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How the merging of medical faculty and academic hospitals in The Netherlands is improving the country's research infrastructure.
Within the last 10 years, eight University Medical Centers (UMCs) were created in the Netherlands. In a UMC, the faculty of medicine, with its responsibility for the initial training of physicians and for scientific research, is merged with the academic hospital, with its responsibility for tertiary care and clinical research and innovation. All medical faculties and academic hospitals in the Netherlands are now a UMC.
Each UMC is a private, nonprofit enterprise with strong links to the University and with an executive board, including a dean of medicine. The finances come from the Department of Education and Science and the Department of Health, as well as health insurance companies that operate the mandatory health insurance in the country. The eight UMCs have a special position in the health care system, because although they are legally private entities, they have a distinct public mission. This mission can be divided into three core responsibilities: teaching and training, basic and clinical research, and (tertiary) patient care.
The added value of UMCs is that they integrate these three core functions—patient care, biomedical research, and biomedical education. Medical students are exposed to patients as well as to basic research from day one of their curriculum and they become part of the UMC community.
Many of them will participate in research projects during their studies and many will opt for a MD/PhD program. Almost every doctor and nurse is involved in the teaching process. And as students enter their clinical rotations they will be an important driver for quality of care, as their supervision requires doctors and nurses to provide a good role model. Increasingly the modern curriculum will include a mix of clinical and basic science around a specific disease, and so both clinicians and scientists often lecture together.
As the science labs are often located within the same building as the hospital, interaction between clinicians and scientists is frequent, but also many doctors continue to work in a lab as well. Good clinical epidemiology in most UMCs has supported many clinical researchers (doctors and nurses) and the close vicinity of patients has proven immensely important in the recent developments in the area of genomics, proteomics, and other fields of translational medicine. This is visible in the position of Dutch biomedical research in the international scientific community.
Increasingly, results of research are taken further, either as direct innovations in patient care after thorough evaluation studies or through patents, spin out companies, or other forms of "valorization" of science. Innovation in clinical therapeutics and diagnostics has always been important in academic hospitals.
UMCs also are becoming more responsible for innovations in the process of care delivery, not only in the hospital setting but also for their departments of family practice in primary care or nursing home care. Innovations can be thoroughly evaluated before becoming standard practice and their value in improving outcomes for patients or in reducing costs can be critically assessed. In that way the whole health care system profits from academic medicine.
Finally, UMCs have an important responsibility in tertiary care. Patients with rare diseases, difficult to manage complications, or who are in need of very complex interventions are often referred to a UMC. Transplantations, neonatal intensive care, genetic diseases, rare metabolic disorders, and complex cancers are examples of patient groups that are concentrated in some or all UMCs so that sufficient volume guarantees expertise. However, despite the unique responsibility for tertiary care, all of the UMCs provide a certain amount of regular hospital care, if only for training purposes. For those patient services, the UMCs compete in the health care market just as general hospitals do.
UMCs in The Netherlands
Since 1992, the Netherlands has increased the number of first year medical students from 1485 to 2850 a year. Each UMC has an average of 315 to 410 new first year students.
After six years of training, two of which on average are spent in clinical rotations (50% in a UMC and 50% in another health care institution), physicians can enter specialty training. UMCs offer all specialties including family practice and public health; but during most specialty training the physician will spend approximately 50% of his training in a general hospital. Around 60% of the Dutch hospitals participate in specialty training in regional networks around each UMC. The UMC plays an important role in providing courses and lab skills for students and teachers.
All UMCs also have at least one degree program in biomedical sciences (around 500 students a year) and all participate actively in the training of nurses and nurse specialists.
The UMCs together are responsible for one-third of the scientific output in the Netherlands in terms of publications, and on average they have a citation score of almost 40% above the international average, with variations by field in the different UMCs. Together, the UMCs award 800 doctoral degrees a year, which means that on average each UMC has 400 PhD students.
UMCs have both clinical and basic science research groups. Increasingly, the combination of the two creates powerful groups specialized in translational medicine. Although UMCs have a certain amount of funding for research through the medical faculty, most get a much larger amount of funding from the research councils at the national or international level, from charities, and from projects together with industry. Both other faculties of the university and biotech companies collaborate with UMCs in solving biomedical mechanisms, developing new methods for diagnostics or therapeutic interventions, and evaluating the results in clinical trials.
The tradition of sound clinical evaluation studies has proven to be a very successful field in medical research, not only in large industry driven trials but also in the much smaller investigator driven trials, which have helped practitioners decide the best course of action when there is doubt and have formed the basis for many clinical guidelines. These papers are often among the most cited publications.
Each UMC has a research infrastructure and in certain cases close collaboration between them provides a unique scientific environment. An example of this is the Pearl String Initiative (PSI) in which eight UMCs are jointly building prospective patient cohorts for which both clinical data and biomaterials are collected in a standardized fashion. For some diagnoses this means that all patients with that diagnosis in the Dutch population are included in one database. This PSI bio-bank will provide unique material for research on the interaction between genotype and phenotype.
Another example of the strength of cooperation in research is the recently established MCRN, the Medicines for Children Research Network. UMCs feel children deserve evidence-based medicine and thus a critical evaluation of the medications they take. That will require careful assessment using randomized controlled trials.
Recent European legislation has emphasized the necessity of trials for children. UMCs feel it is part of their public mission to provide a methodologically sound environment to do so. It is always difficult to explain to the public that the essence of a successful randomized controlled trial is that one of the two study groups will prove to have a worse outcome, thereby helping to decide what treatment is best. They often find it extra hard to understand when it concerns children. However, parents are often appalled to discover that there has not been an adequate evaluation of the treatment proposed for their sick child. With the MCRN, the UMCs propose a safe environment for parents to allow their children to participate in so needed clinical studies.
Together the UMCs have taken responsibility for technology assessment studies, partly financed through the Medical Research Council (ZON-MW). Outcomes of such studies have been instrumental in deciding which new treatments are included in the basic benefit package and in disseminating innovation to other hospitals. Many of the researchers in UMCs are involved in advisory bodies to the government, such as the National Health Council.
UMCs have a long tradition of close collaboration with private partners as well. Many of the new medical devices have first been tested and refined with physicians from UMCs. Pharmaceutical companies have traditionally worked together closely with UMCs for the required evaluation of new drugs. But in the future, one can expect a new kind of collaboration.
As the importance of patient material for the understanding of biomedical mechanisms that will lead to new products becomes apparent, the interest in working together closely with the basic scientists at UMCs will grow. The Netherlands has invested in that public–private partnership in a number of large innovation programs in the field of translational medicine. The Dutch UMCs are convinced that these new partnerships will prove very productive, but they also require a good understanding of each partners' interests.
The Valorization Code of the joint UMCs provides a good start to avoid a conflict of interest while allowing for the joint effort to improve patient care through research.
Although all UMCs provide basic hospital services, their public function is primarily determined by the top clinical services they provide together with their last resort function for referrals from other hospitals. Such tertiary care should build on the knowledge infrastructure that the UMC provides, their clinical research, innovation, and multidisciplinary approach, which provides continuity of expertise, 24 hours a day, seven days a week. Such continuity is important for patients and also for preserving centers of excellence so that tertiary care is not dependent on one person.
Increasingly as the market for care evolves, more complex or more costly patients will be referred to a UMC. That is why the financing of UMCs requires special measures; otherwise, academic medicine would be in danger.
"Part of the health care market where possible, separately financed when necessary." This credo, explained then Minister of Health Hans Hogervorst to parliament, is why UMCs needed a special position in his reforms of the Dutch health care system. As he transformed the health insurance system to achieve universal coverage with risk and income solidarity, executed by private insurance companies, he introduced a special financing scheme for UMCs.
Of course, UMCs are financed in many different ways. Part of their budget comes from the Ministry of Education and Science, through the universities, both for the faculty and the academic hospital to provide the infrastructure for teaching and research. A major part of the research money for UMCs is secured in the fierce competition for grants at a national or international level.
For their patient care budget, however, a distinction is made by the insurer and the UMC between the negotiated budget for regular services and the lump sum provided as a so called "academic budget" for the excess costs of tertiary care patients. This last budget is strictly limited to UMCs.
With the creation of UMCs, academic medicine in the Netherlands has entered a new phase. While the International Campaign to Revitalize Academic Medicine worries about the position and the power of academic medicine in the future, the eight UMCs have shown that merging two traditional institutions—a medical faculty and an academic hospital—provides a good environment in which innovation and quality of care can be developed, assessed, and passed on to the next generation of doctors and nurses.
The three core responsibilities of education, research, and patient care are intertwined and as such can no longer be evaluated in separation. Together they are the essence of academic medicine and the R&D of any health care system.
Part of this text has been used in a short brochure by The Netherlands Federation of UMCs.
Louise Gunning-Schepers is chairman of the executive board of the academic medical center of the University of Amsterdam and dean of the medical faculty of the University of Amsterdam, both in Amsterdam, The Netherlands, email: L.J.Gunning@amc.uva.nl