The argument for rationalising small rural hospitals, while broadly accepted by health managers and professionals, remains political dynamite. The electorate has yet to accept the connection between duplicating resources in small, out-of-date hospitals and inadequate health services.
Small maternity units remain open because of the county jersey argument - "how can we have a local GAA team when no one is born in the county?" Yet Leitrim has no maternity unit since the facility in Manorhamilton closed - Leitrim babies take their county status from their home address and not from their place of birth.
Whereas in the 1980s hospital closures took place against the background of cutbacks, today it is hospital "reconfiguration" which health boards seek to achieve. The idea is that a few hospitals should come together to share services rather than duplicating them in small unviable units. Thus a "regional centre of excellence" in a speciality can be developed.
Evidence of differing death rates around the State from quite common procedures underlies this argument. "We are really talking about centres of competence," says one senior health professional.
"We are trading convenience for safety. From the initial bad political decision to keep small hospitals open comes a cascade of consequences. Patients avoid them and go to the bigger centres. The sort of people you want to work in the system won't go to them and the Medical Council does not regard them as suitable for training."
The 1993 Tierney Report on Medical Manpower said smaller hospitals should co-operate. Two hospitals, each with a small maternity unit, should centralise the unit in one while the other might take on another area of care. Yet, today, most obstetricians work in two-person maternity units which from next January will no longer be recognised for training purposes and will be unable to fill training posts.
Dr Mick Molloy, vice-president of the Irish Medical Organisation, predicts the choices we avoid will be made in Europe. In three years, when the EU insists on a 56-hour week for junior doctors, the staffing crisis will become so extreme "this will end up rationalising hospitals very quickly".
More than 30 hospitals operate casualty units around the clock, yet there are only 16 accident and emergency consultants in the State. If the Department of Health was to achieve the rostered senior doctor presence which it seeks in the Medical Manpower Forum, each hospital would need large numbers of casualty appointments.
Most of the units see few patients but the local community wants a service for that one terrible multi-car pile-up on their doorstep.
Medical professionals argue that a larger hospital down the road with greater experience and expertise would give crash victims a much greater chance of survival. To achieve the Department's aim of providing senior trained doctors around the clock in all acute hospitals necessarily implies rationalising the hospital network.
Prof Gerard Bury, UCD professor of general practice and president of the Medical Council, points to "excellent evidence in the medical literature" for moving from general care offered by small local hospitals to a more specialised service in the region.
"A surgeon who works almost exclusively on breast or bowel cancer has much better results than a general surgeon. Three or four working together have far better results than some one working in isolation. There needs to be a catchment area of some 200,000 to 300,000 people for doctors working in an acute hospital to maintain their expertise.
"There is probably a threshold below which people served by an institution get less than acceptable care."
Battles continue at local level.
The Midlands Health Board, with a population of 200,000 and three general hospitals, two years ago acted on a plan drawn up by TCD oncologist Prof Donal Holywood and attempted to establish a regional centre of excellence for cancer services in Tullamore.
This was coincidentally the home town of the then Minister for Health, Mr Cowen, although it had originally been nominated when Fine Gael's Mr Michael Noonan was minister.
Portlaoise protested strongly. A demonstration attracted 6,000 people - one tenth of the population of Co Laois - and a High Court action was taken challenging the choice of Tullamore. Physicians in the area argued that the new service should be split between Portlaoise and Mullingar.
Tullamore won. It was the geographical centre of the region, and that is where the regional oncology unit is now sited. Complex cancer surgery will take place there but consultants will attend other hospitals in the region to conduct assessment and aftercare clinics.
What was the argument about? Portlaoise is 20 miles from Tullamore. Although Portlaoise had some cancer services which remain, 80 per cent of cancer patients in the region formerly went to Dublin. Now the issue is breast cancer services. Despite competing claims from Portlaoise, the national cancer forum has recommended their siting in Tullamore to take advantage of the regional oncology unit. The Midland Health Board meets to discuss this today.