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So that’s it. Our Lady’s Hospital in Navan is as good as finished. Patients needing emergency or elective surgery must go elsewhere – or go without, if the hospitals that are supposed to fill the gap cannot cope.

Our Lady’s is the latest in a long line of small hospitals to effectively disappear from the national patchwork, the victim of a vice-like grip of dwindling funding on the one side and well-founded (or maybe not-so-well-founded) fears about safety on the other.

It is unlikely to be the last. HIQA is running the rule over Mallow Hospital, having received specific information relating to the safety of patient care in that case. HIQA has confirmed the inquiry at Mallow is the only active investigation under way; it is not currently examining services at other small acute hospitals. That said, it is watching closely to see that the measures it announced, following its review of safety at Ennis, are being put into effect by the HSE.

Unique take

The HSE has its own unique take on the political dictum coined by President Obama’s chief of staff, who said a serious crisis should never be allowed to go to waste. In the US, that became a rallying call for radical reforms like extending health insurance to the millions who did not have it, and reining in the Wall Street excesses that had brought the world’s largest economy to the brink of ruin.

Over here, it is more a catch-cry of the slash-and-burn merchants, who are using it as easy cover for desperate measures to put the public finances back in the black in an impossibly short/optimistic time frame.

Such is the meltdown in the public finances that wholesale hospital closures are now on the cards, if not this year, then quite possibly next. Whether the pretext is a dwindling budget or safety fears, or a mixture of the two, the end of the small hospital is nearer now than it has ever been.

Ever since the Fitzgerald Report called for the closure of nine out of every ten in just 11 years, small acute hospitals have been in a Catch-22. If only they could secure the necessary resources, the argument went, they could hire the staff and develop the facilities to comfortably meet exacting safety standards. Conversely, any hospital that was starved of funding for the one, and favour for the other, was destined to die a slow death.

No arse in its trousers

But if the scale and speed of the closures proposed by Fitzgerald in 1968 was never achieved, partly it was because the country had no arse in its trousers back then. It always seemed fairer – if not necessarily efficient – to spread around what little there was. The problem now is we do not have the proverbial pot – and we will not for years to come. Today it is Navan. Tomorrow, it may be Mallow. Soon, it could be Roscommon.

As HSE West struggles to rein in runaway spending, Roscommon County Hospital is in the firing line. The slow decline from acute hospital to ‘glorified county home’, which local people always feared and local politicians fought to prevent, is gathering pace, as the meltdown in the public finances joins the grinding forces of centralisation and specialisation, both traditional enemies of the small acute hospital.

A determined campaign has brought thousands of locals on to the streets, and events may lead to the election of a Hospital Action Committee TD. But 2012 is a long way off and, in the meantime, the mandarins are watching the red ink bleeding from the books and striving for further savings of €60 million, including €2 million from Roscommon Hospital.

Deep in debt

The question they are asking is, how the HSE West could manage its finances so ineptly as to be this deep in debt, barely half-way through the year? Consultants Mott McDonald, whose report has been leaked, have identified a range of remedies to rein in runaway spending, including the closure of a hospital. The HSE will not go that far – yet – but it is intent on closing beds, cancelling surgery, cutting overtime and firing as many as 1,000 temporary staff.

Even all of that may not be enough to prevent even deeper cuts on the frontline next year. If all of the savings are not found in the coming months, they will have to come out of next year’s budget, which itself will be sharply lower as Government tries to pull off the impossible trick of feeding the banks, appeasing the bond-holders and muddling through on a decimated tax-take.

The HSE insists that the County in Roscommon and Portiuncula in Ballinasloe are not being fitted for the shroud, but the reality is that huge savings are being demanded this year, even bigger cuts are coming down the tracks this December (and every other December for the foreseeable future), and there is a distinct possibility that funding cuts alone could close 24-hour emergency-department services at one or even both hospitals by 2011.

Well before he left the top job at the HSE, Prof Brendan Drumm was warning about the wisdom of maintaining multiple 24-hour EDs.

HIQA will be watching whether budget cuts make it unsafe to continue providing any particular service at either hospital. This will do nothing to alleviate local concerns, especially in Roscommon. The fear has always been that, starved of the funding and favour that always flowed more freely to Portiuncula, the County Hospital was doomed to wither away. If it could not get funding for facilities and favour for specialist staff, eventually it could be deemed ‘unsafe’, which in turn would reinforce the case for closing it down altogether.

The HIQA template for Ennis suggests that the quality and safety watchdog is not necessarily in the business of closing down acute hospitals, though it does have firm views about the quality and quantity of services a small hospital can safely provide. This distinction, however, may ultimately prove academic; the end result will likely still be the same.

Historically, the debate about the development of acute hospital services was framed along two key dimensions: quality and accessibility. The re-organisation of cancer services during the tenure of Prof Tom Keane showed that the quality of care was being put centre-stage.

A third dimension, austerity, is now to the fore and all the indications are that it will soon eclipse accessibility. How it will affect the quality of services remains to be seen.