Response to interpellation 2024/25:117 on incorrect prescription of medicines

Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker! Mikael Dahlqvist has asked me what my plan looks like to resolve inaccuracies and irregularities within the prescription of medicines and what I am prepared to do now.

Initially, I want to emphasize that the government and I myself are well aware of the challenges highlighted by the program "Uppdrag granskning" regarding Ozempic. It concerns, just as Mikael Dahlqvist points out, among other things, inaccuracies in the prescription of medicines, where we see a growing problem with unserious or criminal actors. But the problem is larger than that. We have seen an increase in illegal and counterfeit medicines and illegal medicine sales via fake online pharmacies. These are part of the criminal economy and a source of income for organized crime. Furthermore, the program also sheds light on the increased problem of shortages regarding medicines. If we take the example of Ozempic, it has been repeatedly backordered since 2022. The government takes all these problems very seriously and is actively working on them.

The Health and Social Services Inspectorate, Ivo, has an important role in preventing and countering welfare crime within health care, dental care, and social services. Within the framework of its supervisory mandate, Ivo has the authority to prohibit certain activities within health and social services and to revoke permits, so that unscrupulous or criminal actors are not allowed to continue operating. Earlier this year, the government gave Ivo two different assignments to strengthen the supervision against welfare crime within health care and dental care and social services respectively. To be able to carry out the assignments, the authority has been allocated a total of 14 million kronor for 2024.

Ivo can make decisions criticizing an individual prescriber but has no possibility of combining such a decision with an injunction or a prohibition. Furthermore, there are limitations in the supervision of medicinal prescriptions that Ivo can exercise. The National Audit Office points out, among other things, in its report on medicinal prescriptions that Ivo lacks the possibility of using the information needed to be able to carry out a risk-based self-initiated supervision.

On 12 September 2024, the government therefore commissioned an investigator to investigate certain issues regarding documentation, limitations, and supervision concerning medicinal prescriptions (dir. 2024:82). The purpose of the investigation is to ensure that there is a system that counters incorrect medicinal prescriptions as well as to prevent public funds from going to criminal and unprofessional actors. The investigator shall, among other things, analyze whether Ivo needs more information on prescriptions of medicines to be able to conduct a more effective supervision, review the supervision of medicinal prescriptions that burden the medicinal benefits, as well as analyze whether there is a need to be able to limit the right of prescription and also the right to dispense medicines during shortage situations. The assignment shall be final-reported by 12 March 2026 at the latest. Given the increase in shortage situations for medicines that we have seen recently, the government has however chosen to move forward the reporting of the part of the assignment that concerns limiting the prescription and dispensing of certain medicines during shortage situations. The assignment in that part shall instead be reported as early as 15 April 2025.

Incorrect or improper prescriptions also risk leading to shortages and scarcity situations within the pharmaceutical supply. In this area, the government has taken a large number of measures. Guaranteed access to medicines is now also a point in the Tidö Agreement so that the work to increase the ability to prevent and manage shortage and scarcity situations regarding medicines shall continue. In May 2023, the government tasked the Medical Products Agency with preventing and managing shortage and scarcity situations in Sweden. The agency shall map out, analyze, and propose measures aimed at preventing and managing shortage and scarcity situations regarding medicines for the Swedish market. On July 1, 2023, legislative changes also entered into force which shall strengthen the supply preparedness and thereby also prevent or reduce the consequences of shortage situations. The regulation includes, among other things, a possibility to impose sanction fees on pharmaceutical companies that do not report sales suspensions in the prescribed manner and a stock-holding obligation for outpatient pharmacies.

To counter the increase in illegal and counterfeit medicines, the government has today tasked the Medical Products Agency with conducting an in-depth mapping and analysis of the occurrence of and problems linked to the purchase of medicines outside of legal trade. The assignment also includes analyzing and proposing relevant and powerful countermeasures, as well as informing the public and relevant authorities and actors about the risks associated with counterfeit medicines and pharmacies. The purpose of the information campaign is to increase awareness of the major health risks of purchasing counterfeit medicines and to increase knowledge that only pharmacies with the approved pharmacy symbol should be used.

To conclude where we began, with Ozempic, which is intended for the treatment of adults with inadequately controlled type 2 diabetes but is used off-label for patients with overweight, I also want to briefly mention the assignment that the government has given to Socialstyrelsen to map, analyze, and evaluate the care for the common disease obesity. The increased prescription of Ozempic for weight loss highlights the great needs that exist among obesity patients, and the objective is that this assignment will ultimately lead to better care for that patient group.

With that, I would like to thank Mikael Dahlqvist for the questions. I look forward to the debate.

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Mikael Dahlqvist (S)

Madam Speaker! I thank the Minister Acko Ankarberg Johansson for the answer, which is well-considered and exhaustive. Many initiatives are underway, which I welcome. But the Minister's answer points to a major societal problem that may be larger than many are aware of.

With and including the audit program on Ozempic, which is intended for the treatment of type 2 diabetes, many Swedes became aware of the acute problem. Ozempic is, in fact, prescribed incorrectly by doctors since it has been shown to have a good effect on overweight. The indication for obtaining a medicine subsidy for this preparation is solely diabetes. Nevertheless, the subsidy list is signed even if the medicine was prescribed for, for example, overweight, which burdens our taxpayers in an incorrect way.

Perhaps the most serious thing about this problem is that there is more or less a shortage of medicine, which means that patients who really need this medication and who have difficulty getting good values without Ozempic do not get it. The journalist who made the program was themselves incredibly surprised by how easy it was to get this preparation out. The journalist felt that those responsible at the clinic where this happened did not take the issue fully seriously.

Madam Speaker! Unfortunately, this is not a new problem. Since 2022, for over two years, Ozempic has repeatedly been reported as out of stock. Almost a year ago, the Medical Products Agency issued a statement asking prescribers to follow the regulations when prescribing Ozempic, which should be obvious. The Swedish National Audit Office has noted the problem in an audit that we debated here in the chamber a short time ago.

Madam Speaker! The problem is, however, larger and deeper than that. Ozempic is only a small part. Incorrect prescriptions of medicines can, of course, occur due to both ignorance and mistakes. That is a completely different issue to debate. I mean that there is welfare crime even within this area, and that is also how I interpret the Minister's answer. This is done deliberately by unserious and criminal actors.

Madam Speaker! Another problem is when the doctor prescribes narcotics-classified medicines on completely incorrect grounds, often for economic reasons. Such activity can continue for many years without measures being taken. There are many reasons for that, for example, a lack of information transfer between authorities and pharmacies. My point with this entire interpellation debate is that these are not new tasks for us who work with these issues. The problem is that it takes so damn long to rectify this.

I welcome the Minister for Health and Social Affairs' answer that several investigations and measures are underway. But both the Minister and I know that it may take several years before concrete measures are decided. Therefore, Madam Speaker, I ask the Minister once again: Is there anything specific we can do here and now to accelerate the process?

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Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker! I thank the member for the interpellation. It provides clarification to the question so that we can discuss it in the chamber today.

Let me begin with the question of how fast it can go. The member is right that investigations take time. I think it is necessary that they are allowed to take some time. We agree on the problem, but when one is to find solutions, one must also evaluate them. Which solutions are good? Are there solutions that are worse? What consequences do they have? After an investigation, there is also a consultation period. Then one must settle on what one thinks. It therefore takes time. Now we have chosen to shorten the time in some parts, so that we can get answers a bit faster. I want to emphasize, however, that one cannot just read in the newspaper or watch a TV program and then make a decision. We need time to ensure that we take wise measures.

Just as the member says, it is clear that this has been known for quite some time. I remember that Ivo left a list with the previous government with 40 points that were to be addressed, but there has been a pandemic. In some sense, there are reasons why everything could not be done during the pandemic. Instead, there are quite a few measures that we need to take now, and we are doing so on a broad front.

What is also problematic is that it is not just a medicine shortage in the sense that medicines are used for the wrong things. Let me use the term semaglutide instead of the names of different products, Madam Speaker, because semaglutide is the active ingredient in the medicine. Semaglutide has proven to be very effective against quite a few diseases, not just type 2 diabetes or obesity. There are many more diseases where one can see that it is effective against.

It has meant that the companies producing these medicines have not managed to produce the quantity that people want to buy or that one wants to prescribe. It is done in different ways in different countries; sometimes they can be bought over the counter, and sometimes they need to be prescribed – as in Sweden. The companies have thus not managed to produce the medicines that have been needed. This may also be the reason why counterfeit medicines appear online. In the worst case, people risk being hit extremely hard by ill health or injuries from medicines that are not controlled and correct. It is important to act in that part as well, which we do.

The shortage situation is therefore partly due to the fact that companies do not have time to produce the medicines that are needed, and partly due to the fact that Europe's competitiveness is too poor. I would like to highlight that part in today's discussion, because regardless of which president won the election in the USA, I believe that the president would have protected the USA. It is not strange that one wants to protect one's own country, but the USA is a country that has set up trade barriers against other parts of the world and also worked with state aid. It is a challenge not only for Sweden but also for Europe.

Now Europe needs to unite in a competitive pharmaceutical legislation that ensures we get products on the market in Europe. That is where I am very concerned, but I am pleased with the broad political consensus we have in Sweden that we shall strengthen competitiveness through good pharmaceutical legislation. I believe therefore that it will be a constant part of the future work to ensure that we have the good supply of medicines that patients need, Madam Speaker.

When it comes to what we do here and now: the Medical Products Agency can already now urge – not force, but urge – prescribers to consider which indication it concerns. They do this repeatedly in various types of shortage situations. I want to say, therefore, that the Medical Products Agency is using its tools fully today. What we want, however, is to give them more tools, and we also want to give Ivo more tools to act when inaccuracies are discovered and when one actually needs to take a sharper stance.

I therefore judge that we still have many measures underway, Madam Speaker. It concerns both what can be done now, in a short time, and the investigation that is being conducted.

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Mikael Dahlqvist (S)

Madam Speaker! I thank Acko Ankarberg Johansson for the answer.

The Minister touches upon several parts of the problem that I am fully aware of. One part naturally concerns the availability of medicines both in our country and globally. It is a particular chapter, which I welcome the Minister's engagement in. We Social Democrats support it fully and extend our hand and truly want to help, because it is needed. We certainly also need to strengthen Europe's preparedness, but that the Minister and I have discussed previously.

This is actually a sad discussion to have to have. Here we are talking about highly educated labor that has been given an enormous amount of trust in connection with the free prescription right and which abuses the system, consciously or unconsciously. It is even sadder when we see that it is done in an organized form or, frankly, for economic gain. I know that Acko Ankarberg Johansson shares my frustration regarding these welfare crime problems.

Time is ticking, however, and I feel that we are somewhat stuck on square one or square two and treading water, Madam Speaker. My point with this interpellation debate is partly to raise the issues, which I think we have done in a good way, and partly to see here and now if there is any fast track. Is there any shortcut? Can one pick any fruit that hangs low?

I am thinking, for example, of the national medication list we have today. It provides a comprehensive overview of which medications are prescribed, which patients receive them, and who prescribes them. This can be useful in many ways, but I contend that this possibility is not fully utilized. One can early on obtain indications of inaccuracies in prescribing. Now we are talking about the unserious part, but there is also a possibility to prevent preparations that patients have received at different hospitals from interacting with each other. This does happen, and it is something the Minister would like to comment on. Is there more to be done regarding the national medication list and access to it?

The second thing I am thinking of here in the speaker's chair, Madam Speaker, is workplace codes. Workplace codes are needed for patients to receive a subsidy for medicines. Then, naturally, a prescriber code is needed and so on, but the basis for a workplace code is that patients should be able to take part in the subsidy. It can be questioned whether the handling of this is efficient. In that case, it is the regions that can review the conditions and subsequently hand them over to the National Board of Health and Welfare for a decision. Is it done to the full extent? Is the answer no? I do not have a clear understanding of how this happens, but I get a feeling that there is a bit of room for adjustment there.

There are surely more things we can do here and now, and I naturally have respect for the fact that investigations must be conducted and referral processes must take place. But this is somewhat symptomatic of Sweden, and perhaps we could dare to loosen the reins a little bit? That is why my concluding question in this round is: Is there any fast track that the Minister sees? Is there anything that can still be done a bit faster, here and now?

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Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker! I thank the member for his supplementary questions.

It is entirely correct that both incorrect prescription and criminal prescription occur, if I may put it that way. Errors can be made due to carelessness and so on, but there can also be other things in the background. That must, of course, also be handled. Incorrect prescription must always be handled in the best possible way.

We have had a successful effort in reducing the use of antibiotics in Sweden. We know that antibiotics are incredibly powerful but that they also have a downside: They breed resistance. Antibiotic resistance is life-threatening if someone truly needs their antibiotics and the body does not accept them. It has devastating consequences, not least for many cancer patients who need antibiotics.

That is why we in Sweden have worked for a long time to ensure the correct use of antibiotics, but incorrect, that is to say excessive, prescription of antibiotics can still occur. It is an area where we are working broadly today and where we are at the forefront. The work that takes place is called Strama and is conducted with the help of statistics and follow-ups, and I want to say that we have actually reached good levels. We can say on good grounds that we do not, in general terms, have an incorrect prescription of antibiotics in Sweden today. We are actually at the top, and that is why we have been driving for the declaration that could be adopted by the UN in September. I was on site then.

However, there is also criminal misappropriation, that is to say, that one is not there because they want to serve healthcare or help patients, but rather uses our system to make money. Just as the member points out, the system with workplace codes is one of the ways that can be used to quickly get in and be able to use our common funds.

The problems are however quite large, for if one has a license, it must be approved regardless of where within the EU it was obtained. That is what we agree on within the EU. One may have received their education in a country other than Sweden, and in several of those countries, it is a bit more theoretical. It is not so much practical but more theoretical, and when one finally arrives in Sweden with such a license, it can lead to incorrect prescribing. What we have seen just regarding this part is, however, that the workplace codes are used in criminal activity, which is devastating for all the others with a foreign education who, of course, want to do a good job in Sweden. They are blamed, and we must absolutely ensure that we do not end up there.

We must also take action against those who actually use our system for criminal purposes. The problem is that we are not allowed to deny them the right to prescribe or to obtain a workplace code in Sweden. That is how the agreement looks within the EU – we accept each other's credentials. But we need to do something, and that is why we have asked an investigator to look into this.

It is possible that the investigator views it differently, but today I assess that the regions have small chances of stopping this. They say themselves that there may be up to 10,000 who have a workplace code but for whom there is not even a personal identity number. We do not know, therefore, who they are. The regions have nevertheless felt forced to so to speak approve the system, and it is the same for Socialstyrelsen.

This shows that we must find out this. We must ensure that we know who is prescribing, that we have the legal possibility to request personal identity numbers or coordination numbers, and that we can follow the prescription so that one works in accordance with the evidence that we use in Sweden.

There are quite a few questions that need to be investigated. That is why Anders Ahlsson has been appointed as the investigator, to see what we can do. I believe that we will need to make changes in laws and perhaps in regulations to address the problem, which is very large today.

I want to say a few words about NLL, the national medicine list. A unanimous Riksdag has stated for quite some time that it is important. The regions are working as much as they can, but they will not fully manage to meet the legal requirements that apply for 2025. We will need to go to the Riksdag and ask for a certain extension. But I still want to say that the regions have significantly increased the pace over the last year to be able to implement this. Some parts are therefore already in place, but as the member says: If everything is in place, we can better follow this and perhaps get better tools.

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Mikael Dahlqvist (S)

Madam Speaker! Thank you, Acko Ankarberg Johansson, for your answer!

I do not have much more to add – what has been said has been said – but I want to emphasize the importance of the government and the minister working as quickly as possible. I believe that all welfare crime occurring today undermines trust in Swedish health and medical care and in the welfare system in general. This does not only concern this area, but we also have the debate about HVB homes and about boards in companies. This is, therefore, a widespread problem.

It is also the case that this is a new era that we must manage and which one needs to reflect a great deal on. This is, in any case, an acute problem. I know that the minister and the government are aware of and engaged in this issue, but I want to emphasize the importance of the work that is taking place here and now.

I believe it is possible to achieve better information exchange. There is quite a lot of knowledge that is not shared between the regions regarding individuals who circulate and who might be dismissed from one place and then suddenly work at another – even within the Nordic countries.

There is an enormous amount of this kind of thing that one becomes frustrated over, and I believe the public also becomes frustrated. Our task is to ensure that it works as well as possible, with a system that is as effective as possible.

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Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker! I thank the member for raising the question that there is no coordination or transparency between the regions. They have no possibility today to see if someone has been stopped in another region. We need that kind of synchronization of registers and sharing of information. The healthcare system is, in my opinion, not 21 different systems in Sweden but one unified system, and we have one and the same law. They should have the possibility to share information. If it has been judged that someone has acted inappropriately, and if they perhaps have received a reprimand in some way, this information must be easily accessible to other healthcare providers.

Unfortunately, we have seen examples in the media of people traveling from one region to another and working. The same problem persists, which means a risk for every patient who encounters a staff member who does not perform their work in the best possible way.

In conclusion, I want to point out that we will need to make legislative changes and certainly changes in ordinances and regulations. I will be mindful that we maintain the balance, so that we do not abolish a lot of control systems that make things difficult for the staff and for everyone who behaves correctly and does the right thing. It is important that we find the right measures and that we do it in a balanced way.

I think we have built up a functioning operation that relies heavily on trust. We must not destroy the trust that exists through a multitude of control systems because we suspect everyone; instead, we need to find a balance. Let us maintain the trust where it works and is efficient, and then supplement with control to ensure that the resources end up in the right place.

We need every single krona of the welfare's resources, and we fear that it concerns billions that end up in the possession of criminals. We must stop this, also because every patient runs the risk of receiving an incorrect prescription or an incorrect medication.

I thank the member for the question and for the debate.

The interpellations debate was hereby concluded.

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