14th Greek Australian Legal and Medical Conference
Cape Sounion, Greece 2013

“Protecting the Unprotected”
Reflections from the National Health & Medical Review:
The Way Forward for HMR in Australia

Simon McKeon

I am delighted to have been invited to speak at this 14th Greek / Australian International Legal and Medical Conference being held at Cape Sounion. And, before going any further, I do want to compliment Conference Committee Chairman Jack Harty AM, Program Chairman Professor Neville Yeomans and their team on a superbly organised conference with a fabulous program.

I’m feeling for Jack that he’s been unable to be with us and, like all of you, trust that his health improves soon.

I know that everyone present has had a wonderfully enriching and fulfilling few days. We’ll leave Cape Sounion wiser, refreshed and ready for whatever we are called to do back at home.

I wish to start with a confession. Much to my partner Heather’s consternation, I am a hoarder. Yes, I keep things. All of critical importance to me, of little significance to anyone else. And accordingly when I scratched my head recently and wondered as to when I was first approached to participate in this conference, I knew I would have some evidence somewhere. And “Exhibit A” is an email from Neville Yeomans dated 23 November 2011 in which he ever so politely requested a time that he could talk to me about a conference that would occur in mid 2013. A few days later we spoke and he told me about this quite unique gathering. I was all ears as I was looking forward to life after a particularly hectic 2011. For many reasons, none the least being the bringing together of two of society’s most important professions, the conference appealed and I left Neville, I hope, with a feeling that I was humbled and delighted to have been approached.

Subsequently, I did a little research and learnt about the fine traditions of these conferences and the fact that typically there were three speakers, namely one who would focus on legal matters, one who would inspire us with culture and a third who would captivate us about advances in health.

It was only later that I started to become a touch nervous. You see, I did actually practice law for what now seems a few minutes very early on in my working life. But in due course I learnt that a certain High Court Judge, Justice J Dyson Heydon AC, would be speaking and it became plain that there would be no competition as to who would give the legal key note address.

But, I wasn’t done. I’m very appreciative of the importance of art and culture to society. Heather is head of drama at one of Victoria’s largest secondary schools. I am a musician, a pianist. No, not an accomplished one and indeed not one who typically plays for an audience any larger than myself and a pet. Nevertheless, I was willing to put my hand up for the cultural key note address. Alas again I missed out by a mere whisker as I learnt that this conference would be taken to a rare place by Dr Gerard Vaughan AM who has been a living treasure looking after the NGV for so long until his recent retirement.

That left the final box – the health and medical area. As I think about some of the extraordinary Australians who have given this particular address in previous conferences, such as Professor Richard Larkins AO in 2011 and prior to that Professor Ian Frazer AC, I needed no reminding that my achievements are insignificant. Still records are made to be broken and standing before you is someone who not only fails miserably as a global authority in the area of health but has never even practiced let alone been trained in this vitally important vocation.

And so I shall need a little courage. And so will you. As Winston Churchill said – “Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen”.

And on the topic of courage, it was the great Greek philosopher and polymath, Aristotle, who said:

“You will never do anything in this world without courage. It is the greatest quality of the mind next to honour.”

The theme of this year’s conference is “Protecting the Unprotected”. And I would like to think that this theme strongly resonates with everyone irrespective of one’s professional path – it certainly resonates with me.

In an era where we have the potential to be materially better off than ever before, better connected than ever before and able to enjoy the very best of things this world can offer, surely there is a need for each and every one of us to do something for the vulnerable. Of course, our two great vocations of law and medicine are replete with numerous people who are assisting the vulnerable every day of the week. And I am someone who takes every opportunity to also extol the virtue of doing this on a voluntary basis – indeed I would suggest that there is scarcely a person on the planet who is not in the position to give something freely, voluntarily to another. And such an act of kindness which to others may appear not to be of great significance – it might just be a smile or a word of encouragement – but so importantly goes two ways. It provides an obvious benefit to the person in need. But I would argue provides an equally important benefit in terms of relevance, purpose and fulfilment to the giver.

Giving can occur in a number of different ways. We can provide financial support, our expertise or simply our time as a general volunteer. In my case, I try and give a little of each, but most of all I just love being passionate – an encourager. I have no need, and frankly no ability, to be a global authority on anything. But I have been privileged to end up being involved in numerous causes from the indigenous challenge through to the environment, from homelessness through to human rights, from global aid and development through to health and medical research.

Many of these causes are the domain of the charitable or not for profit sector. This is the sector that does all the stuff that neither business or government is able to do. Put simply, its mission statement is to protect the unprotected!

So often my motivation has been to simply hang around and support inspirational people. They don’t necessarily have a public profile and they might not even be particularly charismatic – but they tend to be committed, effective and provide real confidence that transformation can be made.

One such individual is the CEO of The Big Issue, Steve Persson. As many of you know, TBI provides a terrific opportunity for the homeless to generate income and also to connect with mainstream society. In recent years, it hasn’t just involved the publication and distribution of a magazine – TBI has created various initiatives ranging from the phenomenally successful Homeless World Cup street soccer competition through to hosting a competition amongst competing universities for the best social business idea of the year. Steve Persson is an inspirational fellow who can garner the support of some of Australia’s most influential business and political leaders. But he doesn’t abuse it. And, furthermore, he ensures that everyone who is involved voluntarily as a board member, or just someone who spends five minutes making an introduction – all of us experience something special which is typically not something that our paid employment provides.

Occasionally, I think it is a good idea to become associated with a cause out of, frankly, a degree of self-interest. This occurred with me some years ago. During the 1990’s, I had been approached on a number of occasions to join the board of MS Victoria. I politely declined on each occasion saying that my “not for profit dance card was full”. And then something profound happened. I experienced a number of “episodes” which involved anything from blindness to paralysis. There was no conclusive diagnosis at the beginning but as time went on, I was told that I had MS.

It was at this point that I reverted to those involved with MS Victoria and politely enquired as to whether the invitation might still be open. I’m just an ordinary bloke. I find going to a doctor, let alone a specialist, something that is not necessarily the highest priority of my day. And I don’t need to be told that that really is a silly attitude. On the other hand, I try and take any position of governance very seriously. And I knew that if I were allowed to join an MS Board that not only would I start taking a much more serious interest in the condition that I apparently had but, more than that, every month or two I would be sitting around a table with some of the nation’s authorities on this condition.

I don’t tend to talk about my MS publicly – it’s not that I’m in any way embarrassed because I’m not. It is more because I have, thankfully, ended up in a position where it hardly affects me nowadays. I am right up the easy end of the MS spectrum and the last thing I want to do is to divert any attention away from those, like Betty Cuthbert, who have been so cruelly afflicted.

When I first became engaged in the work of MS Victoria, and subsequently MS Australia, much of the focus was on providing support for those who have been diagnosed with the condition. My journey into the world of health and medical research really began when MS USA sent MS Australia a somewhat confronting letter more than ten years ago. It made the obvious point that research into improving the lives of those who live with MS as well as finding a cure was a truly global initiative. And, indeed, in that global research patchwork quilt, Australia undeniably performed a number of critical roles. That was the good news. The bad news, however, was that our fundraising for research was woeful – and the Americans were calling us to account!

That letter led over the next year or so to the establishment of a specific national organisation focused on research fundraising – “MS Research Australia”. And after we appointed an outstanding CEO, Jeremy Wright (who has only recently retired), we set about putting in place best practice in terms of fundraising, and a strongly peer reviewed process for setting strategy and awarding grants.

It doesn’t seem that long ago when, having first been diagnosed with MS, I was lying awake at 3am in a hospital bed not knowing whether I had sailed my last yachting race or kicked the last footy with the kids. I can’t tell you whether my good fortune with this condition has in anyway been enhanced by my involvement as the inaugural chairman of MSRA. All I know is that from the moment I was diagnosed I decided never to take any day for granted and to be grateful for every opportunity to stand on my own two feet.

I went to a school which had a very strong capability in the maths and sciences. So much so that many students automatically pursued those subjects knowing that this would enhance their marks and enhance their entry score into the tertiary sector. Around about the time I was making decisions as to what subjects I would pursue in years 11 and 12, the school made a decision to actively promote humanities. Looking back, I was relatively laid back and an easy target for a school that wished to encourage some of us into non-scientific subjects. And, let me be clear, I have no regrets about the path that I have followed. My focus on humanities led to commerce and law degrees, a short but enjoyable career in corporate law followed by a lengthy stint in investment banking. It has not been a scientific career but it has been one where I have been enormously privileged to come into contact with a very large number of talented and influential people right throughout the three great sectors of society, namely government, business and the community.

But deep within there is a little science gene which pokes and prods me from time to time.

My chosen sport is that of yachting. One of the reasons I enjoy it is that many aspects of it are quite cerebral and involve an understanding of physics, aerodynamics, hydrodynamics, meteorology, materials science etc. etc.

I was fortunate to be the helmsman for an Australian syndicate which held the outright world sailing speed record for most of the last twenty years. In truth, it was less about sport and more a large scale science project. Whilst I received so much of the credit as I was the yacht’s helmsman, in all probability I had nothing more than one or two per cent to do with the syndicates’ success. Most of it was attributable to our two technical geniuses.

In typical, Australian style, we ran on the smell of an oily rag. In 1992 we had been provided with a quantity of high modulus carbon fibre but needed some assistance to develop the correct resins and layup techniques to build the structures that were needed to keep our radical craft together. In those days, carbon fibre was relatively rare and seen as much more exotic than nowadays. Fortunately, at the time, CSIRO agreed to assist us at no cost. What we didn’t know at the time, however, was that CSIRO had a reason for doing this. It was simultaneously dealing with Boeing and was being asked to assist in the development of techniques which would ultimately lead to the fabrication of many of the carbon fibre components that have been used in aviation such as internal bulkheads and ailerons and ultimately leading to the all carbon Dreamliners. CSIRO was happy to use us, in effect, as guinea pigs because whilst it was never pleasant when our boat fell apart at high speed (which it did several times!), it wasn’t nearly as catastrophic as a jet airliner falling out of the sky.

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Nevertheless, our project was a success and we first set a new world record in 1993 and we went on to increase it a number of times In 2009, we became the first yachtsmen to sustain more than 50 knots and in so doing peaked briefly at more than 100 kmh (54 knots). And, all along the way, my greatest enjoyment of that endeavour has not been necessarily the exhilaration of sailing faster than any person previously but actually the opportunity to engage with truly fascinating, technically literate people.

And accordingly you might understand my feelings of astonishment and humility when I was asked whether I wished to be interviewed for the role of Chairman of CSIRO. I can recall vividly at the various interviews saying that I was not technically trained and had nothing to offer the talented CSIRO people in the laboratory, but felt I did understand the importance of the work of the organisation. And especially at a time when humanity, as it inexorably grows towards a population of 9 or 10 billion, is facing some of the most confounding challenges that it has ever experienced.

And it was just a couple of years later when I experienced these same feelings having been asked to head up a Strategic Review into Health and Medical Research in Australia. It was a rare opportunity where our Panel would be allowed to gaze forward a decade or so and make recommendations as to how to advance the effectiveness of such an important sector.

My one request of the Federal Government was that the other five panel members were of the highest calibre and ultimately that proved to be the case. The Panel had deep technical health sector expertise in Professors Melissa Little, Ian Frazer AC and Henry Brodaty AO. And then Elizabeth Alexander AM and Bill Ferris AC brought terrific university, philanthropic and business expertise around the table. Singlehandedly I was able to lower the average IQ quite significantly!

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The process that we conducted was unremarkable. The Government’s terms of reference were collectively very broad such that really any issue that anyone had in relation to the sector could be raised. The Panel requested written submissions and around 400 organisations and individuals responded to this in two waves. First, the Panel sought submissions early in the process at the beginning of 2012 and then subsequently invited further submissions following its release of a Consultation Paper in September which summarised the major issues and proposed recommendations. And throughout the process, the Panel conducted meetings in every State and Territory. In each place, public meetings were held and, in addition, the Panel met with more than 300 individuals from universities, medical research institutes, governments, hospitals, businesses and not for profit organisations.

The Panel concluded an intensive 16 month effort when we handed its 300 page report and a separate 70 page summary to Minister Plibersek on 28 February 2013. The logical place for the Panel to start was an examination of Australia’s present health system and performance of health and medical research. Overall, Australia has a very good system.

For example, whilst life expectancy is a somewhat crude measure, it is able to be compared easily from nation to nation. There are very few countries which have a higher life expectancy at a lower health cost per capita than Australia. Japan is the standout with Israel, Italy and Spain having similar life expectancy at lower cost. Plainly diet plays a significant role, as we all know with Japan. And having spent the last fortnight or so around the Mediterranean enjoying mostly local food, I also appreciate the head start that the other three nations have. Importantly, the US spends almost twice as much as us per capita and yet is still three years behind in terms of life expectancy.

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As for the performance of the health and medical research sector, it appears to perform very well with relatively high citation rates, particularly for research emanating out of our medical research institutes. In particular, Australia has a high share of publications in major global medical journals relative to our performance in comparable scientific journals.

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A very major challenge which we share with other developed nations is the increasing cost of health care driven by two major factors, being firstly, an ageing population and secondly community expectation for improved care, particularly utilising new technology. In its 2010 Intergenerational Report, the Department of Treasury made it plain that there was no plan and, in all likelihood, no capacity to respond to this enormous funding challenge over the next two or three decades.

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Health economics is a relatively underdeveloped field in Australia. One of the outputs in this area is what health outcomes are achieved for a given investment. The chart below shows the very high returns on investment that arise from preventative health campaigns and vaccination and screening programs. But once we get to the area of open heart surgery and intensive care, whilst obviously critical for those affected, the investment is high and the overall health outcome modest for the nation as a whole. The area of most interest to the Panel, however, was when things went wrong – i.e. lost or unnecessary diagnostic tests, adverse drug reactions and preventable surgical complications.

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And if there is a health sector equivalent of Nirvana, then that appears below. Because when these adverse events and wastage are eliminated and, indeed, are replaced by effective translation of existing research as well as continued development of new knowledge and interventions – literally the sky’s the limit!

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It was quite early on in the deliberations of the Panel that it came to its central conclusion, namely that it was vital to “embed” research centrally into the health system. Australia has had a long and proud heritage in health and medical research. Some of the most fabulous medical breakthroughs have occurred at the hands of Australians, such as Ian Frazer’s human papilloma virus vaccine, Fiona Stanley’s emphasis of folate during pregnancy and Graeme Clark’s bionic ear.

But we concluded that this was an era where, as with so many other industries and sectors, it was essential that the health system itself had the constant benefit of improvement through research. This central recommendation built upon the central theme that emerged in the previous major strategic review conducted by Peter Wills AC some 14 years previous. Arising out of that review, the HMR sector received substantially more funding and the grant process through the National Health and Medical Research Council became more rigorous and competitive. Building upon those achievements, we have recommended that this research capability now needs to be steered slightly but significantly towards improving the system itself.

Having regard for this central theme of embedding research, the Panel was keen to understand what actually occurs in the health system, so much of which is represented by the term “Local Hospital Networks”. And this is where it became interesting! Early in our process, we actually despatched more than 50 letters to the CEO’s of major hospitals throughout the nation requesting them to provide us with information concerning how much was spent on research in their respective institutions, what it was spent on and the outcomes generated. Alarm bells started ringing when it became apparent the response rate was going to be very low for this exercise. And as we then visited the various States and Territories, we went out of our way to establish meetings with representatives of this CEO cohort. And on each occasion we asked them the same questions that had been the subject of the letters. And as we listened to the answers, it became apparent why the response rate to our letter had been so low.

A typical response was along the following lines.....”We typically start each financial year with a budget which allocates a certain amount of expenditure to research. As the year progresses, the pressures of running such an organisation are such that we need to make savings in certain areas so that various “essential” activities are funded. And, in an environment where we have essentially no KPI’s relating to research, in many cases the research allocation becomes a surrogate contingency to be used for other purposes”.

And this, in turn, probably explained what I personally found to be a most disturbing aspect of our HMR sector. Early on, I put a similar question on the table to the one we posed to hospital CEO’s except framed at the national level. What did we as a nation spend on HMR, who spent it and what outcomes did we achieve? Very broadly, at the Federal Government level, there was good data. As soon as we delved into the State and Territory level, it became somewhat murky. Indeed, at the conclusion of the Review, we were still not able to have this fundamental question answered.

So we did recommend that there was a need to have proper nationwide data and, indeed, a body that would be responsible for its production. Interestingly, as we probed deeper and deeper over the months into the many issues that we needed to explore, time and time again we concluded that there was a particular activity that needed to be conducted and which was not occurring. Ultimately we concluded that there needed to be an “HMR leadership” body. We’re inclined to recommend that this body ought to be a reformed and reconstituted National Health and Medical Research Council with expanded powers but we were not opposed to it perhaps

being an entirely new body. The important thing was to have such a body, well connected with the States and playing vital leadership roles ranging from advocacy through to reform implementation.

Returning to the central theme of embedding research into the health system itself, I was often asked what does this actually mean? My response was to use an illustration from another industry, aviation. Our health sector is not the only area which deals with life and death. My understanding of the aviation industry is that when there is an equipment failure or some other incident, the relevant operatives (particularly pilots) are required to prioritise the careful and thorough reporting of what occurred. There is a culture in that industry that requires documenting of problems, investigation and dissemination of best practice policy. To some extent this is enhanced by the oligopolistic nature of the industry such that globally much of this research process is controlled by a small number of aircraft suppliers.

Interestingly, on the way to this conference, shortly after take-off, our Emirates captain told us of a small malfunction of the landing gear. If we were to continue to Dubai, the crew needed to lower and then retract them again which is what occurred and satisfactorily. I can only presume, however, that that incident became part of the research effort, documented and subsequently assessed and used as a basis for further improvement.

But so often we appear to have a health sector which fails to have the right mix of incentives and disciplines to replicate this.

To a large extent it starts with funding. If a large public hospital starts a financial year with a budgeted research item but inevitably concedes it so that other activities are funded, we can never have a system which improves in the way it ought. And the Panel acknowledged early on that to a large extent funding is at the root of this. And whilst time today does not allow me to provide a detailed breakdown of the funding of our various recommendations over 10 years, I do want to emphasise that we felt that it was important that our nation ought to adopt a research target of around 3-4% of total government health expenditure on defined and well managed health and medical research. This percentage would comprise amounts spent on research in local health care networks, the existing NHMRC program and a collection of new health system competitive programs that we recommended.

Currently, the Panel estimated that such expenditure amounts to around 2.5% of health expenditure and we suggested that this needs to be increased over a 10 year period to around 3-4%.

As far as our recommended new initiatives were concerned, I’ll briefly mention now some of the more significant ones.

It was felt that there was a strong argument to formalise research clusters that could bring together different sector players such as hospital and community-care networks, universities and medical research institutes. Some of these “Integrated Health Research Clusters” as we termed them, may be more virtual than physical. There would need to be a clear set of criteria around integration, excellence, translation, strategy, leadership and governance and, importantly, we suggested that funding of around $10 million per annum be provided for each one. We have some examples in this country of where clustering is working. But we have nothing that approaches leading examples overseas such as Johns Hopkins Medicine in Baltimore.

Time and time again we heard from individual clinicians and researchers who said that Australia is a difficult environment in which to mix these two disciplines. Indeed, many of our best potential researchers ultimately cave into the better financial compensation associated with a clinical focus. We suggested that it was important to have protected research time created by way of practitioner fellowships. We recommended a program commencing with 100 such fellowships and growing over 10 years to around 1,000 fellowships assuming satisfactory performance from such a program during the ramp up.

We singled out a couple of areas of research which we felt ought to be given particular encouragement. Public health programs such as vaccination, smoking reduction and safe sex are driven by research evidence and have delivered very significant cost effective health outcomes. Secondly, there are relatively fewer researchers in health system research despite the importance of this activity to ensuring efficient health care. It was suggested that the NHMRC project grant process should be reweighted to focus more on an assessment of outcomes and relevance.

We had much to say about clinical trials. Australia has become increasingly uncompetitive in this important activity. And this has not arisen simply as a result of a strong currency. Some of the major difficulties revolve around the plethora of ethics committees that exist and we suggested that their number ought to be significantly reduced. We also suggested a government sponsored insurance scheme as the relevant class of insurance has been increasingly difficult to obtain in recent years.

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We also mentioned, however, the importance of government support for non-commercial clinical research trials. Not every initiative gives rise to a commercial opportunity, especially in health.

Australia has had a long history of investigator driven research. And there is considerable logic behind this in that when our best researchers play to their respective strengths, clearly outstanding results can be achieved.

Having said that, however, with the vast bulk of funding coming from the public purse, there ought to be some balance between investigator driven research and research which addresses our national health priorities.

We suggested that a modest portion of the NHMRC budget, around 10-15%, should be allocated to fund top-down strategic, priority–driven research.

The leadership body which I referred to earlier would have an important role in setting these HMR priority areas. And each priority area would have its own panel of experts to assist with the adoption of the research agenda and evaluation of outcomes. And whilst we made it plain that over time this priority setting was an important role for the leadership body, we did suggest a handful of areas that we felt deserved strong consideration as being national health research priorities, including:

- Indigenous health research

- Rural and remote health research

- Global health research

- Genomics

Our research effort will only be good as the people who are encouraged to enter the sector, their training and the equipment to which they have access.

The Panel concluded that in Australia we make life far too tough for our typical HMR researcher. Continuing the theme of poor data, there is a paucity of relevant data about the state of our HMR workforce and it is plain that it is not actively monitored or managed.

We concluded that more support was required for early stage investigators and in particular that Australia Postgraduate Award stipends were too low.

We suggested that overall there needs to be more flexibility in the system and a decrease in emphasis on track record. Sometimes the greatest potential is not resident in someone who has continuously persevered within the system. And, of course, this is particularly relevant for women when they have children. There is a need to build workforce capacity through research fellowships such that emerging disciplines can be encouraged and grown including genomics, bioinformatics, biostatistics, public health research, health services research and health economics.

We received many suggestions as to how to improve the existing NHMRC grant application process. Ultimately, we concluded that the grant application process ought to be streamlined in various ways beginning with the standardisation of submission process elements with other major competitive granting agencies such as the ARC (including the adoption of a standardised CV template). Importantly, we felt that the predominant term of a grant ought to be increased from around 3 to 5 years and that the present inadequate indirect cost regime ought to be increased to 60c per direct research dollar and paid on a basis that entitled every organisation to receive this irrespective of whether they were a hospital, university or MRI.

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We also pointed out that the long term future funding of major research infrastructure was not settled following the completion of the National Collaborative Research Infrastructure Strategy (NCRIS) program. We suggested that a long term commitment of around $150-200 million per annum was required for large infrastructure. And we also suggested that there was a strong need for national patient databases in response to the fact that less than 20% of the identified clinical registries in Australia have national coverage.

Australia presently spends around $135 billion on health and this expenditure is dominated by the public sector which provides more than two thirds of this funding. Having said this, obviously commercial participants do play an important role and pleasingly growth in this sector has been very significant. The chart below shows that exports of medicinal and pharmaceutical products have grown at 12% per annum over the last 20 years and now comprise Australia’s largest manufacturing export centre.

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So whilst the growth in this commercial activity has been pleasing, the Panel nevertheless identified two concerning “Valleys of death”. These two valleys exist in the top left part of the diagram below.

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The first valley is at the pre-clinical stage. Our response to this concern was to suggest that each of the 20 consistently most successful NHMRC peer reviewed grant recipient organisations ought to receive $0.5 million per annum for this early stage activity. Our thinking was that it is these organisations that are at the coal face of what is most prospective at the pre-clinical stage and that it would be a good investment on behalf of the nation if this investment was made providing that the organisations were able to arrange matching funding.

The second valley of death was at the early clinical stage which essentially encompasses funding for phase one and two clinical trials. The Panel proposed establishing a $250 million Translation Biotech Fund managed by globally qualified external management and selected through a tender process. The Federal Government would provide half the funds with the other half provided by institutional investors on terms designed to compensate them for the high risks involved with this early stage investing. In other words, preference would be built into the terms of the investment in favour of these external investors.

The Panel was specifically asked by the Government to consider measures designed to attract more philanthropy into health and medical research. Philanthropy has been an area of interest to me for some time. On some measures, we are a reasonably generous nation but much of that generosity is ironically attributable to the less well off in our society. Our overall level of giving as measured by a proportion of GDP is not dissimilar to a number of other countries although is dwarfed by the experience in the US. But it is our very wealthy that do let the country down.

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I’ve often pointed out publicly that whereas the US has around 20% of its 500 billionaires that have made a public commitment to give away at least half of their wealth, until recently, not one of our 43 billionaires had done likewise. And it was only a month or so ago that Andrew and Nicola Forrest made their commitment to similarly give much of their wealth away during their lifetime. I also find it staggering that around 40% of Australians, who according to the ATO have earned more than $1 million in a year, fail to apply for any tax deduction based on charitable giving. They don’t appear to have one $2 tax deductible receipt!

Now obviously our lack of a philanthropic culture, particularly at the top end, is an issue that goes way beyond the funding of health and medical research. Nevertheless, the Panel was of a mind to recommend that the Federal Government set aside funding of around $50 million per annum which would be used to match proposals by philanthropists to invest in HMR. So that this investment by the Government could be put to best use, we also suggested that this pool be allocated in favour of those proposals that required less rather than more Government funding and also which were more consistent with national health research priorities which I mentioned earlier.

One of the most complex areas of our report related to the ongoing funding of the HMR sector. Part of this was explained by the absence of good data as to what is being funded today, particularly through the States and Territories. We also acknowledged that the present fiscal position in Australia is tight and any program requiring a substantial amount of immediate funding was simply not practical.

So, we set out a 10 year plan the early years in which were focused on initiatives that didn’t necessarily cost an enormous amount of money. Examples include, establishing a leadership body, instigating the first of the practitioner fellowships that would create protected research time on a basis that could be steadily ramped up over 10 years, the clinical trials reforms and streamlining NHMRC grants.

In terms of new investment, we suggested by around 2019, an extra $1.1 billion per annum would be required and five years thereafter in 2024 the net new investment would then be in order of $2.9 billion per annum.

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I wonder if Athenians 2,500 years ago would ever have contemplated the Acropolis precinct looking as it does today. Would it have saddened them? Would they have vowed “This must never be!”

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Do we as Australians wonder what Bennelong Point might look like in 2,500 years? Perhaps some of us consider that the Opera House itself may not endure but the precinct itself will surely still be a place showcasing human talent, whether architectural or cultural, and one in which great pride is taken.

According to one of our greatest contemporary thinkers, the Bennelong Point precinct in 2,500 year is likely to resemble the ruins that dominate the Acropolis today. A few weeks ago, Professor Stephen Hawking said, in advocating for more research funding into space, that is was likely that our planet would be uninhabitable in 1,000 years and accordingly there was a need to explore other options.

We’d all like to think he was wrong – but spending time in places like Greece, Angkor Wot, Machu Picchu and Egypt, confirms for me that he may be right, sadly, it is very hard for great civilisations to be sustained. They don’t always act in their own best interests and the same may be true for mankind as a whole.

There are inevitably particular reasons. Fighting between city states and an over reliance on slavery and military mercenaries are often cited in the Greek context.

But I would suggest that common to many declines has been an under investment in mind power combined with a move away from appropriate values.

From my perspective great civilisations are not those that had the strongest armies, the greatest geographical footprint or had the largest populations. For me, the great civilisations are those that promoted fair and ethical systems of justice, focussed on the broader wellbeing of all their citizens, understood the universality of human rights, felt an obligation for future generations and accordingly thought strategically about sustainability, in every sense of the word, not just having regard to the natural environment. Most importantly they appreciated the importance of teaching and research and leaving an intellectual legacy to subsequent generations.

In Australia, we occasionally refer to ourselves as the “cleaver country”. With respect, we are kidding ourselves. We have patches of sheer, world leading brilliance, including among our jurists and medical specialists.

But we do not have a national culture that embraces cleverness, learning and innovation. Frankly, too often I see a national culture more focussed on entertainment and enjoying oneself. I’m not a wowser – these are excellent things in moderation. But I suspect we would learn something from Classical Greece during which, as we learnt earlier this week, theatrical performance, even temple worship, was as much entertainment or religious observance as they were pedagogical.

The Gonski Review reminds us that the world, particularly the developing world, is far from static. To be serious about learning, a nation needs to make a serious commitment; otherwise it can fall behind surprisingly quickly.

We may not, today, be the clever country, but I believe we are the lucky country, indeed the “luckiest country”.

But for all the natural resources of space, pristine environment, minerals and energy, lack of bordering nations, combined with being part of a dynamic Asia and a rich multicultural heritage, success or greatness is far from assured.

For example, our mineral and energy wealth should continue for centuries but the timing of cyclical highs in terms of volume demand and pricing will neither be predictable with any precision let alone never be within our control.

But the rewards that come from investing in our minds are within our control. And an important part of that is our investment in health and medical research.

What I failed to mention earlier is that a critically important part of our Strategic Review was justifying substantially increased government investment. We argued the case on a number of fronts including the health and wellbeing of Australians, and a positive impact on national productivity, employment and business including export opportunities.

If Hawking is to be proved wrong; if Bennelong Point is to be a place loved and respected possibly with a well preserved 2,500 year old Opera House, mankind will have to want that to happen. Fortunately, that is possible. And I would humbly suggest that each and every one of us has a role to play and our own small legacy that we can leave.

As Aristotle said, “Whatever lies within our power to do also lies within our power not to do”.