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So without further ado, I will introduce our evening lecturer is Neil Ferguson.

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He currently works at the international level with a number of health technology assessment

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agencies really with a remit to try and align process and mechanism across those agencies.

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He is the chair of the HDI International Patient and Citizen Involvement Group,

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so he has a strong working relationship with patients and involving patients in health technology assessment processes.

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And he's also on the board member of patient focussed medicines development.

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And that's really trying to better promote how evidence can be generated for all different stakeholders views in a decision making process.

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So without further ado, I will hand you over to Neil. Thank you very much.

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Thank you, Stuart, and thank you for having me here and thank you for being here.

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So what I really want to take you through today is, you know, I've seen that,

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you know, the kinds of information those of you that run on on the MSE course,

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the kinds of information you've been looking at and you've been going into sort of health economics,

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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,

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how they learn from each other and how sometimes they can't learn from each other and they can't

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work with each other because I think that's really important to understand where the barriers are.

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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.

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I want to take a deep dive into patient involvement in how to see the perspective I'm bringing.

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This just builds on what Stuart has said.

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But really, I work with chapatis and regulators, with patient groups, with industry, with academic researchers,

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all with the aim of getting people to play nicely together for a change and learn from one

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another and really understanding the different perspectives and the different limits.

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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?

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And he often finds it really difficult to change because of the rules behind which they're being set up.

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There's a lot of reasons why it's quite hard to change processes like to,

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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.

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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,

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Stewart and I, that's how we got to know each other on Paradigm, which was an international collaboration and in particular,

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the area that I was looking at was how patients can be involved in early dialogues with bodies and those

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early dialogues that first time that a company that's developing a medicine can go to a party and say,

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Can you give me a bit of advice here? What kind of evidence would you be looking for?

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And we worked with about 15 bodies to develop that piece of work and with patient focussed medicines development,

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I just wanted to flag up a new and emerging discipline of evidence, which is called patient experience data.

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And it's new is coming along. And one of the things we're trying to do a patient focussed medicines development is say,

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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.

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So from the very start, we're trying to pull everybody together to say,

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let's make sure this new class of evidence is usable, both for regulatory and to purposes.

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So what I'm going to take you through today, I'm going to talk a little bit about the context,

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the context within which to sets and what is the impact of that context for international alignment.

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Then we'll take a deeper dive into patient involvement, and I'll go through a couple of case studies.

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So when we think about the context, you've probably seen this, but this is the 2020 definition of.

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And I want to just flag there's two elements that you can see in bold that this is a multi-disciplinary process.

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So not no. One stakeholder is able to do on their own.

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They need the other stakeholders to come together in order to make that process and informs decision making.

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And I've. Really want to focus on that inform, because there is some myths that people have about.

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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

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access to or that determining access to medicine becomes purely evidence based.

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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,

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it's done by the World Health Organisation and the European Union, and they look at this interface between state and health policy.

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And they say H.J. provides evidence based input.

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So again, this input informing it promotes evidence informed policymaking.

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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.

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So you can already see that state lives in this very unsafe world.

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On one side, you've got all these people creating evidence and on the other side, you've got all the policy makers.

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And it's to that sort of sits between those two and tries to make sense of it.

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So policymakers decide within each country the overall resources available to health care.

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They decide what is more spent on schools and less on health care or vice versa,

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for example, within health care, they will decide where the priorities should be.

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So in one country, they might say we have a real problem with long term conditions like diabetes and heart disease,

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so we want to put more money into treating diabetes and heart disease.

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Another country could say, we think that's OK, but we think we have a real problem with rare diseases.

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So we want to put more money into understanding and treating rare diseases that policy decisions, they're not decisions.

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Importantly, it's also the policymakers and the governments that decide how much resources a body has,

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how many people can work in that body, how much money do they have?

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And that has a massive impact on the methods that that body can use.

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They can't do anything too complicated if they only have a few people in order to do all those things.

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And finally, it's the policymakers that decides what kind of happens in their country.

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So what's the focus of that is only going to look at the clinical evidence?

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Or is it also going to look at the health economic evidence? Is it going to look societal evidence?

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Some of them do that to all of those are political decisions that are told to the FDA.

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This is how we want you to operate. And so I think it's really important to keep that in mind.

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And I want to show you one example to show how much politics determines access to medicines.

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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.

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So new cancer medicines would come out. They would be assessed by the Health Technology Agency called Nice.

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Here in the U.K., a nice would say usually we will not recommend this for reimbursement within the National Health Service.

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And yet people in France had access to the medicine, and people in Germany had access to the medicine.

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So this suddenly became a lot of political pressure.

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Why do we in the UK not have access to the same cancer medicines as people in other countries?

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And there were three strategies the government could have tried here.

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The first thing they could have tried is to say, we're going to do nothing because we believe in our process.

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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.

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The second thing they could do is to say, we think this shows as a problem with how to is conducted in the UK.

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So we want to change the methods of stay in the UK so that we get more access to cancer medicines.

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So they could have said the third thing,

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which is we will just throw money at this problem and we will sidestep the process using separate pots of money.

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And of course, they went for the Option C, so they created something called the Cancer Drugs Fund.

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And you can see this is a quote from The Lancet at that time, saying this is a triumph of political expediency over rationality.

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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.

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But it didn't go away. So this is just a few years later.

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You know, the government at the time having to inject another 400 million pounds into that fund just to keep it going.

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And you can see from the headline that this is seen as a party. Political movement is not seen as a movement.

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So you can see how politics can determine the access to medicines regardless of what a body says.

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And this creates a challenge when we're thinking about aligning systems, because if systems are not purely they're evidence based systems,

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but if they sit within political context, then it becomes much harder for alignment to happen.

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So let's talk about that. When I think of alignment, I think of it in two ways.

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On the left hand side, I call informal alignment and on the right hand side, the more formal kinds of alignment.

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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.

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You should try it too.

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They partner on projects together doesn't mean they're going to change their system, but at least they partner and projects together.

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And in terms of discussions with regulators. Yet they can have discussions with regulators.

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They can hear what each side is doing. Does it mean that they have to change anything on this side, though?

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On the right hand side, you have more formal networks that have been created.

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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.

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So you had formal networks created like you netter really charged with coming up with a common model for how you do,

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which would hopefully then filter out to all the countries. So alignment would happen.

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That didn't work at all. And so they said, OK, let's come up with some legislation.

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Let's make laws at the EU level that force people to align the way that they do.

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And I'll talk about that later, and you can see that that's not really going to happen either.

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And then what is successful is what happens in a country so often.

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The really good alignment you see is at the national level between different parts of the health care system, including how to.

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So it tends to work very well with other parts of the health care system locally.

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They just find it really hard to make decisions that change the way they work at the national level.

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So when we look at this informal side, you know, different ways that this can happen,

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it can happen through organisations like, I think to a lot of best practise sharing.

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It can happen through consortium that have multiple parties involved working on a project together,

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and it can happen through just discussions that naturally happen between different bodies,

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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.

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They invite bodies from around the world to that forum, as well as people from the industry and others.

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And they look at these bigger issues that they don't quite know how to solve yet.

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How are we really going to deal with managed entry agreements in the future?

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How will they evolve? How do we get better at disinvesting from old technology or inefficient technology?

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And how do we deal with manage value based decision making?

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What does good look like there? They also have a lot of specialist groups that look at one particular area of HCA.

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So there's a group looking just at real world evidence trying to understand how real world evidence is used by HCA bodies,

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and they're thinking about the future as well.

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How this artificial intelligence and machine learning lead to better real world evidence that creates better information for.

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And of course, they have an annual meeting, an annual conference,

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and that is probably the place where most alignment happens four days in one place, everyone together.

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That's where the magic happens. But the right hand side of that circle, I'm sorry to say, is really, really hard.

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You know, this idea that this can change the way they work just by sharing ideas.

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It doesn't really work.

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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.

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National bodies. And actually, it always hits up against this wall of in my country,

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I think we're doing better than that model, so we want to stick with what we've got.

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You know, so it's not invented here syndrome, you know,

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we've developed the best that that reflects our societal values and we don't want to change that.

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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.

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I honestly don't see how it's going to work, but and then we see positive things happening at the national level.

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But let's talk about that EU thing. The challenge is still that health care budgets are set and managed by national governments.

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They're not managed collectively across multiple nations.

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And so the danger is, or the fear is that if you have an international process that could force governments to spend money that

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they were not planning to spend or to make different investment decisions than they were planning to make.

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And so there was a lot of pushback about how much of a limit would this a system have.

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And the second thing is the thing I was alluding to a few minutes ago that they are really focussed on.

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We have the best model for how to see if you're going to create a European wide to which model do you choose,

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whichever one you choose, a lot of people are going to be unhappy, you know?

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So what they did was they said, OK, we will take the least controversial part of a and only make that Europe wide.

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So the very first, if you like the main analysis of who is looking at the clinical effectiveness relative to what's available today,

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so relative clinical effectiveness, that assessment is due to happen jointly.

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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.

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But the economic and pricing in all of those other things that lead to a yes or no that stays at the national level.

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So it still means you're going to have very divergent decisions from country to country.

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And actually, even the first thing I said is not true because there was a lot of pushback about certain countries saying,

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but we think our system is better than what you're planning to do.

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So we don't want to take this Europe wide reports.

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We don't want to use it. We want to do our own. So they've made it.

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So it's not mandatory for countries to use this, this new EU wide report.

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And so we've left with a system that's even more fragmented and nobody knows who's

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going to take those reports up or not when it actually starts going forward.

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I sent them my last slide for this section is really, you know,

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I think the fragmentation is part of the nature of having national health care budgets.

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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,

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you know, supranational level and you're always going to have for societal reasons and economic reasons.

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Different focuses to your to you're going to have to that look.

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Some of them will say, actually,

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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.

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And you'll have others that say, Yeah, but we think the patient impacts also need to be part of the value.

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So we want to look at that as well.

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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.

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You know, in some Scandinavian so sweet and in some of in some of the results, they go that far along there.

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And you're still going to have arguments about what evidence they accept.

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You know, some will say, we don't agree with your model. We don't agree with the the surrogate end you've used.

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We think you should have looked for actual hard outcomes,

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and some will love patient relevant evidence like patient reported outcome measures and some hates it.

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And I think we're still in this fragmented world.

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But for those of you that are interested in, that's what makes it so interesting.

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I mean, if everybody did exactly the same, there would be nothing to learn.

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And there would be nothing to compare. So I love the fact that this is still quite difficult to navigate because.

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Each of those difficulties, each of those hurdles is an opportunity to learn what works best and what doesn't.

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Moving on to part two patient involvement, it's related, actually,

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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.

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OK, so this idea that alignment doesn't happen. Patient involvement, I think, is an exception to that rule.

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So 1970s, would you believe that was really invented by America in the 1970s?

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It was mainly. The Office of Technology Assessment was a federal office founded in the early seventies.

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I think it ran until about 1992, and in 76 they produced some guidance of how to do health technology assessment.

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And they said it's impossible to do it without thinking about patients, families and society as well as everything else.

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OK? And yet when the port is in Europe and Canada and Australia and elsewhere started to form in the 90s and 2000s,

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they just forgot that advice and they didn't bother involving patients.

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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.

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And he said quite clearly, if you're not involving patients, you're not doing.

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So there was a massive change that happened between the 2000s and by the time we get to 2017,

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OK, and today what we see is we see patients being involved in multiple parts of the process.

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Yes, they input into the assessment process, but they also get active in the early dialogue's years before an assessment,

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their input and increasingly into managed entry agreements, especially to make sure that they're manageable for patients.

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The first managed entry agreements included a lot of monitoring trips and extra

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visits for patients in order to prove that their medicine was still working.

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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.

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They're increasingly providing their own data into HCA processes, helping HCA bodies understand what it's like to live with this disease.

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They advise on the impact of the healthcare system.

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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.

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Patients will not be treated in the old way.

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Once we have this treatment, and that's great because you need to check if the health care system needs to change,

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what's the impact on that change on patients?

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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,

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they often do scoping meetings to understand from a patient what it's like to live

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with that disease so they can think about that before they get into the HCA thesis.

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This changes all the time, this map, by the way,

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so I wouldn't focus too much on how this all details out because next year it will be different again.

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But you have a lot of countries have something called patient group submissions,

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so that's where they invite patient groups, not individual patient patient groups, to submit evidence into a HCA.

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Others have consultations, so public consultations where the whole public they could be nurses,

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doctors, patients, family members, whoever they can input into a process.

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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,

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but a really interesting patient involvement process. They do it on two levels.

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They say our assessment will only consider evidence that we think is patient relevant.

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So there's always this argument with drug companies and the GBA in Germany about what is patient relevant, you know,

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but they also have a really interesting mechanism for involving patients where

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they they really basically give money to full patient associations and say,

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with this money, you make sure we have patients in our process.

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And it's a way of ensuring that the patients in the process have not received any funding from the industry.

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OK, so they do it. So why do parties involve patients?

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Well, as I've said before, if? First, they said, we don't want to do this, we don't want to do this.

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So they said, OK, you know what? This is dead easy. We're clever people.

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OK, so the industry provides us with the evidence and we can look at the evidence.

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We can start reviewing it. We can bring in clinicians to the table and we can bring in health economists to the table.

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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.

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And if so, to whom? And how do we reimburse it?

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OK, dead easy. Except it's not because the clinical evidence never tells the whole story, especially when it's a new product.

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The clinical studies only provide part of the story they need to be extrapolated to match the health care population in that country.

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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

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really going to be reflected in real people on the ground in our country?

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The second thing is that clinical trials, because the regulators are getting faster and faster,

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approving medicines, clinical trials and shorter and shorter in length, you can almost see it on a graph.

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Yeah, and it means that there's virtually no evidence about the duration of response from a medicine at launch.

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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.

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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?

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How many years is it going to work for that sort of thing?

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Quality of life and patient reported outcome measures are really hard to interpret, especially for a tag.

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There's often really big challenges, with missing data in patient.

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Reported outcomes is often not talked about, but there's always a lot of missing data in patient reported outcomes and how that's

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dealt with statistically can completely change the shape of that evidence point.

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There's also been a move over the last five 10 years to really build new patient reported outcome tools that are specific to

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each particular disease for good reason because you want to know as much detail about what it's like to live with that disease.

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But when you have so many different patient reports that controls, how can a body keep on top of them all?

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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?

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So it becomes really, really complicated. And then there's this old chestnut here.

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This is this is the one that always brings down the is is what did you use as your comparator in your clinical studies?

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You know, and so you often have really credible questions to ask, why did you pick that comparison?

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We don't use that. We don't use that drug in our country. So actually, your data means nothing to us.

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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,

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the clinical trials never reflect the most recent innovation.

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So if you let me give you an example, you've got a new treatment that comes out for skin cancer.

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But just two years ago, there was a great new treatment that came up for skin cancer that changed the landscape of skin cancer.

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But your clinical trial never measured that because that treatment wasn't there then.

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You know, so as a stay, that creates a massive problem. Now, how does this latest innovation compare to a recent innovation?

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And we have to have the answer. So we have all these uncertainties.

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And so the approach breaks down, and you start to ask in the committee meeting these kinds of questions.

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You know, I can see your data, but I'm really starting to question what is the most meaningful part of your data.

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I should be focussing on what outcomes are important.

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You mentioned all of these different populations that we could potentially be reimbursing,

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but do we understand the particular needs of those populations?

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Is there a particular patient population that is really underserved as much higher needs?

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For example, in many diseases, skin diseases are a good example.

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So dermatology, skin diseases, you often have disease scores, you know,

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numbers attached to have severe there's this disease is and it's sometimes really hard to

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link what those disease scores mean and improvement of one point in that disease score.

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What does that really mean for a patient?

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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?

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Ultimately, we're trying to answer this question quite clearly. Who will?

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Benefit most, and let's focus on them and obviously, what is the real value of the treatment?

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So in the round, based on what we know, what do we think the value is?

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And I argue that patients are the missing link in these deliberations.

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They really could, explaining how a disease affects day-to-day life, what they can do, what they can't do.

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They can translate the endpoints being measured. The patient reported outcomes as well into specific impacts that they experience every day.

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They can highlight if there's any change in these scores. What does that mean?

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A two point scale? Oh my god, that's transformative. I could do so much more if I improve by two points.

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And they can clearly articulate how current ways of managing their disease is not good for them is not meeting their needs.

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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,

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people here, I've probably set up at least 50 times already now because I cannot emphasise enough.

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The emotion does not help. So if a patient group comes into a stay and says, Oh my God,

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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.

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It doesn't help the body understand why is your life?

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How? Why is it so bad to live with this disease?

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So what I always say to patient groups is, be specific, say exactly because if this symptom,

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I can't do this every day and the second symptom stops me from doing this other thing.

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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.

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So it helps them link impact to the, you know, the treatment in front of them.

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Oh my God, time's rushing on. OK, I'm going to be a bit quick enough.

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So they add patients into the mix and patients provide that context to them.

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We looked at this guy. We did a Big Delfi study internationally, multiple stakeholders, and we asked why should patients be involved in HK?

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And the list is here, but I really want to focus on this relevance on the first one.

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Patients have information and knowledge and experiences that no other stakeholder has.

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So the doctors cannot answer the same questions they can answer. The economist can't answer those questions, either.

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And it's understanding that missing piece of knowledge that improves the quality of what people used to think that if we invited patients,

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patients would just be demanding. We want access to everything. It turns out they don't.

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You know what they say is we want new drugs, but we don't want any drug and not any price.

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We want drugs that are transformative. We want drugs that are really going to change the way we experience disease.

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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.

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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?

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Why did you when you run the trial for 24 weeks, why did you have this stupid exclusion criteria that doesn't match reality?

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You know, they will be just as critical of the evidence as the other stakeholders.

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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.

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What is the remit of that? What is their role in that health system?

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Have they got the resources to do patient engagement?

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There's no point asking them to do it if they don't have the resources to do it in their country.

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Is there even a cultural and societal acceptance of patients and patient groups doesn't exist in every country?

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So sometimes you can't just transport a concept into a new country setting and expect it to live.

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You have to be respectful of the culture and society.

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The way that we see it work is on this sort of spectrum for informal fruits,

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the most formal hair where you have people from patient groups actually in the meetings.

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And I just want to just flick through this one. But this is a sort of generic process.

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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.

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Happens, really, if there were big questions about we don't understand this disease,

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we've not looked at this disease for 15 years and we need to understand if anything's

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changed or this is a rare disease and we've never looked at this ever in our body,

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then often then have consultation and workshops with patient groups, usually to help understand what are the main aspects of this disease.

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They should be thinking about when they're organising the time. You have the evidence submission phase.

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The industry submits their evidence, but this is also when a lot of parties reach out to patient groups and say,

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Can you also submit evidence which we will consider alongside the industry evidence?

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You have a committee meeting. Patient groups are usually there.

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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.

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There's a lot of distinctions there,

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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.

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They're not official voting members of the committee, just as the industry is not official voting members of the committee.

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So just to be clear about this, you know, we have two governance terms.

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We have to separate the interest of needing a treatment and wanting a treatment, then voting for that treatment.

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So you often have citizens or patients that don't have that disease in the committee meeting who do have a vote,

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but the patients who will benefit from the decision will not have a vote.

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There's just good governance. Yep. Oh, sorry, I didn't finish that one.

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Discuss, discuss the evidence. Make a sort of draught recommendation.

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There's usually a consultation period. Those patient groups that have been involved up to now are part of that consultation,

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but usually that's where it stops is not reopened to new patient groups.

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So you have to be involved usually in order to be in that consultation step.

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And then there might be a second committee meeting in a final sort of recommendation made.

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And you can see here that patients are involved, potentially at every step along the way.

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Not every body does that, but this is a sort of idealistic general example.

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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?

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So this is from Scotland. But these same questions are asked in France, the US, in Canada that, you know,

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most bodies that have this kind of approach where patients have a written submission are similar questions to this.

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They want to know about what it's like to live with the disease, how well is currently managed without the new treatment.

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They want to know if they've been able to talk to anybody who's tried the new treatment.

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Maybe it's already been launched in a neighbouring country or somebody who's been on a clinical trial.

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They want to know how it's expected to improve the quality of life or the medical

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care of a patient and what they think the impact would have on families and carers.

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And finally, a really important one they want to know are there any disadvantages to this new treatment?

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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.

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There will always be something to plug there. Case studies very briefly.

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Right? So this one is a right. It's reasonably recent.

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It's a rare disease treatment. Very, very expensive.

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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.

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OK, so this is for lipodystrophy rare condition quite complicated.

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Different patients have different symptoms. It's poorly understood by the body because it's a rare disease.

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This is quite common for rare diseases and the industry and and the clinical

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partners were having this massive conversation about blood values lab results,

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saying We can tell this medicine's working or not. But by looking at, you know, the liver enzymes, the blood sugar, the triglycerides.

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So the conversation was very technical and was really technical about lab values.

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And what's the difference?

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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?

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The most important thing for us with this disease, and the most important thing is we have this constant feeling of hunger.

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It's like being starved to death. Does it matter if we eat, it never goes away.

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OK, so we cannot stop eating. We cannot stop feeling this intense starvation.

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For us, that means we have no social life. It means we can't go to work.

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It means that we cannot interact with people in a way that they can understand because we just can't stop eating, you know?

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And so they they were fantastic. They brought to life the psychological, the daily, the social, the economic to their own economy.

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The economic impacts of this symptom hadn't even been measured by the company wasn't even part of the health economic model.

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So nobody brought up this subject.

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But they were so passionate that actually, if you look at the final report of this, it's what the committee focussed on.

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In the end, they focussed on this symptom and what an awful impact it had on people's lives.

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And they agreed that they were going to reimburse or recommend to reimburse the treatment

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because at least it seemed to have some effect against this symptom or they hoped it would be.

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But it was just a shame that the company making the medicine never bother to measure this.

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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.

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You've come from outside the UK today, and what a great deal. I learn something every time.

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Thank you, Neal. Thank you.