Senior managers in Northern Ireland are warning that individual trusts are on the verge of collapse, as radical plans for reconfiguration of the province's hospital services are published.
The report of the acute services review group set up by health minister Bairbre de Brun last July recommends that Northern Ireland's 18 trusts should be combined into three, with the four health boards replaced by a single strategic health and social services authority.
Managers are keen that urgent action be taken to establish a new direction for services and that a substantial injection of cash is made. But one HSJ source said there was concern that 'the dead hand of government' would once more stymie change.
He said that trusts, large and small, were struggling to such an extent that they could collapse at any time.
The view was echoed by local NHS Confederation representative Alan Gilbert, who said the worst-case scenario would involve a total collapse of services unless change was implemented rapidly.
'We will be studying this report carefully and we welcome the vision it sets out - what we can't afford is more delays and inaction.
The status quo is not an option. '
The review group, chaired by former ombudsman Dr Maurice Hayes, calls for the 'immediate' merger of two of Northern Ireland's highest-profile trusts, the Royal Group and the Belfast City Hospital trust, together with Green Park Hospital trust, as the first step towards creating a Greater Belfast health and social care system.
The Belfast system would serve a population of 700,000, while systems in the north and south of the province would cover up to 500,000.
It strongly recommends that the strategic authority be at arm's length from the Department of Health, while the three health systems would integrate acute, primary care and community services.
The review recommends that emergency and maternity services be provided at nine sites across the province, resulting in the closure of several smaller units which have been the subject of prolonged and vigorous local disputes in recent years.
Smaller local hospitals would offer day surgery, outpatient and diagnostic services and inpatient care for medical patients not requiring roundthe-clock consultant cover.
But the plan depends on availability of resources - a recommended£1. 1bn in estate alone over the next 10 years - and it assumes that Northern Ireland will get a proportionate share of UK health spending, weighted according to health status.
In fact the province's share of government spending has been declining and one senior manager told HSJ that the greatest concern trusts now face is financing.
'We are struggling just to fund a vascular service in Northern Ireland and a modern cancer service. Whatever the recommendations, we would want to huddle together just for mutual support'.
Institute of Healthcare Management president and chief executive of the Royal Group of Hospitals William McKee told HSJ:
'Trust finances have been squeezed - there is a general English misconception that we do very well, but in fact we have had a steep reduction in our expenditure. '
He welcomed the report's vision but was anxious that progress should be made: 'Northern Ireland has exemplified the weakness of the NHS in that our ability to design a future for healthcare far outstrips our ability to implement it. We have had a series of plans gathering dust over many years.
'We have been calling for a merger between the three hospitals for some time and I believe the overwhelming majority of staff and members of the public on all three sides would welcome it, but they would want to make sure their identities were not lost. '