During an acute recession in Ireland, healthcare organisations were subjected to increasing pressures to provide more services for less money, highlighting the need for resources to be utilised efficiently and for effective management control. This presents quite a rare research opportunity, and the objective of this study is to use it to explore the design and operation of management control practices in what the literature already recognises to be one of the most complex and under-researched contexts, healthcare, particularly in a situation where such a system is under considerable stress. The study of such extreme examples can cast additional light into effective management control in practice beyond that typically available under more “normal” conditions. To achieve the research objective, an in-depth case study of a large, acute, public hospital was conducted. Using qualitative research methods within an interpretive framework, it sought to explore the many complexities associated with the hospital context and to identify possible linkages between contextual factors and the operation of management control practices. The study demonstrates that the economic and fiscal crisis was perceived to have initiated a change in the attention provided to, and use made of, management control information. National healthcare management were perceived to have placed a higher emphasis on cost reduction targets and to use budget information in an inflexible manner. Senior hospital management perceived that this style of usage led them to be more focused on budget information and the achievement of budget targets, but they also perceived higher job-related stress and tense working relationships with national management. Senior hospital management were reluctant to replicate an inflexible style of budget usage within the hospital, but driven by the need to meet national cost reduction targets and frustrated by organisational arrangements, they adopted a centralised style of usage. It was recognised that while initially successful in removing organisational slack, this approach may lead to harmful side effects in the longer term. For example, clinicians were found to be apathetic towards the use of management control practices. The study contributes to the literature by highlighting how management control practices were perceived to operate during an economic and fiscal crisis. Further, addressing some limitations of previous research, it examined perceptions concerning multiple control practices at different organisational levels and among different professional groupings in the hospital, including senior hospital management, services managers, clinicians and clinician managers.