Strengthened medical competence in municipal health and medical care

Christian Lindefjärd (SD)

Madam Speaker! I move for the adoption of the Social Committee's proposal for a decision in the report Strengthened medical competence in municipal health and medical care.

Swedish health and medical care faces significant challenges. We are living longer, more people have complex care needs, and a growing part of the care is provided under municipal management, not least within elderly care. To meet these needs, the municipalities need better opportunities to ensure access to medical competence. That is exactly what this proposal is about.

The legislative change does not mean that the municipalities take over the regions' responsibility for medical care. The distribution of responsibility between regions and municipalities remains fixed. The regions will also continue to have a fundamental responsibility for medical care in municipal health and medical care. Patients will continue to be listed at a health center and have their fixed doctor contact there.

What changes is that the municipalities get the opportunity to hire doctors themselves when needed to ensure good care. It is about increased flexibility and better opportunities to meet the patients' needs. The municipalities know their operations best and shall be able to use the tools required to offer the high-quality care that is needed.

Madam Speaker! The critics argue that the proposal risks creating ambiguity and parallel organizations. I do not share that assessment. The municipalities do not receive any new primary responsibility for medical care. They are given an opportunity to complement the activities they already are responsible for. The distribution of responsibility is clear and continues to be regulated by law.

Andra has highlighted the risk of recruitment problems. The shortage of doctors is a reality that both municipalities and regions already have to manage. But that challenge is not solved by limiting the municipalities' possibilities to organize care in a purposeful way. On the contrary, we need to give the healthcare providers greater possibilities to use the competence that exists where it does the most good.

Finding medical personnel as well as dental care personnel for rural areas is a growing problem in several areas. Here we need to look at how it has been done in other countries, for example Norway: If a person works in a rural area for a number of years, parts of the student loans are written off, or the person receives other benefits. This is an issue that will become more relevant and that we must work further on together if we want equal care throughout the country.

The proposal also means that the government or responsible authority will have the opportunity to issue regulations on the design of agreements regarding physician cooperation. It contributes to clarity, quality, and a more uniform application across the country.

At its core, this is about the patients: about the elderly person in a special housing unit, about the multi-morbid patient who needs coordinated interventions. It is about creating better conditions for close, safe, and accessible care.

The proposal means that municipalities can do this if they want to and can afford it. One is not forced if one feels that one cannot afford it. But I believe that many will do this now that they get the chance.

By giving the municipalities the opportunity to hire doctors, we strengthen the medical competence where the patients are. We increase flexibility without disturbing the distribution of responsibilities. We create better conditions for high-quality care. Therefore, I move for approval of the committee's proposal for a decision.

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

Mikael Dahlqvist (S)

Madam Speaker! I want to ask a direct question to the member from the Sweden Democrats. What is interesting for me to know is the following: How do the Sweden Democrats intend for us to solve the shortage of doctors and nurses in elderly care in the long term by placing a greater responsibility on the municipalities without securing the staffing in the entire healthcare chain?

At the core, the Social Democrats agree with the Sweden Democrats that we must strengthen medical competence within municipal health and medical care, Madam Speaker. But we have somewhat different ideas about how it should be done.

We know that the entire elderly care and healthcare sector is underfunded, and that is one of the challenges today. The other challenge is that it is difficult to recruit doctors to, among other things, primary care due to status and a few other things.

That is why it is interesting how the Tidö parties think, in this case the Sverigedemokraterna. This law gives the municipalities the opportunity to employ doctors, but how does it solve the staffing problems that exist, for example out in the rural areas?

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

Christian Lindefjärd (SD)

Madam Speaker! I thank Member Mikael Dahlqvist very much for the question.

This issue regarding rural areas is something we need to look at together, as I said in my speech. It is very important. What is being done in Norway is a very good example – if you work in a rural area, you can have student loans written off. In Sweden, such a reform has been introduced regarding the police. Clear reforms have also been made within the police regarding work in rural areas. I see that as a good example.

I personally believe that people will want to seek this job. I am not so worried. There are doctors. We actually train plenty of doctors. If all doctors want to work with what they are trained for, we will not have any shortage.

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

Mikael Dahlqvist (S)

Madam Speaker! I thank Christian Lindefjärd very much for the answer.

We agree that we must attract staff to primary care and especially in rural areas. There are many good ideas regarding student loans and a few other things.

Madam Speaker! The fundamental problem is still that there are no doctors available in primary care. Of Sweden's 290 municipalities, it is – if I remember correctly, I don't remember the exact figure – approximately 70, 80 municipalities where we have good staffing in primary care. In the rest, there is more or less a shortage. Some municipalities have only locum doctors, and in some places, you have to close for periods due to staffing.

My follow-up question to Christian Lindefjärd is: Is it not better that the Sverigedemokraterna first and foremost push to solve the skills shortage before giving the municipalities the opportunity to hire doctors?

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

Christian Lindefjärd (SD)

Madam Speaker! Thank you, Member Mikael Dahlqvist, for some supplementary questions!

I do not see that problem. I see that we must have new ways of thinking. You Social Democrats have governed for so many years. Why have you yourselves not done anything about this issue with the skills shortage? You are talking about it now. But you have had many years to do something about it. I pose that as a counter-question to you.

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

Mikael Dahlqvist (S)

Madam Speaker! We Social Democrats share the government's ambition to strengthen the medical competence in municipal health and medical care. It is needed.

More and more elderly people are living longer. More and more people with complex medical conditions receive care in their homes or in special housing. Municipal health and medical care has become an increasingly important part of the care chain and places high demands on medical competence, continuity, participation, and cooperation. This was proven with all clarity during the covid pandemic. But identifying the right problem is not the same as proposing the right solution.

Madam Speaker! The patients in municipal health and medical care often belong to those who are most vulnerable in our society. They need a coherent care where the distribution of responsibility is clear and where different healthcare providers work towards the same goal. Therefore, it is concerning that the government chooses to proceed with a proposal that has received extensive criticism during the referral process.

The government wants to open up for municipalities to be able to employ doctors for patient-oriented clinical work when the regions' doctor involvement is not functioning. It may sound simple. But the risk is that one creates new problems instead of solving the existing ones.

It is not only we Social Democrats who see these risks. It is also a strength in our reservation that all opposition parties stand behind the common line of rejecting precisely that part of the government's proposal that allows for municipalities to be able to employ doctors.

Our reservation means that the Riksdag shall reject the government's proposal for an amendment to the Health and Medical Services Act (2017:30) in the parts concerning Chapter 12, Sections 1 and 3 – that is, the provisions that give municipalities this possibility – and adopt the bill otherwise. It shows that there is a broad consensus in the opposition on safeguarding medical competence, patient safety, and a clear distribution of responsibility between regions and municipalities.

The Government itself notes that a majority of the referral bodies were critical of or even rejected the proposal. Among them are SKR, Sveriges Kommuner och Regioner, Sveriges läkarförbund, several regions, Föreningen Sveriges Socialchefer, and a number of municipalities.

The criticism is also unanimous. There is a warning against unclear distribution of responsibility, the establishment of parallel organizations, and a risk that already limited personnel resources will be moved around instead of being used where they do the most good.

Madam Speaker! We share that concern. The proposal risks creating double organizations and unclear lines of responsibility. It risks undermining the regions' responsibility for the supply of doctors, and it risks leading to more unequal care where the municipalities' financial conditions affect access to medical expertise. That is not the path we want to take.

Madam Speaker! The problem in Swedish healthcare is not that there are too few principals. The problem is that there is a shortage of doctors and other healthcare personnel in many places in our country. What does it help to give the municipalities the right to employ doctors if the same doctors are already missing from the regions' operations?

You do not solve the staff shortage by moving people between organizations. On the contrary, the proposal risks increasing the competition for an already limited competence. Therefore, we want to strengthen the regions' responsibility, not weaken it.

Madam Speaker! At the same time, there are parts of the bill that we welcome. We support the proposal that the government shall be able to issue regulations on how the agreements on physician cooperation between regions and municipalities shall be designed.

There is a significantly better way forward. Through clearer and more uniform agreements, we can ensure that the regions take responsibility for medical cooperation while the care remains unified. It strengthens the patients' security without creating parallel organizations.

But the long-term solution is about something much larger. For several years, municipalities and regions have struggled with major economic challenges. At the same time, we see staff shortages in both elderly care and primary care.

If the government really wants to strengthen medical competence in municipal health and medical care, significantly more than organizational solutions are required.

Investments are required in primary care and healthcare. Investments are required in elderly care. More training places are required and a different way of working with long-term skills supply.

It also requires elderly care where the staff have time to see the human being and where continuity and quality are at the center. It requires a policy that strengthens welfare instead of letting the municipalities and regions bear ever greater responsibility with insufficient resources.

Madam Speaker! We Social Democrats say yes to the parts of the bill that strengthen cooperation and clarify the regions' responsibilities. But we say no to the proposal that the municipalities should be able to employ doctors for patient-oriented clinical work.

Patients do not need more primary providers. They need stronger, more cohesive and, above all, more equitable care. We support reservation 2 under the heading of the government's framework proposal.

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

Noria Manouchi (M)

Madam Speaker! Today we are debating the bill Strengthened medical competence in municipal health and medical care. It is fundamentally a bill about something very simple. When elderly people need care, they should also be able to receive it from a doctor.

Today, unfortunately, reality often looks different. Municipalities across Sweden testify to difficulties in obtaining the medical care that elderly people in special housing and home care need. This leads to unnecessary waiting times, more acute hospital visits, and in some cases, impaired patient safety.

Those who are multi-morbid, frail, or have extensive care needs should not have to fall between the cracks because two primary bodies fail to coordinate their interventions. It is precisely this that the bill seeks to address.

The proposal does not, therefore, mean that the municipalities take over the regions' responsibilities. It is not about creating a new principal. It is not about building up double healthcare systems.

The regions will also continue to have the responsibility for medical impact. The patients will also continue to be listed at the regions' health centers. But the municipalities will receive a tool that they have lacked. They will get the opportunity to hire doctors themselves when needed to ensure the quality in municipal care.

It is, therefore, a pragmatic reform we have put on the table. It is a reform that is based on trust in the municipalities and a reform that puts the patients' needs before organizational boundaries.

Madam Speaker! We know that elderly care needs to change. People are living longer, more are receiving advanced care at home, and patients who previously would have been treated in hospitals are today treated to a greater extent within municipal activities. This places entirely new demands on medical competence.

The municipalities' nurses meet patients with complex care needs daily, and they need to be able to collaborate with doctors who know the operations and who know the patients. Continuity is not an administrative issue; continuity is a quality issue and a patient safety issue. When the same doctor can follow the patient over time, the risk of misjudgments is reduced. It reduces the risk of unnecessary hospital admissions and deficiencies in medication treatment. This is particularly important for the most fragile elderly.

Madam Speaker! The opposition has expressed a concern that the distribution of responsibility would become unclear. I mean that the bill actually implies the opposite. It explicitly states that the municipalities are not responsible for medical care. The regions' responsibility remains fixed. What changes is that the municipalities now get greater opportunities to act when reality actually demands it.

We must remember that the municipalities already today are responsible for extensive health and medical care interventions. They are responsible for nurses, occupational therapists, and physiotherapists. Being able to simultaneously secure medical competence where it is needed is therefore a natural step that should be quite obvious.

Madam Speaker! The most interesting thing about the criticism is actually what the alternative would be. If a municipality experiences that the medical intervention is not functioning well enough – which we know it does not everywhere – should the municipality then just wait? Should elderly people with extensive needs just wait? Should nursing assistants and nurses be left without the support they need in their professional practice? Shall we really say that the patient, this time, is not more important than the system? I do not think so.

We Moderates think the opposite: When healthcare does not function optimally, we must give the operations the opportunity to find solutions. That is exactly what the bill will now ensure.

Madam Speaker! Ultimately, this is about respect for the people who have built our country. It is about the elderly who live in special housing, the person with multiple illnesses who receives care at home, the relatives who want to feel security, and the staff who want to be able to provide good care. They deserve a care system where the right competence is available when it is needed, not a care system where organizational boundaries stand in the way.

Therefore, we now strengthen the medical competence in municipal care with this bill. Therefore, we strengthen patient safety and also the close care.

I wish to move for approval of the committee's proposal in the report and of the government bill.

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

Mikael Dahlqvist (S)

Madam Speaker! Thank you very much, Noria Manouchi, for the speech!

At the core, we are in complete agreement. What the Social Democrats, together with the united opposition, question is the municipalities' ability to hire doctors. We share the view that we need to increase medical competence, especially within municipal health and medical care. This became clear during the pandemic, for example. Then, all parties agreed that we had to take action against what we saw in reality.

I would still like to ask the member: How does the member mean that more principals and a parallel organization in the municipalities are to solve the shortage of doctors and, for that matter, nurses? It is not primarily an organizational problem we have today, I contend. We have a competence supply problem.

What I am particularly worried about, Madam Speaker, is the smaller municipalities in rural areas out in our elongated country which today have no staffing whatsoever in their ordinary primary care, but are instead often sustained by a system of locum doctors or so-called relief doctors. It is not good, neither from an economic perspective nor for the quality for the residents.

My question to Member Noria Manouchi is straightforward and simple: How do we solve the problem of the skills shortage when it comes to doctors?

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

Noria Manouchi (M)

Madam Speaker! Thank you, Mikael Dahlqvist, for your question!

The purpose of the reform is not to solve the skills shortage in Swedish healthcare with a single proposal. That is the honest answer, and it has actually never been the ambition with this reform. The reform's ambition is to ensure that municipalities that today lack a sufficiently good medical involvement can act to ensure that the elderly get access to a doctor. We think that is right and fair.

That the Social Democrats think this is wrong and that municipalities should not have tools to ensure that their elderly, their patients, their multi-morbid and frail elderly actually get to see a doctor – well, that is for the Social Democrats to say.

Regarding the competence shortage, this government has done a lot: over 1 billion in competence-strengthening measures, expansion of educational places, and investment in primary care and healthcare. If the truth is to be told, it is not only this government that has invested enormous sums in primary care; previous governments have also done so. The result, however, has not been that particularly many more doctors have been employed.

Perhaps the 10 percent who are qualified doctors today but who do not work as doctors would find that just this type of workplace is attractive. One should not underestimate the responsibility of workplaces and employers to make themselves attractive. Perhaps there are some municipalities out there that could attract that doctor who has the education but who has not found their place within Swedish healthcare?

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

Mikael Dahlqvist (S)

Madam Speaker! Thank you very much, Member, for your answer!

As I said, we are in complete agreement on the basic problem, and we are also in agreement on a part of the bill. It is clear that we must strengthen the medical quality for the sake of our elderly.

What we Social Democrats do not understand is how this legislative text, which means that municipalities are allowed to employ their own doctors, is going to solve the problem. The municipalities get another tool. But it does not strengthen the whole, because the whole looks in a completely different way. The reality looks like it might be the large municipalities – what do I know – that have the money and opportunities to attract and employ doctors, because doctors often want colleagues.

However, I am thinking of municipalities that perhaps have 5,000 or 10,000 inhabitants and which do not have money or even any staffing at the region's health center. How is this supposed to solve their problems? This is what our different views on the matter are about. It is not about what competence was needed, as we are in complete agreement on that.

Then we can also discuss that resources are needed. Resources are of course not the only problem, but it is manageable. I can take a good example from Region Värmland, which is governed by us Social Democrats together with the other opposition parties in the Riksdag. There, they have offered 50,000 kronor more per month at certain health centers out in the county that are struggling with staffing. And lo and behold – the interest has become huge! Now we are at the beginning of the process, so we do not know how this will turn out when it is finished. But it still shows that it is money that rules. Actually, Region Värmland cannot afford this reform.

It is this that my question is about. How do you solve the staffing for the sake of the elderly?

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

Noria Manouchi (M)

Madam Speaker! If we are to be honest: If all regions always delivered the medical impact that the municipalities need, this bill and this tool would not have been necessary. However, when municipalities across the country describe deficiencies in the availability of doctors, we must act.

This is not a reform to fix a system that already works, but a reform to ensure that the municipalities receive an additional tool when it does not work. It is a reform so that the elderly patients who are affected by the system not working well enough shall receive an additional opportunity.

Perhaps it is precisely the small municipality that prioritizes its core task that will find a doctor among the 10 percent of doctors who do not work within healthcare – those doctors who do not want to seek out the massive hospital in Stockholm or the large health centers in the metropolitan areas, but want to work close to the patients, in a nursing home or in the municipality, with nurses and other staff as colleagues.

We do not rule this out, and the Social Democrats should not either. The Social Democrats should trust the municipalities in their assessment of how they should utilize this reform. The Social Democrats should stand behind the fact that municipalities get more opportunities to themselves ensure that the elderly receive the care they actually have a right to in a timely manner.

If the member is interested in how to streamline a system so that one gets rid of hired personnel and instead employs regular, permanent staff, he can look at Moderatledda Skåne, which has succeeded very well with this during the mandate period.

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

Christofer Bergenblock (C)

Madam Speaker! I thank Member Noria Manouchi for the speech.

I agree when it comes to the fundamentals of the reform. We need to strengthen the medical competence in municipal health and medical care, especially for those patients who live in our elderly care homes or are in their homes with the support of home care. It is often about frail patients or patients with complex care needs.

The chairman states, Madam Speaker, that the background to the reform is that two principals have not succeeded in coordinating their responsibilities and that we therefore need to carry this out. In that case, one part of the government's proposal becomes logical and the other part illogical.

The part concerning writing in requirements in agreements and mandating the responsible authority to formulate how these agreements between region and municipality should look to ensure that the regional medical cooperation functions is logical. The other part, to simultaneously open up for municipal doctors, is, on the other hand, not logical.

The member says that it is not about the municipalities taking over the regions' responsibilities, but that is precisely what is being opened up for. Nor is it about, says the member, creating double structures or parallel tracks, but that is precisely what is being done. It is difficult to truly understand how the government and the Moderaterna have thought when one actually opens up for parallel tracks and for the municipalities to begin taking over the regional responsibility.

Madam Speaker! My question to the member is: In what way does it become better for the patients with double organizations, the municipal health and medical care versus the regional?

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

Noria Manouchi (M)

Madam Speaker! The member describes a split that I do not experience at all in this proposal, on the contrary. It is our absolute ambition that this shall improve for the elderly patients who today do not get access to doctors despite that they have a right to it, perhaps because the cooperation between municipality and region does not work or whatever the reason may be that the doctor does not answer the nurses' calls, which is told about in some municipalities.

That a municipality gets the opportunity to ensure that there is a doctor who can meet the patient, who recognizes the patient, and who can ensure that the patient receives the care they need in a timely manner is absolutely fundamental, I would like to say. Our task is to ensure that patients receive care in a dignified manner.

I don't really understand how one can oppose the municipalities getting a tool to address the problems they describe today. We have doctors who are qualified but who today do not work as doctors. This could be an opportunity for them to return to the medical profession. We have experienced nurses who work in elderly care homes, for example, and describe an enormous workload and poor contact with doctors.

That the municipality gets an opportunity to hire a doctor in such a situation would not only improve things for the staff already working there but, above all, improve things for the patients who are dependent on the care that the doctor can provide.

This is not a mandatory reform for the municipalities. On the other hand, it is another tool for them to address their citizens' problems, and we think that is positive.

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

Christofer Bergenblock (C)

Madam Speaker! I note that the member does not feel that she understands the problems with the proposal. In that case, I would recommend that she reads all the referral responses to the bill that have been submitted, where instance after instance saws the proposal to pieces. Sveriges Kommuner och Regioner is just one of very many instances that are sawing it to pieces.

The reason they do it is that they see a problem in building up double structures. It becomes difficult for doctors who are to work clinically in municipal healthcare to adhere to a medical record system they do not have access to, to adhere to writing referrals, something one does not usually engage in in municipal care, and to adhere to sampling when there are no laboratory environments in municipal health and medical care.

All of this lies with the regions. Are all these things also to be built up in a parallel track alongside the clinically active doctors? The government has not answered this in its bill. It is simply stated that it probably will not be a problem. However, all referral bodies have raised exactly this as a future problem.

One issue that is also raised is the supply of skills. Even today, it is difficult to supply skills in primary care. We have a shortage of doctors who are general specialists, and the proportion of patients in Sweden who experience having a fixed doctor contact is at 31 percent.

Now the member says that these patients shall in the future have a fixed doctor contact, but the continuity that the doctors are to provide shall come from the municipally employed clinical doctor. This will become a mishmash. It will not be good for the patients, it will not be good for the supply of competence, and it will definitely not be efficient – something that the Moderaterna in other contexts demand, Madam Speaker.

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

Noria Manouchi (M)

Madam Speaker! For the Moderates, it is extremely important that we address the fact that the elderly do not receive care in time. If the municipal politicians are not interested in hiring doctors, they do not have to do so. It is a choice they have. This is a tool that the government ensures the municipalities have and can use if one perceives that there is a need and if one has a political will to ensure that the elderly receive care in time in one's municipality.

One does not need to use the tool if one believes that it will only cause problems for the elderly to receive care in time. But if one chooses to opt out of hiring doctors when the possibility exists and the need is obvious, I believe one must be held accountable for that before the voters on election day.

We know that 10 percent of those who are educated as doctors do not work as doctors today in Sweden. Perhaps it is precisely a different type of workplace that would lure them back to the profession. This would be a fantastic side effect of the reform, which I believe the member from Centerpartiet completely ignores.

For the Moderaterna, this is about the municipalities getting more opportunities to ensure that every elderly person in need of care can also receive it in a timely manner and from a doctor. That the Centerpartiet is opposed to this, we think is disappointing.

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

Karin Rågsjö (V)

Madam Speaker! Many will remember the pandemic. It was a blow to the face for many elderly and vulnerable people. Did we learn anything from the pandemic? Has the SD-dependent government strengthened the municipalities' elderly care? Or is it the case that when the economic crisis came, the state grants did not meet the needs? That is something one can wonder about.

During the pandemic, it was constantly the Moderaterna, KD and SD who clearly said that everything was the government's fault. Now it is the municipalities' and regions' fault – sometimes. It is fast-paced.

More and more people are getting older, and we must meet that in different ways. Within elderly care homes and elderly care, there must be trained nursing assistants. It is extremely important to have that requirement. Nurses are needed to lead the nursing work and supervise nursing assistants and care assistants in the complex care that elderly care entails. Specialist knowledge in nursing and medicine is also needed to lead the preventive work and avoid unnecessary suffering. But more geriatric clinics are also needed. There is a shortage there today.

It is always good to listen to, or rather read, the referral bodies. The proposition states that there is an almost unanimous no to the government's proposal. Several referral bodies point out that the proposal may contribute to worsening existing problems with recruiting doctors because municipalities and regions will compete for the same individuals.

The Swedish Medical Association and the Swedish Medical Association (Läkarförbundet) write regarding fragmented care that it risks leading to two parallel care chains, which hinders the holistic view of the patient. Furthermore, they write regarding competence supply that it is feared to drain the health centers of specialists in general medicine. Additionally, they write regarding patient safety that it risks leading to unclear boundaries of responsibility between municipality, region, and health and medical care.

The Swedish Medical Association writes that significantly more resources should be allocated to primary care so that it can focus on ensuring that the elderly and frail are first in line to see a doctor. The proposal also risks having negative consequences for doctors' continuing education and research, competence development, and exchange of knowledge between colleagues. It is a matter of it potentially becoming a lone doctor.

The Swedish Medical Association has written that there are question marks regarding the bill's provisions on access to, for example, laboratories, sampling, premises, and technical equipment that are necessary for the medical profession.

The Federation also draws parallels to school health care, where there are major problems. It is an area where municipalities can already today employ doctors, and there are extensive and structural difficulties with the supply of competence for school doctors and the knowledge and ability of the country's school principals when they are to ensure the shortages.

As has been said, it is always good to listen to the referral responses.

If the municipalities are to employ more doctors to work with what the regions are responsible for, there will be two employers. There is no question about that. And it risks weakening the entire society's ability to work with the group.

In line with the majority of the referral bodies that reject the proposal, we believe that the government's proposal would create parallel healthcare structures and unclear distribution of responsibility. It also risks leading to unequal care because economically stable municipalities get the opportunity to hire doctors while municipalities with slightly poorer finances do not.

Madam Speaker! In line with the Swedish Medical Association and the Swedish Medical Association (Läkarförbundet), we believe that instead, a strengthening of primary care and enough specialists in general medicine who can serve as permanent doctor contacts is needed. It is also important that the healthcare staff working with the elderly have competence and experience regarding the elderly's needs for care, and that more geriatric clinics are needed.

Elderly care is complex. I am thinking of those who work closest to the elderly. They are usually nursing assistants. This is about the whole, about all the laws that the Tidö parties have enacted and how the laws will hit all those Swedes with a foreign background who are currently working within elderly care. According to SKR, there are 33,000 nursing assistants and care workers who work in municipalities and regions who have come to Sweden in the last decade. Then one asks what the education level is for these people. The most common is that foreign-born people who work in elderly care have an academic background, compared to those born in Sweden. A full 39 percent of the foreign-born have higher education, which is partly due to the fact that foreign degrees can sometimes be difficult to validate in Sweden.

It is not the signaling politics that will make the care in Sweden's elderly care better, but rather resources and competence enhancement. Furthermore, the working environment in elderly care must be such that the employees enjoy their work and stay.

I think about my father sometimes. He didn't need a huge amount of help, but still a little help with shopping, laundry, and cleaning. He watched football with the guy from Congo who was a nursing assistant. My father got to meet the whole world, and he thought the conversations were interesting. But he always had a relevant question for those who came home to him: "Are you a trained nursing assistant?" He had a little mini-survey going that we looked at, which was interesting.

So it must be. Closest to the elderly and the frail, there must be trained staff with high competence in their field.

I vote in favor of reservation 1.

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

Dan Hovskär (KD)

Madam Speaker! I would like to begin by moving to approve the proposal in the committee's report.

Today we are debating the Social Committee's report on strengthened medical competence in municipal health and medical care. At first glance, it may appear to be a question of a technical change in the Health and Medical Care Act, but in reality, it is about something much larger, namely about safety, about dignity, and about providing some of our most fragile citizens with care that works when it is needed most.

For us Christian Democrats, the starting point is simple. Care shall be based on the human being, not on organizational boundaries. Today, the municipalities are responsible for large parts of the care for elderly and multi-morbid persons, not least within special housing and within home healthcare. But despite this, the municipalities lack the possibility to hire doctors themselves for patient-oriented work. They are dependent on the region's medical efforts. In many cases, this works well, but we also know that all too often there are deficiencies.

We meet stories from elderly people who meet a new doctor every time they need help. We see how staff in elderly care are forced to wait for medical assessments. We see how relatives have to take an unreasonably large responsibility for the coordination of contacts between different healthcare providers. We see the consequences in the form of lack of continuity, insecurity, delayed interventions, and unnecessary hospital admissions. It is not worthy.

The elderly woman living in a special housing facility in Falköping does not care which principal is responsible for different parts of the care. She wants to know that there is a doctor who knows her, who sees her needs, and who is available when her health deteriorates. The relative son in Skövde who is trying to make everyday life work does not care about organizational boundaries. He wants to know that his mother receives the right care at the right time.

This is precisely what the government's proposal is about. We want to give the municipalities the opportunity to hire doctors for patient-oriented work within municipal health and medical care. This does not mean that the municipalities take over the regions' responsibility for medical care. The distribution of responsibility remains fixed. On the other hand, it means that the municipalities get a better opportunity to ensure medical competence close to the patients. It is an important difference.

The goal is not more organizations – the goal is better care. The goal is not more silos – the goal is to reduce them. The goal is not to create conflicts between principals – the goal is to create better conditions for cooperation. Therefore, the reform also contains clearer requirements for cooperation and agreements between municipalities and regions.

Madam Speaker! Sweden is facing major demographic changes. We are living longer than previous generations, and that is fundamentally something wonderful. But it also means that more people are living with multiple concurrent diseases and extensive care needs.

The municipal health and medical care already performs advanced care interventions today that only a few decades ago would have been performed in hospitals, and the development will continue. We cannot therefore have a regulatory framework based on yesterday's reality. We must adapt the care to tomorrow's needs.

Giving the municipalities the opportunity to hire doctors is therefore not a radical step. It is a logical step, and it is a step that corresponds to the reality that patients, relatives, and healthcare staff face every day.

Madam Speaker! I know that there are apprehensions. Some argue that the reform risks creating insecurity or increased differences between different parts of the country. I respect these views, but the alternative is to let today's problems persist. The alternative is to accept that older people will continue to risk encountering a fragmented care system with a lack of continuity. The alternative is to turn a blind eye to the challenges that already exist.

It is not an alternative that the Christian Democrats can stand behind. Instead, we want to give the healthcare system better conditions to meet the patients' needs. We want to give the municipalities more tools to create security. We want to give the healthcare staff better opportunities to work close to the patients. And we want to give relatives greater security that their loved ones receive the care they need.

Madam Speaker! Christian Democratic policy is based on human dignity. Every human being has an inviolable value, regardless of age, illness, or functional ability. This also applies to the elderly person who has become dependent on care and support. When society takes responsibility for the most vulnerable, we show who we are as a nation.

Care must therefore be characterized by continuity, proximity, and security. We must dare to change systems that do not fully meet people's needs. This reform is important so that the elderly woman living in a special housing unit in Falköping can receive safer care.

Giving the municipalities the opportunity to hire doctors is not just an organizational change. It is a step towards a more cohesive healthcare system, towards greater security for patients and relatives, and towards increased quality in elderly care. Above all, it is a step towards a healthcare system that is to a greater extent based on the human being.

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

Christofer Bergenblock (C)

Madam Speaker! Thank you, Member Dan Hovskär, for the speech!

The Board of Directors says that care should be based on the human being and not on organizational boundaries. Nevertheless, the Christian Democrats are the party that is pushing most for changing the organizational boundaries in Swedish health and medical care by throwing the entire healthcare system into a gigantic reorganization chaos with a director-general who controls everything from Stockholm.

However, exceptions are made, Madam Speaker, for municipal health and medical care. There, we are suddenly to start employing doctors in clinical operations. Or will they perhaps also be employed by the state in the end? The member is welcome to answer that.

The chairman speaks about the elderly woman in Falköping who does not care who is the principal or where the doctor comes from. He also speaks about the importance of continuity. But the purpose of the entire system we are building with primary care and close care is that one should have continuity through one's health center and one's regular doctor contact.

Have the Christian Democrats possibly abandoned the idea of a permanent doctor contact for those who are older and want to replace it with a municipal doctor instead? If so, it is important to clarify that for the voters.

One of the major points of criticism against this reform is the risk of inequality. It is clear that Falköping, with approximately 33,000 inhabitants, may have the opportunity to employ a municipally employed clinically active doctor. But what about equality in municipalities such as Färgelanda, Karlsborg, and Töreboda? Will they also be able to employ municipal doctors?

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

Dan Hovskär (KD)

Madam Speaker! Thank you for the questions, Christofer Bergenblock!

The Christian Democrats have the patient in focus at all times. That is why we want to reorganize care and reform healthcare. We have a regional system from 1862, and these regions have different forms and borders. We do not believe that it benefits the patients, and therefore we want a nationalization and to remove the borders.

The question of municipal doctors is also a step in this. We want to remove boundaries in order to focus on the individual patient instead.

We are now giving municipalities the opportunity to employ doctors, if they so wish. It is up to each one how they organize it. This is not a compulsion. If one in Falköping or in Karlsborg wants to invest municipal money to strengthen care when deficiencies are seen, we think that is good. It is done for the benefit of the individual elderly person, and that is what we start from as politicians.

We Christian Democrats want to both strengthen primary care and improve municipal care. More advanced care is now provided in the home and in the special housing, and when care moves closer to the patient, the medical expertise must also do so. We therefore see this as a step in the completely right direction.

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

Christofer Bergenblock (C)

Madam Speaker! The member says that the Christian Democrats have the patient in focus, but honestly, I know of no other party that has the organization so much in focus as the Christian Democrats. They want to nationalize the entire Swedish healthcare system.

The party leadership says that they want to remove borders. What they have said they want to remove are the regions, but they still want to keep a state health and medical care and, as I understand it now, also a municipal health and medical care. Or do they perhaps want to remove that border as well and abolish the municipal health and medical care? It is a message that is important to convey to the voters, if that is the case. Or else, one is not so consistent in the description of the Swedish health and medical care.

But, Madam Speaker, back to the question of equality across the country. The member continues to speak about Falköping with its 33,000 inhabitants. The reason I bring up Färgelanda, Karlsborg, and Töreboda is that all those municipalities in Västra Götaland have fewer than 10,000 inhabitants. We can pick other municipalities, such as Dorotea, for example, which have fewer than 5,000 inhabitants. How great is the probability that those municipalities will have the opportunity to employ a clinically active doctor?

Or is it that the Christian Democrats do not see inequality as a problem? Some municipalities manage to hire because they have the conditions and finances to do so, and others do not – then those municipalities are not equally important. The very point of our regions is that we have a unified system for health and medical care under a principal who takes the full medical responsibility and the medical responsibility for their patients, regardless of whether they live in a nursing home or somewhere else.

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

Dan Hovskär (KD)

Madam Speaker! That is exactly why we need to take a bigger step, we in the Christian Democrats believe. It should not matter where one lives if we take the big step – nationalization. Today, it does matter. Depending on whether you live in Dorotea or Karlsborg and which region you belong to, you receive care at different levels. That is why we want to nationalize healthcare. Which zip code you have should not determine what care you receive. We want people to be given care based on need and not depending on where they live or on the region's capacity.

If we look at the greatest inequalities, which you also touched upon, we see that they already exist today. Older people's access to doctors varies greatly depending on where they live. The municipalities already cooperate on many activities and will be able to do so here as well.

Municipalities have different circumstances, but that is no argument for denying all municipalities the ability to improve their care. This is what we Christian Democrats work for: to improve care and improve opportunities, not to set up more boundaries.

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

Karin Rågsjö (V)

Madam Speaker! I have a few questions for Dan Hovskär. I am getting a bit confused, I must say.

My first question is why you never listen to referral bodies and read what they think and feel. It is a manifest no to this reform. I find that interesting.

From the referral bodies, quite important issues have been raised. They have raised the inequality across the country, perhaps depending on how large the municipality is. They have raised that the reform risks leading to two parallel care chains. How will the competence supply regarding doctors be organized in the municipalities? Who will take care of it? Will patient safety be maximized?

I also wonder a bit specifically regarding the residency training. If you start as a doctor in a somewhat smaller municipality, you might not have very many friends. How are you supposed to get hold of colleagues to discuss healthcare issues with? And what happens to the competence?

I also think that it is dearly bought information one gets when looking at how school health care has functioned in the municipalities. It is not so fortunate, whether it concerns the competence increase or how one can get hold of school doctors. In what way would it be significantly easier to get hold of doctors in this system? You say that 10 percent do not work as doctors. Are they the ones who are supposed to come running? Why should they come running, to fewer colleagues and a rather diffuse area of responsibility? Why have you not instead seen to it that there are more geriatric clinics, for example?

These are some of my modest questions to Dan Hovskär.

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

Dan Hovskär (KD)

Madam Speaker! Thank you very much, Member, for the questions! There were quite a few and quite large questions, so I will see how many I can get through.

To begin with, there are some referral bodies that are critical. There are also many who see the need for a change. Politics is ultimately about weighing different interests against each other. The Christian Democrats and the government have concluded that the patient's need for continuity, accessibility, and medical presence outweighs the fear of making changes.

Furthermore, you speak about how we should recruit doctors. Staff shortages are a major problem across the entire healthcare system, but the solution is never to forbid municipalities from recruiting. If we were to follow that logic, we would not be able to achieve any development or operations at all if we did not dare to take some new steps. When healthcare moves closer to the patient, the medical competence must also be able to do so. We believe that municipalities must be given the opportunity to use the tools needed to meet the healthcare needs of the future.

You also asked a question about the recruitment of doctors. Doctors have different work tasks, and today it is approximately 10 percent who do not work as doctors within healthcare. This could provide new opportunities to get some of them back. I therefore believe that this could be a way, which does not in itself solve the recruitment but which could be part of still getting some back.

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

Karin Rågsjö (V)

Madam Speaker! Then a new question arose immediately: How is this to be evaluated?

A question that becomes very interesting, I think, is that as a doctor, you must have the prerequisites to take samples, for example. You must have access to labs, premises, and technical equipment that is necessary for a doctor. It is not just a matter of running around with a stethoscope and hoping for the best, but a bit more is needed.

Then I wonder how this is going to work in municipalities with 20,000 inhabitants? Will there be different agreements? Will the municipalities have the conditions to set up what they are to do? It might be about building their own small lab – what do I know. And will the state – the next government, where I hope you are not sitting – in that case have to pay for these laboratories and so on? Or how is it intended?

An enormous number of people have been negative towards this reform, and it is not just about fear but about blunt knowledge of how it works. I think it would have been significantly better if you had instead come forward with a reform for more geriatric clinics – there is a shortage of such in Sweden – or if you had come forward with a proposal that I believe we all here would have signed on to: that one should go by need when it comes to the local doctors so that the elderly, the frail, and people with greater needs would have access to a doctor in the first instance. Now it is approximately 30 percent who have their own family doctor. I think that would have been a good reform.

But I still wonder how it is intended regarding these somewhat more difficult questions? And have you reflected a bit on why the school doctors specifically have not worked and why it is so difficult for them in the municipalities, when there is no competence to lead doctors? How is it going to be resolved in this matter?

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

Dan Hovskär (KD)

Madam Speaker! Thank you, Member, for the questions!

The regions' responsibility for medical intervention will remain. It is clearly stated that we will provide the municipalities with tools to ensure the medical competence where today's system is insufficient. It is actually about the simple question of whether we should protect organizational boundaries or whether we should strengthen care for the elderly. We Christian Democrats choose to try to strengthen the patient before the system. I hear a lot about the organization's structures from the opposition, but I hear less about the elderly woman in Falköping who is waiting for her medical assessment, which we talked about.

We Christian Democrats believe that it is important that healthcare policy begins with the patient. Therefore, we want to implement this reform. The goal is better care. It should not be new silos but fewer silos. We want to create better conditions for cooperation, and for this, we Christian Democrats are working together with the government. There, the patient is at the center.

It is not the organization's boundaries that are what is important, but it is about having the right perspective. It provides more security.

We believe that this reform will help individual elderly people get closer to their doctor.

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

Christofer Bergenblock (C)

Madam Speaker! Initially, I would like to move for approval of the Centerpartiet's reservation 2, under point 2, regarding the government's bill in the report.

There is no doubt that the medical competence in municipal health and medical care needs to be strengthened. Often, it is precisely these patients who are among the most fragile and have the most complex care needs. High medical quality and continuity are absolutely crucial.

That the distribution of responsibility is not functioning sufficiently well today was evidenced, among other things, by the Corona Commission's final report. But the question is, of course, what conclusion one draws from that.

From the Center Party's side, we have, among other things, pushed for the following three things since the commission submitted its report:

The first thing is that we must have access to more advanced care both in private homes and in special housing. This could, for example, involve access to oxygen or the possibility of administering an intravenous drip.

The second thing is that the competence within elderly care must be raised. Therefore, we have set requirements that all staff within elderly care who work in care-related activities have an assistant nurse education.

The third is that requirements must be set for clear agreements on the distribution of responsibility between regions and municipalities.

The final point, Madam Speaker, is addressed in the government's bill on strengthened medical competence in municipal health and medical care. The government, or the authority that the government authorizes, will be granted the right to issue regulations on the design of agreements on physician cooperation. Through clearer and more uniform agreements, we can ensure that the regions meet their responsibility to provide the physician resources that the municipalities need without creating fragmented organizations or double tracks. That is good.

What is less good in the government's proposition is that it now opens up for municipal employment of doctors for patient-oriented clinical work. It is completely the wrong way to go. The proposal risks creating double and inefficient structures, eroding the regions' responsibilities and ultimately leading to more unequal care in the country.

The proposition has also received strong and extensive criticism from a majority of the referral bodies, including Sveriges Kommuner och Regioner, a large number of regions, several municipalities and many representatives of the healthcare profession. Centerpartiet largely shares the concern expressed by these actors.

One of the most fundamental problems with the proposal is the risk of an unclear distribution of responsibility. If both municipalities and regions have doctors working close to patients, a risk arises that the responsibility for the patient is fragmented and split up. Instead of creating a coherent care chain, we risk building up parallel systems that hinder cooperation.

The regions' fundamental responsibility for medical intervention remains, but the proposal creates an ambiguity, and in the worst case, it can also jeopardize patient safety. This concerns, among other things, challenges with coherent medical records, referral management, and sampling. A divided medical organization hinders the coherent teamwork around the patient and risks leading to a fragmented and less secure care for the individual.

The proposal, Madam Speaker, also raises questions about the supply of competence. Sweden already suffers today from a serious shortage of doctors, especially specialists in general medicine. Introducing an additional employer that competes for the same limited personnel resources is not the solution.

The recruitment problems are particularly large in rural and sparsely populated municipalities. Larger and economically strong municipalities can gain an advantage, while smaller municipalities with poorer conditions fall behind once again. The result is a more unequal healthcare system, where access to doctors is governed by the municipality's size and economy rather than by the patient's needs.

I note, however, Madam Speaker, that the Sweden Democrats, the Moderates, the Christian Democrats and the Liberals are not listening to the referral bodies' criticism. They are not taking the issue of inequality seriously. They do not see that the supply of skills will become even harder to manage. They are not taking the issue of parallel systems seriously. The parts in the proposal are not good.

However, in the Center Party, we see no obstacle to municipalities, just as they do today, employing doctors for strategic roles and staff functions, for example as medically responsible doctor or as medical strategist. These roles do not create double clinical structures but can instead strengthen the municipality's commissioning competence and ability to develop healthcare in collaboration with the region. The focus should continue to be on strengthening cooperation and clarifying responsibility within the framework of today's ownership.

Madam Speaker! In summary, I can state that municipal health and medical care needs increased support from doctors, but the Tidö parties' solution is completely the wrong way to go. Swedish care in special housing and in individuals' homes will not become better because we let the municipalities employ doctors for clinical activities. On the contrary, it will create new problems – with parallel responsibilities, difficulties with record-keeping, difficulties with referral management, and difficulties with sampling, not to mention that municipalities and regions will now have to start competing even for the doctors. Furthermore, it will lead to more unequal care, where the metropolitan regions build operations with municipal doctors, while rural and sparsely populated municipalities are left without.

Instead, doctors are welcome to work in staff functions, and requirements must of course be placed on the regions' pharmaceutical cooperation. It is good for our elderly if we utilize the resources we have in the best possible way, so that as many as possible will be included.

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

Malin Danielsson (L)

Madam Speaker! Since 1992, the municipalities have been given increased responsibility for healthcare interventions within elderly care and home healthcare, even though the responsibility remains shared between the municipalities and the regions. In practice, this means that the municipalities now have an extensive responsibility within elderly care and home healthcare for persons with complex medical conditions, while it continues to be the regions that provide the interventions that require medical competence.

To resolve this shared responsibility, cooperation agreements have been established. In cases where it works well, there is a doctor at a health center with geriatric competence who is linked to an elderly care home. This doctor is responsible for following up on patients continuously and also being available during on-call hours. Unfortunately, this does not work well enough in reality. The agreements are not good enough, and the municipalities are generally weak as negotiating parties in relation to the regions.

With and by this proposal, we strengthen the municipalities as contracting parties so that more functioning agreements can be signed and so that reality shall correspond with the ambition of good access to medical competence under the region's management within the municipal elderly care. It is important and good but not sufficient.

Madam Speaker! In rough terms, a quarter of Swedish healthcare is carried out by the municipalities, but they are not allowed by law to employ doctors for patient-facing work. Is this then a problem? Yes, many argue.

Barbro Westerholm was one who early on raised this problem and emphasized that the elderly often have complex clinical pictures and therefore need more, not less, access to doctors and qualified medical competence. She linked this to the view of the elderly – a kind of ageism, quite simply. Those with the greatest needs do not receive the same quality of care as other groups.

Many elderly people in special housing share Barbros's view. In the Socialstyrelsen's annual survey from 2025, the possibility of meeting a doctor when needed was measured for those living in special housing. Only half of those surveyed stated that they thought it was easy or quite easy to meet a doctor when needed. In that case, we are talking about people who often have great healthcare needs – otherwise, they would not live in a special housing facility.

The Corona Commission also raises the issue and points out that it is a problem that elderly care is dependent on the regions' priorities for medical assessments that only a doctor can make. They also point out that doctors can basically not participate in the municipality's planning work in the healthcare area, not even in the crisis management work that the municipality has to perform, for example during a pandemic.

The Corona Commission also states that a corresponding division of responsibility between different authorities does not exist in our neighboring countries and that it is difficult for doctors within the region to lead the development of medical routines and interventions at individual special housing units. There is also a great need for the latter within elderly care, as the elderly today have a significantly more complex clinical picture than they did in the 90s, when the elderly care reform was implemented and much of the responsibility was moved to the municipalities.

Other authorities that for a longer period have raised that municipalities should be granted the right to employ doctors are the Public Health Agency and the National Board of Health and Welfare.

Madam Speaker! What are the consequences of the lack of cooperation agreements or the ban on hiring doctors for the everyday lives of those living in the residences and for the healthcare staff?

The investigation underlying the proposal describes this well – and I quote: It occurs that the medical intervention is deficient, among other things, by that tasks which should be performed by a doctor are either not performed or are performed by staff who are not doctors. The deficiencies in medical involvement occur continuously but are perceived as particularly problematic outside of regular working hours.

The investigation also writes that it is not uncommon for a doctor-on-call resource to be missing that can assist the municipal health and medical care. When this is the case, the region's emergency department often becomes the only practical alternative for patients who need a medical assessment during out-of-hours.

In other words: The elderly person receives no medical intervention. The elderly person receives an intervention from someone who is not a doctor even though a medical intervention is required, or else the elderly person needs to go to the emergency room. This does not only create stress and anxiety for the one who needs the medical intervention. The investigation also points out that it creates more work and stress for the staff within elderly care. Plus, we know that this creates a pressure on the emergency departments that could have been avoided.

Madam Speaker! Of course, I and many others hope that the cooperation agreements will be the key to solving all the problems that I have raised. They will certainly be in many cases, but it is also high time to settle the untimely prohibition for municipalities to employ doctors within elderly care.

Next week, Barbro Westerholm would have turned 93 years old. She always used to say that politics is a marathon. Unfortunately, she is no longer with us, but had she been here today, she could have added one more thing to the long list of improvements for Sweden's people that she has contributed to. It is in her spirit that we, who have taken over the relay baton now, take the step over the finish line in the marathon regarding doctors within elderly care.

With this, I move for approval of the committee's proposal in the report.

This is probably my last debate for the Social Affairs Committee and my last debate in the chamber altogether. Therefore, I would like to take the opportunity to thank my colleagues in the Social Affairs Committee for good cooperation and wonderful debates, and the Chamber Office for all the good work that the Chamber Office does. I wish you all a very happy summer and a pleasant holiday when the time comes.

(Applause)

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Christofer Bergenblock (C)

Madam Speaker! I think the member must be very grateful to get an additional four minutes in the spotlight of the Riksdag before the speaking time ends here.

I noted that the member said that the elderly need more, not less, access to doctors. We are, of course, in complete agreement there. Medical involvement in municipal health and medical care is currently neglected in many places, and it needs to be improved. That is why it is so good that we are now placing additional requirements on the agreements between municipalities and regions. In that way, we ensure that the regions must provide medical competence. They have, for all intents and purposes, already been obliged to do so, but now this will be structured and defined in a different way. That part is good.

What is difficult to understand, however, is the second part, which concerns creating the possibility for clinically active municipal doctors. I am thinking of the entire battery of criticism that has been put forward by a number of referral bodies. It is about the fact that we will create parallel tracks and that there will be difficulties with record-keeping, referrals, and sampling because it is not organized in this way today. This implies difficulties with the supply of competence and with continuing education. Above all, we risk creating an unequal system – it will then be unequal between the municipalities in Sweden. One will have different access to medical care depending on whether one lives in a rural municipality or whether one lives in a large city municipality.

Then my question, Madam Speaker, is how the Liberals view inequality.

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

Malin Danielsson (L)

Madam Speaker! One can always rely on getting a reply from the member Bergenblock – it is appreciated.

Inequality already exists today, and this is one of the problems that we are trying to rectify with the help of the cooperation agreements. Just as I said in my speech, I believe that it is an important piece of the puzzle – that we get the cooperation agreements – when it comes to achieving better equality across all of Sweden. But we also need to remove this prohibition. Where this does not work, there must, in fact, be another possibility for the municipalities to ensure the care in our elderly care homes, now that we have placed a very complex mission on them.

I do not see that these parts need to be opposites of each other. I see it rather like this: In cases where a municipality chooses to employ a doctor, this must also be included in the cooperation agreement. It is about finding solutions to the various problems you raise, for example with sampling and referrals, so that one gets it to work.

I see opportunities with both legislative proposals. I also see that we, ahead of a coming pandemic – such things will come again – need to have an organization that is equipped, where we can be quick-footed and where one does not need to break the regulations. One breaks the regulations now if one hires a doctor, which some wanted to do and almost did during the pandemic. This is needed in order to be able to handle a coming pandemic, for example.

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

Christofer Bergenblock (C)

Madam Speaker! I do not quite share the member's analysis, but I will let that part pass.

Since it is perhaps the member's very last debate in the chamber – we do not know; there may be more opportunities – I would like to take the opportunity to thank her for the work she has done, perhaps not so much in health issues but above all in disability rights issues where we have had very much to do with one another within the framework of the Riksdag's disability rights network where we have both been involved. The member has demonstrated commitment, interest, and great passion for these issues. I also know that she is held in great respect within the disability rights movement; there are many who listen to what the member says.

I do not know if the Speaker noted it, but since the member said "you" to me in her remark just now, I nevertheless intend to conclude by saying: Thank you so very much for this time and for the fine cooperation we have had! Good luck in the future, Malin!

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

TREDJE VICE TALMANNEN

The Speaker has noted that it has occurred in many contexts in the committee's debate, from several members. In four years, we have not resolved this issue.

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

Malin Danielsson (L)

Madam Speaker! I apologize for the whispering, but we are a friendly group who socialize quite a bit.

I thank Christofer Bergenblock for the kind words! It warms me, and I wish you continued success as well. Keep the flag flying high when it comes to disability rights policy!

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

Nils Seye Larsen (MP)

Madam Speaker! I thought I would begin with a few brief words from a study visit I made during our last plenary week. During that visit, I visited Ljungby's hospital and primary care, and it was very interesting to hear about their work and cooperation with the municipal home care, especially regarding the special housing units.

The entire process of working with a transition to a good and close care takes time, and we must not forget that a large part of it is carried out under municipal management. Equally important is the clear division of who does what, and the most important focus should perhaps be how one can strengthen and improve the cooperation. How can one ensure that the collaboration with this clear division of responsibility works well?

I vote in favor of reservation 2 and would like to begin by saying that the bill nevertheless takes its starting point in a real problem. Patients in municipal health and medical care are often older, frail, and have complex care needs. Many have several diseases simultaneously and are dependent on the care functioning in the home, in special housing, or in other municipal activities. In that case, there needs to be good access to medical competence, clear lines of responsibility, and a functioning cooperation between the municipality and the region.

Miljöpartiet therefore shares the government's ambition to strengthen the medical competence in municipal health and medical care. It is also good that the government wants to create better and clearer conditions for the agreements on physician cooperation between regions and municipalities. Those agreements need to function better. They need to be clear and capable of being followed up. The regions need to take their responsibility to allocate the physician resources required so that patients in municipal health and medical care can receive good and safe care.

But the bill also contains another proposal, and that is that municipalities shall be allowed to hire doctors in the operations concerning municipal health and medical care. It is that part we oppose.

Madam Speaker! The referral criticism against this part of the bill is strong and extensive. A majority of the referral bodies reject or are negative towards the proposal. This includes, among others, SKR, several regions, several municipalities and representatives of the profession.

The first and perhaps most fundamental objection concerns precisely the distribution of responsibility. If both the region and the municipality have doctors working in close proximity to the same patient groups, a risk of ambiguity arises. Who has the collective medical responsibility? How is the care chain to be kept together? How do we avoid the patient falling between different actors, different medical record systems, different referral paths, and different organizational logics?

The government says that the distribution of responsibility does not change and that the region shall continue to have the responsibility for medical interventions. But if the municipality simultaneously is given the opportunity to hire doctors for patient-proximate clinical work, a parallel structure is created in practice. In that case, it is not enough to say that the responsibility formally remains with the region. For the patient, the relatives, and the staff, the distribution of responsibility must also function in everyday life.

It is here that the criticism from the referral bodies must be taken seriously. They warn of double structures, inefficient use of resources, and a healthcare system that becomes more fragmented. It concerns patients with great healthcare needs, where continuity, coordination, and clarity are crucial for patient safety.

Madam Speaker! The second major objection concerns equitable care. The Government describes the proposal as a voluntary opportunity for the municipalities, but that is also part of the problem. Municipalities have very different economic, organizational, and practical conditions. Larger and economically stronger municipalities may have the opportunity to hire doctors. Smaller municipalities, municipalities with weaker economies, and municipalities in the part of the country where I live, where the region already has difficulty recruiting doctors, will likely have significantly worse opportunities. Then, access to doctors in municipal health and medical care risks becoming dependent on which municipality a patient lives in. That is not the right way to go. Care should be provided based on need, not based on the municipality's size or economy.

This will be particularly important in those parts of the country where the supply of competence is already very strained. In northern Sweden, in rural areas and in many smaller towns, it is already difficult to staff health centers and ensure access to specialists in general medicine and geriatrics. If municipalities and regions are to compete for the same limited medical resources, we risk exacerbating the problems that already exist. In any case, it is not a solution.

The Government notes that the shortage of doctors is a reality that municipalities and regions need to contend with, but the conclusion should then not be to create additional employers who will compete for the same doctors. What is needed instead is a strengthening of primary care and better conditions for the regions to take the responsibility they already have. It is about more specialists in general medicine, better continuity, functioning permanent doctor contact, and a primary care that has the resources to also be present for patients in municipal health and medical care. It is also about securing the supply of competence regarding ST-places moving forward.

We say yes to the part of the bill that concerns clear regulations for agreements on medical cooperation, because through better and more uniform agreements, the regions' responsibilities can become clearer and the municipalities' position can be strengthened. It is the right direction. It strengthens cooperation without creating fragmented organizations.

Madam Speaker! There are further problems that several referral bodies point out and which I want to highlight. The previous speaker, Karin Rågsjö, highlighted them very well. Relevant criticism comes from various organizations and healthcare professions. It concerns medical record keeping, sharing of medical record data, referral management, sampling, medication prescription, and so on. Sveriges läkarförbund has additionally raised questions about continuing education, collegial exchange, research, premises, technical equipment, and responsibility during on-call hours. These are important objections that I believe the government dismisses too lightly without providing proper answers. It is regrettable.

Madam Speaker! Miljöpartiet wants to see a stronger municipal health and medical care. We want to see better access to medical expertise and better cooperation between municipalities and regions, but we do not want to go down a path that risks leading to parallel care structures, less clear responsibilities, and greater differences between municipalities.

I want to take the opportunity to highlight some examples, because it is very tough in northern Sweden. However, there are positive examples. I just spoke with a person who chose to move from Stockholm to Storuman and work in the clinic there. There, they work successfully with new, digital technology to be able to assist patients. They have a well-functioning cooperation with the municipal home healthcare. Another example that I thought was nice was the news report about Maja Johansson, who moved from Lysekil to Arjeplog. She had seen pictures on Google of the fantastic nature there. She was happy and is still there – and in Arjeplog, they are extremely happy to have succeeded in filling their first ST position in several years.

It is therefore valuable to move to northern Sweden, but we must understand that there are still enormous challenges with recruiting general practitioners there. This reform does not solve the fundamental problem.

In conclusion, I want – even though I have not sat on the Social Affairs Committee during the entire mandate period, far from it – to take the opportunity to thank Malin Danielsson for the work she has done. This applies in particular to issues regarding disability rights. It is also about the person and the politician she is. I feel that it has been very valuable to have a person who, with a burning heart, respect, objectivity, and a fine tone, has worked extremely hard for these issues. We do not belong to the same party, but we have great respect and appreciation for each other. A big thank you! Good luck in the future!

The deliberation was hereby concluded.

(A decision was to be taken on 9 June.)

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