Fear stalked the health service last week and things are only going to get uglier as we face into a winter of serious discontent. In Roscommon and Ballinasloe, they came out in their thousands. Genuine fear was expressed at the prospect of the downgrading or possible closure of hospitals in both towns. The spectre of lives being lost, of money taking precedence over welfare, of some being treated as second-class citizens, was writ large.

That is the perception among the protesters, and when it comes to fear, perception is as relevant as reality. As with politics, all health is local and it will take a great effort to try and make people observe the bigger picture.

Since the publication of the Hanly report in 2003, the consolidation of hospital services has been to the fore of health policy. All the evidence-based research suggests this is the way to go. Centres of excellence, in theory, result in the best care for everybody.

Already, the approach appears to be working in cancer care. Figures out 10 days ago show that while mortality rates in breast cancer fell by a quarter between the 1980s and 2006, they still remained the second-highest in Europe. There is widespread agreement that the cancer care strategy implemented over the last three years will make serious inroads into that position. A key element of the strategy, which faced serious resistance in many areas of the country, was the establishment of centres of excellence.

The same principles must apply to general care. A report last year on the facilities of a typical smaller hospital, Ennis General, illustrated the point. The Health Information and Quality Authority (Hiqa) found Ennis to be unsafe to provide acute surgery, intensive care, round-the-clock emergency care, paediatric and maternity care. In this day and age, the standards required in all these areas cannot be maintained in every single hospital around the country.

Improved road services add ballast to the policy. Ennis is 20 miles down a motorway from Limerick, Ballinasloe 40 miles along a new stretch to Galway.

So goes the solidly-based theory. Attempts at implementation have been dogged by the usual fare in Irish public life – incompetence and vested interests.

The characterisation of the HSE as a byword for incompetence and spin may well be unfair, but that's a communication problem that is of the executive's own making. One way or the other, the characterisation engenders fear, particularly when it comes to change. How can people trust the HSE with the promise of centres of excellence until they see them with their own eyes? The urge to hold on to local hospitals, whatever the argument against it, is all the greater when local people are expected to trust a system that doesn't appear to be functioning properly. Trust is a two-way street.

Some will point to the HSE itself as an argument against consolidation. The theory of having one body to look after the nation's health is sound. It was designed to take politics out of health and serve the greater good. The results have hardly been encouraging but, to be fair, a lot of the problems can be dated to the hotchpotch manner in which the executive was set up.

Whatever shortcomings the HSE has are greatly exacerbated by each and every vested interest in the system doing everything possible to protect their own patch, irrespective of the cost. In fact, the HSE's reputation makes it a perfect scapegoat for vested interests. All problems are now laid at the executive's door.

One of the more odious aspects of media coverage of health is witnessing hospital consultants decrying the system, and particularly the HSE. With few exceptions, none of these practising or retired consultants acknowledges that their profession must shoulder some of the blame for the mess.

For instance, last week it emerged that at least 35 consultants are exceeding an agreed limit of 20% treatment of private patients in public hospitals. Some of the private work went as high as 50%. This work is in addition to the €220,000 annual salary.

Instead of acknowledging that a problem might exist, the Irish Hospital Consultants Association hit out at the methodology used to compile the data. Translated, it's not us, guv, it's that incompetent shower in the HSE. Consultants are far from the only vested interests in the system, but they don't offer much in the way of leadership.

And leadership is a major problem in health. Only proper leadership in politics and at the upper echelons of the service can tackle the pervasive fear about the change that is required. Politicians use health as just another issue to batter the other crowd. No real attempts are made by public representatives to address the fear. Instead, it is easier to pander to it.

The leadership required in health wasn't there in the illusory times of plenty. Then, the imperative was to ensure that nobody was upset before the next general election. Today, there is little prospect of leadership from a beleaguered HSE, or a government limping through a recession.

In such a vacuum, fear prevails. Things will hardly improve in the teeth of a recession. Cuts engender further mistrust. One way or the other, it's going to be a harsh winter. If ever there was a time to start getting things right, this is it.

mclifford@tribune.ie