The threats to Dunedin Hospital and consequently to Dunedin itself, the Dunedin School of Medicine and the people of the South keep recurring.
Dunedin regularly has to staff the ramparts and fight for its hospital's advanced status and that battle might soon begin again. Neurosurgery services, so often threatened in the past, are under fire with proposals that all six South Island neurosurgeons be based in Christchurch.
The alternative of four in Christchurch and two in Dunedin, as part of a combined operation, seems an obvious solution but has failed so far to find sufficient favour. The matter is now being thrashed out between South Island DHB chief executives and chairmen in an endeavour to reach a consensus. If that fails, the Minister of Health would become involved.
Inevitably, the South does not have the population numbers to support many modern-day medical sub-specialties. When advanced child cancer treatment was lost to Christchurch in 2000 the arguments for that proved compelling in the end.
Neurosurgery, though, is basic to "level six" intensive care; that needed to train staff in advanced intensive care, advanced anaesthesia and for some surgical specialties like heart surgery. If it is moved from Dunedin, the flow-on effects for services at the hospital, for medical school training and for medical staff recruitment are stark and frightening.
As Dunedin School of Medicine dean Dr John Adams said this month, the loss of neurology has the potential to affect the whole teaching environment.
The service deals with about 350 patients a year, including scheduled surgery and, most significantly, emergency treatment. In accident situations, for example, it is a very long way from Te Anau or Invercargill to Christchurch, even by helicopter, when half an hour can be crucial to survival.
Many patients, too, might not actually need immediate neurosurgery but they might need to go north to be examined just in case. While Dunedin's emergency department medical specialists are skilled and dedicated, they are not neurosurgeons.
How much less satisfying it would be for them and more dangerous for patients if the injured or ill were flown straight to Christchurch, or just "patched up" and sent along. When Prof Martin Pollock retired as neurology clinical practice leader at Dunedin Hospital in 1998 he laid out the issue bluntly: people would die unnecessarily if the unit was downsized or closed.
Recruitment difficulties to what is seen as an outpost like Dunedin will always be raised as a reason for centralising clinicians in Christchurch, where they are likely to have more collegial support and undertake more complex cases.
Dunedin, indeed, has had difficulties staffing neurology - in part exacerbated by the uncertainly over the service itself - relying at different times on locums or Christchurch support. On that basis, however, Invercargill would be stripped of most of its surgical and advanced medical services and Southland patients would have to shift far more often to the bigger centres.
While it makes clinical and financial sense to concentrate "super-specialties" in one or two New Zealand hospitals, neurology is fundamental to a tertiary hospital like Dunedin.
Every few years - it happened in 1998, 2000, 2003 and 2006 - the matter is raised and sometimes a fight to save the service has to be waged. The community so far has rallied in different ways, most spectacularly in 1981.
When the Government backed down on a promise to buy a new neurology body scanner, a public appeal raised more than $2 million, also funding other hospital upgrades. Hopefully, public outrage and a public outcry is not required in 2010 and sense can prevail.
But because it is usually much easier to apply pressure before a decision is made - no-one must be seen to back down - efforts should be being stepped up now. When a meeting on the issue convenes in Dunedin, planned for the next few weeks, the city's emphatic position much be clear.
Hopefully, too, even while the decision-making process continues, influential citizens such as the mayor, the city chief executive and the university vice-chancellor, are keeping up to date with what is happening and, in various ways, emphasising the importance of neurosurgery to the city, the South and the medical school.
And, hopefully, the correct recommendations can be made and the wider populace does not have to fight again for a service so essential to the South.
