Response to interpellation 2023/24:282 on pharmacies in rural areas
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
KD argues that the freedom of establishment has led to more pharmacies and increased opening hours. KD emphasizes that the rural area grant exists to stimulate access where profitability is limited and that a significant increase in the trade margin has been proposed to improve the pharmacies' economy 1. KD wants to utilize the pharmacies better in the healthcare system, investigate possibilities for remote pharmacists 2 and emphasizes the importance of emergency pharmacies 1. KD considers that the deregulation was necessary and good 3. C argues that pharmacies in rural areas have a unique role 4 and that the rural area support should be strengthened 5. C proposes that remote pharmacists be allowed 5 and that the Government Offices should create proposals that provide greater opportunities to operate pharmacies in rural areas.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Anders W Jonsson has asked me what measures I intend to take to prevent the closure of further pharmacies in the Swedish countryside.
In the current sense, a freedom of establishment for actors in the pharmacy market means establishing pharmacies anywhere in the country. Before the deregulation, there were just over 900 pharmacies across the country in Sweden. Currently, there are more than 1,400 pharmacies. Even the opening hours at the pharmacies have increased significantly during this time.
To stimulate good access to pharmacies even in areas where profitability may be limited, there is the state so-called rural area grant (glesbygdsbidrag), which pharmacies can receive a share of. The regulation on who can receive the grant was changed in 2020, so that more pharmacies have the opportunity to receive a share of it. In 2022, 45 pharmacies applied for rural area grants for the 2021 financial year, and 44 pharmacies received such a grant. In total, the Dental and Pharmaceutical Benefits Agency paid out 12 million kronor in rural area grants in 2022.
Pharmacies are often dependent on proximity to, for example, health centers and often find it difficult to maintain their profitability if such activities cease. The regions' responsibility to ensure good access to care for the citizens is therefore also of importance in this context.
In addition to physical pharmacies, there are also other opportunities to purchase medicines. For example, some pharmacies operate in the form of pharmacy agents, where one can order and pick up prescription medicines and also purchase certain non-prescription medicines. In 2022, there were barely 600 pharmacy agents across the country. Pharmacy agents may only exist in places where there are no physical pharmacies. In rural areas, it is for example common that pharmacy agents are available in grocery stores.
There are also a number of pharmacies that have focused their operations on distance trade with medicines, including through e-commerce. It is a phenomenon that is increasing and which accounts for an ever larger share of the total market. It is also a valuable complement to physical pharmacies.
The Medical Products Agency has issued regulations on distance trade of medicines which regulate, among other things, requirements for the handover to the patient. During the autumn of 2022, the Medical Products Agency consulted on a proposal for revised regulations with requirements for ID checks at the time of handover in distance trade. The proposal met with criticism from the consulting bodies.
The Medical Products Agency on 4 December this year referred a new proposal for regulations on distance trade. In the new proposal, the requirements for the pharmacy operator regarding, among other things, self-monitoring, mapping of distribution, risk assessment and follow-up of deviations, and requirements for hiring subcontractors have been clarified, and the requirement for ID check at the time of dispensing has been removed.
The question of access to medicines in all parts of Sweden is urgent, and I continue to follow it closely.
Anders W Jonsson (C)
Madam Speaker! I thank the Minister for the answer.
Pharmacies are not just any kind of business. Therefore, when we carried out the deregulation around 2009, 2010, it was immensely central that we should secure the access to pharmacies in the Swedish countryside. This is because in places where there is only one pharmacy and perhaps also not great access to healthcare, the pharmacy takes on a completely central role. They handle much more of the healthcare there than in many metropolitan areas.
This has also been shown in research. Charlotta Melander, professor of economics, has shown that in the Swedish countryside, pharmacies have a completely unique role with a long series of different functions.
Therefore, it is important to ensure that those who more than ten years ago claimed that this would lead to the death of pharmacies in the countryside do not get it right.
It is also that which is the reason why TLV, which is the state agency that handles the economic conditions for the pharmacies, annually submits a report to the government on the state of the Swedish pharmacy market.
There is an alarm signal, I think, in the report that came from TLV this autumn. It is written like this: "A continued declining and deteriorating profitability means that pharmacies in certain geographical locations may need to review their service range, opening hours or, as a last resort, close pharmacies. A simplified vulnerability analysis shows that just over 11 percent of Sweden's pharmacies can be judged as extra vulnerable in the event of increased costs without corresponding increased revenues."
Now, the fact is that the 11 percent that are threatened do not only exist in rural areas. Of Sweden's 290 municipalities, there are approximately 100 municipalities that have only a single pharmacy, and that is where it is particularly vulnerable. A number of these 11 percent are in such municipalities where there is only one pharmacy. But it also occurs in metropolitan areas, where there may have been an over-establishment.
It was because I read this report and received this alarm signal from TLV that I wanted the Minister to come here to the chamber to report whether the Minister shares the view coming from TLV. Is it this many pharmacies that are threatened? But above all, I want to know what the government plans to do to ensure that what TLV points out does not become a reality and that a couple of pharmacies close down in rural municipalities where there is only a single pharmacy, for once they have been closed, it will be extremely difficult to start them up again.
There have been examples in the media of a health center or a primary care center closing down. It is clear that in those situations, it is also difficult to operate a pharmacy. The most well-known example is probably Lima in Dalarna, but now we also have Ljusne here at my home in Gävleborg. There I realize that one cannot operate a pharmacy, but this is about so much more.
Therefore, my question to the Minister: What measures does the government plan to take so that this does not become a reality?
The Minister has presented in a very good way what is happening today and what the regulatory framework looks like. But what I am requesting is a statement on what will be done to ensure that this does not become a reality.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Thank you, Member, for the question!
Just as the member says, it is truly serious if we lose pharmacies. They are part of the healthcare system and provide a continuity and expertise that benefits patients, so they are an important part of the entire healthcare system.
I share the member's assessment that it will be difficult to maintain pharmacies if health centers and other services are shut down. That is the case, but just as the member points out, there are other things we need to look at here.
Two things I want to highlight further for the member.
One is the trade margin. TLV has a continuous mandate to look at it, and now this autumn, it has been proposed to increase it significantly. Not by the small amount one usually does – one is usually a bit more modest. The trade margin that is now proposed to be increased to actually corresponds to 650 million kronor. It is therefore a quite significant amount that would benefit the pharmacies.
This is out for consultation, and it is TLV that makes the decision. But TLV is doing entirely correctly by constantly following the developments and assessing what measures should be taken, and this measure is in line with what needs to be done. Now we have to see what the consulting bodies say, but it is an important measure to raise the trade margin so that more can achieve profitability and can continue their pharmacy operations.
Another thing I want to highlight for the member is the work we are doing to secure emergency pharmacies. We also need, in the perspective of civil preparedness, to have access to pharmacies throughout the country.
None of our chains have pharmacies in all municipalities, rather one sees white spots regardless of which chain one looks at - not if one looks at distance commerce, of course, but if one looks at physical pharmacies.
One finds deficiencies no matter who one turns to, regardless of whether it is the community-owned Apoteket or any of the private chains. No one has operations in all the country's municipalities. But we have a responsibility, a social responsibility, to ensure that we have emergency pharmacies that cover Sweden in some way. We are now looking at that perspective together with the relevant authorities to see what measures we could take so that we have emergency pharmacies ready to step in on the day it is not just a minor crisis but a major crisis and ultimately high alert and war.
That question can also mean that we secure the existence of many of the smaller pharmacies that are located in rural areas or in sparsely populated areas, but we are not there yet. It is a matter of finding a wise method that, of course, does not produce incorrect effects on the market but achieves exactly what we want: a good civil preparedness throughout the country.
I assess that both the trade margin and the work with emergency pharmacies will be important parts moving forward for all pharmacies.
Anders W Jonsson (C)
Madam Speaker! This is at least a measure that can have some effect on what TLV points out.
But the question of emergency pharmacies is something else entirely. It is the question of what we do in the event of a major crisis. How do we secure this then?
What the TLV shows in its report is that given the changes that have occurred regarding parallel imports and so on, the pharmacies are now so pressured that 11 percent are potentially threatened with closure. That is where the government must step in with measures.
I think it is a positive message from the Minister regarding the trade margin. TLV has proposed it as an important way forward, because it is clear that if the large pharmacy actors get more muscles in the form of a not so pressured economy, they also get the opportunity to take a greater responsibility. But it will not be enough, rather, additional things are required.
One thing that the government could start looking into immediately is the rural area grants that actually exist for pharmacies in the smaller towns, which the Minister also pointed out in his answer. One could ensure that the rural area support becomes significantly stronger so that it can be used in these municipalities where there is only a single pharmacy and cover the costs so that we secure the pharmaceutical supply in these hundred municipalities which, therefore, have only one pharmacy.
One of the reasons why the small pharmacies are threatened is, of course, the economy, but it is also about obtaining competent staff. Not infrequently, the reason that one cannot run a small pharmacy is that the travel time for staff from the larger urban area out to the smaller one is far too long. Here, a simple measure would be to allow remote pharmacists. In Sweden, one can get help with most things via digital healthcare providers, for example from doctors, psychologists, or even veterinarians. But at a pharmacy, there is no possibility to get help from a remote pharmacist.
If the government opened up for this possibility, one could on-site use personnel other than just pharmacists. An experienced pharmacy technician could handle the medicines physically and be in constant contact with a pharmacist who performs all the important control functions. This would truly benefit the pharmacies in the nearly one hundred municipalities where they are threatened.
When the government agency TLV rings the alarm bell in the way I mentioned in my interpellation and says that a number of pharmacies in, among other places, rural areas are threatened, the government must take it seriously and respond. It is not just about accommodating a change in the profit margin, but other measures are also required. I have pointed out two, rural area support for pharmacies and remote pharmacy services, and there are others.
I call on the government to take the serious signal from TLV to heart. We must not put ourselves in a situation where perhaps up to a hundred municipalities in Sweden lose their only pharmacy.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! It is truly important to increase the trade margin, and 650 million is a substantial support that provides better conditions to be able to operate. The member mentions that being able to use the pharmacies in another way in the healthcare system is in the government's program. It appears from the healthcare section of the Tidö Agreement that we want to utilize the pharmacies better and use well-educated and competent staff for more services. This also increases the possibility to operate as a pharmacy, not least in rural areas and sparsely populated areas, where the pharmacies often have a larger role than in urban areas. The member also mentions remote prescription counters, which could also be an opportunity. We are looking at these issues, have been given mandates, and will return when we have good grounds and know what can be done in a patient-safe manner.
The work with distance commerce has developed, and the Medical Products Agency is now introducing new rules. This also provides support to look at these types of issues in a different way. How do we ensure that it is patient-safe? That is something we will never compromise on. It is a matter of finding a method and function that makes this possible with distance commerce as well. Then digital competence could also be relevant for physical pharmacies.
Much is going in the right direction, and I do not think the member should wave away the emergency pharmacies because they are part of securing the entire network of pharmacies in the whole country, not just along Sweden's coastline. Many different parts are required to secure the pharmacies as a part of the healthcare system. We have recently changed the rules for the rural area support, and we will continue to look at that, not least those who apply but do not get, to see if it would be reasonable to adjust the rules. As far as I know, 42 pharmacies applied last year, and 40 were granted. From what we have seen so far, it seems to be a reasonable balance, but we will of course continue to follow this issue because pharmacies are a necessary part of the healthcare system.
Anders W Jonsson (C)
Madam Speaker! I am by no means waving away the emergency pharmacies, for they are extremely important. But TLV's alarm signal is about something else entirely: In a normal state, a large number of pharmacies in the Swedish countryside are threatened.
Today's interpellation debate shows that there are at least some thoughts on this, but since the report from TLV is a few months old, there should be more activity in the Government Offices and a readiness to submit the proposals that provide a much greater opportunity to operate pharmacies in rural areas. During the pandemic, we saw how well it worked to use pharmacies for something other than the dispensing of medicines, and there is much else that could also be done there.
At its core, however, it is about the fact that there must be staff, and in that regard, remote pharmacist is important. Furthermore, the finances must be secured, because if the pharmacies are to engage in something other than just pharmaceuticals, it must be financed.
I really hope that this interpellation debate ensures that the issue lands high on the agenda. The pharmacy regulation has been successful in many different ways. But we must not put ourselves in a situation where a hundred municipalities lose their only pharmacy, because that development will be very difficult to reverse.
I thank the Minister for the debate and wish a Merry Christmas and a Happy New Year.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! I agree that the deregulation was good. It was necessary and has given us many advantages. But just like all other reforms, it must be nurtured. Therefore, I am pleased that pharmacies are on the government's agenda and in the Tidö Agreement. This cannot be taken for granted but must be nurtured and reformed so that we ensure that pharmacies function in the best possible way throughout the country.
The government takes the issue seriously, and the trade margin is not unimportant in this context. That TLV raises the price ceiling on certain simpler medicines is necessary, otherwise we will face medicine shortages. At the same time, we struggle to be able to pay for the most expensive innovative therapies. I do not believe that we will be able to lower medicine costs in the near future, because we must do what we can to prevent medicine shortages. It must be profitable to produce the simplest medicines and run pharmacies, and we must also find a model to manage the most innovative and fantastic therapies. This balance will be difficult to achieve, and in that case, it is good that the Riksdag and the government help each other in this work. But strengthening the pharmacies will be necessary to ensure good patient safety and a functioning healthcare system.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.