The National Audit Office's report on the state's supervision of pharmacies and wholesale trade of medicines

Christian Carlsson (KD)

Mr. Speaker! Today we are debating the government's communication regarding the National Audit Office's report on the state's supervision of pharmacies and wholesale trade of pharmaceuticals. The overarching question for the report is whether the state's supervision is effective.

To begin with, I want to say that we Christian Democrats are fundamentally very proud of the pharmacy market that exists in Sweden today. When the Christian Democrats took responsibility for the pharmacies in 2006 during the Alliance years, Sweden was at the bottom of the OECD when it came to the number of pharmacies per inhabitant. It was against that background that we carried out a deregulation of the pharmacy market in 2009 with the goal of ensuring a secure and good pharmaceutical supply for everyone.

The Swedish National Audit Office's report on the state's supervision of pharmacies and wholesale trade of pharmaceuticals

This is still a relatively young market. Of course, there are still things that could work better. But all around the country, there are today pharmacies with generous opening hours and knowledgeable, highly educated staff. Citizens have a high level of trust in the pharmacies.

Since the deregulation of the pharmacy market, the pharmacy density and availability have increased. Figures from the Swedish Pharmacy Association's industry report 2021 show that the number of pharmacies has increased from just over 900 in 2008 to over 1,430 today. This represents an impressive increase of a full 54 percent.

We Christian Democrats would like more people to have the opportunity to start and run their own pharmacies. We want to see more companies that can offer new services to all the country's patients. But it is, of course, a matter of being able to secure both quality and accessibility.

That is why an effective supervision of pharmacies and wholesale trade of medicines was needed. It is important so that we can address irregularities and actors who do not meet the requirements of the law, which ultimately risks affecting the patients.

But it is also important because the opposite, ineffective supervision, leads to pharmaceutical benefits and other subsidies being utilized in a completely wrong way. It also means a waste of the taxpayers' money.

Against this background, the Christian Democrats, like the government, have welcomed the National Audit Office's report. We share the conclusion that the supervision that the state carries out over pharmacies and wholesale trade with pharmaceuticals needs to become more effective.

It is particularly important that the supervision functions better in light of the government's increased ambitions to strengthen the role of pharmacies in the care chain so that we can relieve primary care and utilize the competence that exists among the staff at our pharmacies.

It should also be seen in light of the fact that the pharmacies and the wholesale trade will be given an ever-increasing responsibility moving forward to ensure Sweden's supply preparedness in these dark times of crisis and war in Europe.

The Christian Democrats agree, in the first instance, that a possibility should be introduced for the supervisory authorities to divide tasks to a greater extent than today within the framework of the pharmacy supervision.

Even though the question of how the exchange of information should be regulated needs further investigation, it is good that the government in the letter is clear with the assessment that the report can serve as a starting point in the development of such a regulation.

Secondly, we share the assessment that there are grounds to introduce an expanded reporting obligation for the E-health Authority in order to streamline the supervision. Large amounts of data are to be handled. This naturally requires thorough analysis. It is very privacy-sensitive data that is to be handled, but we share that policy direction.

Thirdly, there may also be reason to consider whether provisions should be introduced to prevent pharmacies from charging excessive prices on medicines that are not included in the pharmaceutical benefits but are nevertheless subsidized by the state or the regions.

However, it is necessary that the consequences are investigated very carefully so that measures are not taken with good intentions that ultimately worsen accessibility for those who are in need of medicines.

In conclusion, Mr. Speaker, it is good that the government opens up for allowing TLV and the Medical Products Agency to levy sanction fees to a greater extent than what can be done today, with the aim of achieving more effective supervision.

It feels reassuring that the issue of more effective supervision of pharmacies and wholesale trade is also pointed out as a priority for the government. The government intends to closely follow the work that is already ongoing at the departments.

We in the Social Affairs Committee will have reason to follow the government's work with a more efficient state supervision of pharmacies and wholesale trade with pharmaceuticals. With that, I move for the approval of the Social Affairs Committee's proposal in the report.

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

Karin Rågsjö (V)

Mr. Speaker! Christian Carlsson is absolutely jubilant about the deregulation and how it turned out. I believe those who are happiest are probably the large companies that stand behind the pharmacies.

When you deregulated and were in government, there was a dream scenario that you spread. It was supposed to be the small pharmacies that would flourish across Sweden. Now it didn't quite turn out that way. Very many could have calculated that. There is a lot of money to be made here and a lot of business.

And with the deregulation, the pharmacies have ended up more in shopping centers and in inner cities. Myself, Mr. Speaker, can reach five different chains within 500 meters. Still, we are quite healthy in the inner city while it looks significantly worse in other parts of Sweden where very few of the private pharmacies want to open their store.

Mr. Speaker! I wanted to ask the member if there are more thoughts on this. How are the pharmacies to be spread to the rest of Sweden? How is it intended? It cannot be that there will be a horde of pharmacies in the inner cities with the large chains and very few in the countryside.

Mr. Speaker! I also want to say that one could have influenced Apoteket AB by speaking with them and ensuring that they increased [their supply]. The problem is that the state somehow loses the pharmacies from its toolbox. One cannot control the private market in that way.

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

Christian Carlsson (KD)

Mr. Speaker! Those who are most pleased with the deregulation of the pharmacy market that the previous center-right government stood for are, naturally, those in need of medicines. They were hit hard by the fact that we had such low accessibility to pharmacies before the reform. This applies to all those people who have seen how the number of pharmacies has increased by 54 percent between these years, as I previously described.

It is worth pointing out that all counties have received more pharmacies. The number of pharmacies open on Sundays has also increased from 154 to 575. Additionally, all pharmacy chains today also offer e-commerce via internet pharmacies.

Of course, there are things that need to be improved. But overall, the increased accessibility means that it can be regarded as a very successful reform. It also shows the high customer satisfaction.

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

Karin Rågsjö (V)

Mr. Speaker! I still maintain that it is the shareholders in the large companies who are most pleased.

According to the Dental and Pharmaceutical Benefits Agency, TLV, it can now be seen that pharmacies in rural areas and near rural areas are decreasing. One can wonder how to fill that gap. I wonder if the government has any proposal for that. Perhaps the member has knowledge of that. It should be an incredibly important health issue.

Pharmacies do not sell just any goods. They are part of healthcare in some way. There is a risk if it becomes very unequal with pharmacies, if it becomes harder to get in contact with pharmacists and talk about one's medication, and if people receive less help. It can partly be a health hazard.

When looking at the report, one can also see that there is a risk that, through increased competition and so on, the number of pharmacies is being reduced. Then there are fewer opportunities to have time to speak with a pharmacist.

I would very much like to see that there was some kind of plan for how to rectify it and simply make it better, Mr. Speaker.

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

Christian Carlsson (KD)

Mr. Speaker! People need to have access to equal care of good quality throughout the country, and people across the country need access to medicines and a presence of pharmacies. That is how it is.

It was actually the Christian Democrats who introduced a rural area support to ensure access to physical pharmacies in the countryside during the Alliance years. The rural area support still yields better results today when it comes to presence in sparsely populated areas. But from our party's side, we are of the opinion that this needs to be continuously followed up and reviewed, because we need to increase the access to medicines for people in the countryside. In that case, for example, an update of the rural area support could be something to look further into.

We share the ambition to make things even better regarding this successful reform, which, after all, has increased the availability of medicines for people in need of them.

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

Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much, Christian Carlsson, for the speech! I also intend to build upon Member Rågsjö's points regarding the semi-privatized pharmacy market.

I share the member's view that there has been higher accessibility and better opening hours in large and medium-sized cities. I do not, however, Mr. Speaker, share the member's view of how it looks in rural areas and in sparsely populated areas. I myself come from a small municipality in the middle of Värmland called Hagfors. There we still only have one pharmacy, and there will not be more. And that is how it looks in large parts of Värmland. Where the development has moved forward, Mr. Speaker and Christian Carlsson, is for example in Karlstad. That city has received more pharmacies.

I therefore think that one should have a more sober view of what effects the reform will have. Christian Carlsson is aware that the market does not solve the rural problems because a rural area support has been introduced. Support from society is therefore needed.

Mr. Speaker! My question was actually another. In connection with the deregulation of the pharmacy market, the pharmacies' responsibility for pharmaceutical issues also disappeared. This came up partly in the report that we are debating today. It was Apoteksbolaget AB that had the assignment to have a warehouse for the pharmacies, partly to be able to serve patients who have prescriptions, and partly to function in times of shortage and crisis. My question is: How do you view such a development – having a centralized warehouse?

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

Christian Carlsson (KD)

Mr. Speaker! First, I must admit that I am a bit confused when the member claims that he does not share my view regarding how the situation looks in rural areas and in sparsely populated areas. What I said was that there is still potential for improvement when it comes to how the pharmacy market functions.

The need to increase the accessibility of medicines for people living in rural areas and in sparsely populated areas was something that I confirmed. I also pointed out several conceivable proposals for how we could improve the situation, and I mentioned the rural support in that regard.

We therefore seem to be in agreement, on the contrary, that we need specific initiatives to ensure that the availability of medicines is equitable throughout the country.

Regarding the supply preparedness, it is something where Sweden has needed to do its homework. Responsibility for crisis preparedness and for defense preparedness has not been taken in this country for very many years. There is a need to improve the availability of medicines when it comes to supply preparedness; it is crystal clear. We will also contribute to that during this parliamentary term.

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

Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much for the answer, Christian Carlsson! I do not think we misunderstood each other, but my starting point in the discussion was that I concede that there are partial advantages with the privatization of the pharmacy market. But I interpreted your statement and your answer to Member Rågsjö in the previous exchange of remarks as that you were satisfied with how it looks across the entire country.

My assertion to you, Christian Carlsson, is rather that we in sparsely populated areas and in the countryside do not see any improvement from this market regulation. That is, unfortunately, many times; the market is an incredibly good servant as long as one has a foundation and makes money.

My point of entry into this is that it also shows that the state must take a responsibility. I believe that we must take a greater responsibility for both the pharmacy market and perhaps also other activities in the future.

Mr. Speaker! When it comes to the crisis preparedness or the stock preparedness that Apoteksbolaget previously had, it became unfortunate here. This cannot be blamed on any single government, as several governments have ruled since then, but it is a problem.

Another problem was - and it is still a problem even though we have come a bit of the way - the pharmacies' supply and the possibility of obtaining medicines. For a period, there was even a shortage of insulin and certain other medicines when one presented their prescription, and different pharmacies could not borrow from each other or speak with each other. It has become better - I must be honest and say that - but it is still a problem.

My entry point regarding Christian Carlsson is that it is not only praise when it comes to the deregulation of the pharmacy market.

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

Christian Carlsson (KD)

Mr. Speaker! We must be satisfied that all counties have received increased access to pharmacies. Then, Member Dahlqvist is entirely correct that this will not benefit rural areas and sparsely populated areas as much as other parts of the country.

We predicted this already when we governed last time, during the alliance years, when we introduced the rural area support. Obviously, it has not had sufficient effect, but it is still something that contributes and something that may need to be developed further. That is the Christian Democrats' view.

Even though I describe the reform as a very great success, which it is, we Christian Democrats also realize that rules were needed in a market. One area where more regulation was needed is ensuring the supply preparedness. A government bill will be submitted to the Riksdag during the spring concerning exactly how the pharmacies and the wholesalers of medicines can take a greater responsibility for storage and so that we have access to medicines.

This is an area that needs to be improved as it is now, when there is no crisis and no war, and that says something about what a great challenge we have ahead. We will come with proposals in the area, and I look forward to a constructive cooperation so that we get the pieces in place and can take a joint, larger responsibility for the supply preparedness in Sweden.

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

Mikael Dahlqvist (S)

Mr. Speaker! Today we are, as mentioned, debating the Swedish National Audit Office's review and report on the state's supervision of our pharmacies and of the pharmacy market in general when it comes to pharmaceuticals.

There is every reason for us to have careful control over cost development and availability of medicines for our citizens.

Mr. Speaker! When it comes to the cost development that Sweden has had in recent years, the latest figures I have seen before my speech concern the difference between 2019 and 2020. At that time, costs rose by approximately 2 billion kronor. The total bill for the state's costs, including regions, is 32.6 billion kronor. It is therefore a fairly large cost item in our budget system.

It is important that residents in Sweden have access to modern, safe, and purposeful healthcare in an equal manner throughout the country. The same applies to the availability of new medicines, which represent great opportunities for the patient. At the same time, there are great challenges with ever-increasing costs for new medicines and access to new treatment methods across the entire country.

Mr. Speaker! The Swedish National Audit Office's overall conclusion is that the supervision that the state conducts over pharmacies and wholesale trade with pharmaceuticals is not effective. The Swedish National Audit Office notes that the ultimate consequence is that patient safety suffers and that the state's and the regions' expenditures become unnecessarily large because pharmaceutical benefits and other subsidies for pharmaceuticals can be misused.

In the report, the Swedish National Audit Office has a number of recommendations on what should be addressed by the government to increase control and achieve better efficiency. Several measures that are now recommended have already been initiated by the previous S-led government. Now we must hope that the new government continues to work on the proposed measures and strengthens the supervision and efficiency so that the taxpayers' money is used well.

A number of proposals for measures from the opposition in the committee report would provide better opportunities for streamlining and safer pharmaceutical management, Mr. Speaker. Unfortunately, the majority in the committee chooses to reject the motions from Vänsterpartiet, Miljöpartiet, and C. We Social Democrats have chosen to stand behind some of these proposals, which we believe will give the state better tools to, via the supervisory authorities, have control over the pharmacy market.

It is worth highlighting the Swedish National Audit Office's observation that the cooperation between authorities is limited or hindered by our secrecy legislation, which makes it difficult for the supervisory authorities to share information with one another. Here, the government should develop proposals for secrecy-breaking provisions that enable increased exchange of information between the authorities. The government also agrees that the supervisory authorities should be able to share more information with one another. One might ask whether the representatives for the government parties and the Sverigedemokraterna do not share the government's opinion, since a rejection of the motion from C, which aims precisely to provide better information exchange, is proposed.

In conclusion, Mr. Speaker, the National Audit Office notes that the deficiencies in control can also have consequences in the form of unnecessary costs for the state and the regions. One example is overprices on special food for children and on medicines that are not included in the pharmaceutical benefits but are subsidized by the state or the regions. Here it is important that the government promptly handles the previous government's review of the subsidization of special food for children.

The government should also ensure that the possibilities for exchange between medicines are expanded. There is potential to replace more original medicines with both biosimilars and generic medicines. If there is an opportunity to achieve lower costs for society and for the individual citizen with the same safety and quality requirements, I see no reason to delay legislative changes that enable this.

I move for approval of reservation 3 under point 2 regarding overprices on medicines.

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

Jesper Skalberg Karlsson (M)

Mr. Speaker! Thank you, Mikael Dahlqvist, for the speech, which also clarified why one stands behind the other parties' motions! My questions are about exactly that.

My first question concerns reservation number 3 regarding overprices on medicines and special food for children. The previous government appointed an inquiry last summer on precisely overprices on special food for children. I thought that was good. But now they want a new large inquiry and review of also many other medicines. Then a natural question arises as to why it wasn't done from the beginning. Was it that the previous Minister for Social Affairs was blind to the problems that are seen now? Or was it a rebellious coalition partner in Centerpartiet who said that you absolutely must not investigate this? What was it that made it so that one didn't take this large step from the beginning, if it is so important now?

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

Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much for your question, Jesper Skalberg Karlsson!

I clarified in my speech how the Social Democrats thought regarding overprices on medicines. It was good that the previous government took the initiative to investigate the issue of special foods for children. I also assume that the current government will handle it in a positive way when the report arrives.

But there is also reason to review the competition in the pharmacy market generally when it comes to medicines and medicinal products, Mr. Speaker. In that regard, I am thinking primarily of the fact that, as I explained in my speech, there are several reports showing that it is possible to substitute original medicines in an even more efficient way. We are good in Sweden at this with the "medicine of the month," and the pharmacies ask customers if it is okay to switch. But we are not good at switching what are called biosimilars, which are biologically similar medicines. There, it has been estimated that there is potential to save up to half a million per year. That was why I felt there was reason to stand behind the Miljöpartiets motion.

That the previous government did not act, I believe simply stems from the fact that it acted in many other issues, and then the pandemic appeared. It was surely about a lack of time and a lack of investigative capacity. Several matters that will come to the Riksdag in the future concern exactly crisis management. Many investigations have been initiated and are ongoing that the new government is now to handle. It was about prioritizing among the masses of measures that the previous government needed to do.

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

Jesper Skalberg Karlsson (M)

Mr. Speaker! I thank Mikael Dahlqvist for the answer. I agree that the amount of investigations and questions one can prioritize is limited. This is also what my second question is about.

I have read reservation number 1 on improved control and sharing of information, which I think is an interesting reservation. The new investigation on pharmaceutical statistics was published in January this year, but despite the fact that many of the proposals mentioned in the reservation are also addressed there, the reservation suggests that the government should promptly prepare the issue and return to the Riksdag with proposals on necessary legislative amendments etc. – i.e., new investigations that we have actually already conducted.

Then the question is: If this is to be prioritized, what should be deprioritized? When I look at the opposition parties' budget proposals from last autumn, I can observe that not all of them include increased resources for the Government Offices. On the contrary, they propose reductions. Then the question is: Where are all these resources for the investigations that are proposed, and which have actually already been carried out, to come from?

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

Mikael Dahlqvist (S)

Mr. Speaker! Thank you very much for your question, Jesper Skalberg Karlsson!

It is not my business to judge how the government should prioritize its investigations. I do not even have insight into how one prioritizes. If one considers that there are important investigations and important proposals to be taken, one must prioritize ahead of money. That is something we are usually quite good at, regardless of which government is in power.

I understand your question, Jesper Skalberg Karlsson, but I am still a bit surprised. I think you in the majority parties should have supported this motion because it is about the same thing. We also want to promptly achieve, among other things, this regarding confidentiality-limiting measures. The government itself is favorably disposed in its response. Just as the member says, we have also received reports that this was needed.

Our reservation simply aims to put the government on blue lights so that action is taken quickly and effectively. That is the primary purpose. We look forward to results.

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

Anna-Lena Blomkvist (SD)

Mr. Speaker! Every day, approximately 390,000 people visit a pharmacy in Sweden. That means 140 million visits per year.

In 2009, a deregulation of the pharmacy market was carried out. As a result, pharmacy density and accessibility have increased. According to the report presented by Sveriges Apoteksförening in 2022, the population has gained closer proximity to pharmacies as we now have just over 1,400 pharmacies. This is an increase of over 50 percent since the deregulation.

Today, the population can also, to a large extent, purchase pharmacy products over the internet in the nine e-commerce pharmacies we have. It is a huge difference for the residents and meant a great relief during, for example, the corona pandemic.

At these pharmacies, which are more accessible due to having better opening hours and more options, one possesses great knowledge and has a large selection of both prescription and non-prescription medicines, as well as a large range of other products for our residents.

The Sweden Democrats safeguard the pharmacy industry's opportunities to provide the Swedish population with a safe, secure, and well-functioning pharmaceutical supply as a service. In light of the large increase in the number of pharmacies, it is extremely important for us that these pharmacies and actors are audited, so that we know that their work is carried out in a safe and correct manner, and that the cooperation between the Health and Social Care Inspectorate, the National Board of Dental Care and Pharmaceutical Benefits, and the eHealth Agency functions.

The National Audit Office's overall conclusion is that the supervision that the state conducts over pharmacies and wholesale trade with pharmaceuticals is not effective. This can lead to pharmacies and wholesalers operating businesses that do not in all parts meet the requirements of the legislation.

Mr. Speaker! The National Audit Office notes that the ultimate consequence is that patient safety suffers and that the state's and the regions' expenditures become unnecessarily large because pharmaceutical benefits and other subsidies for medicines are misused. This is serious. We must review these areas. Work is being initiated now and is already underway in several areas.

This report on the state's supervision of pharmacies and wholesale trade with pharmaceuticals clearly shows how sensitive and difficult this is. We are dealing with sensitive information. It concerns personal privacy. We must come up with a way that is secure for all parties.

Mr. Speaker! The Sweden Democrats support the committee's assessment and move for approval of the proposal in the report.

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

Karin Rågsjö (V)

Mr. Speaker! Pharmacies are truly important. It concerns accessibility, that there is medicine available, and that there is someone to ask about the medicine.

I live in the city center of Stockholm and have very close proximity to very many pharmacies. One could say that it is maximum accessibility for those of us who live in large cities and specifically if one lives in the city center.

After the decision to sell off Apoteket AB, new business models have emerged in order to increase shareholder value. There are different clusters and chains. A grocery store combined with a pharmacy is not entirely unusual. There are also healthcare companies with pharmacies and so on.

I consider that the public health aspect is pushed a bit into the background when the necessary cooperation between competing pharmacies cannot be carried out or when the flow of information regarding the availability of medicines is not openly reported. My view is that the focus today is on competition.

A Novus survey was conducted in 2020. It showed that just over six out of ten Swedes want to re-nationalize the pharmacies. It is not something that is currently topical, but we still want to conduct a review of the conditions for doing so. That would be interesting.

As was said, it did not become those small pharmacies, which were tried to sell in as a picture of how it would become. One was supposed to see family-owned pharmacies a bit everywhere. They must almost be said to have died out. It became, of course, instead the big dragons, with their capacity when it comes to economy, flow and so on, who could open large chains. You who pushed this through should have seen that.

Access to medicines must be secured even in rural areas. I think it is a bit naive to believe that market forces will fix it. That can be seen now. It is difficult for both rural and more sparsely populated rural areas when it comes to pharmacies. It is not where the pharmacies open.

Despite the fact that pharmacies' distance trade of medicines through e-commerce is increasing, there is still a great need for local agents. In the National Audit Office's report, Mr. Speaker, it is mentioned that there are risks of deficiencies in distance trade, partly in terms of the advice, of course, and partly in terms of the storage of medicines during transport.

According to the establishment analysis from the Dental and Pharmaceutical Benefits Agency, TLV, the number of pharmacies in rural areas, where access is already quite poor, is also decreasing, where it is worst. Access increases in cities, where access is already good. That is what happens when you let private actors loose where profit is the guiding principle. It is not strange. If I were the director of a large such company, I would of course try to maximize my margin. One has to be a bit self-interested when one stands outside the state - isn't that right?

The National Audit Office writes in its report that because the total number of pharmacies is increasing, especially in densely populated parts of the country, there are many more pharmacies that supervision must be exercised over. There have been some problems with that. And that is perhaps what we are discussing here today.

One can also see some rule violations. Specifically, small pharmacies have been responsible for it.

According to the Swedish National Audit Office, it can also be seen that there is no support or conditions to intervene against all pharmacies that have become profit-driven and where supervision is currently lacking, because there are so many of them. There is simply a lack of capacity to follow up. That is what we are trying to say here in various rounds.

One example is the cases where pharmacies charge unreasonably high prices for prescribed special food for children, because there is free pricing on such, and let the pharmaceutical benefits and the regions pay.

Another example of abuse that the National Audit Office describes in the report is when pharmacies take advantage of the fact that the regions in some cases are obliged to pay for medicines that are not included in the pharmaceutical benefits but are nevertheless subsidized. This can concern medicines prescribed according to the Communicable Diseases Act and medicines prescribed to persons who are mentally very ill and lack insight into their illness. As you know, there is free pricing on medicines that are not included in the pharmaceutical benefits. This can lead to overpricing. This has been seen on medicines for, for example, hepatitis B.

Mr. Speaker! The Swedish National Audit Office also highlights the risks that the advice in self-care and the safety in dispensing are not at their peak. This may be due to time pressure and high workload. It also concerns increased competition between pharmacies. Then one might do as everywhere else when one wants to save money, that is, have fewer staff members.

We mean that it is extremely important to look at this. The supervision must be tightened. To the people in this chamber, it sounds like it is already underway. I do not quite know if I should perceive it that way.

We want an updated plan and to look at how it is intended. What should the structure look like? And how are the supervisory authorities, which already have quite a lot to do, to strengthen the control over the larger number of pharmaceutical actors?

I vote in favor of reservation 1.

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

Jesper Skalberg Karlsson (M)

Mr. Speaker! It is always difficult when we in the chamber present individual examples and try to paint a picture of society based on them. But it is still charming that we, who come from different parts of the country, can provide our own stories about how the pharmacy market works for us specifically.

It is interesting to hear Karin Rågsjö talk about Stockholm's inner city. The closest inner city I have is Visby's inner city. It is not surrounded by tolls, but by a wall from the 1100s. There are no pharmacies there. They are scattered outside the city wall, on Gotland.

We have actually received more pharmacies since the deregulation. But that is not the most important thing for me, rather the most important thing is that the opening hours are so much better. According to the Swedish Pharmacists Association, pharmacies are on average open eleven hours longer per week than they were before the deregulation. That is excellent, because sometimes it simply needs to go fast, and then you want it to be open when you are near the pharmacy.

My question to Karin Rågsjö is: Is it not good that we have more accessible pharmacies today than before?

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

Karin Rågsjö (V)

Mr. Speaker! Jesper Skalberg Karlsson is trying to make it sound as if I have made this up and that what I am describing is my own story based on the views from Kungsholmen. That is not the case. This is something that TLV also says: One sees a decreased number of pharmacies in the countryside, where the availability is already worst, while the availability increases in the cities. That is how it is, and it is sad.

If one looks in the rearview mirror, I think that instead of the reform – now, this was long before I started working with politics – one could have conveyed to Apoteket AB exactly what was wanted, i.e., that the pharmacies should have increased accessibility for customers with Saturday, Sunday, and evening openings in the way the pharmacies we are talking about have today.

I belong to the faction here in the Riksdag that does not think that infrastructure for either health or electricity should be deregulated. It always ends with the customers paying a fairly high price, that it becomes unequal and that it is the market that rules. That is my view of this.

It is very good that they in Gotland have done exactly as the member describes. It is not the accessibility we are against, but that it becomes unequal across the country. The discussion before the reform was about it being small and family-owned pharmacies. But that did not happen, instead it became exactly as we predicted, namely large dragons entering the arena. The big dragons are not interested in establishing themselves further inland. I can say that.

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

Jesper Skalberg Karlsson (M)

Mr. Speaker! Thank you, Karin Rågsjö, for the answer! In her speech, Karin Rågsjö told us that she thinks it is a bit unfortunate, difficult and inconvenient that pharmacies are now located in connection with, for example, grocery stores or in shopping malls. Here, I believe there is a chance for us to reach a bit more agreement.

For example, I want life to be simple. If I take the car into town, it is nice if I can do my errands at, for example, Systembolaget, Coop, and the pharmacy at the same time. Karin Rågsjö's party is, in many respects, critical of car use and does not want me, when I come into town, to drive around and accelerate and contribute to emissions there. Isn't it then a fairly good idea that pharmacies are located where many people also move about? Then the pharmacies are accessible. They should be accessible, perhaps especially on those days when the broadband at home is down, because we country folk can also order things online.

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

Karin Rågsjö (V)

Mr. Speaker! I would not dare put the word "lantis" in my mouth. I would probably have to leave the Riksdag running. It is perhaps easier for Member Jesper Skalberg Karlsson to say so.

There is no abundance of shopping malls in large parts of Sweden. In the interior of Västerbotten, there is no abundance of shopping malls, but there is in the large cities.

If you shop at the pharmacy, you can sometimes also get a bonus in the store next door. It becomes a bit of a business over the whole thing. I am so incredibly old that I can think that a pharmacy is a pharmacy. A pharmacy is a place where one should be focused on medicine, be able to buy medicine, and be able to ask the pharmacist about the medicines one buys. In the report, it is obvious that that possibility seems to decrease precisely because of that kind of competition between the pharmacies.

When there is competition between different companies, one usually saves on the employees. Then there is a risk that there will be fewer people who one can ask about one's medication. In surveys, it is a number of people who say this. It has become harder to get concrete help.

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

Jesper Skalberg Karlsson (M)

Mr. Speaker! The new Moderate-led government has not come to a set table. The situation in Swedish health and medical care is serious. Long care queues, too few staffed care beds, and an unequal healthcare system are three major problems and challenges that deserve the attention of politics and a will for reform. Now is the time to get the healthcare system in order for the sake of both patients and employees.

Mr. Speaker! Today's report regarding the National Audit Office's report is timely and provides guidance for a problem-solving government that wants the state's supervision of pharmacies and wholesale trade of pharmaceuticals to be purposeful and effective. Naturally, a great responsibility falls on the previous government when the National Audit Office finds that the supervision is not effective. It should, however, be noted that questions regarding sanction fees, confidentiality rules, and pricing are complex and require careful consideration.

Mr. Speaker! It is important that patients get access to the medicines needed to alleviate and cure. In this context, it is worth noting that the pharmacy industry has had a positive development since the deregulation about a decade ago. We have more pharmacies today than before in all counties, but above all, the pharmacies' average opening hours are longer today. According to Sveriges Apoteksförening's industry report 2022, pharmacies are open an average of eleven hours more per week today than before.

The security provided by open and accessible pharmacies should not be underestimated. But more can also be done to ensure that the shelves do not stand empty.

Mr. Speaker! The National Audit Office proposes that the supervisory authorities should be able to share information between each other more easily. The Government agrees with that assessment. It is important that authorities should be able to share information so that the supervision of pharmacies and wholesale trade becomes more purposeful and effective. Increased cooperation within the state is a priority. This has also been investigated previously, for example by the Treklöverutredningen.

But more needs to be done before such a change can come into full effect. During 2022, 88 million prescriptions were dispensed, which testifies to the scale of the pharmacy market and the amount of data that must both be handled and, above all, analyzed. Being able to guarantee that the information exchange then functions, not least considering sensitive information, personal privacy, and data security, requires continued preparation in the Government Offices.

Mr. Speaker! The question of pricing for products that are not covered by the pharmaceutical benefit but are financed by the state or the regions is also complex. Perhaps that is why the proposals from the 2017 partial report of the New Pharmacy Market Investigation have not been implemented in all parts. The points of view received in the referral testify that the regulations being proposed will not necessarily lead to the desired outcome.

The new government, however, argues that there are reasons to consider regulations that prevent pharmacies from charging excessive prices, for example when it concerns special food for children, and in that regard, we are waiting for the investigation that was mentioned earlier during the debate and which was commissioned last summer.

Mr. Speaker! In January this year, the Inquiry on Pharmaceutical Statistics submitted a report titled Access to sales data on human pharmaceuticals. That inquiry contains several proposals to create a long-term and sustainable legal regulation for the disclosure of sales statistics concerning pharmaceuticals. Also, the various actors' obligation to provide data to the E-hälsomyndigheten are addressed, as well as exceptions from statistical confidentiality and an expanded duty of disclosure for the E-hälsomyndigheten towards the supervisory authorities. It is good that the government is continuing to work on those proposals in the usual manner.

Mr. Speaker! The Tidö parties consider the work to streamline the supervision that the state conducts over pharmacies and wholesale trade to be prioritized. The Government is therefore closely following the work that is ongoing and in which we will also be involved. But we also want to do more on the pharmacy side. In the agreement that we have concluded between four parties, we also establish that the role of pharmacies in the care chain needs to be developed. We want, for example, that certain services such as health examinations, not just blood pressure checks, should be able to be offered at pharmacies. We will also come forward with proposals for a pharmaceutical range that shall be an intermediate position between over-the-counter and prescription-only.

The work to ensure available medicines for people throughout the country who need cure and relief now continues with renewed vigor.

I vote in favor of the committee's proposal for a decision.

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

Anders W Jonsson (C)

Mr. Speaker! When dusk falls over Stockholm, it is a pure pleasure to sit and listen to this debate. I was about to say that it concerns everything between heaven and earth. Perhaps it does not, but it concerns the entire pharmacy issue, whether pharmacies should be in shopping malls or in the countryside and whether we should nationalize them or how we should proceed.

Mr. Speaker! There is a great deal of this that I would like to comment on, but I intended to try to stick to the matter at hand. This is not the great pharmacy debate, but it is a debate about the Swedish National Audit Office's report on the state's supervision of pharmacies and wholesale trade of pharmaceuticals. There is enough in the report from the Swedish National Audit Office to discuss. It is very interesting. However, it does not come with anything that is actually new. The conclusion in this report is the same as the conclusion has been previously: that the state's supervision in this area is not effective.

Mr. Speaker! The reason for this is largely about the very strict confidentiality rules that apply within the entire healthcare area. Furthermore, it is in this area that three different state authorities are engaged in supervision. They are Läkemedelsverket, Ivo, and TLV. There is no one suggesting that these should be merged and that only one authority should be able to engage in the supervision of pharmacies, as these authorities do this based on completely different legislations and approaches.

However, it is a self-evident matter that it will not be effective in a situation where there are clear confidentiality barriers between the three authorities. That is why the Swedish National Audit Office's report emphasizes that something must be done here.

This is news to no one, but one can ask oneself why nothing is happening. It actually has nothing to do with political parties or which government we currently have, but I would like to say that it has to do with the very strong struggle between those who refer to the fact that healthcare needs to be able to function in an efficient way and those who say that confidentiality and personal privacy are more important than anything else.

It is obvious that the Riksdag would need to send a clear signal to this government, just as we have done to previous governments, that the issue must be resolved. It is not possible to postpone this to the future.

Mr. Speaker! The second example is almost even more obvious. In this area, we have perfect statistics, I would say, in that the E-hälsomyndigheten handles the entire prescription registry. They know exactly which prescriptions are dispensed, at what time, to which patient, who is the prescriber, and which pharmacy it concerns. But they are not allowed to share that information with the three authorities responsible for supervision. This has, Mr. Speaker, completely absurd consequences.

I will just take one example. We have in Sweden a number of doctors who earn a very good living by prescribing narcotics in very large quantities to patients. It is devastating. It should not be allowed to occur. They should be behind lock and key. E-hälsomyndigheten can basically monitor this on a daily basis: Now, there is a 75-year-old doctor in Östermalm who is prescribing enormous amounts of narcotics. But they are not allowed to pass this on.

One could imagine that Ivo could request statistics once a week. What does the prescription pattern look like among Sweden's 40,000 doctors? Who are those who prescribe abnormally large amounts of narcotics? And when one receives that list, one could sort out those doctors who, for example, provide palliative care for cancer patients, where one is supposed to prescribe a lot of narcotics. Then one could directly have supervision over those individuals who exhibit this behavior. But this is not allowed, depending on the fact that the E-hälsomyndigheten cannot release this type of information.

Even here, it would be beneficial if the Riksdag, in a motion, could tell the government that this must be resolved. I do not feel, Mr. Speaker, at all satisfied with what we now hear the current government parties say: Preparation is ongoing. We have investigated this, and there are proposals there. I have, in fact, been involved for long enough to know that the risk is obvious that this will get stuck in a discussion between, on one hand, the Ministry of Justice and on the other hand, the Ministry of Social Affairs, just as many of these issues have done.

Mr. Speaker! That is why we from the Centre Party, when we received this report, proposed a notice on precisely these two points. They are the ones that are the most serious. Unfortunately, we did not get a majority in the committee for this.

We have a reservation, and I would like to move for its approval. I am well aware that there is extensive documentation and that preparation is ongoing in the Government Offices, but I feel a sense of disappointment. Even this time, the important reforms could get stuck in the Government Offices, in discussions between the Ministry of Justice and the Ministry of Social Affairs. It would have been good, Mr. Speaker, if we in the Riksdag could have put our foot down and said: Solve this! We cannot wait for another number of years for it to be fixed.

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

Ulrika Westerlund (MP)

Mr. Speaker! Dear fellow committee members! It is very ungrateful for me to be the last speaker, especially after this committed speech from a person who truly is an expert in precisely this area. I would, however, like to say a few words.

In the National Audit Office's report, which we are discussing here today, it is very clear that the state's supervision in the area is not good enough or effective enough. The National Audit Office has several different proposals. The Government responds to the criticism and actually agrees with most of it, which has been commented on by several previous speakers. But, in our view, they do not want to proceed clearly or quickly enough.

The majority in the committee want to reject motions concerning, for example, improved control and on quickly addressing overprices on medicines. Some things are said to be in progress, and other things are so complex that they must be investigated further before anything can be done about them, and so on.

We have heard various examples of personal experiences of how the pharmacies function. I also live in Stockholm's inner city. I have plenty of pharmacies very close to me, but they do not always have the medicines that I want. I think that is connected to the deregulation. It is not so profitable to stock medicines that are not the most common. Therefore, they are not available in the four or five different pharmacies that are very close to me.

The questions we are discussing today are both about patient safety and about the fact that the state's and the regions' expenditures are becoming unnecessarily large. But they are also about the trust in the pharmacies. When one enters a pharmacy, one should not have to wonder whether deregulation has led to paying overprices for goods or to being pushed into something that one doesn't actually need, or whether the competence of those who work there is sufficiently high. Unfortunately, it is such questions that arise during pharmacy visits, and this report provides absolute grounds for that feeling.

We were against the deregulation of the pharmacies, and we were concerned about exactly the type of development that we have now seen. We see that the access to medicines in different parts of the country has deteriorated since the privatization. Medicines are not just any commodity, and we believe there are reasons to investigate whether the pharmacies need to be re-nationalized or if the rules need to be tightened to ensure that the right medicines are available at the pharmacy for those who need these medicines.

In our motion, we highlighted, among other things, that the government should return with legislative proposals that prevent pharmacies from charging excessive prices on medicines that are not included in the pharmaceutical benefits. We have talked about special food for children, but also this issue with excessive prices on medicines that are not included in the benefits is worth highlighting. It is, to say the least, sad that we have created a system where this occurs and that many resources need to go towards controlling how the pharmacies operate and towards curbing abuses.

It is positive that the government, in line with the National Audit Office, considers that there are grounds to consider this, but we would like to see a more clearly stated ambition and a slightly clearer concerted effort that one intends to move quickly with this so that we do not have a situation where overprices exist and burden the public's or private individuals' finances.

We also raised in our motion that we believe the government should ensure that the Medical Products Agency and the Dental and Pharmaceutical Benefits Agency are given expanded opportunities to issue sanction fees. The National Audit Office points out in the report that there is a limited possibility now and that it hampers the agency's supervision. Even the Medical Products Agency needs, according to the report, to be given expanded opportunities to levy sanction fees.

The Government writes that they agree with this in principle, which is of course positive. However, they want to investigate further. Here too, we therefore want to see greater clarity regarding the Government's intention to proceed with the issue in the near future.

We also raised the issue of error reports and the importance of these being made and followed up. Among other things, the report from the Swedish National Audit Office highlights the large difference in error reports between different pharmacies. This concerns both large differences in the number of reported deviating incidents in self-monitoring and Lex Maria reports. This has not been followed up in a consistent manner, and neither the Medical Products Agency nor Ivo can explain why these large differences exist between the pharmacies.

The National Audit Office also writes that none of the supervisory authorities can guarantee that there are still no unscrupulous pharmacy actors on the market. This shows that the issue is complex and that there is a need for follow-up.

We hope that this is an area that will be given high priority by the government going forward. I understand that resources are limited and so on, but there is reason here to act, for example, to elevate some of the proposals from the investigation mentioned in our report and which was also raised in the debate just now.

Since I am from Miljöpartiet, I would like to conclude by saying something about the environmental issue linked to pharmaceuticals. It is not something that is addressed in this specific report, but we just want to include a message that it is important that pharmaceuticals are developed with high requirements for both humans and the environment. EU's pharmaceutical legislation currently allows no possibilities to set environmental requirements related to the manufacture of pharmaceuticals, and we hope that the government wants to push forward on this issue.

We stand behind all our reservations, but I move for approval only of reservation 4.

The deliberation was hereby concluded.

(A decision was to be taken on 22 February.)

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