Successive administrative integrations have eroded the distinct identity and operational autonomy of hospitals within Portugal’s National Health Service (SNS). The creation of sprawling Local Health Units (ULSs) — some with budgets exceeding €1 billion — has not been matched by adequate management capacity, leaving facilities ill-equipped to coordinate care, manage resources or respond to demand spikes. The dysfunction manifests in visible emergency problems — overcrowded trolleys, delayed ambulances and stressed staff — and points to a need for targeted governance, management investment and policy reform to restore operational effectiveness and protect patient care.