Response to interpellation 2023/24:651 on Ivo's audit of LARO clinics

Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! I have been asked if I intend to increase the funding levels to the Inspectorate for Health and Care, IVO.

IVO's role as the state's supervisory authority for health and social care is unique and of utmost importance to ensure that the population receives care and social services that are safe, of good quality, and conducted in accordance with laws and other regulations.

The Government is keen to provide Ivo with the right conditions as the agency's mandate grows. For example, Ivo has been allocated permanent funds for the agency's work, including among other things, delivering data to and handling intelligence from the Swedish Payments Agency. The agency has also received permanent funds on account of the reform on protected housing.

We also see a growing problem with unserious or criminal actors within, for example, dental care, health centers, and aesthetic businesses. Ivo has an important role in preventing and countering welfare crime within both health and medical care and dental care as well as elderly care. Within the framework of its supervisory mandate, Ivo has the authority to prohibit operations within health and elderly care and revoke permits, so that unserious or criminal actors are not allowed to continue operating. Even when it concerns operations that are not subject to permit requirements, Ivo can hinder unserious actors through its supervision of compliance with regulations on, among other things, quality, patient safety, and competence. Earlier this year, Ivo was awarded two mandates to strengthen the supervision against welfare crime within health and medical care and dental care respectively as well as elderly care. For these mandates, the authority was also awarded a total of 14 million kronor for 2024.

The government's ambition is that Ivo shall have good conditions to carry out his assignment. Any increases in appropriations to agencies are presented in connection with budget proposals.

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

Yasmine Bladelius (S)

Mr. Speaker! Medication-assisted rehabilitation for opioid addiction, LARO, is the most well-tested and widespread method for treating long-term addiction to opioids, for example heroin. Research has clearly shown that LARO leads to reduced morbidity and mortality, reduced illegal drug use, and reduced spread of HIV. If LARO is performed correctly, it is often a life-saving and crucial intervention for persons with opioid addiction.

Mr. Speaker! However, there is a great deal of dissatisfaction with LARO care in my home region of Skåne. Since 2014, LARO in Skåne has been organized according to a choice of care. Private providers are free to establish clinics anywhere in the region. This has led to a situation where no fewer than six LARO clinics have established themselves in my home municipality, Helsingborg. The vast majority are concentrated in the central parts of the city, and the vast majority are private actors.

At the same time, the accessibility to addiction care is significantly worse in the rest of northwestern Skåne. This means that many patients from the surrounding municipalities, sometimes even from other regions around Sweden, must travel to or eventually move to Helsingborg to access care. This in itself makes it difficult for the municipality's social services to collaborate with the healthcare system and provide the support needed for the constantly growing number of people with addiction problems, many of whom are also the responsibility of other municipalities.

This has led to a completely unsustainable situation. Every month, reports are submitted to the Inspectorate for Health and Care, IVO, regarding deficiencies at the LARO clinics. The vast majority of the reports are directed at the private actors, who have now established themselves freely. I can mention a few examples, Mr. Speaker, which are taken from Helsingborgs Dagblad on March 22, 2024.

A patient can "take almost any drug or line and still get their stuff". The reporter is irritated that the partner "can both smoke and get medications".

Another LARO patient who is an addict has developed a psychosis, and the doctor at the home location refuses to provide methadone. He then travels 16 miles to Helsingborg and receives his dose at a private LARO clinic.

Another LARO clinic is prescribing benzodiazepines to patients who are abusing them while simultaneously receiving methadone. The informant claims that the clinic is risking the patients' lives.

It is therefore about many serious cases and a large number of reports to Ivo. Despite this, Ivo rarely initiates any investigation, but the cases are simply closed. In response to Helsingborgs Dagblads question to Ivo as to why they do not initiate an investigation despite there being reports of serious deficiencies, the inspector answers that it is simply a matter of lack of resources.

Mr. Speaker! Ivo has an incredibly important and extensive mission. Ivo argues in its budget basis report for 2024-2026 that in order to fully succeed with its mission and also to be able to fulfill the agency's mission in the future, additional resources are required. They argue that the estimated appropriation levels for 2024-2025 in the budget bill are insufficient.

In view of this, I would like to ask Minister Acko Ankarberg Johansson: Does the Minister and the Government intend to increase the appropriations to Ivo?

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Karin Sundin (S)

Mr. Speaker! When my colleague here in the debate, Yasmine Bladelius, told me about the situation in Skåne and that one has placed LARO, medication-assisted treatment for opioid addiction, under LOV, I first thought I had not heard correctly.

It must be one of those activities where it is absolutely least appropriate to send patients to private actors. What is obvious, and what Yasmine Bladelius has accounted for in her post, is that the healthcare providers – the private LARO clinics – do not manage their mission but turn a blind eye when patients abuse substances during treatment.

It is not strange that this happens, whether it is that the patient abuses [the system], since the addiction is the very core of the problem for which the patient needs care, or that there are private actors who do not fulfill their commitment in a correct manner. These are basic market mechanisms – there is money to be made by making the customer, in this case the patient, satisfied, even if it is not the purpose of the care and it is not in the patient's long-term interest.

LARO must be one of the activities where it is least appropriate to send patients to private care as well, because they are patients with substance use disorders who have large and complex care needs, since long-term abuse can lead to a number of follow-up diseases.

Studies show that as much as 80-90 percent of the people who receive LARO treatment are smokers, that a large proportion have diseases such as hypertension, diabetes, asthma and COPD and that a majority of the patients have hepatitis C. These are serious diseases, and it concerns patients who, more than many other patient groups, need care contacts that see and take responsibility for the patient's entire care needs.

Mr. Speaker! This patient group's specific and great need for coherent care chains was the reason why the then Social Democratic government appointed the Samsjuklighetsutredningen, whose final report was submitted to the Ministry of Social Affairs in January 2023.

The investigation proposes that all treatment of harmful use and addiction shall be the responsibility of the regions' health and medical care and that treatment for harmful use and addiction shall be provided in coordination with treatment for other psychiatric conditions.

The investigation finds that a coherent care chain in the patient's immediate environment requires cooperation between different branches of healthcare and that there is competence and resources available to perform the different parts of the treatment and a close collaboration with other actors who provide support to the patient, for example, the social services. The investigation's assessment is that care provided by a principal who has access to both inpatient and outpatient care near the patient provides the best conditions for developing care in such a direction.

In the conversations I have with various representatives for addiction care, everyone is currently asking the same question: What is happening with the Co-morbidity Investigation? We are waiting for the proposals that will enable us to provide our patients with better and more coherent care with better interaction between the different actors in healthcare.

In addition to the question posed in the interpellation regarding ensuring that Ivo has sufficient resources to be able to carry out his supervisory mandate, I wonder: Where has the Samsjuklighetsutredningen actually gone?

(Applause)

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

Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! I thank the members for the interpellation and for the follow-up remarks.

LARO is an important activity, and I am glad that several parties in the Social Affairs Committee changed their position regarding addiction care during the last parliamentary term.

We have previously lived with a situation where the social services have had responsibility for the majority of addiction care and substance abuse care, where the health and medical care has had responsibility for a part, and where patients have been forced to be sent back and forth between them. No one has done anything wrong, but patients have not received care.

When this became apparent both through the media's work and through discussions in the committee, several of our parties jointly agreed to change their opinion. We reached a new position, namely that care needs to be coordinated. We must ensure that the regions have responsibility for addiction care, because if one is affected by addiction, it is indeed healthcare that is needed.

It was an important position, Mr. Speaker, that we took jointly and for which we received the full support of the Riksdag to proceed. I am very pleased about that. It was one of the most important things that happened during the last parliamentary term. Therefore, it is important that we can proceed with this. We have a good investigation underway, which took some time. It also needed time, I would say, because it was no small matter that they were going to look at.

Now there is a task, but just as the member obviously knows, it is not the undersigned who is responsible for this, but the Minister for Social Affairs. The member is welcome to return in matters regarding addiction care, which the Minister for Social Affairs is responsible for.

What the interpellator has asked me about today concerns Ivo, and the example is LARO. Ivo has a very important role. That is why new money is added when it concerns both welfare crime and other assignments, as I explained in the response to the interpellation in accordance with the question that was asked.

Ivo needs more money when they receive new assignments. That was the case when we introduced the law called the Beauty Act, which concerns aesthetic surgical operations and treatments. Then they received new money to manage the new supervisory assignment. Now they have received new money to also manage the risks and major problems that we see within parts of healthcare, dental care, and elderly care when it comes to welfare crime.

We will continue in that manner. If authorities receive new assignments and we see new problems, the government will provide funds, but it is clear that they never get what they demand from the Riksdag. In front of me, I have, for example, the budget proposal from Ivo for 2021-2023. For 2021, when the Social Democrats led the government, they wanted 782 million, but they received 754. The year after, they wanted 821 million, but they received 760, and so on. If one follows this every year, one sees that they demand something for a need but that they do not receive this. It is a situation that all governments have lived with.

What we need to consider is, of course, in what way we can strengthen Ivo's operations so that it yields the best effect. In that regard, they themselves have worked in recent years to obtain more resources and tools so that they can work more efficiently, cross-reference registers and use data that exists at other agencies, which they cannot always do today.

Ivo has even submitted proposals to the previous government regarding 40 different constitutional changes needed for them to be able to work more effectively. The previous government managed one and a half, even though I am fully aware that a pandemic occurred in between. We continue with the other proposals. I do not know if all 40 were needed, but many of them will be needed. This results in many investigations that are already ongoing, and more will be added to those.

I do not believe that money is the only solution, but that one of the solutions is better tools for Ivo so that registers can be cross-referenced, things can be detected in time, and inspections can be carried out that are not always advertised in advance, but where one can actually arrive unannounced and see what activities are being conducted. I believe that the government needs to continue with those parts as well, and that is what we intend to do.

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Yasmine Bladelius (S)

Mr. Speaker! Online, Helsingborg is known as the country's LARO capital. On the online forum Flashback, there is an endless number of tips from people all over the country that one can travel to Helsingborg to easily get a dose. In other regions, the requirements are stricter and the queues longer, but in Helsingborg, no fewer than six clinics have established themselves in the central parts of the city, and there it is quite easy.

The LARO clinics are competing with one another. The more patients, the larger the profit distribution to the owners. In other words, it is a good business for the Skåne drug clinics, which earn millions as the patients continue to abuse. As an example, Skåne's largest clinic, LARO Kärnan, turned over 24 million kronor last year. Since 2020, they have distributed 4.8 million kronor to the owners.

Mr. Speaker! As I mentioned earlier, it is a completely unsustainable situation. The free choice of care and the free right of establishment for LARO clinics in Skåne have led to a LARO tourism to Helsingborg. It has created a market of abuse care that only benefits the owners, not the patients.

In Helsingborgs Dagblad's article series about the drug clinics, one can read some of the posts that have been written online about the private LARO clinics in Helsingborg. I am going to read some of them, just so that you will gain a further understanding of the issues regarding the choice of LARO care that I am raising here in the rostrum.

A person writes: "Call a private clinic, Laro Lejon in Helsingborg is the best. They will help you, I am a hundred percent sure, believe me." It is a reply to a post by a woman who was denied treatment in another municipality.

Another quote is: "It is claimed that you get in on the same day you apply there." One person writes this about LARO Kärnan in Helsingborg. Another person in the same thread writes: "Apply to Laro Sund instead. They take anyone."

At the same time, Mr. Speaker, the Inspectorate for Health and Social Services, IVO, receives countless reports every month regarding serious deficiencies in LARO activities. They receive so many reports that they are forced to drop many of the cases without initiating an investigation because resources are lacking.

The Minister for Health's colleague, Minister for Social Affairs Jakob Forssmed, answered a written question I submitted to him regarding whether he and the government can consider reviewing the free right of establishment so that it is up to the regions themselves to make those decisions. The regions can absolutely do that, and Region Skåne is the only region in all of Sweden that has made a decision to introduce choice of care for LARO. But I know that both the Minister for Social Affairs and the Minister for Health know that it is fully possible for the government to decide that free right of establishment or choice of care within specifically addiction care is a rather bad idea and should not exist.

My question to the Minister for Health and Care is therefore whether the Minister is open to speaking with his colleague Minister for Social Affairs Jakob Forssmed about finally tackling the failed privatization of addiction care. It is, in fact, my firm opinion that criminals, fraudsters, and unserious actors should not be present in the Swedish welfare system, Mr. Speaker.

(Applause)

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

Karin Sundin (S)

Mr. Speaker! People with a long-term drug addiction need care based on their individual needs. They should not be sent out into a private market where the overall goal of the operation is economic profit and dividends to shareholders. They need care based on individual needs, a professional approach, and well-functioning care chains, including functioning aftercare.

Parts of today's private healthcare market can be described as nothing other than a failure. The picture we get of the LARO operations in Skåne shows a failure. Furthermore, we see that within addiction healthcare across the country, it is difficult to staff with the right competence. This is partly due to the fact that we have a general competence shortage, and partly because one is currently competing with, among other things, the Prison and Probation Service, which in its strong expansion seeks competence similar to that within psychiatric and addiction care.

In this situation, a well-functioning permit process and a well-functioning supervision were needed more than ever, and it is good that the government, after several pressures from us in the opposition regarding irregularities in private healthcare companies, has given Ivo the mandate to prevent and counteract welfare crime within elderly care and healthcare. But clear mandates to Ivo are not enough if Ivo does not have enough resources to fulfill them.

This debate is about the fact that we within the Riksdag, the government, the state authorities, regions, and municipalities have a shared responsibility to ensure that society's most vulnerable and ill receive the care and treatment they need. Therefore, the proposals from the Samsjuklighetsutredning need to land on the Riksdag's table. We do not need ministers who shovel responsibility between one another. Ivo needs more money for his job, we need order and clarity in healthcare - and we need LARO activities that prioritize the patient's best interests and not the patient's ability to generate economic profit.

(Applause)

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Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! I thank the members for their supplementary comments.

I want to say that one can certainly be cynical and think that ministers pass questions between one another, but it is the questions that are submitted – the interpellations – that we answer. Questions concerning another minister's area are impossible for me to answer. It is a self-evident matter, and I assume that one sticks to that line. Otherwise, it becomes difficult to provide the government's answers to the questions.

I think it is necessary that we get better addiction healthcare and that the change that is needed actually happens. It is necessary that we get a unified responsibility, just as we see that addiction is a disease. That is the great shift we need to achieve. For quite a long time, we have lived with a situation where it has been believed that it is a person's character or traits that cause them to have fallen into addiction, but no, it is a disease.

This was the important insight that we completely agreed upon in the Social Affairs Committee during the last parliamentary term, and it is necessary that it be reinforced in various ways. It shall be reinforced in laws and regulations, as well as in activities that support the people who have been affected by an addiction and give them a chance to get out of it and become healthy from the illness they have.

Then there is much we can do in other ways to reduce the risks, regarding things such as risk farming and many other things. In that regard, an active ANDT policy is necessary in various ways. Addiction healthcare must, however, exist within healthcare in order for it to be integrated and for people to receive help with the illness they have.

What other disease are we asking the social services to take care of, Mr. Speaker? None! It is, in fact, obvious that the social services and its social workers have their mandate, which is something completely different. We cannot ask them to take responsibility for diseases; instead, it must be to the health and medical care that people go. Therefore, the change that is underway is extremely urgent. One is welcome to return to the responsible minister for a conversation about precisely the Samsjuklighetsutredningen.

Regarding what the interpellator raises today, the choice of care in itself is part of the discussion. I believe that many measures are needed. Which form is chosen is decided by each region, as that is the order of things given that the regions have autonomy. When the region designs its choice of care, it is however extremely important that it is done in a careful manner. One has every opportunity to set very many and far-reaching requirements on how the operations should look, on continuity and quality, and on how the operations should be followed up.

It already appears today in the Local Government Act that a region or a municipality has full responsibility for everything it delegates to another. One does not divest oneself of any part of the responsibility for care; rather, the region or the municipality has the full responsibility even when the care is performed by someone else. When agreements are entered into with others in various ways, one must therefore ensure that one can follow up on the care in a full manner. One needs to ensure that it follows the Health and Medical Services Act, that it is need-based, and that it is safe, so that there are no risks with what is being done. There is therefore reason for everyone who works with agreements in different ways, either through procurement or according to the LOV procedure, to ensure that one has agreements that work.

What the interpellor raises today, however, concerns Ivo's possibilities to exercise supervision, and it is clear that this is dependent on what resources the authority has. It is therefore why we have added more resources from the government's side, and we will, of course, follow the development. It is also about the other part I raised, that is, the importance of actually having tools that make it possible to exercise supervision in the best way. One does not have that today.

We are working in different ways with government inquiries to obtain legal basis so that Ivo can do this in a different way, and we will return to the Riksdag to be able to make the necessary decisions so that the supervision becomes more effective.

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Yasmine Bladelius (S)

Mr. Speaker! The problem with the choice of care in specifically substance abuse care in LARO activities that I am trying to highlight here is that those who need LARO care, those who are in need of the important LARO care, do not receive it in a correct way when it is based on choice of care.

It is clear that at those clinics in the LARO operations that are private and that live by making money from the patients who come to them, that live by competing to survive, the patient does not receive the good and important care that LARO operations are supposed to offer.

It becomes extra clear in Helsingborgs Dagblads review that it is precisely at those clinics that are forced to compete and are forced to attract patients in order to make a profit that these problems exist. I do not think it is worthy, Mr. Speaker.

That is exactly why I would like to see a stop to freedom of establishment and choice of care in addiction care and LARO activities. It is so clear that it is not working. It is also very clear that the patients are not receiving correct care.

The very idea behind the LARO activities and LARO treatment is that those who have an addiction and need help out of it should receive treatment for a shorter period in order to then be able to go out into real life and avoid the treatment. But it is very clear in the review that has now been conducted, and the minister highlights this, that the private LARO clinics on the contrary do everything they can to keep the patients in the activities because the patients generate cash.

I also just want to say for the sake of the listeners that in our budget motion we added an extra 40 million to Ivo - exactly what Ivo requested, Mr. Speaker.

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Statsrådet Acko Ankarberg Johansson (KD)

Mr. Speaker! Thank you, Member, for the question and for the opportunity to discuss Ivo's important role!

It is necessary that we have a supervisory organization. We obviously have full confidence in those who work in health and medical care. But we must have a way to be able to follow up, because sometimes it is a systemic error. Sometimes it is a handling error by an individual. That must be handled. That is also why there are regulated professions. But sometimes it is a systemic error and things that concern structure. That is why Ivo is there both for what is a handling error by an individual and for what can be a systemic error, and therefore Ivo's supervision is necessary for both the Riksdag and the government in order to be able to follow the development.

It is clear that one usually gives the money that authorities desire when one is in opposition, but not when one is in government. There we have a similar situation, both with previous governments and the current government. But I am glad that we have added more money to Ivo, because one needs both more money and better tools to be able to do what needs to be done.

Then to what the member highlights regarding LOV: When one enters into agreements with someone else, it is indeed necessary to enter into wise agreements. The member points to a situation where one receives a lot of care but perhaps not the right care. It is also important to get the right care to the right patient, because it is not always the case that many interventions are the right intervention. I believe that is a task that is necessary for all healthcare providers today to consider in reimbursement systems and in agreements, regardless of whether it is in their own management or in some other way.

That is also why the government has entered into a letter of intent with Sveriges Kommuner och Regioner regarding knowledge management, where we particularly highlight the importance of wise clinical choices. We did that in March. We need to ensure that we get the right care to the right patient because it is about patient safety - not just a lot of care, but the right care.

I thank the member for raising the question. We will certainly have every reason to return to Ivo's important work in the future. I hope that the members will return to the responsible minister regarding the issue of addiction care, as that is also a very important issue.

The interpellations debate was hereby concluded.

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