Response to interpellation 2022/23:139 on medicine deliveries in rural areas

Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! Anders W Jonsson has asked me in what way I will ensure that people in rural areas do not risk being affected by worsened opportunities to obtain their medicines.

The Medical Products Agency may, with the support of authorizations in law and ordinance, issue regulations in the field of pharmaceuticals. Relevant regulations regarding distance trade at outpatient pharmacies are such an example. As Anders W Jonsson has pointed out, the authority has referred a proposal for new regulations for distance trade at outpatient pharmacies. The consultation period expired on 2 December 2022, and the authority is now working on reviewing the submitted views. I am following the authority's work in preparing the new regulations.

The possibility of ordering medicines via the internet is significant for people in rural areas. Furthermore, the state takes a special responsibility for the availability of medicines across the entire country. To begin with, there is a special grant for pharmacies in rural areas which was added during Göran Hägglund's time as Minister for Social Affairs. The Dental and Pharmaceutical Benefits Agency paid out just over 12 million kronor in 2022 regarding a total of 44 pharmacies. Furthermore, Apoteket AB has the task of maintaining existing pharmacy outlets to the extent necessary to maintain a good medicine supply in the location where the outlet is active.

In conclusion, I want to emphasize that the accessibility of medicines throughout the country is a very important issue for me and the government. Equally important is the importance of ensuring that good patient safety is maintained. This applies regardless of whether the medicines are distributed through physical pharmacies or ordered on the internet.

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Anders W Jonsson (C)

Mr. Speaker! The Swedish administrative model with independent agencies is fundamentally good, but time and again concerns arise because certain agencies have a very narrow perspective based on their own area. During the pandemic, there were several such examples, not least Arbetsmiljöverket and Folkhälsomyndigheten which made completely different interpretations of what protective material is. The government at the time chose not to intervene and in no way steer it. Here is again such an example.

In recent years, there has been a completely fantastic development regarding the possibility of getting prescription medicines directly to your mailbox. It has meant an enormous amount, not least for the elderly who have difficulty getting to collection points and for people in sparsely populated areas and in the countryside. There, it can even be very far to the Icab store where one can otherwise collect their medicines.

50 percent of medicine deliveries to the countryside are today made via distance commerce. One receives what has been ordered in the mailbox. I believe that this also applies to up to 30 percent of other deliveries. It is highly appreciated among patients and likely also leads to more patients actually picking up and using their medicines. Otherwise, it is a major problem in healthcare that doctors prescribe medicines which the patient then, for various reasons, do not pick up and do not use.

Now, the Medical Products Agency, based on what I would almost call anecdotes, has concluded that theft of shipments to mailboxes and in the cases where they are hung on a door may occur. In the agency's proposal for a regulation, there is absolutely no statistical basis for this. The large distance retailers in Sweden that deal with this simultaneously say that they have a firm grip on how many shipments are stolen, because if a customer has ordered a medicine and it is then not delivered, it certainly becomes a process at the distance retailer to find out where it disappeared.

The Medical Products Agency now chooses to submit a proposal for a new regulation that in principle prevents this possibility by requiring that the recipient must be able to identify themselves at the time of delivery. It will of course work in central Uppsala and Stockholm, where there are courier companies that can say that the person who is home between 7 p.m. and 11 p.m. can receive their package by signing for it. But it will not work at all in large parts of the country, and that is very concerning.

In the draft regulation from the Medical Products Agency, it is not described with a single word what the consequences of this will be for the elderly and people with disabilities who have difficulty getting to collection points - or for that matter, what consequences this will have in rural areas and in the countryside where this has truly been a godsend. This is seen, not least by the fact that it is primarily there that this is used.

The Minister correctly pointed out that it is up to the Medical Products Agency to look at this regulation. They have the right to ignore all political views and simply decide this. We do not know if they will do so or if they will be wise enough to listen to the many negative views that have come in during the consultation process. They have not only come from Hela Sverige ska leva, pensioner's organizations and those most affected, but also from quite heavy consultation bodies.

My question to the Minister is what the Minister will do. There is a risk that the Medical Products Agency will proceed with this proposal, and it could have devastating consequences - not least for those patients who actually use the medicines that a doctor has prescribed.

Based on how the management model looks, I understand that it is difficult for the Minister to come up with any concrete proposals, but I still want to raise the issue and hear if the Minister has any thoughts.

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Fredrik Lundh Sammeli (S)

Mr. Speaker! The interpellator Jonsson has in an excellent manner described the problem and the concern. As a Norrbotnian, I can only agree. The deregulation of the pharmacy market has by all means caused the pharmacy supply to flourish here along Drottninggatan in Stockholm, but it is not the case that the pharmacy operations in the whole country have become better.

Politics needs to constantly ensure and guarantee that there are accessible pharmacies, and this issue truly rings in one of the challenges. In this debate, I want to ensure that the government follows the issue and guarantees that the regulations being developed do not in any way worsen the possibility of living and residing in our entire country. Even if it concerns an agency decision, I think that the consequences of that decision will definitely become politics.

My hope is, of course, to get clarity and a clear statement on how the Minister will follow up on the issue and that we can calmly meet all the worried citizens across the country who see that this threatens their access to medicines.

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Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! Once again, I thank the members for an important issue. Being able to live in the whole country and still receive a share of social services and health and medical care is a matter of course. That is why it is sad every time a pharmacy needs to be closed; it has happened a few times. The most recent, I believe, was relevant in Ljusne.

This is basically always linked to the fact that the health center was closed first. So that was the first time in Dalarna. When the region no longer felt they had a basis to keep the health center and instead closed it, the pharmacy followed because the connection and the possibility to operate disappeared.

This shows how important it is for every healthcare provider to reach out with their health centers and primary care centers, which are an important network for not least the pharmacies.

I am very pleased with the development of distance commerce. It is still a rather new phenomenon. Some companies have led the way, and today this is possible at almost all pharmacies. It is absolutely excellent that one can have the medicines delivered to the mailbox.

I know, of course, that if we had had a fine-meshed network for postal shipments throughout the country, perhaps it would have gone even better. We do have certain problems today. We have, for example, a different view on the postal service than we had before. But it is very good that one can get this home as a package.

It is very easy for me and the government to reach an agreement with the members regarding the importance of accessibility and being able to live in all of Sweden, but I note, Mr. Speaker, that none of the members this time are raising the issue of patient safety. That question was raised in the previous interpellation debate, but no one is raising it now. It is this that the Medical Products Agency has to balance.

Just as the members mentioned, I cannot in any way control what an agency does. In that case, I would have to be reported to the KU immediately. I have, as they say, to follow the question. But I note that the agency must handle both accessibility and patient safety when they work with this. They must take patient safety into account.

We know that there is some form of identity control in other countries in the Nordics that have similar systems. Finland and Norway have their variants of this. There are both advantages and disadvantages with all these things. I think perhaps a bit nostalgically about how it was before in the world when one had a rural mail carrier who could vouch for someone. This person knew who you were. Even if it was not Mrs. Larsson herself who received the medicines, the mail carrier knew it was Mrs. Larsson's son or someone else who did it and could vouch for the identity.

That is rarely how it looks today. I know that, and this is a bit nostalgic. But we must handle the new reality.

The possibility of distance trade must exist, but we must manage to combine it with patient safety. Patient safety is not a word that we can use when it suits us. It is a word, a reality and a legislation that we have to follow in all the decisions we handle.

I know that the Medical Products Agency, as always, reviews all referral responses. It remains to be seen how they land in what becomes a revised proposal on one or more points; I know nothing about that. It is a matter of them managing both accessibility, which is an important societal goal, and patient safety moving forward.

Based on the current order we have, this shall be my answer today.

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Anders W Jonsson (C)

Mr. Speaker! It is obviously important that an authority in such a situation weighs patient safety on the one hand against lack of or impaired accessibility on the other. The medical results of the treatment depend on both. Accessibility is actually a part of patient safety, because if it becomes much more difficult for patients to be able to get their medications, it leads to fewer patients taking the full course of penicillin or the treatment that the doctor has prescribed. This worsens the result for the patient.

Let us look at patient safety, which the Medical Products Agency says is important in this case. What is the problem, really? Well, it is pointed out that a pharmaceutical shipment can be stolen. But when it concerns, for example, narcotic preparations, one already has to sign for such a shipment today. It is nothing else.

One can, of course, also imagine that other medicines are stolen. But all of us who have tested this service know that the medicines come in a gray bag, and it is completely impossible to know what is inside it. The thief who wants access to a specific medicine will have to steal a hundred bags before having such luck that it becomes exactly the preparation one is interested in.

Then we have patient safety in a situation where the patient does not get access to their medication. Perhaps it has been overlooked by Postnord, or perhaps the neighbor stole the gray bag to see what is inside it. The risk that arises is that the patient becomes very upset. "I have not received my medication. It was supposed to arrive this morning." This can be rectified within a day or two. It is this risk that is jeopardized in that case.

Perhaps the Medical Products Agency claims that children have stolen medicines and consumed them and in that way been harmed, but some such examples do not exist at all.

If the Medical Products Agency had been interested in these problems, they would of course have told all distance pharmacies that they want to receive complete statistics on how many shipments have disappeared during the past year, how many of them can be suspected of being stolen, and what the result of this has been. This statistics are held by the distance trade. But nowhere in the regulations is there any such risk and consequence analysis.

One rather encounters reports that someone has found a package in a garden and that something has been stolen. Given the volumes involved, surely a number of packages have disappeared. But the negative consequences have not been raised at all in their proposal for a new regulation. There is not a word there about the elderly and people with disabilities, and there is especially not a word about people who live in rural areas and in sparsely populated areas. If they had included that and tried to make a balancing act, I could have understood the reasoning, but that is not the case.

I know very well that the Minister cannot intervene actively and publicly, for example here in the Chamber. Then a report to KU from some member regarding ministerial rule will surely be filed immediately. We do not want the Minister to be affected by that in this case.

However, there are a number of other tools that the Minister can use. These range from informal agency dialogue at various levels to requesting the underlying material, reviewing it, and asking questions about it. In instructions or regulatory letters, one could point out that it is important to weigh in accessibility and, not least, rural and remote areas. One could even consider removing certain parts of the delegation to the Medical Products Agency in a situation where they cannot make these assessments.

There are, therefore, a number of things that the government could do, but I understand that the Minister cannot report them here in the Chamber.

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Fredrik Lundh Sammeli (S)

Mr. Speaker! Patient safety is obviously incredibly important in all perspectives and in all the debates we have about healthcare. In the same way as it was important in the interpretation debate, it is also important here. It is also from this perspective that the Medical Products Agency looks at the issue.

The debate could take a completely different shape or receive a follow-up in the form of the right's deregulation failures. Certainly, one can look at the pharmacy market, which provides endless beauty products but far from always the medicines we need, or the postal service, which is an entirely separate tragedy. There, it is about the delivery around the country that really is a major problem for very many.

In this situation, however, I think it would be interesting to hear about and be able to feel reassured that the Minister shares the concern for what is being raised here regarding regulations. Does the Minister see that this could become a problem for people living in rural areas? How does the Minister intend to follow up on the issue? What does the Government intend to do so that new regulations aimed at patient safety in the area do not have negative consequences for those people who do not live in central locations and cities?

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Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! I thank the members for important points.

The development within the postal service has moved from fewer letters to more parcels. It is a huge transition. I understand that the distribution network must be changed because they cannot deliver more letters when they do not exist.

I am among those who gladly use the opportunity to send packages. It is a fantastic opportunity to be able to do so. Then, of course, the postal service must also expand its system so that it works throughout Sweden.

I consider it a problem, of course, if we cannot maintain distance trade with the level of service that we provide today. Just as Member Anders W Jonsson points out, accessibility is also linked to patient safety and compliance with what has been prescribed by doctors.

It is also important to have a fixed doctor contact or a fixed care contact. The things we are discussing are connected. If we have a fixed doctor contact and know which prescription we have, there is also a possibility to manage a shortage situation, which is exactly what we have today. I am glad that MP Lundh Sammeli highlights it. We have troublesome shortage and transport situations today, and they have increased. This means difficulties for many patients. It also means difficulties for those who prescribe medicines and do not even receive information in time; otherwise, they could choose another medicine for the patient. This can truly lead to medical consequences for a patient who does not receive the medicine that is needed.

This entire question is large and urgent and is connected to the issue of preparedness. The government has raised the ambition when it comes to preparedness. The important decision on total defense that we made in the chamber was the basis for the work that was started by the previous government and which we continue.

I am glad that I was able to present a number of proposals yesterday following a partial report from Åsa Kullgren's investigation. We are moving forward with sharper proposals to ensure greater security of supply and better information, not least in the event of a shortage. In that context, this issue is a part of it. That the medicines that are needed are reached is also a part of the preparedness.

I am pleased that the question is raised, and I am quite certain that the Medical Products Agency will review the referrals in a thorough manner, go through them and provide an answer. They will then return with the regulations they find appropriate. The members themselves have assisted the Chamber with information on what a minister may and may not do, so I do not need to go into that further. But I fully share the views on the need for high availability and patient safety. This is what must be balanced from the Medical Products Agency's side. I am firmly convinced that they will manage it in a good way.

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Anders W Jonsson (C)

Mr. Speaker! The reason I am interpellating the Minister is that this must not become another example where the Swedish countryside and rural areas are affected due to the administrative model we have, where state agencies only see their own small silo and do not look at the consequences at all, in this case for the elderly, people with disabilities, and people in rural and sparsely populated areas. In this case, it is obvious to me, who is in any case an amateur in the field, that the advantages of the changes that Läkemedelsverket has now proposed do not weigh heavily enough in the balance when it comes to risks for patient safety and other negative consequences.

As I have previously said, I know that the minister does not have the right to intervene directly in an agency's area of responsibility. But as I have pointed out, there are a number of opportunities for a minister to act, and I hope that the minister intends to consider them in the future. There is an opportunity for an informal agency dialogue, which occurs frequently and often. There is also an opportunity to review the instructions to Läkemedelsverket and, in a regulatory letter, provide further prompts to analyze the issue carefully. There is even an opportunity to review the delegations that exist to Läkemedelsverket. Here in the Riksdag, Fredrik Lundh Sammeli and I, of course, have the opportunity in the near future to invite the Director General of Läkemedelsverket to the committee in order to be able to ask the questions there.

This is an issue that truly upsets people, both older people with disabilities and not least people in rural areas and in sparsely populated areas. I believe that many of us here in the Riksdag will not let this go. I hope that the Minister will not forget this issue now that the interpellation debate is soon concluded, even if she cannot account for exactly how she intends to act.

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Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! I thank the interpellor again for the question. No, I will not miss it. It is necessary that we raise the preparedness regarding access to pharmaceuticals and medical technology products. It is also necessary that one receives them as a patient and is not hindered by shortages in the possibility of pharmacies, pharmacy outlets, or distance trade. As said, the development we have had with distance trade is very advantageous.

I want to highlight an opportunity that many pharmacies have. If I am chronically ill and have a medication that needs to be renewed regularly and which is important to me, I can subscribe to it and have it delivered to my home. It is very good. If we now improve the possibilities for national situational pictures and information in a timely manner, the healthcare provider, the prescribing doctor, can also act in time if a shortage situation were to arise and discuss with the patient how to manage the medication and how to get the right medication when it is needed.

Getting your medication when you need it is no small matter. It can be life-saving. Quite a few people are completely dependent on receiving the deliveries they need at all times. The state's responsibility cannot end at Stockholm's borders or where one leaves the larger cities. It must be possible to live, reside and work in all of Sweden, and distance trade has truly contributed to making that possible.

We must find the right forms to weigh accessibility against patient safety, and I am confident that the Medical Products Agency will do that. It is perfectly excellent that both the Riksdag and others reach out with their views. That is how democracy works. One takes in many views during the course of the work, and then one gathers them together and comes up with a proposal. One also has the right to make decisions in the Medical Products Agency.

Thank you for the interpellation and the debate! I take the question with me.

The interpellations debate was hereby concluded.

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