'It's all about peace of mind," said John Blackie. The leader of Richmondshire district council is explaining why the people he represents in the Yorkshire Dales are so opposed to the maternity unit and children's services disappearing from the local hospital, the Friarage in Northallerton. For people in Hawes, where he runs the Bay Tree Cafe, local already means at least an hour's drive east along country roads to get to Northallerton 36 miles away. Under local NHS plans to improve quality of care for people in North Yorkshire and Teesside, these two units will be shifted to Middlesbrough's James Cook hospital, another 24 miles and ahalf hour's drive past the Friarage.

"Our nearest out of hours GP is 25 miles away in Catterick and we're 36 miles away from an A&E. These plans mean we will be 60 miles from a consultant-led maternity unit. At times when you need immediate, urgent or unplanned healthcare, you want to be able to get somewhere pretty quickly. These long distances rest uneasily in your mind. You are a long way from help. You feel isolated and remote, and that the NHS has overlooked you, even though it's meant to be a universal service," said Blackie.

A "Save our Friarage hospital" sticker adorns his sheepskin coat. He has nothing against the James Cook, having received "wonderful care" there over the last 12 years for heart problems and two lots of mouth cancer. He is not reassured by the 122-bed Friarage's double loss being mitigated by the creation there of both a midwife-led unit where low-risk mothers-to-be can give birth and a paediatric day-care unit where children can be assessed, and some treated, though no longer staying overnight..

NHS Hambleton, Richmondshire and Whitby clinical commissioning group is behind the plans. When its GP Council, made up of 22 local practices, assessed options for the Friarage they rated keeping the services there the best thing to do on grounds of patient safety, clinical effectiveness, patient experience and equity of access. But once they factored in low scores for affordability, sustainability and cost effectiveness, that option was deemed the "least clinically preferred option". Staff shortages mean locum doctors are often needed to ensure rotas are filled.

Opposition is strong. A march in Northallerton last year drew 4,000 protesters. Blackie spoke, as did the foreign secretary, William Hague, MP for Richmond, many of whose constituents would be affected by the plans. "It's impossible to defend going that far and so services of this kind at a hospital of that kind are so important," Hague said. Hospitals in other mainly rural parts of England have managed to find ways to keep a 24/7 consultant-led obstetric unit open, and so should local NHS bosses, he believes.

Across England, from Northumbria to Dorset, East Sussex to Manchester and North Kent to North Yorkshire, dozens of NHS bodies in some 20 areas are pursuing plans to reorganise care. In each case, doctors and NHS leaders have sought to persuade locals that change is necessary to ensure patients receive better care, increase chances of survival and in future treat more people near their own homes. The moves will also help the NHS cope with the growing demands being placed upon it by our ageing population and rising numbers of people with long-term conditions such as diabetes and asthma, they say.

But each proposal raises concerns and in some cases vocal campaigns of opposition from residents, councillors, MPs and sometimes even doctors and nurses. Attachment to the bricks and mortar of the NHS – to a hospital where generations of the same family have been born, for example – breeds fear, suspicion and anger. Campaigners say the reason for hospital closures is cost-cutting – the need to save more of the £20bn that the NHS chief executive Sir David Nicholson says must be shaved from the budget by March 2015.

In 1962, the NHS's Hospital Plan envisaged that every community should have access to the services of a district general hospital (DGH). But for several reasons, that era seems to be over. East Sussex Healthcare NHS Trust wants to divide orthopaedic, surgery and stroke services between its two hospitals (both currently provide all three). But in future Eastbourne general hospital would provide stroke care and Conquest hospital in Hastings the other two. Liz Walke, chair of Eastbourne's Save the DGH group, said: "These are services that are needed in a hurry and they should both be provided at both hospitals. There is no doubt there will be a domino effect and other services will follow."

Dr Andy Slater, the trust's medical director, argues that if the plans went ahead fewer than 15 patients a day would have to go further afield to be treated. "We want Eastbourne DGH and Conquest hospital to remain thriving hospitals. This recommendation is not a threat to that ambition but a means of achieving it," he said.

There is an unprecedented consensus among NHS leaders, doctors' groups and health thinktanks that radical changes are needed. They say restructuring is needed above all to improve the quality of care. The patient population is changing – they have become older, with chronic illnesses such as dementia and Parkinson's, not curable infectious diseases. Meanwhile, science and technology have transformed what can be done, but have become increasingly complex. People need to be taken for specialised care to the fewer hospitals where the real experts are. Hospital has long since ceased to be a one-stop shop. Even the victim of a car crash, needing urgent treatment for serious head injuries, would do better bypassing the local hospital for a trauma centre where brain surgeons are available 24 hours.

Mike Farrar, chief executive of the NHS Confederation, which represents hospitals, supports significantly shrinking the hospital sector and hugely expanding community, primary and social-care services, which are all delivered outside hospitals. In his view between 30% and 40% of patients admitted to hospitals could and should be treated elsewhere. "It is a safe bet that we do not need 30% of our acute capacity," he told MPs on the health select committee in October. Alternatives to in-hospital care were "absolutely critical to being able to reconfigure hospitals" as part of "a major reform of health services over the next three to five years".

Professor Norman Williams, president of the Royal College of Surgeons, lists the huge challenges facing the NHS in England this year: implementing the coalition's unpopular NHS reforms from April, making billions of pounds of efficiency savings and next month's report of the public inquiry into the Mid-Staffordshire scandal. But "intelligent reshaping of services" is bigger than any of them, he said, because "without it, many of the inherent problems in the system are likely to continue". Politicians must show "brave leadership" and back clinically justified reorganisations, explainingto the public why such schemes are necessary.

Lord Darzi, the surgeon turned health minister who led restructuring for two years under Labour, says quality must be the only driver and never linked to saving money. Sir Bruce Keogh, NHS medical director, says the argument gets muddied, because they can be interlinked. It is always hard to persuade people "that sometimes radical change is about saving lives, not saving money", he said. "In a context where we have a lot of evidence that better care costs less, that complicates the argument." He cites US data from the Society of Thoracic Surgeons showing the cost of heart surgery in Virginia ranged from $20,000 to $30,000 – and the best-performing hospitals were the cheapest because of fewer complications.

The biggest-ever NHS restructuring exercise to be attempted is under way in north-west London, with the proposed closure of A&E units in four out of nine hospitals: Charing Cross, Central Middlesex, Hammersmith and Ealing. They would keep an urgent care centre but complex cases would go instead to Chelsea and Westminster, St Mary's in Paddington, Northwick Park in Harrow, the West Middlesex in Isleworth, or Hillingdon.

The fight to save Ealing hospital is led by Onkar Sahota, a GP and Labour member of the London Assembly. MPs from all three political parties took to the streets of Ealing, in a 1,000-strong protest march in September.

Yet Ealing hospital, a bleak barracks of a building on a major London arterial highway, has an unimpressive A&E record. Relatively few seriously ill (classified type-1 A&E) patients are brought to Ealing by comparison with other hospitals in the area – ambulances tend to take them elsewhere. Only a third of its emergency surgeons can do minimally invasive keyhole surgery and Ealing does not meet the four-hour target for admitting patients arriving in its A&E department. Its urgent care centre, which will remain after the re-organisation and takes care of those with minor illnesses and injuries, exceeds its target. Sahota fears that once the A&E department goes, the rest of the hospital will follow – maternity and children's beds too. "A&E is the front door – the lifeline of a hospital," he said. Ealing would be an out-patient hospital with an urgent care centre only. Patients will not know whether they should go there or to an A&E elsewhere. Nor will the urgent care centre GP until he or she has a chance to examine them, he argues. Northwick Park A&E, which would take some of them, is already overstretched; in the 18 months to August last year, ambulances had to be diverted elsewhere on 45 occasions, according to an Freedom of Information request.

Yet Sahota accepts the principle of NHS change. "I don't have an ideology that we don't close any A&E departments at all. I accept that the ageing population is increasing. I accept that we should give the right care in the right setting for the right condition for the right patient," he said. "It may be that in 10 years we can revisit this when we have built up capacity in the community, but at the moment this is too much, too fast."

Opposition to closures can delay important decisions for years. The case for change in children's heart surgery was universally accepted more than a decade ago in the wake of the Bristol babies scandal of the late 1990s. Babies with complex heart conditions died in operations at the Bristol Royal Infirmary where surgeons were not skilled enough. After years of investigations, discussions, hearings and evidence, the NHS opted to concentrate services in seven hospitals instead of 11. Oxford, Leeds, Leicester and London's Royal Brompton were the losers. Everybody accepted the case for change – but no doctor, parent or local politician wanted their unit to be the one to close. The decision has been hard fought in all except Oxford, where a series of deaths led to the service being suspended. Campaigners are still using every legal and political process to fight the closures. Councillors and MPs have been joined in Leeds by the archbishop of York, John Sentamu, and in Leicester by Tony Blair's former spin doctor Alastair Campbell in opposing the plans.

MPs often support the case for reconfiguration generally but oppose the loss of services at their own local hospital. They talk of the fear of being "Kidderminstered" – a reference to the result of the 2001 election in Wyre Forest in which sitting Labour MP and minister David Lock lost by 18,000 votes to Dr Richard Taylor, a hospital consultant who ran as an independent candidate seeking the return of A&E services to Kidderminster hospital. Taylor was re-elected in 2005. But the hospital never did regain its A&E. While medical and NHS leaders endorse widespread change with increasing urgency, and an accumulating weight of evidence shows that patients ultimately benefit, Kidderminster – Darzi calls it "the K factor" – has spooked politicians.

Back in Hawes, Dr Pam West, one of the three GPs at the town's sole surgery and a doctor for 30 years, has mixed feelings about the plans for the Friarage. "When I first heard about these plans, my heart sank. My patients like the Friarage and it's a great hospital. As a local resident and their GP, I understand people's concerns," she said.

But she understands that the paediatric services at the hospital have to go because its small caseload means it cannot attract enough doctors to staff them. And if it has to go, then the maternity unit has to follow, she adds, as the two areas of care overlap so heavily. "As a pragmatic doctor who's proud to work in this area, I have to think about the long-term viability of these services at the Friarage and the sad reality is that they aren't sustainable. If patients are safer going elsewhere, then that's what's got to happen ... It's a false reassurance for patients to be able to keep going to the Friarage because if there's no paediatrician, if a newborn baby is very ill that's a disaster for the baby and the family. There are a lot of politicians and others living in cloud cuckoo land."