Many European countries face similar dilemmas: what to do with smaller hospitals providing acute medical services, particularly those which are geographically remote or otherwise less accessible.  It may be difficult to attract and retain sufficient numbers of specialist staff, and/or thought to be financially inefficient to maintain these services.  But are closure or downgrading really the only answers?  The Nuffield Trust (UK) was recently asked to examine this issue, and to suggest possible solutions.  Their thoughtful and well-researched report is available here.  The context will vary between jurisdictions, and one size rarely fits all, but the report offers a lot of food for thought.