NHS hospitals face mounting financial and workforce pressures. Reconfiguration of hospital services can provide a powerful means of improving quality in an environment where money and skilled health care workers are scarce. In some places, reconfiguration is needed urgently, in order to protect patient safety. However, the current reconfiguration process is lengthy, wasteful and carries significant risks to the delivery of safe services. There are also risks that prospective legislative changes will make an already complex and bureaucratic process become more so and that there will be a lack of the strategic leadership required to lead and deliver change. A major stumbling block in many hospital reconfigurations is public concern and political opposition. While there are opportunities to improve the process within the proposed legislative framework, we believe that ways need to be found to de-politicise the process and to make decisions on the basis of quality, safety and efficiency, while retaining strong public engagement in local decision-making.