Response to interpellation 2023/24:830 on forensic psychiatry
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
KD considers it important to review the ownership of forensic psychiatry and that the government takes the situation seriously 1 2. KD argues that Socialstyrelsen should strengthen psychiatric compulsory care, that the state has allocated funds to support the regions 1 3 and that better cooperation between regions and municipalities is needed to improve discharge processes 1 3. KD wants to work systematically to prevent suicide upon discharge 2 and argues that the supplements the regions have received are historically large 4. KD considers that Socialstyrelsen's mandate should include improvement of compulsory psychiatry and forensic psychiatry 4. S considers that the need for places has increased, that the regions' finances are strained 5 and that the resources are insufficient 6 7. S argues that lack of municipal interventions causes people to remain in inpatient care unnecessarily 6 and that the staff is under heavy pressure 6. S considers that a greater state responsibility for forensic psychiatry is needed 6 and an increase in competence for young people 6. S considers that improved supervision and increased knowledge are good 7.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Socialministern Jakob Forssmed (KD)
Madam Speaker! Eva Lindh has asked me what measures I intend to take to handle the situation that has arisen within forensic psychiatry.
It is the healthcare authorities, with directly elected politicians at the municipal and regional levels with taxing rights, who are responsible for providing good and equal health and medical care. The question of responsibility, including cost responsibility, for forensic psychiatric care has been debated for a long time. In these contexts, it has, among other things, been highlighted that the occupancy situation within forensic psychiatry is strained, that there may be reasons to review who should hold the responsibility for forensic psychiatric care and how the care offered can be developed. These are issues that the government takes very seriously.
In order to achieve a health and medical care system that is provided with better conditions than today to offer good and equal care for the entire population, including forensic psychiatry, the government commissioned a parliament-appointed committee, the Vårdansvarskommittén, on June 1, 2023, to produce a basis for decisions that makes it possible to introduce, in a gradual and long-term manner, a full or partial state ownership for health and medical care (dir. 2023:73). The assignment shall be reported on June 2, 2025. The committee's conclusions will be important for the continued development within the area.
To support the regions in their work, the government further instructed Socialstyrelsen in May 2024 to strengthen and develop psychiatric compulsory care and forensic psychiatric care. The assignment includes, among other things, carrying out mappings and analyses to develop knowledge of forensic psychiatric care from various aspects. This is an important first step to be able to gain a closer understanding of the development needs that exist, for example regarding occupancy rates, treatment times, and the need for cooperation between regions and municipalities to achieve an efficient and purposeful discharge process.
When it comes to the economic situation for the regions, the state cannot fully compensate for the region sector's deficit. To support the regions in a challenging situation, the government has however allocated approximately 10 billion kronor during 2024 within the framework of partly a sector grant to the regions amounting to 3 billion kronor, and partly agreements between the state and Sveriges Kommuner och Regioner, SKR, all of which concern different parts of health and medical care. Against the background of the economic development, the government is allocating additional supplements to the regions in the form of a second sector grant of 6 billion kronor.
To provide the regions with the conditions to strengthen and develop the work with mental health and suicide prevention, the government also allocates over 1.6 billion SEK in 2024 through an agreement between the state and SKR. These funds can, depending on the principals' priorities, be used to develop forensic psychiatric care, for example by increasing the number of care beds.
In summary, the government is implementing several measures to support the regions as the primary providers of health and medical care and forensic psychiatry in a challenging economic situation.
Eva Lindh (S)
Madam Speaker! I thank the Minister for the answer. The reason I wrote this interpellation was that I was made aware of how incredibly strained the situation is within forensic psychiatry across the entire country.
The need for forensic psychiatric care for seriously mentally ill persons convicted of serious crimes has increased. The increased need for places within forensic psychiatry has been particularly clear during recent years. The number of persons within closed forensic psychiatric care has increased by 9 percent.
It is, of course, the regions in the country that are responsible for care within forensic psychiatry. Several regions have had to provide resources to deal with the shortage of places. But as things stand, the regions have a very strained economy. I do not quite share the view that the Minister conveys, that is, that healthcare has received many resources. We both know that we have different opinions on that. The whole thing means that when there is a shortage in healthcare, it also has consequences for forensic psychiatry.
Forensic psychiatry cannot, however, control the inflow and nor can it really control the outflow of places, that is to say, people. This means that it is difficult to influence exactly that which I want to talk about here today.
We agree that tougher sentences are needed, and we need to address the terrible spiral of violence in Sweden. That is not what we are talking about; rather, this is about the consequences of the tougher sentences.
Both our party and this government have expanded the criminal justice system, prisons, but it has not reached forensic psychiatry. That is why I think it is important to bring this up.
The problems are many. During the past weeks, I have visited the forensic psychiatry and spoken with experts and those concerned to form an impression. I want to convey to the government the picture I have seen, even if it may be beating on open doors, but everyone listening may not know what the situation is.
First and foremost, we have increased queues. On average, the national occupancy rate is now 105 percent. There are therefore not only deficiencies in Östergötland, which I am raising and which are close to me, but there is a deficiency in all of Sweden. In Östergötland, 34 patients who have been sentenced to forensic psychiatric care are waiting to get a place. It may not sound like much, but it is.
An increase is expected because the number of judges will increase. It will therefore not become shorter in the queue going forward.
Where are these 34 people who are waiting in Östergötland and those who are waiting around the country then? Well, they take up places in already full prisons. They also take up places within psychiatry, where there is very high pressure, and this leads to a so-called displacement effect. It is also the case that there are people who receive neither care or supervision but who have been convicted of serious violent crimes and need the care that can be obtained within forensic psychiatry. They should be there, because that is what they have been sentenced to.
Socialministern Jakob Forssmed (KD)
Madam Speaker! I would like to thank Eva Lindh for the interpellation, because I think we discuss forensic psychiatry and its conditions a bit too infrequently. I believe we can both feel a concern that this type of issue is sometimes deprioritized, as it is not quite as public as other issues concerning health and medical care.
The situation within forensic psychiatry in Sweden is strained. As Eva Lindh states, it is reasonable to review ownership and other matters, which we are now also doing, in order to achieve the most expedient arrangement for these types of issues.
But we must do things here and now. We have given assignments to analyze this in order to see what further can be done to increase the quality of the care and the interventions one receives. There is a great need for development here, both regarding coercive care in general and not least regarding forensic psychiatric care.
When people are discharged from forensic psychiatric care, there is an increased risk of, for example, suicide. We really need to work on this actively, and I look forward to doing so in the coming years. We will receive an investigation from Emma Henriksson on how one can work more systematically to prevent suicide. This naturally includes these types of operations. Within the framework of them, we shall do more of what we can and find out why it sometimes happens that people take their own lives in connection with discharge or shortly thereafter. That knowledge needs to be fed back. We know that we are a bit too poor at taking in that knowledge.
We have a difficult situation, and we take it very seriously. The shortage of care beds is something that the government is working very actively on trying to do things about with various measures and steps. We have also given a special assignment to the Health and Social Care Inspectorate to develop supervision and follow-up of forensic psychiatric compulsory care and forensic psychiatric care. With the help of supervision, we can ensure that it becomes better and functions better, which is one of the solutions to the capacity issue; it is often when one has the conditions to leave forensic psychiatric care that it ceases. It is important that we work with quality issues and the care bed issue, but also, of course, ensure that we organize this in the best way possible.
These are vulnerable people. Yes, they have committed serious crimes. But they are also often in very vulnerable situations. It is required that we handle this in a way that protects the public but also takes into account their interests of receiving good care, so that they can be discharged and return to society in a good way and function there in different ways, obviously with support measures from open forensic psychiatric care and other health and medical care. We all benefit from that.
Eva Lindh (S)
Madam Speaker! I truly agree with what the Minister for Social Affairs began by saying: We talk far too little about forensic psychiatry. There are several reasons why I believe this. Naturally, there should be good care for those who are there. When one is released, one should also have good conditions to not commit crimes and to live a better life. It is also clear that it is worrying when some of the people who have committed serious crimes and suffer from serious mental illness have no supervision or care and, as it is called, are at large.
I want to return to some other problems. As I said, one does not have control over the discharge of patients. In Sweden, we have a somewhat different system, where in most cases it is the Administrative Court that decides when a person should be allowed to leave inpatient care. Right now, we have quite a few people who are in forensic psychiatry and remain in inpatient care because the municipalities do not have the interventions needed for treatment in outpatient care. We must do something about this, so that we can manage it. It is indeed unjust that one remains when one has served their sentence and could be out and receive outpatient care instead. It is also the case that it occupies quite a few places. Given human rights and in order to get more places, this is something that I think we should address.
It is also the case that 97 percent of those within forensic psychiatry have had contact with psychiatric care previously, which is sad. It means that we must devote a lot of effort to truly building upon the psychiatric care that we have in Sweden. Had we made those interventions, perhaps we also could have prevented one from ending up in this situation.
The working environment within forensic psychiatry is incredibly pressured. When you have an occupancy rate of 105 percent, it means that the staff is pressured. But a consequence of it being full and crowded is also that it risks deteriorating the care that the staff can provide.
I also want to raise an issue that I myself have not really seen before, but which actually becomes very clear in, for example, the forensic psychiatric examination that was conducted on the girl suspected of the murder in Landskrona. If she is convicted, it may perhaps result in forensic psychiatry. She is very young. When the State Institutional Board cannot manage this, one ends up within forensic psychiatry. A competence increase and a different way of working within forensic psychiatry are needed when such young people are there and will be there in the future. We really need to look at that.
I am not a friend of nationalizing healthcare. But when it comes to forensic psychiatry specifically, I believe that a national intake and a greater state responsibility may be needed, because one cannot control the flow in and out. I really want to emphasize that we as a nation - we in the Riksdag and the government - have a great responsibility for the situation that exists within forensic psychiatry. We have a great responsibility for the care - I think we provide insufficient resources. When it comes to forensic psychiatry specifically, it becomes very clear that we must provide support, so that there are better conditions.
Socialministern Jakob Forssmed (KD)
Madam Speaker! I thank Eva Lindh again for this. I have no other opinion. These are important issues. I feel a general concern that in tough economic times, psychiatric care is not prioritized. This applies in particular to compulsory care and forensic psychiatric care.
This is important, because it is a matter concerning vulnerable people. When it comes to forensic psychiatry, it is people who potentially can be dangerous to their surroundings but who truly need support and interventions, just as Eva Lindh said, in order to be discharged. They shall receive the support measures they need in order to be able to live good lives.
This is the background for why I tasked Socialstyrelsen with strengthening and developing psychiatric compulsory care and forensic psychiatric care. Mapping shall be conducted, knowledge shall be developed, and awareness shall be gained regarding what development needs exist, not least regarding the cooperation between regions and municipalities, in order to manage the discharge processes in a better way than today. They shall also look at occupancy rates, lengths of stay, and such things.
We have a shortage of care beds in many areas. The government is working very actively overall to produce more care beds. It is an important matter.
Since then, we have worked on reviewing whether the care should be governed more by the state and, if so, in what way – whether it should occur entirely or partially. There, one naturally also needs to analyze the conditions for forensic psychiatry. As a Christian Democrat, I am a supporter of nationalization, but it is correct as Eva Lindh says: There are some specific conditions concerning just the forensic psychiatric care.
I believe we have reason to return to this issue and develop how the work shall be carried out. What does the availability of places look like? How can we ensure that the referral processes work better, so that different support measures can be obtained in outpatient care when it is possible? It should not be the case that a lack of cooperation or that these measures do not exist keeps people within forensic psychiatry even though they would not need to stay in that way. This is important. I hope that we can continue the work with those issues.
Eva Lindh (S)
Madam Speaker! I have devoted my first two remarks primarily to describing the problems. I note the point here about improving supervision, which I believe is very good as we see that there are deficiencies today. I also believe it is good with increased knowledge; I never oppose that.
I would, however, really like to urge Jakob Forssmed to answer the question regarding the situation here and now, which I also posed in the interpellation. Much of what the Minister for Social Affairs is talking about is long-term, and even if we may have different opinions on the primary responsibility, we can surely agree that no change will occur today. It lies further ahead. Even improved supervision and increased knowledge lie further ahead. It is not happening here and now.
My question is therefore what the Minister for Social Affairs intends to do about the situation here and now. I can only state that the lack of resources that I and many with me believe the government allocates regarding welfare in general, and particularly healthcare, will also affect forensic psychiatry. Can the Minister for Social Affairs therefore answer what he intends to do here and now? Can the Minister for Social Affairs work to ensure that the resources that are to be allocated to welfare also become greater? Today, it is insufficient.
Socialministern Jakob Forssmed (KD)
Madam Speaker! Thank you again to Eva Lindh for this interpellation! These are important issues, and I will continue to work so that we can achieve better forensic psychiatric care in Sweden.
I do not share the view that the supplements the regions have received are small or insignificant. They are historically large, but it is a very tough economic situation. I can feel a concern that psychiatric care is being de-prioritized more than I would wish it were, but I do not have control over the regions' priorities when it comes to this. With the ownership system we have today, it is not I who decides on it.
However, we have an agreement with Sveriges kommuner och regioner to develop and improve psychiatric care, including forensic psychiatry, and it is also important for me to follow up that these funds are used to truly improve psychiatry and are not used in general. The funds shall go to exactly this.
The assignment that I have given to the National Board of Health and Welfare is not only about developing knowledge but also about improving and developing forensic psychiatry and forensic mental health care. Not least, it is about cooperation between regions and municipalities to achieve a better discharge. I also see that this is something to work on when it comes to suicide prevention: to see these people, to take them in and do more so that they simply do not take their own lives, which in today's system there is an increased risk for when one is discharged.
I am open to doing further things and gladly accept input from Eva Lindh and others regarding what else can be done regarding this. We also continue to analyze the issue of beneficial ownership when it concerns this and other health and medical care.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.