 Well, welcome to this afternoon to this very interesting hybrid event. A special welcome to our audience here in North Grade Georgia Street and an even more special welcome to those of you joining us online. The session entitled opportunities to improve Irish healthcare is the inaugural event of the Ireland from the European Health Union series hosted by the IEA and sponsored by Janssen Sciences Ireland. The format of today is a presentation by a keynote speaker from the European Commission, followed by a discussion amongst our panelists here today. We're very lucky to have Professor Mary Holgen, Mr. Tony O'Brien, Dr. Sheila Connelly and Professor Paul Brown. You're all very welcome. After the panel discussion, you the audience can join in. For those of you who are watching online, you can use the Q&A function on your screen. Please feel free to send the messages in during the questions in during the course of the presentations and we will come to them later. In putting a question, please identify yourself and any organization with which you are affiliated. Both the presentations and the Q&A are online. Feel free to join the discussion on Twitter using the handle at IEA and we are also live streaming today's discussion. So a very warm welcome to all of you tuning in via YouTube. So now to get to the good part. It is a very great pleasure for me to introduce our keynote speaker today, John F. Ryan, who is the director of the EU Commission's Public Health Directorate since September 2016 and Acting Deputy Director General for Health since December 2021. He is also currently the commission representative on the board of the European Centre for Disease Prevention and Control. Over to you, John. Just sorry, could I interrupt you? We're just having a problem here with the sound. John, you're muted. Yeah, I'm on muted now. Can you hear me okay? Is that okay for you? Perfect. Well, first of all, thank you very much for this very kind invitation. What I wanted to do during my presentation this afternoon is to give you a bird's eye view of what's going on in the health area at the European Commission level at the moment. And of course, maybe to dig down deeper in the question and answer session afterwards on any specific questions people might have, but I thought I would use my time to give you a general overview of what's going on and a little bit of the context as well. So, without any further ado, I would say that the EU competence in health is an important point to understand. When we talk about EU competence, I'm thinking here mainly of the legal competence, and this is set out in the treaty. We, in order to have an activity in a particular area, the Commission and the European Union more generally, of course, have to have a legal basis. And there is an article in the treaty on public health, which says that the health issues generally are an issue for our issues from member states under member states responsibility and competence, but that the European Union can encourage cooperation, sharing a good practice and coordination of activities in this field. And we do that through a number of instruments, either legal or legal or financial, for example, incentive measures, which we can take. So very often people come to you and they say, well, why don't you do this and why don't you do that? It's very much an issue of what you can do and what you can't do under the legal basis which we have. So that was the first point I wanted to make. However, of course, with any legal rule, there's always a whole series of exceptions, and the exceptions are sometimes more interesting than the actual rule. So I wanted to explain to you that besides this general principle that the member states are responsible for the organization delivery of health care, you have this community competence for coordination, cooperation, sharing a best practice. And that's generally speaking describes what we do in non-communicable diseases. So everything to do with cancer, the cancer plan, the mental health initiative, all of our other activities on public health are in this framework. It's a non-legal framework or a self-law framework. And as I speak this afternoon, the colleagues in Brussels are discussing a new recommendation, a council recommendation on cancer screening, which is perhaps a good example of this self-law coordination mechanism that we have in the field of non-communicable diseases. Speaking now on the exceptions to the rule, there are a whole series of exceptions to the rule and you see that these are quite topical. You have the area of pharmaceutical law, you have medical devices, you have blood organs, tissues and cells, you have the tobacco legislation, you have cross-border health care, digital health and communicable diseases. These are a list of exceptions to the rule that the European Union does not legislate on health. And you might say, well, how is that compatible with what I've said earlier on about the article in the treaty on public health, which says that all of this is for the member states? Well, the legislative examples which I gave you just now on pharmaceuticals, medical devices, blood, tobacco, cross-border health care and communicable diseases, digital health. All of these examples arise from the internal market legal basis, where we have a very wide and strong legal basis to harmonize European legislation. And in all of these areas, there are current activities going on, which are legislative in nature and which involve either new or strengthening of existing legislation. And just to spend a few minutes on this, the legislation on pharmaceuticals, for example, dates from way back to a considerable period of time and the European Commission published a white paper on reforming our pharmaceutical legislation with the intention of, and this was in November last year, with the intention of ensuring access to affordable medicines, addressing on medical needs, and also improving the resilience of our health systems by having a high performing pharmaceutical industry. These were some of the ideas that were set out in the pharmaceutical strategy of the European Commission. It had over 50 different initiatives. The one I wanted to focus on today is the pharmaceutical package, as we say, the legislation on pharmaceuticals, which is in the process of being revised and reformed at the moment, with the intention, as I said, of, at the same time, improving access of patients to innovative medicines, encouraging an innovative and high performing pharmaceutical industry, and tackling these inequalities which we have in Europe in access to new medicines, new therapies. So as part of our better regulation philosophy in the Commission, there's a whole series of different stages of stakeholder consultation, which involved member states, the industry, patient groups. This ended up in what we call an impact assessment, which is an analysis of the evidence that's out there for different policy options. We're in the process at the moment of finalizing that analysis, and we hope to make a legislative proposal on pharmaceutical products at the beginning of next year. We will cover pharmaceutical products in general, but it will also include currently separate legislation on pediatric and orphan drugs. Orphan drugs are those medicines which obtain a specific regime, legislative regime, because they're intended for rare diseases, for example. The package will also include specific proposals regarding the issue of new antimicrobial agents. Because we know that there is no business case for a company to develop and produce new antimicrobials because the idea is that you don't sell those antimicrobials afterwards because if you do, then we're back to square one. So we're trying to figure out a mechanism where we would provide an incentive for the production of new antimicrobials, which is a global problem which we're confronted with in the framework of antimicrobial resistance. So that's one example where the European Union is actively revising and improving, I would say, or hoping to improve our legislation on pharmaceutical products, which is a product that everybody in this room, everybody is watching, consumes some sort of pharmaceutical product, if not daily, well, certainly on a regular basis. So it's really something which I think is of interest to everybody and not only to the industry, not only to governments, but also to citizens. Second example would be the area of medical devices where we have a bit of an issue at the moment because we have new legislation again adopted under the internal market rules, which enabled a free circulation and approval of medical devices across Europe. And the problem there is that the deadlines for the introduction of this legislation are catching up with us. In other words, the legislation which sets out the deadlines for implementation will be very difficult to respect. And we're coming to a cliff edge at the moment where if we don't move the goalpost somehow in terms of the implementation deadlines, we can find ourselves with products which will no longer be able to be put on the market. So this is an issue which has been discussed actively at the moment in order to avoid this cliff edge situation where products which are on the market would have to be removed. And an example perhaps of health legislation or health products legislation which really affects more or less everybody because everybody consumes these sorts of products. Third example would be the blood organization sales legislation. And if you remember the scandal of tainted blood or contaminated blood many years ago, this actually led directly to the implementation of this European legislation. And this is being revised at the moment as we speak in the European Council and the European Parliament to put in place new new arrangements for the approval and transfer of blood organizations themselves. Quite a very strong ethical aspect to all of this of course because the question of whether donations should be paid for the question of the transfer of cells for example it's all quite complicated from an ethical point of view. Tobacco legislation I probably don't have to say too much about this but it's a good example perhaps of where in fact the internal market allowed us to bring in rules which assured a high level of health protection. And I must say when I started in public health in the commission, this was my first dossier and developing the tobacco legislation and in fact our justification at that time for introducing an internal market directive on tobacco was because Ireland had introduced a national law which we wanted them to consider from the internal market point of view. And the result was that we introduced the European directive. Because if the Irish and some other member states had introduced national legislation this would have meant that the internal market would have been obstructed. And that was really the purpose of the directive was to ensure common rules for tobacco products across Europe, which is what we have now we have very strong tobacco legislation on ingredients on labeling and advertisement so on. But it all stems back to this Irish law in the 70s which really kicked off the whole discussion and gave us a legal basis which we wouldn't have had otherwise. Further example might be on digital health where we have legislation which is being proposed now on introducing eHealth on sharing of data and introducing ePrescriptions, eHealth tools across Europe which we hope will be of interest to patients. But also used to researchers and to people who are trying to develop new therapies that this data would become more easily available under the condition of confidentiality and anonymization of course. And I would mention as well the legislation which has just been adopted on cross border health threats, which sets in place a system for surveillance of communicable diseases like Zika Ebola, seasonal flu, hepatitis, HIV, all these diseases, about 52 diseases which are subject to EU surveillance on the basis of a common case definition. And this data is reported to the European Center for Disease Prevention and Control. And on that basis we know whether TB is increasing, whether HIV is increasing, whether seasonal flu is increasing and so on. On top of this we also have an alert system which we use for immediate electronic alerts. So when there's a case of Ebola in a passenger traveling through Frankfurt Airport, for example, we can inform the 27 member states in real time of this particular passenger is or her personal data and that contact tracing can then take place. So it's a very effective way of tracking the spread of communicable diseases. Third element of this legislation is in relation to risk assessments. So the European Center for Disease Prevention and Control advises member states on the measures that need to be taken in a particular outbreak. So for example, if you have the case I gave you of an Ebola passenger traveling through Frankfurt, the risk assessment would advise on the measures that need to be taken to limit the spread of that outbreak. And that legislation also covers joint procurement, which you've all benefited from in one way or the other, because the European Union jointly procured masks, gloves, ventilators, therapies and vaccines for COVID. And this is still ongoing as we speak. So this is a very operational legal provision which allows the Commission on behalf of the member states to jointly purchase these medical countermeasures. I think the total amount of the investment we made jointly was about eight billion euros so far on these types of products. Now, these are some examples of the legislative activities. Let me mention in a few words the non legislative activities and I've mentioned here that this covers most of our public health activities. Most of our activities are in the area of non-communicable diseases, which represents 80% of the disease burden in Europe. So I'm talking here about things like cancer, diabetes, cardiovascular disease, mental health and so on. And in order to have a joined up approach, an integrated approach to prevention of these types of diseases, representing again 80% of the disease burden, they're very closely linked to each other. So if you're talking about the determinants of health, one determinant of health such as smoking can very often affect lung cancer, but also cardiovascular health and perhaps other conditions as well. So it's important that we have a joined up approach and we adopted together with the World Health Organization, what we call Healthier Together. It's an initiative designed to support the member states and the stakeholder communities like the NGO groups, the patient groups, health professional groups to take specific activities in relation to non-communicable diseases. Thinking here for example about an Italian project on cardiovascular screening, which was evaluated shown to be effective and was then proposed to the member states to be scaled up to I think 14 or 15 member states who had an interest. And this was done using European finance. So we select the best practices, we evaluate them, and then we scale them up in relation to some of these non-communicable disease challenges. In addition to this, we have specific flagship initiatives, and I'm thinking here of the European cancer plan, which is running at the moment, it was adopted last year. And the European cancer plan consists of activities on prevention of cancer. So nutrition, the tobacco activities I mentioned already, but also other initiatives to try and reduce obesity, for example, which is also a determinant of cancer. So we have a number of these prevention activities. We also have early detection. I mentioned that the council administered discussing today, the new council recommendation on cancer screening, to extend cancer screening to prostate lung cancer, and also to lung cancer to prostate cancer, and we'll be reinforcing the existing recommendations on breast cancer, colorectal cancer and cervical cancer. So that's an example of the type of activities we would be proposing under early detection of cancer, but we also will be levering the pharmaceutical package and the reform of the pharmaceutical legislation to try and improve the access of new therapies for cancer through the pharmaceutical legislation. And finally, issues like the right to be forgotten for cancer patients. More and more patients are surviving their cancers, but they have difficulties in accessing, for example, financial services. So we're working with Commissioner McGinnis in order to try and develop a code of practice which would encourage the financial services industry to put in place the possibility for survivors of cancer to access more easily financial services. So this is one big initiative that's going on at the moment in relation to cancer, but there is also a new initiative announced by President von der Leyen in the State of the Union speech, where she wants us to develop initiative on mental health. And of course we've seen an explosion of interest in mental health since COVID. I think people became much more aware of the issue. And the European Union, the Commission at the moment is trying to bring together the different strands of initiatives we might take to support citizens, citizens with mental health. So you see here a number of initiatives on cancer on non-communicable diseases. I should mention as well the topic of vaccination because vaccination is not only a COVID issue. It's much wider and there is a lot of vaccine skepticism which has not disappeared. I would say it's increased over the last few years. And therefore the commission is also trying to support the public health promotion of vaccination as a public health tool. And we're working very closely with our member states with the Czech presidency at the moment, particularly also with health professionals, whether it's physicians, doctors, nurses, pediatricians to try and encourage them to engage and support vaccination. Now say a few words about health in all policies or global, you know the introduction of health in other EU policies. That's quite an important part of what we do. I was online yesterday with the European Environment Agency on looking at the links between climate change and health. And of course climate change is something that's happening very much in the background sometimes in the foreground as well, but it has huge health implications both for vulnerable groups in our population, but also for our health systems, I would say. And this was something which was discussed yesterday in the context of the European Environment Agency report. We try, through our context within the commission, working with Digitima, I worked with the Environment Agency to try and identify where mitigation and prevention measures might be taken by the member states health systems. How can we equip the health systems in the member states with the tools to deal with these sudden events, which can be quite catastrophic. Looking as well at issues around environment and health, you know, we have a lot of legislation on the environment and health. How do you improve the quality of the air, for example, to avoid the problems that occur with poor air quality or poor water quality, noise pollution. All of these things are dealt with in European legislation and it's our job to make sure that we try and include a strong health protection in all of these other pieces of legislation. Climate change and environmental examples. Third example is the reform of the common agricultural policy where we're arguing, not arguing, we're discussing at the moment with our colleagues on how a high level of health protection could be included in the reform of the common agricultural policy. For example, through the promotion of healthy food in our schools, we have a school's food scheme. We have agricultural promotion scheme. How do we ensure that we're not promoting biscuits and alcohol products, but that we're promoting healthy products. The issue of red meat, of course, is also an issue linked to climate change as well. But it's linked as well to the agricultural policy so you can see we're trying really to identify those levers within other policies such as agriculture, environment, climate change. Taxation, of course, is another example where we're trying to make sure that the taxation rules don't undermine the alcohol control policies or the tobacco control policies which the health departments are trying to put in place. A few words on global health where the Commission will be shortly publishing a white paper on global health at the end of November. The idea being to better link our international activities on global health. We've seen how an international cooperation is important in the case of COVID where it's very much an international outbreak. We're seeing the same thing at the moment with Ebola in Uganda and this is something which is not only limited to communicable diseases, it goes much further. So we need to try and promote global health in all of our policies. And I would say, in my final words, I would say that we have a number of support mechanisms. We have our agencies which support us in all of this work. We have the European Environment Agency I mentioned already. The European Medicines Agency in Amsterdam which analyzes and approves new vaccines, new medicines. We have the European Centre for Disease Prevention and Control in Stockholm, which controls all of the collection of data and surveillance on communicable diseases. We have the Bilbao Agency dealing with health and safety of work. And finally I mentioned the Lisbon Agency on Illegal Drugs. So you can see we have quite a lot of scientific agencies which feed into our policy making work at European Union level, which of course support the member states directly. And perhaps in my last word would be about finance. I think COVID has had one benefit, which is that it has woken up on the need for stronger investment in health. And we now have a quite a strong EU for Health programme, which finances the type of activities I've just been talking about. We have the Horizon Europe programme, which provides research funding for health, also very strong budgetary resources available there. And probably most importantly of all we have the Recovery and Resilience Fund, which is something specifically set up in the context of COVID, where over 40 billion euros have been spent already on health projects. This Recovery and Resilience Fund far exceeds the money that's available in the health programme and in the research programme. So it's not something you should forget about. And it does provide the actual financial tools for the member states to invest in antimicrobial resistance stewardship, providing for strengthening of hospitals, primary care and so on and so forth. So I hope I've given you a quick helicopter view in 20 minutes, 25 minutes of what's happening at the European Union level. I'd be very happy to engage in the discussion as we go through the meeting. Thank you again. Thank you very much, John. That was really, it was very informative, but it was also very interesting. Thank you for that. And we'll now turn to our panelist and our first panelist today is Professor Mary Horgan. She is the current president of the Royal College of Positions of Ireland and the first woman in the roads 1654. I think that means never. She is also the former Dean of the School of Medicine in UCC and an infectious disease expert herself. You have the floor, Mary. Thank you and thank you for great talk. As an infectious disease doctor, one of the areas that was spoken about was the human health, animal health, the environment, they're all linked. And I think there is an onus on us as a country to really highlight the one health issue. I think we're really strong in agriculture. And I think that troubles us most as infectious disease infection community or two things, emerging infections, which are predominantly go from animals to humans that's happened with HIV, SARS-CoV-2, Ebola, Zika, and secondly antimicrobial resistance, which is really a global threat because we have very little development in new antimicrobials and that was pointed out. So it's really welcome that the commission is looking at ways of encouraging farmer to produce new classes of drugs and antibiotics. But as a country and certainly at a university level from a research point of view, I think an intergovernment collaboration I really think we need to strengthen that one health initiative. We do have vet schools, we've helped sciences in most of the universities here. Tagus is part of it and there's really strong research there. But I do think we should be coming together as a country stronger in that area. Thank you very much, Mary. We move on to you. I think you are well known, a former head of the Health Service Executive here in Ireland. And also I am told that you are an emergency first responder amongst many other things. You're now a lecturer in health strategy at Trinity College Dublin, you're a charter director, honorary member of the IMI. So Tony. Hopefully there'll be no emergency in this room. I also think that John's rundown of competency is here that struck me. I guess I've already struck me that in every area, whether he has competency in the health space, it has been for the benefit of the city of Ireland. And that kind of leads the view that we need more of that. And we need that competency to be developed and used by its greatest success. For example, the role of the European medicine rate is very important then. I think we need within Europe to see a streamlining of the way we provide rapid authorization, speed, use of patients. And also to look at the way in which citizens in different parts of Europe get differential access to different speeds, the benefit of innovation. And so while that obviously has to be a balance between that which member states control and that which you control, there is certainly scope for improving equality of access to health innovation. Whether that's in Altec or you follow suit of innovation in a way that ensures that some countries are not significantly left behind. Ireland is one of those countries that for a variety of reasons, the citizens tend to get left behind to wait long enough for access to some of those innovations. So either by increasing the competency or by the EU, looking at the differences that exist in the member states in the way that it has in some other areas, I think there would be significant benefits to help out from the island and other countries. Thank you for that, Tony. Sheila, Sheila is Dr. Sheila Connelly is a senior research officer in the social research division and joint research area coordinated for health and quality of life research in the ESRI. Our main area of research is in health system reform with particular reference to health care financing and access. Could I ask you maybe in your presentation for your views on how you see these EU and these initiatives at EU level, assisting Ireland and inform our own health care system. Sure. So, I suppose a lot of our work that we've done over the last number of years, these sort of cross country comparisons and I will put very much detail I suppose on findings from these studies, but just I suppose some caveats from them. One around that when we're doing these sorts of things, the importance of looking at the definition and knowing what is being measured and so being measured, you know, in a consistent manner across the countries. And I suppose the other is that understanding the context for the particular countries and what is happening within that country. I think, you know, there's a lot to be learned from other countries of what is, you know, is done in other countries. But I think we also need to be careful. So I think back into 2011, we had a new proposal for Ireland around assistive universal health insurance, which is going to be based on the Dutch model. And the idea was that we would try and import that system and bring it into the Irish context but I think it didn't happen for a number of reasons but I think one of the reasons that it didn't happen and one of the things that maybe wasn't caught out of. Initially was that in order to have that sort of system you need quite a significant population in order to have a number of insurers to have sufficient level of competition. And I suppose from my kind of in the work that we've done it's really to think about the context and not necessarily take off the shelves solutions from other countries and try to buy them in Ireland and yes there's a lot of things that we can learn, but it's often about digging a little deeper and see what we can take, what is applicable in the Irish context. And our final panelist is Professor Paul Brown, who is a consultant hematologist and director of the National Adult Stem Cell Transplant Programme in St. James's Hospital Dublin and a professor of hematology at Trinity College Dublin. What potential do you see in the European Health Union. So thank you and thank you john I mean I think there were two things I mean my two areas I suppose a professional background they relate to this excellent discussion. John summary, I was heavily involved obviously both the blood and tissue directive implementation its implications for delivering, you know, new cell treatments and other related treatments and we've just come literally meeting to highlight the importance of European collaboration. This morning involving many European colleagues here in Dublin, between the National Blood Center, the National Transplant Center, and the relevant competent authority individual representatives in this country, and our European colleagues. And I would absolutely echo what's just been said around the panel in terms of the hugely positive contribution of these particular competencies. Specifically, as you said exceptionally John mandated within what is otherwise in some ways I'm learning this account, a cooperative framework. I suppose my secondary related area professional interest over many years has been gaining access by working in rare diseases blood cancers in particular but as a cancer specialist, and someone's been heavily involved in many years and implementing new treatments for blood cancers is working, finding ways to, and again echoing what Tony in particular is just alluded to the important gap that exists, particularly and differentially across Europe, between EMA approval, the relevant indication or marketing authorization being put in place, and our patients on an equitable basis and I mean this across Europe because of differential paying models and historically not in Ireland actually for most innovative treatments. Until I would say the last 10 years, really new therapies were made available so to speak at the same time, independent of one's capacity to pay a disturbing trend that probably isn't fully appreciated. In general now is that there are now examples I'm aware of where the capacity to pay or particular insurance model may in Ireland give access differentially to new treatments and this is simply not a tenable position. And I think there's an important gap and one of the lessons you alluded to John, but from COVID and apart from the mandated and the competence legal functions. I mean the enormous degree of cooperation engaging with industry, whereas individual countries who simply wouldn't have had access in a competitive way to an expensive new vaccine that we all received. There was a European approach and cancer community and I mean we're part of this internationally has been lobbying to find commonalities that are appropriate within the European frameworks and welcome therefore the further initiatives around the pharmacy package I think John described it. There's a commonality in engagement, and we have to do this they the every single I just finished by saying every single successful innovation through the ones we discussed this morning, have a reason by partnership between health professionals scientists and our colleagues in industry and it requires support through the legislative model, and certainly in Ireland we've seen the final thing I say just an example, look into the technical details but a particular cancer. The Irish cancer registry which is an enormously valuable resource and trying to see in the real world in Ireland how we're doing in a very simple way, how long have people living with different cancers, and the Irish cancer registry in court have just published an update and it was very pleasing for us to see that, the top of the list of success was a particular blood cancer, and I could we've done a detailed analysis in that particular case, where we can show clearly that access to community based treatments about 10 to 12 years ago. So, and that's important has now had a phenomenal improvement over one third improvement survival which means many hundreds or several probably several thousand patients in Ireland with that particular disease, but it took 10 years to see that impact on outcome. If we go back to what Tony has alluded to within his previous role had to deal with in another angle. If we allow, how would I say access to these drugs to be driven by very well intention but particular communities that put particular cases following having a coherent approach, we're going to have more and more challenges. So that'd be my observations at this point. Thank you very much now it's over to you the audience and here and online to send in their questions and to identify who you are are in the process but I'm going to get, you're going to take the prerogative of putting into questions first to john. And the first one is, how do you see the health emergency preparedness and response authority interacting with states outside of the EU but close neighbors for example how do you see interacting with UK post Brexit. That's the first question. And the second one is, and I think it relates to the questions that you raised there Tony and does the health, the health union paved the way to a single centralized route for authorizing medicines in the member states, where we still have this authorization at EU level and then again a national level. So thank you very much. I hope you can hear me okay. Yes. Good. Okay. So on the first point on here, the health emergency response authority is a mechanism that was put in place as part of the European Health Union package. And is one of the direct lessons learned from COVID. And I described before the process we put in place for joint procurement of medical countermeasures. This process was very much on the roof. It was very much ad hoc. Because we had never before used this joint procurement mechanism in peacetime or in a situation of urgency so it was a completely new mechanism which has really to be made operational very, very quickly. And we carried out a whole series of procurement mechanisms on gloves and, you know, logistical support like syringes, gloves, gowns, ventilators, therapies, and then finally vaccines. It was considered by the commission that it would be good to have an agency in place that would permanently take care of this type of procurement. And if I might quickly describe the health emergency response authority, it's designed to identify upcoming threats. We were talking earlier on about the risk of genetic diseases. This is certainly one of the areas where we think a future threat would originate. So horizon scanning for these future tracks is important. It would also include antimicrobial resistance because this is something that's there already we know it's a problem. This is within the framework of the health emergency response authority. Identifying the threats, supporting research and development of medical countermeasures, whether it's anti toxins, vaccines, therapies, whatever it might be to try and encourage research in these, in development of these products. And thirdly to encourage the production and to actually arrange for the procurement of these products, which can be done, of course, in advance by terms in terms of reserve reserve contracts and so on. You don't actually have to have the products on the shelf in real time, which you can reserve the production capacity. So this is the idea of the health emergency response authority. It's largely based on the barda mechanism, which is a similar mechanism in the United States. And I would say, finally, that on this issue, that security of supply is a real concern because if you have pharmaceutical products or parts of pharmaceutical products, which the supply which can be endangered in an emergency. And we saw this thing in COVID. Then you have a problem. You may have the products in existence, but you may not have access to the products. So ensuring security of supplies is a real issue here. Now, in terms of the international aspects of of this operation, there have been contacts with the United States context going on at the moment, which Japan and with other parts of the world. In particular with Africa on local production of vaccines, and we are engaged in international discussions on pandemic preparedness carried out at the moment through the G7 G20, through the WHO, through COVAX and all the other mechanisms that have been put in place. So Hera is very much involved in the international aspects of pandemic preparedness and response as well. The contacts with the United Kingdom are dealt within the framework of the withdrawal agreement and the framework agreement which we have with the UK. And therefore there's no specific Hera component to that, that relationship, I would say, but it's something which takes place in the framework of the general legal arrangements in place for contacts between the European Union and the United Kingdom. Thank you. And on the issue of the centralized route for authorizing medicines in the, in the EU, do you see that becoming a reality or will we continue to have authorization at the European level and then at the national level. Well, there's a terminology thing here because authorization exists at the moment at both the central level, you know the evaluation carried out by the European Medicines Agency and then the product is approved by the commission after that evaluation and you have in parallel the national authorization process. What you're probably referring to is the, the reimbursement arrangements which are at the moment decided on a national level and that will continue. Right. I'm looking around the room to see if there are any questions that we give you a question here that I've got from Sarah Hanola, who's from the Finnish Embassy in Dublin. She says thank you John Ryan and all other speakers. What is our allocation of funding from the ORF into healthcare? Yeah, I replied to that question in the chat already. And I invited a colleague to write to me so that I can find the figures but basically I don't have the figures on the national basis I have the European figures. And as I said there are 40 billion euros have been spent on health projects from the recovery and resilience fund which is really an enormous investment and on request I'll find the figures for Ireland. Thank you. Thank you John. And turning to our panel. Can I ask you how you see the the proposals at European level impacting on reform in the Irish healthcare sector. Where do you see the real benefits to us are and what sectors do you see the benefits. Mary, if you'd like. I think traditionally our relationship had been with the UK when it came to healthcare we modeled a lot of what we did on that. I think we need to take that leap across and really strengthen our relationships with our colleagues in Europe. And Sheila said our health services differ, often nuanced depending on the population, but I do think that the relationships really do need to be strengthened here to for we didn't really have that. We're starting to do it, certainly at a training level, where we're exchanging trainees across who obviously I'm talking about medicine that may very well be done in other areas. And for us to have a presence in Europe. I know there's a lot of engagement easy DC. But I, despite, you know, we traditionally went to the speaking countries when it came to training, but I do think that that strength strengthening is really important. And I certainly saw the benefit of it during the pandemic where we were able to change exchange information policies really quickly with other scientific advisory groups. So I think, move away from the tradition of English speaking health services and go into mainland Europe. Tony, what would you, where would you say the opportunities. I'm pretty fully with what, with what Mary said, obviously, I think there are huge variation. The way healthcare is moving across all of your six to three years. We're learning from each other around strengths and weaknesses of each system and every and every system does have extra. But obviously things like the cost for the directive, even the particular challenges we have in our health system and I are important safety of our patients. Otherwise, that further delays and access to treatment. And I hope that we will see more of that in the irrespective of which country you live in as an European citizen. And I would hope that we will move towards an equity and a quality of access towards the healthcare that we need. And that obviously exists in a whole series of domains that I already mentioned about new medicines. And John is right, reimbursement is the pointy end, but that's not currently within the company. I hope one day it will be because as long as you have twin speed or multiple speed processes around access to the healthcare you need, you do not have a quality of access for healthcare that you should have as a European citizen. I think it's an inevitable trend. I suspect it will take longer than any of us would want. But I'm hopeful that the experience of working together in the COVID response, I would demonstrate that once and for all, the European countries are much stronger. In terms of purchasing, finding the intelligence and so on, that that will eventually translate into every part of the way we develop. Could I ask you, Sheila, in light of your research, you know, in comparative research, what do you see or is it possible to know from the data? What are the barriers to a deeper cooperation in the health sector at the European level? Yeah, so I suppose I think kind of echoing what Mary and Tony have said is that we have very much looked towards the UK as our model. And, you know, there are some similarities between the systems in terms of the, you know, the very much kind of tax, taxed finance systems and the GQ is the gatekeeper. But the way the Irish health care system has developed over the last 30 or 40 years, and I suppose in particular the importance of private health insurance, the amount of people that are covered by private health insurance and private, within the private health care sector, it means that our system now is quite different from the UK. And I do think we need to start looking at, you know, other systems which have a higher percentage of private health insurance and a private market and see what we can learn from them. You know, there's nothing to stop us making that learning and to looking, it's just, I think, changing the mindset a little bit to looking at Germany, to looking at France, to looking at the Netherlands potentially, those are the countries, and just trying to harness the learnings from those. And so we can actually learn the Irish on the fourth year. Paul, what do you see as the potential in this? Well, I think just building on, I mean, I think what's been very informative, even with the discussion from John's presentation is, I think an appreciation of, as you described it, for example, in the non-communicable disease, and again, the area I'm speaking to specifically in cancer, where whilst there isn't how to say, necessarily directives or specific competences, there are clearly through the EU support, if you will, which is very facilitatory. While I think back to the earlier point, it's not simply about national reimbursement policies for particular medications, but if you frame this as a community versus, let's say, in terms of how healthcare delivery is across Europe, it is a fact that some of the, many of the innovative treatments, in effect, if you're going to link those, for example, to area detection screening programs, are the sorts of treatments that increasingly can be delivered not in hospital, but actually not only in a clinic, but as we've learned through COVID, largely potentially at home. And I think there are definitely supports that just listening to what I've learned today, through the EU supports, if you will, even if certain things are clearly national and certain things are not, where we can, I would say, drive forward so that it doesn't take as long as Tony and perhaps myself and the panel think to ensure a better distribution. And I think, for example, the use we've heard specific anecdotes over the years in Ireland of Irish people accessing, let's say, medical care or a program of care in another EU country, it's an incredibly valuable resource and it's been well described in the public domain, obviously by Tommy Gorman, but there was no secret, I mean, he's written about it and published it. But I think that sort of has been historically underutilized and whether that needs to be a driver as COVID was for innovation. So I think this dialogue is incredibly useful and I would certainly put my hand up where many of us who are heavily involved in many ways, but we don't fully appreciate how the EU framework can help us. I learned through the competency side under the Tissue STEM and I reiterate, we have used that in reality it has meant a European standard, European interaction across all of the domains, including delivery of care within those areas that are governed by those directives. I fully appreciate that not everything is directive based, but the second piece that's been described by John, as I say, what you would call these initiatives, I don't know what the correct term is. This is incredibly useful, and I think we have to be more active. And I would also reiterate, historically, until, and we had this discussion on yesterday, in terms of the real world access in Ireland, very often, if we were working with, let's say, industry, typically for organizational reasons, it was UK Ireland, in terms of who you would have to negotiate with. And I think people don't always appreciate that the reality is that, again, in bringing in innovative treatments and being able to present those for national reimbursement, there's a whole set of complex interactions behind the scenes. But in reality, very often, that would be head offices in UK somewhere, clearly. And if you will, our colleagues in Amsterdam or Frankfurt or in Barcelona, they would be doing a different framework. So we have to completely change our methods of engagement as well on the ground. Maybe my just as with real world observations. You're saying we have to do this. Are we doing it? Well, I think we are. And I think Ireland has been very good at it. And I think it's just extraordinarily good to hear what John and his colleagues are doing. As I said, I'm meeting this morning with another Irish, I mean, I think we've been very good. Possibly we, in the health field, I think we probably, as Mary also said, Tony possibly held back a little and, you know, we always had the UK interaction. This is particularly in bringing forward certain initiatives. I think we have to take a fresh look at that. Thank you. I have a question here from Grace O'Malley, a senior lecturer or CSI and clinical lead obesity service. And she asked, I think this is a question for you, John. In terms of emergency response or principles of access to rehabilitation services and healthcare also included, or is the focus solely on accessing pharmaceutical products, medical devices. She says she's thinking here about climate disaster cyber attacks. Yeah, I actually already answered that as well in the chat, as I was listening to you. We have a whole mechanism in place for emergency assistance of the member states and it goes from earthquakes to forest fires to health events. And just to give the example of the COVID outbreak, because it's the most recent one. I've been using the civil protection mechanism in order to evacuate and move patients from one member state to another. I mean, at some stage the French hospital system was overwhelmed by cases of hospitalized patients with COVID and we arranged for the transfer of these patients to other member states on a voluntary basis using EU funds and EU mechanisms. And I said it was the most recent example. The most recent example is actually the Ukraine war where we're currently in this situation where we're evacuating patients from the Ukraine medical system, whether they're civil patients or military injured persons to again to voluntary member states. So we've set up in place a Medevac scheme to enable the transfer of these patients, which is extremely complicated, as you can imagine, because we can't actually access the Ukrainian territory. The patients have to be moved from Ukraine to a neighboring country and then from there to a receiving member state. And we use our mechanisms, for instance, to support the logistics of this transfer of patients, but also the repatriation after, hopefully successful treatment, or even the organization of prosthetics and that sort of thing. The transfer of essential medical products to Ukraine for the hospital system in Ukraine, thinking here of difficulties about access to HIV medicine, for instance, where you can imagine that the Ukraine population had access to Russian medicines in the past. And now we have to try and replace those with European authorized medicines. So it's extremely complicated, tricky business carried out in wartime with very, very short deadlines. But that's something that's become routine business, I would say. And we work very closely from the public health side with the emergency civil protection people in order to try and provide assistance in real time. I'd just like to go back maybe and speak a little bit about the cross-border healthcare file, because this again is an example of an internal market legislation, a legislation which was introduced because of the internal market. What actually happened was there was a guy in Luxembourg where I live, which this guy wanted to buy a pair of glasses more cheaply. And across the border in Trier in Germany, the glasses are about half the price. So he decided to go to Trier and buy his glasses there. And when he came back to Luxembourg with his glasses and he asked for reimbursement, the Luxembourg said, no, you can't have reimbursement. You got to buy Luxembourg glasses. And there were a multiplication of these cases across Europe. And finally, the commission was encouraged by the court, the European Court to try and introduce legislation. And that's the basis for and the origin of the cross-border healthcare directive. And without going into all the details, just to give you, it does allow for a patient in one member state to seek treatment in another. And the reimbursement is actually on the basis of the reimbursement arrangements in the country of origin. But it also, as Professor Brown was saying, allows the creation of what we call European reference networks. And we have about 24 of these reference networks, which are basically networks of hospitals in the member states on a voluntary basis, which we pay for. So in other words, you're not actually transferring the patient, you're transferring the expertise. So imagine that a patient comes in with a rare disease into a hospital in Poland. The doctor, the member of the network in Poland can then seek advice on the appropriate treatment for that rare disease from the other members of the network. So this is an operating mechanism which we use to avoid that patients are pushed around Europe in order to get a diagnosis or to get a proper treatment, but that the expertise can travel more easily in a virtual way between the members of the network. So this is a little bit the consequence of this guy who went to buy his glasses across the border, a whole system was put in place. And we talked earlier on about e-health, that's also a consequence because that's also part of the cross-border directive, the possibility of having e-health tools to be able to transfer your prescription from one country to another, or to be able to share medical imaging between member states, for example. But I would really think as well that it's important that you realize it's not only healthcare we're talking about here, but also the importance of the European Union in terms of prevention of disease. I think it's really important and the tobacco file is probably the best example I could give where European legislation has saved lives in terms of reducing the danger of tobacco products and trying to remove them from normal business by prohibiting advertising. So I think prevention for me is really important as well because we know that a huge number of cancer cases, for example, cardiovascular diseases, diabetes can be prevented. So why don't we invest more in prevention and use our legislative tools to try and reduce the exposure of the population to these commercial determinants of health. Thank you. Thank you very much, John. Any questions here from the audience? Please. Mark Hanifan, Janssen Sciences Ireland. I just have a question around the European health status base and I suppose we fare so well in many aspects of our Irish health service, but one area which you could never accuse us of doing well in is around health information infrastructure. And I guess just in general, the use of data for many beneficial purposes when our health service. We heard recently from the Hickwa published a really good report last week on what the potential positive implications I guess and the push factors I guess coming from Europe on health information infrastructure. And how that might really force us finally to develop, you know, a cohesive electronic health records to put in place framework around secondary use of data for, you know, better clinical research, better, you know, patient care, better cost effectiveness studies and things like that within our health service. My question to the panelists and all of them, including John, I think is, what are the risks for Ireland if we don't fully grasp the net land and participate in electronic in the in the health status base by developing your health information infrastructure and fully invest in it. And I guess what might be the benefits in your various areas of clinical health service expertise. Mary, would you like to kick off on that? I mean, what can I say? It should have happened years ago. It's absolutely essential that we use some unique patient identifier. We all have a PPSN number. I'm not too sure and Tony may have more insight into that, why we aren't using it's absolutely essential. Our country is changing demographically hugely, and we need to meet the needs of our new Irish and the older population all that we can't do that without good data but also not only longevity but the quality of life that people have given all the spend that we have and with a huge spend in the country, and the data, our ability to base things on data is really poor because of that. I mean, Tony might have more insight into why we haven't been doing it up to now. We all actually do have a unique health identifier we have since 2016, because none of us actually know what it is, because it hasn't been deployed apart from through the vaccine program, which has been a bit of an accident. The truth is I think that there has been a governmental hesitancy around two issues, one is the cost deployment, the replacement of many existing manual systems with the enabled systems necessary for this deployment, and in the years I was in the health service I think I had my first discussion around the necessary legislation in about 2008, it was a very long time for those discussions to get to anywhere because of real sensitivity around privacy issues, and now obviously addressed to the GDPR mechanism. But to answer your question, I think the real danger for us is that our electronic health records at the moment in many hospitals are a room full of leverage files. That is a clear and present danger to the safety, patient, client and health system. And so, that is addressed in the rest of the country, that danger can't be removed. But also, if the system continues to lie behind comparison systems, our appropriate needs to take advantage of research opportunities, development opportunities, innovation opportunities will fall further behind. And that will also be the direction of our system and everyone. So it's a really good question you are. I don't think the answer is when that's going to be resolved unfortunately. There are significant needs taking place, which lead me to have more opportunity now than I would if I do. Paul, could I ask you to address that? Yes, I, you know, it beggars belief and I think just by chance the meeting I was at, there was presentations from colleagues in the Netherlands through their blood service and in Denmark, both of which in many ways are countries that within the EU framework we have often looked at for certain system analysis. And of course, they presented excellent and very relevant informational research, you know, what you might call evidence based analysis in the relevant domains, based on exactly what we're just discussing, completely electronic and totally compliant with GDPR by definition since they're both highly effective members of the EU and in the framework. It beggars belief I was fortunate to work in a hospital during the cyber attack, which continues to have an EPR system. I have an electronic system at least within the hospital I work in. I have to say, I couldn't go back, I mean, and nor can anyone I know, but the problem is that all of our nursing staff are pharmacists, and our junior and non, you know, temporary medical staff are rotating in and out of these hospitals. And I think the conversation we did on Wednesday with two of them. We said, I just can't do this. I have to go to center X where I'm looking for charts. It just beggars belief and not to have this reprioritize that the government and about a door level. I, you know, I think we really will be deeply exposed as a country in terms of our credibility to engage in innovation and development without immediately and rapidly now addressing this there's been millions of excuses. Well, anybody I'm no IT expert, but there are people in this room and others who are standing capacities in relation to implementation of technology week, but we've, I did get a smart phone 10 years ago and I realized pretty quickly. It doesn't matter what the big system says that people will find ways to communicate when we learned that through Kobe. So I really think if you will, the regulatory and the governmental system is way lagging behind this is it's a very urgent question. And we keep putting it off to the next committee. So I feel quite strongly that we're going to deny our own population decent healthcare within the European framework so really welcome he did in the mention of as a push, as was said by those who know more about this than I do. Before asking she could I just ask you is the problem, political space political attention or is the problem and anti resources or is the problem resistance. I mean my sense talking individually with people who would be in that domain are excellent and very well disposed and absolutely see it and we've brought policy makers and opinion and farmers and politicians to see how yours work and I don't think there's any resistance I don't quite understand and maybe you know I really don't maybe there's people more attuned to I think maybe communication with our very educated population we've seen how educated and the Irish are to say why it's a good thing, why it's absolutely necessary, and but the drive should come from the public to demand this because of its, you know it ends up that you get quality care quality research engagement with our colleagues in Europe. And so I think if the public knew the benefits of it just would drive the issue. I mean the one, how to say politically informed piece I would have I mentioned earlier at analysis we're able to do with our colleagues in the Irish National Cancer Registry service which Tony will be very familiar with his previous domains is an outstanding resource and this is the establishment of the Irish Cancer Registry so that it could actually have access to data was in fact debated extensively and all Aaron and discussed and was underpinned by a piece of legislation as you know, to allow access, if you will, to the files and so there was actually an exceptional piece of the was able to exception made for those who know more about this again than I do but I do know this, and that has allowed us to be at least able to say well, whatever, but when you come to match what they're allowed access through the registry and this is just in the cancer domain with the important other pieces of technical information protecting the rights of the individuals and their confidentiality and the less the same time. You can't do it, and I know Mary would know about this as well. So, you know, I think these are frustrations that the relevant experts have represented and I don't think there's an intrinsic resistance perhaps it hasn't been prioritized but I would see it. It's as urgent an issue in terms of our strategic policies of countries anything else. So there are some real islands of excellence around the use of data and the whole system registry. St. James's primary care reimbursement so that our real strong islands what there is not is a total ecosystem part of the reason for that is historically, if you look at the percentage of our health spend that has been spent to be enable our investment very small and unfortunately I came home to risk with the cyber attack in terms of, you know, there were still windows 2000 broken confused with operating rather than it was. And terrible if the cyber attack has been enormous cost of it has been I think probably the trigger for completing your approach. And I know that, you know, it's a central feature of the slouching their project. It's something that the current minister has been speaking about recently in terms of the investment that's needed to bring the health by CT of taking up to spec. But it's not going to be an instantaneous flow and I think that are many signs that we're hitting. Cheetah, are we an outlier in Europe in this area. Yeah, we certainly are and I think in the health services research space of every report with the SRR, you know, produces the conclusion is always we need more and better data. We try and publish international journals and everybody looks at those and goes well, why don't you have this data, you know, it's a major issue. I think it's there's improvement over time in the hospital setting and you know the high data again from research perspective really useful on the community based side very, very poor data and talking to people working within this space. I don't think they, you know, they're doing what they've always done, and maybe they just haven't had a headspace staff and think well you know how can we get data that is useful for by other people that we can kind of aggregate it as a community level or at a national level. So, maybe even getting that space for those individuals to come in and to do that. Could I could ask john, how can the EU and the EU health union proposals assist Ireland in this area. Well, I think we've had many, many years of projects dealing with the health and developing tools as long as I've been around we've had European networks and European projects. And I must say there are some members states who are far in advance of Ireland. I mean I've witnessed this myself some countries have jumped on the bandwagon years and years ago, it took advantage of investment funds they set in place the legislation. I have not been aware that the same thing has happened in Ireland in my home country. You know when I go to a doctor here in Luxembourg, the doctor is in a paperless office there is literally no paper in the office. Everything is on screen because we have an electronic health record. The doctor can see when I would last at the dentist they can see when I last had a colonoscopy. They can see virtually everything so I think there are huge advantages for the patient. And that's really where I like to start there. You know we've got to sell the case for digitalization of the health systems as a patient safety issue I think, because we have clearly shown. Through the introduction of electronic health records in some of our member states with the most serious antimicrobial resistance problems. We have shown that the introduction of electronic health records can actually track where the problems are occurring with stewardship of antimicrobials. It's an electronic tool which allows you to dig down and see where the prescriptions are taking place, where the use of antibiotics in a wrong way is happening in the hospital system. And where the resulting infections, drug resistant infections are occurring. So there are really practical examples also in terms of adverse reactions and so on. The fact that you're able to link these in real time with the patient and with the medicine systems is also an advantage for the patient. I would say Europe has one of the strongest regimes for personal data protection in the world. We're always being attacked by third country such as the United States saying that our rules don't allow this, our rules don't allow that. But I think the patient should be reassured that the intention is never to remove patient confidentiality. The intention is really to improve patient safety and to make data available outside the silo of the individual healthcare provider. To make that data available to research so that innovative products can be developed more easily in Europe. And secondly, it's also an advantage, a big advantage for the health professionals who doesn't have to search around for the results of screenings for the results of the history of the patient is all there in black and white. And it's done in a holistic integrated way. So the commission has proposed legislation on European health data space which pursues this objective of making data, putting data at the service of patient safety and improved care. Secondly, helping the health systems to manage this data and manage their patients more effectively, particularly as they go between different parts of the health system. And thirdly, then encouraging access to data through sharing of data, through sharing of patient data with researchers. And we've heard mentioned here of registries. The European Union has been supporting registries for years in the area of rare diseases, cancer, but also in other disease areas. And I would say it's really important that we try and have a much more integrated approach. And that's why this legislation will open the door to an improved data sharing system in the European Union, fully respecting patient confidentiality, together with the investments which we have put aside for the introduction of these systems at national level. Thank you, John. And there's two questions here that back grow and then the lady in front of you. Thank you, Bernard Milley. I work for EFA represent the research based pharmaceutical industry in Ireland. And two questions, mainly directed for john. The first is that Europe's, you know, ability to attract investments, or indeed, particular is declining against competition from Asia and from the US. Back in the past 20 years, and the global share of R&D activity in Europe has contracted by about 20%. And so it's quite a, quite a big draw. So I guess the question is, will the EU pharmaceutical strategy arrest that slide. Can we be confident that we will be in position to get more R&D activity in Ireland. And the follow on on that then of course is the manufacturing production investments on the back of that innovation as well here in Ireland. And the second question is around against strategy, which seems to confuse, I think, IP rights and access, suggesting that maybe access is related to IP, and that IP is a driver for medicines price, which we believe is not the case. And does John believe that those two things are completed. And what might be the plan to ensure that IP is protected in the months ahead, particularly as policymakers way changes in the legislation. John, would you like to take that. Well, yes, the answer is yes and no, I can't give too much detail on what will be in the pharmaceutical package because it's still being developed and decided so I can't really speak in detail on the approach to IP rights and access and things like that. But I would say that the issue of improving the access of European population and citizens to innovative medicines is at the core of the pharmaceutical revision of the pharmaceutical legislation. We are trying to put mechanisms which link the authorization of new medicines at the European Union level with and the protection which is granted under the pharmaceutical legislation to particular products with the topic of of access of the European population in the different member states to those medicines. So it's a question of, it's a difficult question because some of the, the levers are some of the drivers are covered by the legislation some of the drivers are outside the legislation we talked earlier on about the authorization mechanism where the products are analyzed and evaluated by the European Medicines Agency and then the authorization to put on the market is granted by the European Commission for putting those products on the European market but there is the phase afterwards, or in parallel concerning the health technology assessment in other words the value added of those products is evaluated by the member states. And there is a separate directive on this which is the health technology assessment directive. And then you have the decision on reimbursement so it's not a, it's not an easy subject really to analyze and what we are talking about today is the reform of the pharmaceutical legislation. We will be using that reform to try and improve as much as we can the possibility for innovative products to be developed and manufactured and authorized and used in Europe. So that will be one of the concerns of the legislation. And at the same time, of course, we will be looking at reinforcing the possibilities for European companies to develop a new product that's been done through our research program principally. And there's a third issue which is the issue of security of supply and that's being discussed at the moment with Commissioner Breton. There has been a commission working paper published a few weeks ago on security of supply of pharmaceuticals something we really became aware of, as I said during the COVID outbreak. So it's not a very simple question to try and answer, but I would say pharmaceutical legislation does look at this topic of access to innovative treatments and the encouragement of production and innovation in Europe. Thank you, John. I think we're beginning to run out of time so I hope we can time for two more questions. I think this lady here has a question. Thanks very much. I'm Georgia Murray. I'm a public health physician. I'm director of the cancer registry. So thanks very much to the professor. I didn't. But and obviously I echo what people have said previously on the on the health information system. My question really is for John on inequalities or inequities, you know, and either the health initiative or other initiatives is, you know, where is European? European focus on those I know in the cancer space is obviously a big development and the cancer inequalities registry, but I suppose as Professor Horc one of said we have a lot of new Irish, which are currently with the air systems we've no way of individually identifying ethnicity, and there are ethological ecological other methods, but it would be helpful if there was a, you know, a standard method for all health services, you know, coming out of EU that would be very helpful. I think for me for my position. Thank you. John. Yes, so I would say there were many, many years of work on health inequalities at your opinion level and I remember in particular that the Welsh, your neighbors in Wales were very strong on the issue of health inequalities. When the UK was still in member states. We thought on the commission side that this was a bit of a theoretical philosophical discussion on, you know, health inequalities are so unfair, let's do something about it. But actually nothing concrete came out of that process I would say except good intentions and therefore having ministerial declarations and calls to action and lists of recommendations are not very practical, which is why in the European cancer plan, we proposed and we implemented a quite an innovative approach, which is the measurement of indicators of inequalities between the member states in respect of different aspects of the cancer plan. And this covers, for example, the access to early detection, because you have some member states where the rate of take up or availability and take up of breast cancer screening is over 95%. And you have other member states where the access to the access and take up availability of breast cancer screening services is less than 5%. So you might say, well, the same breasts are just in different member states. So why do you have a situation where in some countries it's over 95% and in some other countries is less than 5%. This is not from an ethical point of view, it's not acceptable. So we really wanted to try and identify these and map these inequalities, not for the purpose of pointing fingers, because the countries concerned they know that there's a problem, but the idea was to try and then target the investments in those particular countries where the inequalities are greatest. I participated yesterday in a meeting on access to prep for HIV. And the differences are enormous in some member states you have to pay 60, 70 euros a month to have access to prep in other countries they handed out three. So I mean, this creates all sorts of inequalities as well for very often reasons which are difficult to understand. So I think it's really important that we move away from a philosophical discussion into a real, a real life discussion on where the differences are and how can we target the countries with the worst performing indicators and target support to those countries, either in terms of offering training schemes for health professionals, which is one of the things we do, or targeting support through the recovery and resilience fund for hospital reinforcement in those countries, or offering support schemes for screening campaigns or for, you know, putting in place guidelines and then implementing those guidelines. So I'm talking here really about not increasing the inequalities through European action but reducing the inequalities through European action, because the very fact that we have 10 or 15 years difference in life expectancy, even within the same city in some European countries is really incredible. It shows the link between health outcomes and economic and social factors. There was a study published this week by INSEM, which is the French Research Institute, if I remember correctly, which showed that immigrants into France had seven times more likelihood of having hospitalization for COVID than the native population. And this is really why it's important that you're able to measure these things and that, regardless of the ethical considerations of which we're familiar with about race and so on and trying to, you know, our nationality and trying to gauge people's origins, that nevertheless you're able to target your activities on the most vulnerable populations and really migrants are one of the most vulnerable populations. So you've got to find some way of having a health information system that can identify these areas of problems and deal with them. One very final question over here in the corner and we've about one minute left. That's fine. I'm Vicky McGraw. I'm the Chief Executive of Rare Diseases Ireland. And what we see happening here now with the introduction of the European reference networks is just going to be transformative for rare disease care in Ireland. We're, I guess, in a situation right now, for about 37% of the rare disease community doesn't have access to a specialist in this country. And, you know, that's what the ERNs are designed to do. But I guess what I'm concerned about is when that recommendation when we're really up and running with the ERNs and that recommendation comes out to give them this particular treatment. The treatment is not available in this country. How are we going to, you know, handle that, I guess, inequality? How is the reference network system actually going to be able to manage that? And I think Europe really, really needs to do an awful lot more for the small countries in that regard. When we look at a situation where we have a drug community that meets for two hours a month, and you have other situations in other countries where they're meeting for 20, 30, 40 hours a month, we just don't literally have enough thumbs on seats in the country to do everything that we need to do to keep up with the more popular countries. And how can Europe get us over that and get us through that? Any views? Maybe it goes back to a discussion we've had before about the gap between an EMA market authorization and the accessibility in real time, in real life, as it works, about medicine. And I think there is this scope, or I hope there can be this scope, for the European Union at commission level to at least examine the reasons for these variations and to bring forth recommendations for standardized approaches. Because there are tremendous variations. They come from different places. Ireland experiences with some manufacturers, they might get an EMA authorization, but they don't even apply for reimbursement. Because that particular company is dominated by headquarters in the UK, and Ireland doesn't seem very important on the one hand. On the other end of the spectrum, the lag time for approval in Ireland, it's clearly much longer than in many other states on many, many drugs. And that's why we turned it to an outlier. But I would hope that if European competency can be used to achieve it, we can be assisted to recognize and improve our position for the benefit of everyone. Thank you. I think we've come to an end. Can I thank all of our panelists and thank you all and I look forward to the next in this series. Thank you. Thank you.