Taoiseach Enda Kenny has signalled further turmoil lies ahead over the future of smaller hospitals as campaigners stepped up their protest against cutbacks at Roscommon hospital.
Defending the coalition's shutdown of Roscommon's A&E department, Mr Kenny said the decision was not easy but was made on the back of serious fears about patient safety from a health watchdog and consultants.
He pointed out a Health Information and Quality Authority (HIQA) study which also highlighted recommended reforms at ten hospitals.
They include Roscommon, Navan, Louth, Portlaoise, St Columcille's hospital in Loughlinstown, south Dublin, Ennis, Nenagh, St John's hospital in Limerick as well as Mallow and Bantry hospitals in Cork.
He said it was a fact of life that conditions in a number of smaller hospitals were not satisfactory and Health Minister James Reilly was committed to reform of the health system.
"This is not just an isolated issue here," he said.
"This is a leviathan structure that did not deliver what it was supposed to deliver and it has got to change direction and change its structure and change the way it does its business, and that is not an easy task minister Reilly has taken on.
"But that is what the government is going to do in the interests of the care of our patients and the quality of services provided."
Mr Kenny insisted serious concerns about patient safety because of a lack of medical staff, as outlined in the HIQA report, was the sole reason for the changes at Roscommon.
"It is not an easy situation to have to say 'we've got to change this', but it is in the better interest of the patient and the service that is being provided," he said.
But Fianna Fail leader Micheal Martin accused Mr Kenny of abandoning pre-election commitments to smaller hospitals around the country.
Mr Martin said Fine Gael had made a straightforward promise to the people of Roscommon to retain emergency, surgical, medical and other services.
Sinn Fein leader Gerry Adams said the Labour Party had also promised it was 100pc behind Roscommon hospital and would not tolerate any cuts to services.
The closure of the A&E was the most brazen of all Mr Kenny's u-turns since he took office, Mr Adams said, adding that the Taoiseach was not managing a US-sized country.
But Mr Kenny said running a small state meant "you can't have everything at every crossroads".
Under the reforms at Roscommon, an urgent care centre run by non-consultant hospital doctors from 8am to 8pm will replace the emergency department.
A GP co-op service will run a call-in centre in the outpatient department from 6pm to 9am, with a GP roster system continuing at the weekends.
People suffering deep trauma, like heart attacks and stroke, will be taken to larger hospitals in Galway, Sligo or Mayo.
Four ambulances will be on standby in Roscommon - two of them based in Roscommon town - backed up by rapid response vehicle staffed by paramedics.
Last night, Mr Reilly released figures showing patients with heart problems have a better chance of survival by being brought to larger hospitals rather than Roscommon hospital.