The National Audit Office's report on prescription of medicines - state governance and supervision

Christian Lindefjärd (SD)

Mr. Speaker! I begin by moving to approve the committee's proposal for a decision in this matter.

The Swedish National Audit Office has submitted the report Prescription of Medicines - State Governance and Supervision. The report is good and provides constructive and justified criticism, and it also contains many good suggestions for improvements.

In our society today, the management of pharmaceuticals does not function optimally. Many times, certain medicines are completely out of stock. A recurring problem in Sweden is that special medicines cannot be obtained at all and it takes a long time before they are approved. Here there is another problem where different actors do not cooperate properly but pull in different directions and delay the approval of special medicines. Many patients have to travel between several pharmacies to get hold of their specific special medicines. We really need to address this problem, and here third parties and their families are affected by this recurring problem.

The state's governance and supervision of pharmaceutical prescription is not effective. There is a great deal to be done here, and several proposals are raised in the report. More proposals will need to be quickly investigated so that these can become a reality. The longer we wait, the more noticeable the system's deficiencies will become, both for the authorities and for those who truly need their medication.

One example is to clarify the authorities' supervisory responsibility for the incorrect use of pharmaceutical benefits. Another example that the Swedish National Audit Office raises is to transfer the state grant for pharmaceutical benefits to the general state grant for regions within the appropriation for municipal financial equalization. In that case, it must be investigated thoroughly so that all parties can be informed about this. We must also keep in mind that it is up to each individual doctor or other authorized personnel to prescribe the medicine they believe is best.

The prices of medicines vary greatly, and that is due to several factors. Even here, we must take into account that we are competing with other large international markets for the availability of medicines.

It is also important that the prescription of medicines is good and that one receives equal care regardless of where in the country one lives. This applies both to patient safety and to ensuring that the cost-effectiveness of the state's subsidizing of medicines is maintained. The classic saying that every wasted tax krona is a theft from the people is a motto we shall always strive to pursue in this assembly.

An important matter is Ivo's powers. It is an incredibly important authority in our society, but with the increased welfare crime, these powers have truly been put to the test. The authority must receive more resources and more staff working with the new complex issues.

It is absolutely not okay that the processing times for pharmaceutical cases and for doctors who have prescribed medicines incorrectly are years long. During that time, the prescription can have catastrophic consequences. It is because the number of cases has increased even though Ivo has worked actively to try to reduce processing times by allocating resources to the area.

When it has gone so far that there are grounds for the Case Officer to limit or withdraw the prescription right or even revoke the license, the matter ends up with HSAN, the Health and Medical Care Responsibility Board. There, the processing time is an additional year due to high workload. In the report, it is proposed that in very serious cases, one should be able to intervene and stop the prescription right provisionally, and the processing times for that type of case must therefore be shorter than for other cases. But all cases are assessed based on the circumstances in each individual case.

An important matter is that Ivo can gain knowledge about deviating prescription patterns. That is good. It makes it easier to detect risk individuals and certain patterns in time. Here, it is a question of reports from primarily pharmacies, healthcare providers, or the general public.

Another important point is to clarify the rules for the allocation and withdrawal of workplace codes. Having a workplace code is a prerequisite for prescribing medicine within the framework of pharmaceutical benefits. The current system is far too complicated, and one must turn to the National Board of Health and Welfare. Any inaccuracies must be stopped in good time. It must not take as long as it does today, which results in the cases falling between the cracks where one party says one thing and another says something else.

I am pleased that the rules for the allocation and withdrawal of workplace codes are to be reviewed. There is a consensus here.

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Anders W Jonsson (C)

Mr. Speaker! One of the more remarkable proposals that the National Audit Office has put forward is that the regions should take over the entire cost responsibility for pharmaceuticals. Today, the regions cover the requested pharmaceuticals while the prescribed ones are the state's commitments. There, the member from Sverigedemokraterna says that that question must be investigated further.

What is interesting to know is what the Sweden Democrats think on the merits. Should the entire cost be transferred to the regions or not? It is not possible to simply refer to the fact that one must look further into that question when it concerns a cost of 50 billion.

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Christian Lindefjärd (SD)

Mr. Speaker! Now it is like this: I am completely new; I have just entered this committee. I have only entered in the last few weeks, so I am not briefed on exactly where we stand in this issue. That is my simple answer.

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Anders W Jonsson (C)

Mr. Speaker! I have great respect for that answer.

Ever since the 90s, when the agreement was made that the state would take half the cost and the regions the other half, this proposal has been put forward time and again. The regions say a flat no. They refuse to take over this cost, for understandable reasons. They have a heavily pressured economy, and we foresee what cost increases there will be regarding pharmaceuticals.

I and the Center Party think it is time to bury this issue. It is not reasonable to place this cost in a pressured situation, instead, a completely different solution must be found here.

That is why I became so curious when I heard that the Sweden Democrats are open to investigating this further and looking at it once again.

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Christian Lindefjärd (SD)

Mr. Speaker! Thank you, Member Anders W Jonsson, for your views! I can take them in and listen to them.

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Mikael Dahlqvist (S)

Mr. Speaker! Welcome to the Riksdag and the chamber, Christian Lindefjärd! I assume it is the member's debut today.

I also have great respect for the fact that the member is not familiar with all the issues and has not been present during previous parliamentary terms. But I still want, Mr. Speaker, to remind our listeners of what has happened.

During the previous parliamentary term, there were a number, quite a few, announcements in the Social Affairs Committee. There was a bit of inflation in that. An announcement means that there is a majority proposing something that the government shall then handle. I have enjoyed looking a bit at what happened during the previous parliamentary term. In some cases, even Christian Lindefjärd's party was involved in pushing it forward.

The long-term financing of pharmaceutical prescriptions is perhaps the running point in the entire debate today. The question is how the economy is distributed long-term between regions and municipalities and, above all, how one ensures that new medicines reach the entire country.

I just want to hear if the member can reflect generally on this issue. He does have a mandate here in the Swedish Chamber even if he is not well-versed. How does he view the issue, and what is the reasoning in SD? How will you drive the issue of securing the financing of medicines in Swedish health and medical care?

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Christian Lindefjärd (SD)

Mr. Speaker! Member Mikael Dahlqvist knows that I am new, as I said earlier. We have met, after all.

Regarding this question, I have joined so recently that I am not briefed. I only joined in the last few weeks. Therefore, I cannot answer. I do not intend to stand here and guess and throw things out. Instead, I will say that I have to look into the question and get back to you. We can meet in the committee and discuss the question.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much, Member Christian Lindefjärd, for your answer! As I said, I have great respect for the fact that you are new. The Member needs time to get started but not for too long, I hope. We shall return.

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Christian Lindefjärd (SD)

Mr. Speaker! I have nothing to add.

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Karin Rågsjö (V)

Mr. Speaker! I can understand the member's reflections in this area, for it is an area that is very non-transparent and difficult to follow for us members—it is precisely pharmaceuticals. There are different levels and so on. It is super difficult, I must say. I also had great problems in the beginning with understanding the situation. We have difficulty seeing which pharmaceuticals are let in and why, how they are approved, and who has access to the pharmaceuticals regionally and at an individual level.

But one thing is crystal clear, Mr. Speaker, is that costs are rising when it comes to pharmaceuticals. We can also see that your policy, that is, the SD-dependent government's policy, makes it very difficult for the regions financially right now. No region wants to take over the cost for pharmaceuticals.

I really wonder if it is not time for SD to also review this a bit. Since pharmaceuticals are so important, it might be better that the entire part is placed on the state. That is what we think.

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Christian Lindefjärd (SD)

Mr. Speaker! Thank you, Member Karin Rågsjö, for your questions!

Yes, that sounds very good. But as I said earlier here, I would like to get into this with pharmaceuticals. The issue is very complex. One does not get into this in two weeks. I can say that I understand the member, because it is a great deal, and I have not worked with these issues previously.

But I agree with the member that pharmaceuticals is a very diffuse industry. One does not know who gets them. One also does not know what it costs. The prices vary. It is a very complex industry.

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Karin Rågsjö (V)

Mr. Speaker! Yes, it is complex. I will not press the member further, because I understand the situation. It took me time to understand the entire pharmaceutical structure. I just want to point out that you in SD and the government should review the funding.

Perhaps you should also look more at the budget you presented and consider whether this was sufficient for health and medical care. But those debates will come later.

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Christian Lindefjärd (SD)

Mr. Speaker! I can only thank Karin Rågsjö.

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Mikael Dahlqvist (S)

Mr. Speaker! Initially, I just want to apologize. I have a severe cold today. If I need to take some fluids or blow my nose, it depends on my condition.

On the table today, as we have said, we have a report from the National Audit Office which points out deficiencies in the state's engagement in issues regarding pharmaceutical prescriptions - or, in more formal language, the state's governance and supervision of whether the activity is effective or not.

The review is extensive. The investigation covers the government's governance of Sveriges Kommuner och Regioner, the state's knowledge management within the operations, and the state's supervision of the incorrect use of pharmaceutical subsidies.

The overall conclusion in the report is that the state's control is not effective. What does this mean for the common man? The most absolutely serious thing is that the deficiencies discovered entail an increased risk for the patient. Specifically, it can mean that the risk increases for incorrect treatment, unnecessary side effects, and healthcare injuries. In the worst case, the patient may die. The deficiencies lead to a deterioration in access to equal care, but also to taxpayers having to pay extra much money because the system is inefficient and used incorrectly. The report shows that medicines are subsidized on incorrect grounds.

Mr. Speaker! Unfortunately, these conclusions are already known by most of us. For example, there is a current issue that SVT's Uppdrag granskning took up a month ago. It concerns a medicine called Ozempic, which is a new and important medicine for type 2 diabetics. The medicine is prescribed by doctors on completely incorrect indications because it has been shown to also be effective for weight loss. But it is approved only for the treatment of diabetes. Despite that, it is prescribed. Despite that, the box for medicine subsidy is also filled in. In other words, the state is participating in financing a medicine for people who actually should not have it.

Not enough of that, Mr. Speaker. Not even a year ago, the Medical Products Agency urged prescribers in a letter to use the medicine correctly based on diagnosis. That alone is quite remarkable, Mr. Speaker – that an authority needs to tell prescribers how a medicine should be used.

The previous S-led government appointed a pharmaceutical investigation when we saw that a holistic approach was needed. There was a need for clearer responsibility and clear rules for pharmaceuticals. Even the government parties' representatives in the chamber today raised this issue in the Social Affairs Committee many times during the previous parliamentary term and also, as I said in my previous exchange of remarks, were behind a number of announcements.

The Government also agrees with many of the report's conclusions. Nevertheless, the Tidö base in the committee chooses to reject our committee motion, which concerns our desire to take a holistic approach and solve the difficulties – to solve this issue once and for all and the flaws the entire system has regarding medicines and medicine prescription.

Mr. Speaker! Given the government's criticism and proposals, it should, with the support of the Sweden Democrats, be on its toes and come up with solutions to the problems. After half of the parliamentary term, the government's decisiveness is conspicuous by its absence. I also note that this area was not clearly prioritized in the government's statement.

Yes, this is a serious issue, and these are serious conclusions we have been made aware of. I expected the government to humbly take the criticism to heart. Unfortunately, the answers are vague formulations and investigations that mean this issue will not be resolved in the near future.

Mr. Speaker! That is why we Social Democrats, in our committee motion, demand that the government appoints a new pharmaceutical investigation to resolve the long-term financing of pharmaceutical benefits. But the investigation should be broader than that. Our goal is, of course, that changes should be implemented that provide equal care throughout the country. Today, there is inequality among the population, an inequality that unfortunately is increasing. New treatments must be available to the entire population. It must not depend on where one lives, what gender one has, or what economy one has.

The second thing we raise in our motion is the Swedish National Audit Office's views on the pharmaceutical benefits and a number of other recommendations. The Government states that it intends to return with proposals on certain recommendations, which we naturally welcome. However, we know that investigations tend to take time and that some end up in the wastebasket, so we would very much like to see a timetable for when and how the Government intends for this to take place.

I believe we are quite in agreement on our challenges within the pharmaceutical area, so let us act swiftly together for the benefit of the citizens!

Mr. Speaker! I also move for approval of reservation 1.

(Applause)

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Lina Nordquist (L)

Mr. Speaker and Member Dahlqvist! I had intended to drink my coffee and conduct this debate in tranquility, but I became a bit frustrated when I heard the Social Democrats' criticism that the government is doing nothing, that we are doing too little, and that we are not taking this seriously. When I read your reservation just now, I saw that one of the very first things the Social Democrats claim is that at all costs one must "avoid that pharmaceutical costs crowd out other health and medical care." Pharmaceutical costs simply must not rise, because it will occur at the expense of healthcare.

I would like to ask Member Dahlqvist to elaborate: In what way would medicines not be a part of healthcare? And in what way would they crowd out healthcare? This is, therefore, what the Social Democrats want to implement according to their reservation.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you, Lina Nordquist from the Liberals, for your question!

Of course, healthcare must cost money. The member only needs to check our shadow budget. Unlike your party and the government, we prioritize welfare and, above all, healthcare in general with general state grants at a much higher level. There, we have completely different starting points, I believe, Lina Nordquist.

Regarding this issue, it is as the member also knows, that the development of costs in the pharmaceutical area is moving quickly. If we look into the crystal ball, we see that the development will move even faster as the therapies become increasingly advanced. This is to be interpreted, member, as a general statement – one must always be careful with the taxpayers' money. But I can promise the Liberals that we are guarantors that healthcare will receive the resources that are needed.

In our committee motion in the area, we also highlight the need to review long-term funding. Let us then have the discussion on how the funding shall take place, at what level, and who shall have the responsibility.

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Lina Nordquist (L)

Mr. Speaker! In light of the rapid developments, the Social Democrats, just as the member confirms, want to ensure that pharmaceutical costs do not crowd out other healthcare.

I just want to quickly look in the rearview mirror and state that when the stomach ulcer medication Omeprazole arrived, the drug costs skyrocketed while the operation costs and inpatient care costs for bleeding stomach ulcers plummeted to the bottom. It pushed out, one could say, but for the patients, it was incredibly much more pleasant not to have to be in the hospital at all. When the biological drugs arrived so that rheumatics, instead of intensive rehabilitation and long-term sick leave without a chance to return to work, could stay home with these biological drugs, the drug cost also increased by something quite immeasurably, and the healthcare costs decreased. When cancer drugs arrived, people avoided dying - the drug costs increased. When the covid vaccines arrived, the drug costs also increased, and the intensive care costs decreased significantly, as did the number of deaths. So yes, there is a connection, but it does not have to be that something pushes out something else.

I am grateful that the Social Democrats are not governing the development of pharmaceutical costs right now, because with what we see - ATMP, advanced treatments, genetic treatments and tissue treatments - the stance that the cost of pharmaceuticals should be kept down would mean completely unnecessary suffering for people in our country who need better care, not yesterday's care.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much for your comments, Lina Nordquist from the Liberals!

It is up to the voters to decide who they feel safest with regarding the development of Swedish healthcare. I only state that the government, in cooperation with the Sweden Democrats, has caused a national healthcare crisis without equal and furthermore continues to underfund healthcare. As the member knows, the state grant is part of the regions' healthcare budgets.

It appears from the member's contribution that she is concerned about and an eager supporter of treatments – a view that I share. The member also knows that new treatments are constantly emerging which increase the cost, so I believe that one needs to keep two balls in the air at the same time. But it would also be appropriate if the member and the government ensured that the regions received the financial muscles they need. In their budget, as I previously said, the pharmaceutical cost is included.

(Applause)

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Jesper Skalberg Karlsson (M)

Mr. Speaker! Good access to medicines is a central part of a functioning health and medical care. Developments within the pharmaceutical field contribute to extending and saving lives and are in many ways a great success for both Swedish and international research. It is, however, important that medicines are used in the right way and for the right purpose - only then can patient safety and patient benefit be ensured.

Mr. Speaker! In the report from the National Audit Office that we are debating today, there is certainly a focus on countering incorrect medicinal prescriptions. That is good.

It is, however, worth mentioning in this context that the government has recently decided to appoint a special investigator to review certain issues regarding the duty to provide information, documentation, limitations, and supervision of pharmaceutical prescriptions. The purpose is to counter incorrect prescriptions and prevent public funds from going to criminal and unscrupulous actors - or to speak plainly: The investigation is being appointed because it is completely unreasonable that prescribers, sometimes for economic reasons and sometimes under coercion and threats, prescribe desirable medicines to criminals, sometimes by the kilogram, for several months before it is detected and condemned. So, we shall not have that in Sweden.

I look forward to taking part in Anders Ahlsson's investigation when it is completed and hope that it contains several proposals that facilitate fast, efficient and legally secure supervision, preferably digital, so that we can close yet another tap to the criminal economy.

Incorrect prescription of diabetes medication for weight loss, narcotics-classified preparations for intoxication, and growth hormones for bodybuilders can lead to fatal consequences for those who use them. But another side effect is that it burdens the pharmaceutical benefit, which we taxpayers have to cover. It must stop.

Mr. Speaker! Another point in the report that the committee's report addresses is the state grant for pharmaceuticals. It is noted that the state grant is more to be regarded as a general budget support than as a steering tool, partly because the size of the state grant is announced after the regions' pharmaceutical budgets are finalized. Furthermore, the grant structure changes over time, which makes it difficult to forecast. As a former regional councilor in Gotland, I recognize myself in the National Audit Office's description.

There are potential advantages to transferring the state grant for pharmaceuticals to general state grants. It could provide the regions with increased flexibility, more efficient resource utilization, and more long-term planning. At the same time, the issue is complex. There is a risk of uneven access to pharmaceuticals, that pharmaceutical use becomes more difficult to manage, that pharmaceuticals become underfunded, and that national equality is eroded as a result of a general fund being able to go toward what the region currently wants to prioritize.

That it is the case in this way, we have known since before. The pharmaceutical investigation from 2018 proposed the same thing that the Swedish National Audit Office is now doing, but as we could read in the countless referral statements that came in, the issue is complex and requires difficult trade-offs.

Mr. Speaker! From the Moderates' side, we enter the issues regarding pharmaceuticals with both impatience and perseverance.

Let me give some examples: The work on the national pharmaceutical list 2.0 is ongoing, we have recently commissioned an investigator to review how the supervision of prescribers can be streamlined, and TLV has received special budget funds for cost-containment measures. It is good that the government is placing a great focus on these issues.

On the horizon, there are simultaneously great challenges with new, revolutionary medicines against, for example, Alzheimer's and diabetes, which can provide patients with radically new possibilities but will also put old funding models under great pressure.

Our primary priority is to ensure equal access to medicines regardless of where in the country one lives, while simultaneously preventing abuse and over-prescription. We need a robust system that can meet both the medical and economic challenges in a long-term and responsible manner. Much has been done, but much more will also need to be done.

I vote in favor of the committee's proposal.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you, Jesper Skalberg Karlsson, for your speech! Much of what the member said in his speech I can sign off on. I know that there is great consensus among many different parties in the issues being debated today. I also share the member's view of the future.

What I, on the other hand, want to ask the member about, and which is conspicuous by its absence, is precisely the question of financing in the long term. Already in 2021, in the report written by the Moderaterna where a committee majority supported a proposal for a notification to the then S-led government, it was stated that it was considered that the government should prepare a proposal to analyze the responsibility for the financing of pharmaceuticals.

But unfortunately, I have not seen a single syllable when it comes to reviewing a larger part of the pharmaceutical issue. It is good that TLV receives funding. It is good that an investigation is being appointed to review this regarding prescriptions and workplace codes.

Mr. Speaker! I would like to ask a concrete question to Member Jesper Skalberg Karlsson, who is a Moderate and a representative of the government side: What do the Moderates think in this matter - how will you secure long-term funding, and when do you intend to present a sharp proposal in this area?

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Jesper Skalberg Karlsson (M)

Mr. Speaker! Thank you, Member Dahlqvist, for the question! In the reservation and the accompanying motion that the Social Democrats have submitted, it is proposed that the targeted state grant for pharmaceuticals should be converted into a general state grant. I reflected a bit on this in my speech. But to be particularly clear, I can say this: The state grant for pharmaceuticals has some steering effect, which the National Audit Office also states. It is not a large effect, but it exists.

I believe that if one were to only make the change that the Social Democrats propose, it is a poorly chosen time right now. One should not ensure that there is less governance if the supervision does not function. I believe that we need to fix the supervision first, and the investigation into this has been commissioned. After that, one can look at the larger question of where the financing responsibility should lie, if one wants to make a change.

The supervision will, so to speak, come first, so that the system will be robust and long-term. After that, one can consider where the cost item should be placed.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you, Jesper Skalberg Karlsson, for the answer! I share the view that the member expresses. It is clear that one must have an analysis and an idea of how the operations should be managed and developed, and then one adds funding.

But now we are in an acute situation. Pharmaceutical costs are rising. We have debated this issue in the chamber for many years. It is underfunded. Furthermore, the government is providing even fewer resources to the regions with the budget for 2025, which means that the issue is acute. It is important to do something here and now.

Mr. Speaker! What do the Moderates intend to do here and now to solve the acute issue of financing Swedish healthcare and pharmaceutical supply? We know that the costs are ticking up, and we are already seeing displacement effects.

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Jesper Skalberg Karlsson (M)

Mr. Speaker! Let me begin by saying that the most important thing one can do for Swedish healthcare is to get inflation under control. The current budget year looks really bleak for many regions. This has its explanation in the high inflation and the effects it has had, perhaps above all else, on pension costs.

When we look ahead to next year, we see that inflation has been pushed back. It is the inflation figure in June that governs the upcoming pension contributions, which means that the costs for Swedish health and medical care decrease by the magnitude of 23.5 billion next year. This means for the healthcare sector, which turns over approximately 400 billion with the supplements that the government has made in the budget for next year, that the deficit lands at the magnitude of 0.25 percent.

I would not say that there is a funding crisis for healthcare for the coming year, even though the current year has definitely been tough.

When it comes to pharmaceutical costs, I am also concerned that we are seeing increases of between 6 and 8 percent annually. Here, work is being done partly through money and assignments to TLV for cost-saving measures, but also adjustments in the high-cost protection and other parts. It is about refining the system so that it becomes a bit more sustainable here and now. On the other hand, there are larger issues to address further ahead.

I look forward to, for example, the Healthcare Responsibility Committee and other inquiries submitting partial reports that can ensure we get better national governance of perhaps specifically the pharmaceutical area. I believe that it is an area where the state needs to do more, even though I do not believe in the idea of directly transferring all healthcare to state control.

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Karin Rågsjö (V)

Mr. Speaker! Drug costs are increasing – we can see that. It is also happening because very potent medicines are being developed, which mean very much for very many in our country.

We can also see that there is a very unequal distribution in the regions depending on the economy. It is quite obvious - you can see that when you look at different tables and so on.

I have two questions.

In the budget you have presented together with the Sweden Democrats, you propose no specific increase of the general state grants, and you reduce the sector grant from 9 to 2 billion kronor when it comes to healthcare. This will, of course, also affect the entire issue of pharmaceuticals out in the regions. My first question is: How are the regions supposed to fix this?

Then it is a question of who should take responsibility for the financing and where the state's responsibility should lie. We have long considered that the state should take a clearer responsibility for the financing. We will submit proposals in the committee where I sit, and there we seem to have a somewhat similar starting point. But right now and continuing next year, it looks quite bleak for the regions. My second question is: How can the costs be accommodated with the budget you have presented when it comes to medicines specifically?

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Jesper Skalberg Karlsson (M)

Mr. Speaker! Thank you, Member Rågsjö, for the questions! The Government cannot solve all challenges everywhere. Nor is there such a promise. However, issues that only the Government can solve shall be solved by the Government. One such issue, for example, has to do with inflation.

We have had a tight fiscal policy during the first years of this mandate period precisely because inflation has been very high. Now, the fight against inflation has taken hold. We see how inflation has fallen. When we calculate the price base amount and pension costs for next year, we see that the healthcare's finances will look significantly better. One hardly wants to think about how it would have been if other budget proposals had gone through. Then we would have thrown gasoline on an inflation fire and seen how the pension costs and inflation would have remained high.

I note that this government has begun to work with sector grants. I think it is a well-considered reform, somewhat on the borderline between a general state grant and a targeted state grant. I also think it is good that we have focused on fighting inflation precisely because it is the large pension costs that have strained the regions' finances during the current year.

Then it concerned how the regions allocate their pharmaceutical budgets. Yes, we are talking here about that our governance through the targeted state grant for pharmaceuticals has a limited effect. I believe that the regions' own budgets perhaps also do not have a completely far-reaching effect. The prescription occurs between prescribers and patients, and it occurs based on medical needs, not based on the region's budget.

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Karin Rågsjö (V)

Mr. Speaker! The member says that inflation has gone down and that everything is light green and wonderful. I do not quite share that view because it is still approximately 5,000 people who will leave the regions - they are, in other words, laid off. It is clear that it is a problem.

Money matters. Money means something out in the regions, and it is clear that we can see a regional inequality based on which prescriptions are made in different regions. Regions with poorer economies have worse conditions to finance medicines that, for example, are prescribed from hospitals. There is no doubt about that, if I may put it that way. I am, therefore, concerned.

But what worries me even more is that the question we have discussed for as long as anything - it is about medicines, about transparency, about who should pay what and about what happens - feels very vague. I wish that one could find ways forward when it comes to what the state should do, what the state should finance, what the state should host, and what the regions should do.

This is truly a question of the future, and we discuss those types of questions in the Care Responsibility Committee. There are a number of investigations underway, but there is also a lot here and now. I still wonder how the regions will be able to finance their own operations next year. It does not look very bright from the regions I have spoken with.

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Jesper Skalberg Karlsson (M)

Mr. Speaker! Thank you, Karin Rågsjö, for the follow-up questions! In July, Sveriges Kommuner och Regioner, which is the municipalities and regions' own organization, released figures regarding the coming year. They noted that with the new inflation figures and their effects on pension costs, the costs for the regions decrease by in the magnitude of 23.5 billion. For the municipalities, it is approximately the same amount.

One can look at the total healthcare budget of around 400 billion. There, one saw that the deficit for the coming year is approximately 4 billion. In the state budget for next year, we inject 3. Then there is 1 billion left. That is 0.25 percent in deficit.

I am convinced that regions that work long-term, that prioritize, and that use the regional autonomy will be able to resolve that situation. The government is doing its part, but the regions also need to do their part.

I agree with Member Nordquist earlier that pharmaceuticals seem to be a poor item to save on. There are other things one can do if one wants to achieve maximum benefit with the tax money. It is nevertheless a guiding principle for politicians in this house and politicians in various regional councils that we should get as much care as possible for the tax money. This work should not be done when the crisis is a fact. It needs to be a continuous work over time, so that the taxpayers get what they deserve and expect. I am convinced that Karin Rågsjö's solution with panic-like state grants when the crisis is a fact is the wrong way to go.

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Karin Rågsjö (V)

Mr. Speaker! It was lucky that I got the floor immediately after the brief exchange of views we had, because we are not engaging in panic activities but want to see this in the long term.

Mr. Speaker! An area where transparency is minimal is the entire pharmaceutical area, just as I have said before. Which medicines are let in? Which are approved? How are they approved? Who has access to medicines at the individual level and at the regional level? Is it equitable? I am very skeptical about that.

The Swedish National Audit Office's review has proceeded from the question of whether the state's governance of and supervision over medicinal prescriptions is effective. They have reviewed the government's governance through agreements with Sveriges Kommuner och Regioner, SKR, regarding state grants for medicinal benefits etc., the state's knowledge governance of medicinal prescriptions, the state's supervision over medicinal prescriptions that entail patient safety risks, and the state's supervision over incorrect use of medicinal subsidies, which we have discussed previously.

The Riksrevisionen's overall conclusion is that the state's governance of and supervision over pharmaceutical prescribing is not effective. This should make anyone step back and reflect on what we should do more. At the same time, it is noted that there is municipal self-government in the regions, that the regions are the primary providers of health and medical care, and that the regions need to coordinate and streamline governance to reduce regional differences in pharmaceutical use. And that is the case: there are large differences, regardless of what has been agreed upon. It matters where you live and who you are.

The National Audit Office assesses that the state grant is not an effective steering tool. In that case, we must begin to consider what we should do, as this does not seem to work one hundred percent.

The state's governance and supervision shall focus on cost-effective pharmaceutical use. The word cost-effective can be discussed. The important thing, of course, is to save people's lives. Regardless of whether I live in Ångermanland or Stockholm, I should have the same conditions to obtain the medicines that allow me to have a good life and live longer. Given the SD-dependent government's minimalist investments in healthcare, I am a bit worried that this could become a problem. We are looking forward a short period, two years, but we also have a long-term perspective.

The question of the state subsidy's construction has been the subject of many investigations, the latest of which was submitted in 2018. We believe that a new pharmaceutical investigation is needed to review the whole, including the pharmaceutical benefits. A broader approach must be taken regarding which medicines are given to which patients and whether healthcare providers and pharmacies are involved. Everyone must be included in such an investigation.

Vänsterpartiet also wants to see a state fund for medicines and treatments that are expensive, which we have motioned for. We believe that the state should take over this cost, and this will probably be discussed moving forward.

The goal should be a cost-effective model with a focus on equal access to medicines throughout the country, where the potential of the medicines ensures that more people can receive help. The government says that they intend to return with proposals for measures in the near future, which feels a bit stubborn. But we shall have to wait and see.

I vote in favor of reservation 2.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Dan Hovskär (KD)

Mr. Speaker! I begin by expressing my support for the committee's proposal. The Christian Democrats stand behind the committee's position in the report on the National Audit Office's report on prescription of medicines - the state's governance and supervision. We agree with the committee's assessment that the motions should be dismissed, among other reasons with reference to the ongoing work being carried out within the government. The report addresses issues concerning the prescription of medicines and the National Audit Office's observations in connection with the report on the state's governance and supervision.

For us Christian Democrats, it is important with a good and secure prescription of medicines. It is also important to stop the incorrect use of medicine benefits and to stop the incorrect payments. It is of the utmost importance that medicines are prescribed in a correct way to the persons who have the right to them and to prevent errors that lead to very negative consequences. The Christian Democrats also believe that it is important that authorities, such as the Health and Medical Care Responsibility Board, HSAN, work to reduce their processing times. It is important so that an efficient and legally secure processing can take place.

Mr. Speaker! The Christian Democrats and the government welcome the Swedish National Audit Office's review and consider the report to constitute an important basis for the government's continued work with governance and supervision regarding the prescription of medicines. The government agrees in principle with the Swedish National Audit Office's observations and assessments.

The Swedish National Audit Office recommends that the government, among other things, transfer the state grant for pharmaceutical benefits and such to the general state grant for regions within the appropriation for municipal economic equalization and clarify the agencies' supervisory responsibility for the incorrect use of the pharmaceutical benefits. The government should also investigate how incorrect use of pharmaceutical subsidies can be prevented and how the regions can be reimbursed for incorrect payments. Furthermore, the government should clarify the rules for the allocation and withdrawal of workplace codes.

The Government should also give the Health and Social Care Inspectorate, IVO, the opportunity to use the data on prescriptions of special medicines and other medicines that are needed to gain knowledge about deviating prescription patterns and risk individuals before and during the supervision of the medicine prescribers.

The Government should also investigate the possibilities for HSAN to shorten processing times or alternatively give Ivo the opportunity to withdraw or limit the prescription right interimistically during ongoing supervision.

Regarding the recommendation to change the construction of the state grant, the government considers that the issue needs further analysis. The government and Kristdemokraterna argue that this proposal requires careful consideration. The issue is now being prepared in the Government Offices.

The Government is to return in the near future with proposals on measures in this area. It may, however, be good to know that in September this year, the Government decided on a review of certain issues regarding documentation, limitations, and supervision concerning medicinal prescriptions.

There is, therefore, an ongoing process in these matters, and I agree with the government and the committee in the assessment that the Riksdag does not need to take any initiative on the grounds of the motions and that they should be rejected.

Mr. Speaker! It is of the utmost importance that medicines are prescribed in a correct manner to the people who are entitled to them and that we prevent errors that lead to very negative consequences for the individual. These issues are important from many different perspectives. For us Christian Democrats, it is therefore important with a good and safe prescription of medicines.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Mikael Dahlqvist (S)

Mr. Speaker! I thank Member Hovskär for the speech. I am convinced that the Member is interested and committed and considers these issues to be important.

I am, however, a bit surprised by the rather large difference between what one says and what one does. I think a Ferrari is a nice car, but I cannot afford to buy it. But if it were very important to me, I would see to it that I have the money so that I can buy a Ferrari. This can be a metaphor for the government parties and their support in healthcare issues.

Mr. Speaker! During the previous parliamentary term, an announcement was made that the Christian Democrats pushed hard for. It concerned rare diagnoses, which is an immensely important issue, and that special funding was needed for medicines for this patient group. It concerns a small group and narrow specialist competence, which makes the medicines expensive. But then, when one heard the government's statement and read the government's budget proposal for next year, it was completely absent. The entire funding issue for this sector is absent.

A large part of healthcare is pharmaceutical costs, which is now becoming burdensome. My question to the member is therefore when the Christian Democrats intend to contribute to the development of a specific financing for pharmaceuticals, and in the issue you have specifically championed, namely rare diagnoses.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Dan Hovskär (KD)

Mr. Speaker! Thank you, Member Mikael Dahlqvist, for the questions!

The Christian Democrats and the government are working on financing the pharmaceutical issues in a broad way. We are looking, among other things, at the investigation regarding the state taking half the cost and the region half, and seeing what can be reasonable. Should we transfer money to a general state grant?

We are also looking at and working on the costs for special medicines. We see that there are certain small groups that have incredibly high costs and need special interventions. It can be about life-saving medicines for a few individuals. We have that issue, and it is very complex. As said, it can apply to a few. The issue is being prepared, and it is being looked at how one can move forward. It is one of the issues that is being worked on. The answer I can give to Mikael Dahlqvist is therefore that it is an important part of the whole.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you, Member Hovskär, for the answer!

I share the member's description, except on one point - perhaps the most essential in this entire debate - and that concerns how medicines are financed.

Here and now, I do not see an extra krona for the regions, especially for high-cost drugs for a small group. It has nevertheless been the Christian Democrats' heart issue, which they pursued extremely profitably during the last parliamentary term.

Mr. Speaker! My question to Member Hovskär remains. When will the funding arrive until we have solved the problems with transparency, principals, and who is responsible for various occurrences regarding the prescriptions? We need to see an action plan here and now. How does the Member think regarding the essential question?

The speech at riksdagen.se, in Swedish (opens in a new tab)

Dan Hovskär (KD)

Mr. Speaker! Member Dahlqvist probably needs to look at what the Social Democrats write about pharmaceutical costs displacing other healthcare. That is your first important point. We do not see it in that way. We see it as a whole.

We believe that medicines are good for healthcare as a whole to function and that they also help to reduce the number of operations and other suffering. We try to look at this as a whole.

The Speaker is talking about what the government is doing regarding healthcare. We have put in a lot of work to provide various resources from the government's side. We have made historical investments. This year alone, 9 billion is being invested in healthcare, where the government gives the regions the conditions to handle the current situation. Both the Christian Democrats and the government are investing in healthcare, and I feel secure with that.

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Anders W Jonsson (C)

Mr. Speaker! The National Audit Office has reviewed how the state manages the use of pharmaceuticals in Sweden and has come up with no fewer than six proposals. The government thinks four of them are good, and I agree. But the National Audit Office's first proposal is quite unreasonable.

As it stands today and as it has been since the 90s, the cost for pharmaceuticals in Sweden, which is on the order of 100 billion, is shared between the regions and the state with half each. The strange thing about this system is that the one who decides where the bill should be sent is the individual doctor. If medicines are prescribed, it is the state that pays, but if the doctor tells the nurse to order a medicine that the patient can then receive at the clinic, it is the region that is to pay. Time and again, it has been proposed that the entire cost should move over to the regions, but the regions say an absolute no to that. And now the National Audit Office returns with the proposal that the regions should take the entire cost. It is a dead proposal. It will never happen.

Instead, one should look at another model, namely that the state takes over the entire cost. In that case, the state would also have a much better opportunity to control the use of medicines in Sweden and ensure that everyone in the country has access to the same medicines, regardless of whether they are expensive or not. It would not be as it is today, where in a poorer region one cannot afford to prescribe certain medicines.

The second thing I find a bit strange in the government's handling of this concerns the problem we have in Sweden where a few doctors earn quite substantial sums of money by prescribing narcotics to people with drug addictions. They can, in principle, be paid per tablet. It is very difficult to get at. Some pharmacist must, in that case, discover the strange prescription pattern and report it to Ivo. But that could easily be solved because we have a central medicine register where all prescriptions go.

If the E-hälsomyndigheten in Kalmar could perform a run once a month to see which doctors in Sweden prescribe an unreasonable amount of narcotics and then send the results to Ivo, they would immediately see who prescribes perhaps ten times as much narcotics as others do. If it concerns a cancer doctor who is caring for severely ill patients, it is of course only a matter of showing consideration for that, but against those doctors who have their own office in Östermalm in Stockholm and make a living from this, one could intervene immediately. It is a proposal that Ivo has had for many years.

Mr. Speaker! It is strange that when it comes to precisely that proposal, the government says that it really must be thought through because it could be an infringement of privacy. For whom? Would it be an infringement of privacy for the doctor who is essentially committing a criminal act and prescribing narcotics to people with drug addictions? That, Mr. Speaker, is a very strange prioritization from the government that says it wants to tackle crime.

We have just heard KD say that it is important with a correct prescription of medicines. But when it comes to accessing these people, one thinks it is very important to consider and reflect on whether it cannot be an infringement of privacy for the small group of doctors who misbehave.

Mr. Speaker! In view of this, I would like to move for the approval of the Center Party's reservation 3.

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Lina Nordquist (L)

Mr. Speaker! Medicines can absolutely be costly. That is something the Social Democrats spend a lot of time worrying about in their reservation. But medicines are, above all, absolutely fantastic.

There was a time when every third employee at the Akademiska Hospital was a priest. That was because there wasn't much to do for the patients at that time. Today we have medicines that let people stay at home instead of in the hospital and at work instead of in bed. One can get medicines instead of other healthcare and instead of, for the most part, nothing other than care and empathy.

Before the stomach ulcer medications arrived, surgery was the only possibility, and it did not go particularly well. Before the biological medicines arrived for, for example, rheumatism, sick leave was the most common. That was the case for many years. Before new cancer drugs arrived and before medicines for rare diseases began to appear, death was unfortunately the only thing many people had to wait for.

In short: We need new medicines. We need the ones we have today, and we need those that will come tomorrow, next year, and the years after that. Take, for example, ATMP, advanced medicines based on cells, tissues, and genes, where there will be a revolution when it comes to preventing infarcts, fighting blood cancer, and ensuring that immune deficiency diseases no longer destroy people's lives.

We shall not avoid the fact that pharmaceutical costs are displacing other health and medical care, as the Social Democrats say. We shall not do that at all. It is very good if we can have these medicines instead of other, non-functioning care. On the other hand, we need to ensure that incorrect prescription and incorrect use do not take away the resources that sick people need to receive the right treatment.

The incorrect use of subsidies definitely needs to decrease. The rules for the allocation and withdrawal of workplace codes must absolutely be reviewed. There should not be a mass of scammers in the system, and we must put a stop to these people. Ivo's supervision must be effective, but it must, of course, take place without sensitive register data leaking out so that people do not get caught in the crossfire.

The processing times at both Ivo and HSAN need to be as short as possible, again without compromising patient safety or legal certainty. It may also happen that the state grants need to be changed in some way, but it is a difficult process. We do not want to create obstacles for the patients in this. The Government is working on these matters in the Government Offices.

I say yes to more fantastic therapies but, of course, no to nonsense and cheating in healthcare. I therefore move for approval of the committee's proposal. It is very good that things are underway that can give people a better life.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much, Lina Nordquist, for your speech!

I am wondering if the member and I have read the same motion reservation in this matter. In our proposal, it is clear that we want cost-effective use of medicines. I hope that the member agrees with us that every tax krona should go to what it is intended for.

We also write something that the member did not mention in their speech, namely that we want to review the whole to be able to secure cost-effective medicine use so that all patients who need it can benefit from this in the entire country. It is a fairly significant difference.

As I have said earlier in both replies and speeches, we handle the cost increase in a significantly safer way. We ensure that the regions have resources by allocating significantly more than the government and the Liberals do in their budget proposal.

Mr. Speaker! I have a question for Member Nordquist. I know that the Member is passionate about and incredibly committed to these issues. I welcome that. But the Member belongs to the Liberals, who are now part of the government, and there we clearly see that the prioritization of the healthcare system's economic development and thus the prescription of medicines is zero. We already see displacement effects in some regions today because the economy is not good enough to be able to prescribe new potent medicines.

My question to Lina Nordquist is the following: How do the Liberals and the government intend to handle the situation we have here and now and not just wait for investigations?

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Lina Nordquist (L)

Mr. Speaker! I am a bit taken aback when we have such different descriptions of reality. In the Sweden where I live, the state intervenes and provides support when things are tough in healthcare, but it is the regions that have the right to tax, that govern healthcare, and that fund healthcare.

I see quite clearly that every time the Social Democrats are in power, many people are waiting for care but fewer are receiving care, and it is very few who get to work with and start their own care and help patients privately, not region-driven.

For my part, the principle of need is among the most important in healthcare. In that case, it is not just about cost-effectiveness but also about ensuring that there are healthcare clinics all around in every region and that there is an opportunity for people to thrive at work and provide care to the patients.

I cannot quite understand what the government is doing that is more business-friendly, also when it comes to developing new medicines and implementing these in people's reality. I have never seen so many assignments to TLV, for example, as during this government's time, to ensure that we get the best medicines into our country for patients.

Even though I understand that the member has more questions and is not the one who is to answer here, he is welcome to describe to me in what way the development of future medicines will become better with a Social Democratic policy. It exceeds my understanding.

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Mikael Dahlqvist (S)

Mr. Speaker! Thank you, Lina Nordquist, for your answer, or lack of answer! My simple question was and is, once again: How do the Liberals and the government's representatives here in the Riksdag intend to handle the financial catastrophe that is now prevailing in Swedish health and medical care?

Right now, approximately 2,000 employees in Swedish health and medical care are at risk of being laid off. Many have already had to leave. Several regions are raising taxes, and there are red figures next year. This matter of using the tools at the regional level, which the member advocates for, is being done, but the problem is that the fund is too small in relation to the cost development over many years.

The prescription of medicines will be affected by this. This is my simple thesis: It is the money that rules. It will then be interesting to see how the government intends to handle the situation we have here and now. How is it to be financed?

I welcome all investigations and that the system is being reviewed. We share the same view regarding the fact that this is needed, even if we Social Democrats perhaps have a broader perspective. As a Social Democrat, I feel proud of and satisfied with our budget proposal. We increase the funding for welfare, especially when it comes to healthcare, in contrast to the government, which chooses to lower taxes for wealthy high-income earners.

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Lina Nordquist (L)

Mr. Speaker! Yes, what is the government doing to change the situation with long queues and unequal care across the country, which was the reason why I entered Swedish healthcare policy more than ten years ago? The government is doing a lot, I would say.

The government ensures that dental care is secured for people who are older and who have the greatest risks. The government works on opportunities for better competence supply and better opportunities to retain people through a good working environment at work so that one avoids searching with a candle and a lantern for nurses without finding a single one.

The government is working with announcements from the previous parliamentary term that we in the Liberals stand behind. There, we said that one must be given the opportunity to further their education in the workplace. One should be able to feel content. It cannot be that administration is what eats up one's time when what one wants to do is to use knowledge and commitment for the patients.

Just as Mikael Dahlqvist says, the government also has a different tax policy than the Social Democrats. The government's tax policy is not about every person paying as much tax as possible, but about us collectively bringing in as much tax revenue as possible. In that case, it is not only what each individual pays that matters, but also how many of us are working and how many hours people work. If more people enter the workforce, we can all pay less. If we pay less, we can consume, and this also generates a lot of state tax.

Member of Parliament Dahlqvist and the Social Democrats can have their tax policy and their healthcare policy for themselves. I am proud of the government's tax policy, and I am proud of our healthcare policy. I hope that we will finally see the queues decrease so that people receive care instead of worry and waiting.

(Applause)

The deliberation was hereby concluded.

(Decisions were made under § 11.)

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