Interview: Peter Graf, CEO, Tiohundra

Uniquely, we think in Europe, Tiohundra, an organisation serving a municipality of 62,000, has fully merged social care and health care delivery. Social care (elderly care, disabled care, homecare, psychiatry) and health care (hospitals and primary care) – have been melded in to a single organisation. So what are the learnings? And are we going to see hundreds of Tiohundra’s popping up all over the place?

HBI: Tell me a bit about the area you serve and what you do.

PG: We are about an hour north of Stockholm. There is a town, Norrtälje,with a small general, 100-bed hospital with emergency, internal medicine, orthopaedics, surgery and geriatrics and then a big rural area, including many islands. The population more than doubles in the summer as Stockholmers go on holiday. We have six primary care centres, 10 elderly care homes, a homecare service and psychiatry services, including inpatient facilities. So we cover just about everything, except for the criminal social work system and social care in schools.

Tiohundra was set up in 2006 that was when the municipality which had responsibility for social care merged with the hospital and primary care system which was controlled by Stockholm County.

I came in as CEO in 2013, I’m a surgeon and previously ran Danderyd, a much larger general hospital in north Stockholm.

HBI: So what makes things different here?

PG: You don’t have the constant turf battles you see in siloed systems. Everyone knows they are working together in the best interests of the patient and efficiency.

HBI: What does that mean in practice?

PG: Take hospital discharge. In central Stockholm on average elderly patients wait 4.1 days for a nursing home bed before being discharged. In Sweden as a whole it takes around 2.5 days. That is extremely expensive – acute hospital beds cost over SEK 10,000 a day. Here we have no wait at all. It is also common for our hospital doctors to visit nursing home residents.

Let me give you a real example. We had a patient with dementia in one of our homes who had fractured her hip. After the operation in the hospital on Thursday, she woke up Friday morning confused and aggressive. She was literally trying to tear the place apart. Normally, the response would have been to just zonk her with tranquilisers. But we were able to have a discussion with the nursing home which led to her being discharged that morning and then looked after in the home, the environment she knew. So we transferred her that Friday morning and she calmly had her lunch in her own room.

We’ve also eradicated many of the barriers that exist in Sweden between primary and secondary care.

HBI: So what does this mean financially?

PG: For the last five years our costs have risen by 1.2% cagr, compared to about 4-5% in the general Swedish system.

But it is the non-financial benefits which stand out. Integrated care means we perform very well on stroke and heart disease. Operating waiting times are also low. We have no problem meeting the 3-months target for electives and 85% of emergency visits are treated within four hours.

HBI: And what is the secret to running a system like this?

PG: A lot of it comes down to culture. I have a weekly Monday afternoon meeting with all the management team where we discuss patients and system issues. I constantly emphasise that the most important thing is to take care of everyone in the most effective way. We can not blame one another.

HBI: That is interesting because it very much mirrors what leaders say in Wigan in the UK, that cultural change was the most important component to integrated care. There the hardest task was to get employees outside of their siloes and to thinking beyond their former job descriptions and processes

PG: Exactly, that it is precisely what we do here.

HBI: So what next?

PG: I am reaching out a lot to other players. As an integrated system we can work more closely with other groups – the church, the police or fast food providers than players who are working in more fragmented systems.

We are also doing smart things digitally. We are using Doctor24 to merge our digital and physical visits in a robust way so that primary care doctors can change which to use.

HBI: So are a lot more municipalities planning to merge with the county healthcare systems to create more Tiohundras.

PG: Politicians love the model, but there are problems. In Sweden we have 21 counties and 290 municipalities. At Danderyd, for instance we had eight municipalities all working with the same hospital and no one wanted to merge. It is the same problem in Finland where the SOTE reform was recently abandoned.

I think the key is to rationalise the system. In 2007 the Danish Municipal Reform, replaced 13 counties with five regions and cut municipalities from 270 to 98.

HBI: So what is the next step and how do you see value health, where you are paid by outcome as a way forward?

PG: Value health works well for simple operations – prostate surgery or hip replacements. But the experience at Karolinska where I also work shows that where you have complex problems and many co-morbidities it fails. And it still involves payment by activity. I think the future has to be per capita payments – the Alzira model – which encourages prevention.

HBI: What about the for-profit sector? On the one hand, having them involved leads to further siloes. On the other when I talk to them they often express frustration

PG: I worked for Aleris for a while and I learnt that in for-profit operators – Attendo, Capio, you name it – you never do anything unless you are paid to. That said, I see no reason why for-profit operators shouldn’t run an Alzira-style franchise. They can be as effective as the public sector, possibly more so.

We would welcome your thoughts on this story. Email your views to Max Hotopf or call 0207 183 3779.