Response to interpellation 2024/25:172 on medicine deliveries in rural areas
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
The debate concerns medicine deliveries in rural areas and the Medical Products Agency's decision to cancel ID checks for mail delivery. KD argues that the Medical Products Agency has chosen a balance between patient safety and accessibility 1 and that the authority has made a trade-off between different patient risks 2. KD believes that the authority has chosen milder rules for distance trading to ensure deliveries throughout the country 2 3 and that the state is responsible for accessibility through financial support 1. KD emphasizes that the government cannot exercise ministerial rule 4. C argues that the decision is not reasonable, hits rural areas hard 5 and implies limitations for the elderly and persons with disabilities 6 7. C believes that the authority lacks an understanding of the countryside 7 and that the government exhibits poor agency governance 6 5.
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)
Mr. Speaker! I have been asked in what way I will ensure that people in rural areas are not affected by diminished opportunities to obtain their medicines.
asked the same question to me in an interpellation in January 2023. The background then was that the Medical Products Agency in November 2022 had referred a proposal for new regulations for distance trade, which sparked discussion. On the grounds of this discussion, the Medical Products Agency produced a new proposal for regulations which was referred in December 2023. After the authority has now taken note of the referral bodies' views, it has announced that the new revised regulations will enter into force on November 1, 2025. The timing has been chosen to give the pharmacy operators sufficient time to prepare for the changes.
In the authority's first proposal for regulations, requirements were set for ID checks upon the handover of medicines purchased remotely. In the proposal that will now become reality, it is stated instead that the shipment shall be handed over to the correct recipient. The implication of this is that the recipient, just as today, does not need to be home at the time of delivery and that the package can be left in their mailbox. It will, however, not be permitted to hang the shipment on the door or place it on the recipient's stairs. This requirement should be seen against the background that the Medical Products Agency has on repeated occasions received information from private individuals whose deliveries of medicines did not arrive within the promised delivery time. According to the authority's assessment, there may be patient safety risks when deliveries of medicines or technical alcohol are delayed or do not arrive. In this context, I can also state that the authorities are independent in their decision-making.
Through its latest proposal, the Medical Products Agency has attempted to find a balance between the requirement for patient safety and availability. Several of the actors who have been heard in the debate have argued that the Medical Products Agency's requirements will negatively affect availability. However, there are other voices. For example, the Swedish Medical Association is of the opinion that the Medical Products Agency should consider whether distance trading is appropriate for certain medicines at all.
As I mentioned in my response in January 2023, the state takes a special responsibility for the accessibility of medicines across the country through the special support for pharmacies in rural areas. At the last decision point, 55 pharmacies shared a total of 16 million kronor. This is the largest number of pharmacies that have received grants since the support was introduced in 2013. In Västerbottens län, for example, 12 pharmacies shared just over 3.7 million kronor, and in Jämtlands län, 10 pharmacies shared 3.5 million kronor. 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 would like to emphasize once again that the availability of medicines throughout the country is a very important issue for me and the government.
Anders W Jonsson (C)
Mr. Speaker! If it is as the Minister for Health and Social Affairs says, that it is important to ensure that there is a good supply of medicines throughout the country, one might be a little surprised that the authority is presenting this proposal.
Today, 30 percent of medicines are ordered remotely. You get them at home; they are hung on the box or are at the door when you arrive home. Those who primarily benefit from this are people in rural areas, because even though the government invests money and ensures that we can keep pharmacies open in rural areas, it is often two, three, or five miles to the nearest pharmacy.
People in rural areas are a group that needs this. Another group is people with disabilities, who simply have difficulty getting to a pharmacy. A third group is the elderly. Here comes a state agency, the Medical Products Agency, and presents a proposal that entails major restrictions on the possibility of distance trade with pharmaceuticals.
It should, in principle, be permitted if the package can be left in a mailbox. In that case, it is okay. But we know what principles Postnord has. It is not the case that one tries and sees if it fits in the box; instead, during sorting, standardized methods are applied which mean that at the slightest suspicion that a package will not fit in the narrowest variant of a mailbox, it does not go along, but must instead be collected at another location. This will mean that it will become very difficult for these three groups – the elderly, people with disabilities, and people in rural areas who have a long way to a pharmacy – to get access to their medicines.
Just as I said when we had this debate just over a year ago, I would be the first to accept this in a situation where this was a major medical problem – if children came over and took heart and blood pressure medication and had to be taken to the hospital. That is why we asked that time what had happened. Ivo says that no reports at all have been received.
We have now finally managed to obtain the decision basis from the Medical Products Agency. During a period of four years, 2020-2024, a total of 43 reports of deviations have been received, in a situation where it involves tens of millions of shipments. Four of these deviations concern the medicine being stolen. These figures are higher because the first thing the customer who does not receive their medicine does is call Apotea and the others and say: I have paid for a medicine, but it has not arrived. The pharmacy companies themselves know how extensive this is. But there has not occurred a single case where anyone has been harmed. In total, it therefore concerns four shipments that have been stolen over four years. In addition, it has concerned the logistics services in general, and it is clear that Postnord and some of the others may not be the best when it comes to getting the packages delivered. But it concerns a total of 43 reports.
In a situation where one stands and weighs and compares four stolen packages over four years - how much has disappeared from the pharmacies during the corresponding time? - with the significant deterioration this entails for the elderly, people with disabilities, and people in rural areas, this is not reasonable. When it becomes harder for these groups to obtain medicines, it will also mean that fewer people use the medicines they have been prescribed.
I think it is unreasonable that this government allows the Medical Products Agency to have such a narrow perspective that one is prepared to worsen the situation for, I would say, millions of people, because of these four stolen packages, when there is no report at all that anyone has been harmed. This is, I think, a sign of poor governance from the government's side.
Statsrådet Acko Ankarberg Johansson (KD)
Mr. Speaker! That patients must be given access to their medicines in a patient-safe manner is something we completely agree on. Patient safety is very central at all pharmacies. One must be approved - it must be clear that one is the right person - and an ID check is performed. When I order online, an ID check is also performed at the time of ordering but not at the handover. Now the Medical Products Agency says that ID checks are being waived at the handover. Through the new regulations, they have therefore unequivocally taken a step into uncertainty when it comes to patient safety. They still assess, however, that it is compatible with patient safety and that they can ensure it, and then we have to feel that it is ensured - even though the pharmacies now have controls at a much higher level than those performed in distance trading. In the future, a discussion will likely arise as to whether they are necessary, and then we may have to consider how we should view patient safety as a whole.
What is relevant regarding this issue is that the member wants the government to step in and run an agency. We cannot and must not do that. Instead, the member chooses to say that we do not instruct our agencies in an appropriate manner.
This is, of course, always an art. One can have a soft steering and talk about what one considers important. But one actually cannot tell an authority what decisions it should make – that is very clear. The government that intends to do so will end up badly off, on good grounds. It is not just about being reported by members of Parliament and ending up in the Committee on the Constitution, but it violates the order we have decided upon since several hundred years ago: that authorities are independent.
The Medical Products Agency has, based on its mandate to ensure that medicines reach all patients in the entire country, with the geography we have, chosen a method where they waive ID control at the time of delivery so that medicines can instead be left in the mailbox, even though one of course does not know who opens it. They have thus made their assessment based on what is in their regulatory letter and instructions. The Government can therefore not intervene and have views on the decisions that the board has made; it is thus a board decision that has been made on this.
What is the government doing then? Well, we continue with the support that we, as the member raised, provide to pharmacies so that they will be there. But we are also looking at the entire pharmacy work, because we believe that pharmacies can be utilized much more, in very many different ways. We also assess that the physical pharmacies have very great significance. Therefore, it is important that they remain in as many places in the country as possible.
Distance trade is an excellent complement – there is no doubt about that. But can the distance pharmacies, regarding the things we are talking about today, assist the physical pharmacies with more things? It could be about help with inhalation tools and about being able to get better advice. It is clear that this is facilitated if it involves a physical pharmacy. Now, the digital pharmacies or distance pharmacies are trying to complement, not least, the advice, which they provide via telephone in a good way. But not everything can be done as a distance pharmacy. There will always be a certain difference between the physical pharmacies and the distance pharmacies.
From the government's side, we are grateful that someone has developed the idea of distance pharmacies; otherwise, we would only have had physical pharmacies today. The Medical Products Agency has now made its decision on how the work shall proceed, and they have chosen to waive ID control at handover - it only occurs upon ordering medication.
The government will not intervene with any ministerial rule, as it is not permitted by law. But we will, of course, follow the issue, as the consequences for the patients are of the utmost importance. The member himself will well arrive when the Medical Products Agency comes to the committee next week, or so as to get answers and more information about their decision.
Anders W Jonsson (C)
Mr. Speaker! I am fully aware that the Minister cannot step into an individual case and say: In this case, you must make this decision. That is ministerial rule, and it is not permitted in Sweden.
The government, however, has a number of other possibilities to govern a state authority. It can do so through instruction, through a regulatory letter, or via the budget. The government could have said that when it comes to deteriorations for rural areas, for people with disabilities, and for the elderly in the country, very weighty reasons are required to make that type of decision.
Otherwise, one risks exactly what is happening now, namely that state authority after state authority looks at its own small silo and makes a decision that they consider well-balanced from the small aspect they have to deal with without looking at the consequences—what it means for the whole country, for people's opportunity to live all around Sweden, and for people with disabilities or for the elderly. In this case, the Medical Products Agency has not made that analysis at all. It is not possible from there to get answers to the question of how many who will be affected by this.
That is also where the medical risk lies. We know that one of the problems regarding medicines is that people take too much medicine, but a major problem is also that people choose not to pick up their medicines and thus do not receive the treatment that the responsible doctor has ordered. And when it becomes more difficult for the elderly, people with disabilities, and people in rural areas to get their medicines, this will also entail a medical risk. One does not, as the Minister says, have access to medicines across the whole country, but it becomes a major limitation.
As I said earlier, I would be prepared to accept this deterioration for the elderly, the disabled, and people in rural areas if this actually were a major problem—if there were a report that a number of people, children, had been harmed because they found these black bags, managed to get them open, which is not entirely simple, got hold of heart medication, ate a whole jar, and ended up in the emergency room. I would be prepared to accept these changes if there were any such reporting. But the Medical Products Agency has, therefore, during a four-year period, when it concerns perhaps as many as 50 million deliveries to Swedish homes, received 43 reports, where in a few cases it probably concerns someone having stolen the medicines.
It is this balance that must be made: What is the proportionality in this? The deterioration for these vulnerable groups, including people in rural areas, must be weighed against the problem one is trying to solve. I mean that the government, perhaps not least through informal agency contacts, could have solved this in a better way.
For example, one could make it so that a patient who orders their medications digitally can say: I am so worried about my thieving neighbor, so I do not want anything hung on a door - is it not possible to put it in the mailbox, I want to pick it up at a collection point. One could have put forward such a proposal; then it would have become more reasonable.
But in the way this is handled, it becomes unreasonable. It is not the first time a state authority has made a decision that is, as one might think, very wise, which hits the Swedish countryside very hard. This was something I had hoped we would be spared from seeing.
Statsrådet Acko Ankarberg Johansson (KD)
Mr. Speaker! The Medical Products Agency has to weigh patient risks on both sides. The member is addressing one side. It is clear that it is a patient risk if one does not get access to the medicines one needs. We have problems both with people not picking up their medicines and with them picking them up but not having compliance regarding the prescription. There are, therefore, many different risks in this regard.
But it is also a patient risk that things that have been prescribed and ordered can end up in the wrong hands. Heart medicine sounds obviously tempting, but even paracetamol to the wrong person can be life-threatening if it is given in too large a dose. Every single medicine is a potential risk if it does not end up with the right person. That is why the majority of medicines are prescribed, so that one knows they will reach the right person.
The Medical Products Agency, in its decision, has chosen to make a trade-off which means that individuals do not need to show identification in distance trading except at the moment of ordering itself, for then there is super-control with BankID or in some other way, so that one knows who it is that is ordering. But at the time of handover, no ID check was required. One has thus chosen to have milder rules and a lower level of patient safety in distance trading than in a physical pharmacy.
This is the Medical Products Agency's balancing. That decision will apply from next autumn onwards. It will be important to see which models are developed based on this decision: How will people act, and will the market find a wise solution that ensures patient safety?
Anders W Jonsson (C)
Mr. Speaker! The latter also demonstrates the lack of understanding that the Medical Products Agency has for how the situation looks in the Swedish countryside and in rural areas. From the Medical Products Agency's side, they have indeed emphasized the possibility of delivery by courier, but if one looks at the map where that possibility exists, one sees that it is primarily in southern Sweden. Further north, it is practically only in the regional centers. The possibility does not exist at all in the Swedish rural areas and in the countryside, and this is something that the Medical Products Agency has not reflected on at all. They probably haven't even bothered to find out.
In the contacts that the Minister for Health and Social Affairs has informally with the authorities, I think she should emphasize that they must make a reasonable trade-off. One has, step by step, managed to find out how large the problem is - eventually, there was a decision basis regarding four stolen shipments over the course of four years - in relation to the risks it entails. It entails a risk of poorer reception of medicines and a risk that important groups all over Sweden do not get access to what they need. In that situation, this is a poorly made decision.
One should consider whether one should not have as a general instruction to the authorities that, precisely when it concerns this type of decision, they must see what consequences they have. It is not just about how it works in central Uppsala, where the Medical Products Agency is located and this might not be a problem, but also about how it hits the Swedish countryside. That is the message I would like to give the Minister.
This is not a good decision for the Swedish countryside. Furthermore, it is a decision that will not solve any problem at all in relation to the four stolen shipments, for it is also possible to steal shipments inside the pharmacy.
Statsrådet Acko Ankarberg Johansson (KD)
Mr. Speaker! This question will surely recur, not least when we can see how the actors act based on the new rules. But it is impossible to escape the fact that the Medical Products Agency has compromised on patient safety. The Medical Products Agency has chosen a method where one does not need to show ID when receiving the medicine, but only when ordering it. One has, therefore, stricter rules in physical pharmacies than in distance commerce. A trade-off has been made which nevertheless indicates that there is an interest in medicines reaching the population throughout the country.
The Chairman will himself have the opportunity to ask questions to the Medical Products Agency when the Medical Products Agency comes to the committee for a visit. Then he may perhaps be able to get more information about the background and hear what they can tell the committee, which of course is an essential part of the committee's work in reviewing this.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.