Comment: decisions must be taken at local level

For too long the quality of healthcare in London has not been good enough - the way some services are delivered is out of date and often those with the greatest needs lose out the most.

Put simply, no change is not an option in the capital.

The framework drawn up by NHS London is a chance to look sensibly again at the city's health service.

In some areas the evidence in favour of particular changes is strong - such as delivering some services in fewer places, not on the grounds of cost but because it will lead to safer, higher quality care. For example, concentrating care for stroke patients in a smaller number of hospitals may mean some experience slightly longer ambulance journeys but more lives will be saved.

In other areas evidence is less strong and there is a need for some caution, such as moving GPs into much larger polyclinics.

There may be a case for creating some new facilities with a wider range of services but we need to ensure the costs and benefits of moving some clinics and diagnostic services out of hospitals is not outweighed by making patients travel further to see their GP.

Above all, the framework should not dictate the fate of particular hospitals or services - that must be a matter determined at local level by primary care trusts working with local people setting out clearly what services they require.

Professor Appleby is the chief economist of the King's Fund