Thousands took to the streets of Lewisham in south-east London on Saturday to protest against the proposed closure of the local hospital's A&E department and the downgrading of its maternity services. Their grievance was more complicated than just the protection of a local hospital. As they see it – and it is hard to disagree – "their" hospital is being punished for the sins of the adjacent South London Healthcare Trust, which is in administration. A wholesale reorganisation across the region is seen as the only solution and Lewisham, by all accounts well run and solvent, must help to meet the bill.

If this case were a one-off, a single point might be made about the injustice of "robbing Peter to pay Paul" and the mixed message it sends about good stewardship in the NHS. What incentive, it might be asked, is there for managers to run a tight ship, if their reward is to be called upon to bail out the profligate.

That point stands. But this case highlights an issue that goes far beyond one London hospital. Some 20 NHS trusts across the country have declared themselves financially unsustainable. And clinicians are agreed that health services generally have to be restructured – not just for financial reasons, but because medical advances and demographic trends, including the rise in the elderly population, mean that demands on the health system are changing.

The Government's plan is for fewer, but better, state-of-the-art hospitals and more local clinics providing some of the services currently found only in hospitals. This must be the shape of the future. But it comes up against two problems. One is the real affection in which many local hospitals are held – something that, as Sir Bruce Keogh, the medical director of the NHS, complained last week, encourages local MPs to thwart justified closures. The second is the fear that closures are all to do with "cuts" and will not be offset by new provision.

Given the deterioration in emergency provision that many have experienced since GPs were allowed to opt out of out-of-hours services (while also receiving a generous pay rise), people's distrust is not without foundation. The best way for the Government and the NHS to foster confidence would be to fund a few pilot projects first. If the new system is an improvement, patients will vote with their feet.