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Last Sunday the people of Omagh mourned the first anniversary of a huge bomb that took 29 lives in their town.

Their simple gestures of sorrow centred on a memorial garden created on part of the bomb site, most of which is screened behind thick boarding. The boards have attracted flyposters - but not the usual adverts for pop concerts or videos. They contain a simple plea: 'Blair, Mowlam, Clinton - save our hospital.'

The local Tyrone County Hospital, part of Sperrin Lakeland Health and Social Care trust, dealt with more than 200 casualties in the immediate aftermath of the bomb.

Tales of staff heroism abound and to many people in the town the 'County' is not just their local hospital. Its status is a pointer to whether the town can ever pick itself up again.

The threat to the hospital comes in the shape of an acute services review carried out by its local purchaser, Western health and social services board.

The review was under way before the bombing and was halted for around eight weeks while the board took soundings on whether it was appropriate to continue.

The review did restart and, when it reported, one option offered the prospect of an enhanced Tyrone County Hospital, while other options suggested downgrading its services.

Western board is expected to make a recommendation on 2 September. The final decision is due to be made by the Northern Ireland Assembly, but if devolution has not occurred, the matter will remain in the hands of Northern Ireland health minister George Howarth.

If Omagh's Tyrone County Hospital is given the nod, Erne Hospital in neighbouring Enniskillen, Co Fermanagh - part of the same trust - will be downgraded.

The trust has not backed any of the six models put forward (see box overleaf), though it says the do-nothing option is unacceptable and serious questions remain about building a new unit on a greenfield site to replace the existing hospitals.

The review suggests that the earliest possible timescale for major changes would be seven to 10 years and at least£75m of capital would be required.

In the meantime, the trust argues that services at both Tyrone County and Erne should be developed. It wants a recurring cash injection of£300,000 a year over the next five years - a total investment of£1.5m. This would be used to retain the services on the two sites as well as enhancing others, such as accident and emergency.

'We have suggested an investment programme so there will be a sustainable service whatever long-term option is chosen,' says Eugene Fee, the trust's director of acute hospital services.

'There is a need for enhancements now - to address some deficiencies in the service.'

Omagh district council has unanimously backed the trust's strategy of enhancing services in the short term.

But it has gone on to argue for a new hospital to be built in the Omagh area - a move that has incensed the campaign to save Erne Hospital.

Anton McCabe, of Save Omagh Hospital Campaign, is more conciliatory. 'In Omagh and Enniskillen the hospitals have a role in the health of the community in that they are significant employers. Take this away and you remove a significant amount of available work from this community.

'Historically, Omagh and Enniskillen have been played off against each other and, as a result, both hospitals have gone down the tubes. For too long we in Omagh have been directing our fire against Enniskillen rather than the government and the Western board. Inevitably, two areas are stronger than one.'

Western board acute services review project manager Margaret Kelly says the board does not favour any one option. The proposals are not exclusive and it has been willing to listen to alternatives put forward by the trust and other interested parties.

But have the events of last August made its decision more difficult?

'It is a very difficult decision, full stop,' says Ms Kelly. 'The board will consider the arguments and then make a recommendation which will then go to the minister or the Assembly.'

Mr Fee says: 'We have to accept it is a difficult decision for the Western board. I have no doubt that whatever the decision it will be contentious.'

The attention created by the bomb has ensured a lively debate in Omagh about the future of its hospital.

'Clearly what happened last August had a major impact on this town.

'There are at least two groups in Omagh working to save the hospital and there are at least two in Fermanagh with a similar objective,' Mr Fee says.

'It has brought out anxieties in the community that one might benefit at the other's expense.'

But sentiment may not save Tyrone County. Arguments over equity and access could tilt the decision in favour of Erne Hospital, which serves a more sparsely populated area.

'The events of last August probably mean that the government is a bit less anxious to publicly wield the axe on Omagh,' explains Mr McCabe.

'But we have to be careful because hospitals are rarely closed in one bound.

'Services tend to be run down over a period of time. People get a feeling of hopelessness about their local services and go elsewhere. It is only at this point that a hospital will be closed.'

And he is cautious about playing the sympathy card, particularly when Erne Hospital had its own atrocity to deal with - the 'poppy day' bombing.

'While Omagh has suffered, a lot of other communities have suffered,' he says.

'There is no sizeable community that has not suffered tragic and violent death in the last 30 years. We regret all those deaths, not just those in Omagh.'

The consultation period hasfinished and the people of Omagh and Enniskillen face an anxious wait. In two weeks' time they will get their answer.