will be just as critical of the evidence as the other stakeholders.
How do they do it? I'm not going to go through this in detail. It's limited by all the things I mentioned earlier.
What is the remit of that? What is their role in that health system?
Have they got the resources to do patient engagement?
There's no point asking them to do it if they don't have the resources to do it in their country.
Is there even a cultural and societal acceptance of patients and patient groups doesn't exist in every country?
So sometimes you can't just transport a concept into a new country setting and expect it to live.
You have to be respectful of the culture and society.
The way that we see it work is on this sort of spectrum for informal fruits,
the most formal hair where you have people from patient groups actually in the meetings.
And I just want to just flick through this one. But this is a sort of generic process.
Not every day has all these steps and some have more steps than this, but generally scoping phase happens in preparation of an upcoming year only.
Happens, really, if there were big questions about we don't understand this disease,
we've not looked at this disease for 15 years and we need to understand if anything's
changed or this is a rare disease and we've never looked at this ever in our body,
then often then have consultation and workshops with patient groups, usually to help understand what are the main aspects of this disease.
They should be thinking about when they're organising the time. You have the evidence submission phase.
The industry submits their evidence, but this is also when a lot of parties reach out to patient groups and say,
Can you also submit evidence which we will consider alongside the industry evidence?
You have a committee meeting. Patient groups are usually there.
Sometimes individual patients are there. It depends on the day, and it also depends on whether it's a rare disease or more common disease.
There's a lot of distinctions there,
but at a committee meeting the patient's role there are to give testimony and to answer any questions that come up from the other committee members.
They're not official voting members of the committee, just as the industry is not official voting members of the committee.
So just to be clear about this, you know, we have two governance terms.
We have to separate the interest of needing a treatment and wanting a treatment, then voting for that treatment.
So you often have citizens or patients that don't have that disease in the committee meeting who do have a vote,
but the patients who will benefit from the decision will not have a vote.
There's just good governance. Yep. Oh, sorry, I didn't finish that one.
Discuss, discuss the evidence. Make a sort of draught recommendation.
There's usually a consultation period. Those patient groups that have been involved up to now are part of that consultation,
but usually that's where it stops is not reopened to new patient groups.
So you have to be involved usually in order to be in that consultation step.
And then there might be a second committee meeting in a final sort of recommendation made.
And you can see here that patients are involved, potentially at every step along the way.
Not every body does that, but this is a sort of idealistic general example.
These are the questions, you know, I think you were asking me earlier sort of like, what is it that about this consultation with patients?
So this is from Scotland. But these same questions are asked in France, the US, in Canada that, you know,
most bodies that have this kind of approach where patients have a written submission are similar questions to this.
They want to know about what it's like to live with the disease, how well is currently managed without the new treatment.
They want to know if they've been able to talk to anybody who's tried the new treatment.
Maybe it's already been launched in a neighbouring country or somebody who's been on a clinical trial.
They want to know how it's expected to improve the quality of life or the medical
care of a patient and what they think the impact would have on families and carers.
And finally, a really important one they want to know are there any disadvantages to this new treatment?
And they're very suspicious. If the patient groups don't answer that question because there's no treatment ever made, that is only positive.
There will always be something to plug there. Case studies very briefly.
Right? So this one is a right. It's reasonably recent.
It's a rare disease treatment. Very, very expensive.
And I wanted to use this case study to show how patients can bring new concepts to the table that none of the other stakeholders have mentioned.
OK, so this is for lipodystrophy rare condition quite complicated.
Different patients have different symptoms. It's poorly understood by the body because it's a rare disease.
This is quite common for rare diseases and the industry and and the clinical
partners were having this massive conversation about blood values lab results,
saying We can tell this medicine's working or not. But by looking at, you know, the liver enzymes, the blood sugar, the triglycerides.
So the conversation was very technical and was really technical about lab values.
And what's the difference?
What does it mean to a patient if this lab value changes and the patients there were saying, hold on a second you've not even mentioned?
The most important thing for us with this disease, and the most important thing is we have this constant feeling of hunger.
It's like being starved to death. Does it matter if we eat, it never goes away.
OK, so we cannot stop eating. We cannot stop feeling this intense starvation.
For us, that means we have no social life. It means we can't go to work.
It means that we cannot interact with people in a way that they can understand because we just can't stop eating, you know?
And so they they were fantastic. They brought to life the psychological, the daily, the social, the economic to their own economy.
The economic impacts of this symptom hadn't even been measured by the company wasn't even part of the health economic model.
So nobody brought up this subject.
But they were so passionate that actually, if you look at the final report of this, it's what the committee focussed on.
In the end, they focussed on this symptom and what an awful impact it had on people's lives.
And they agreed that they were going to reimburse or recommend to reimburse the treatment
because at least it seemed to have some effect against this symptom or they hoped it would be.
But it was just a shame that the company making the medicine never bother to measure this.
Bring it to a close as we've come to the IMF, I just want to thank you all so much for coming all this way.
You've come from outside the UK today, and what a great deal. I learn something every time.
Thank you, Neal. Thank you.