Wider societal pressures jeopardise the viability of university hospitals [1
]. The basic problem is that these hospitals have become high-tech knowledge intensive institutions providing highly-specialised and complex medical services to the sickest patients. Routine patient care is increasingly transferred out, which is facilitated by the advancements in medical technology and knowledge. Financiers, governments and patients advocate this natural transformation as they consider outpatient care to be more efficient and patient centred [3
The high-tech profile challenges the multiple missions of university hospitals. It raises issues in patient care—how to offer effective, efficient and patient-centred services that neatly fit in with the care delivered by other professionals and institutions; in medical education—how to educate undergraduate and graduate medical students in the full spectrum of medicine while they only see the sickest patients; and in science—how to create new knowledge and evaluating new technologies for medical practices that are located outside the university hospital.
In order to address these issues, academic institutions have adopted several strategies. They primarily started to collaborate and merge with other hospitals. The rationale underlying this strategy is often economic, reactive and defensive—i.e. reducing uncertainty by building monopolies and cartels. These strategies seem to have been successful [6
]. Apart from that, university hospitals also developed more proactive approaches by building organisational and community linkages through which the multiple missions of academic institutions can be fulfilled and secured [9
]. This strategy can be seen as an opportunistic way to get more patients in, to minimise costs, to use community sites for training and research, and thus to maintain the status quo in health care [11
]. However, if university hospitals seriously attempt to optimally serve their adjacent communities, they can contribute to maximise population health within restricted resources. It would mean that they look across all the various community needs and preferences, set priorities among them, and then build collaborative arrangements in which those needs and expressed preferences can be adequately met. Such a strategy is articulated in the vision of community-based integrated care [12
The topic outlined above has been particularly relevant to US academic health centres. There are fewer reports on the situation of academic institutions elsewhere. However, the natural transformation of hospitals into high-tech knowledge intensive institutions is common and visible in many industrialised countries [4
]. Moreover, the International Campaign to Revitalise Academic Medicine has considered the situation of academic medicine on a global level and underscores the aforementioned instabilities [13
]. So, one can expect university hospitals in other countries to be pressured as well.
This is certainly the case for university hospitals in The Netherlands. Generally, the Dutch hospital sector faced a similar restructuring and strategically responded as elsewhere [14
]. In January 2006 the Health Insurance Act will come into force, which will formalise regulated competition among care providers and among care insurers [16
]. In anticipation to this Act, a new system for hospital and medical specialists' reimbursement has partially come into force. This so-called diagnosis treatment combinations approach reimburses hospitals through output prices that are based on the production process instead of the original budgeting system. This approach is broader than the Diagnosis Related Group concept, as it also covers ambulatory care and includes the remuneration of medical specialists [17
]. Moreover, increased competition for research funding and for subsidisations of undergraduate and graduate medical education is also visible [18
Consequently, Dutch university hospitals face more competition and financial pressures in all their core activities, which challenge them to develop sustainable strategies for the future. In anticipation to these changes, 7 out of the 8 university hospitals have transformed into University Medical Centres. They merged with their adjacent faculties of medicine in order to synergistically organise patient care, research and education [19
]. The first university hospital to do that was the Academic Medical Centre/University of Amsterdam established in 1992. This merger was followed by the introduction of a community-based integrated care strategy, called the ‘academic population’ [20
]. Since its introduction in 1996, the evolution of community-based integrated care throughout the Academic Medical Centre has not been systematically monitored or evaluated. Thus, there was a need for conducting a multiple case study as presented in this paper. We focused on all collaborative initiatives in patient care, which we systematically identified, described and characterised. Collaborative initiatives in science and in medical education were excluded. In this paper, the results of this multiple case study are reported and discussed.