John Selby, hospitals trust chief executive, talks to Health Correspondent Barry Nelson about his plans to ease the beds crisis on our overcrowded wards.

THE new boss of County Durham's first united hospital trust is keen on maximising bed use for his patients. But the beds he has in mind are the beds in patients' homes, rather than in the three district general hospitals he now manages.

John Saxby, chief executive of the County Durham and Darlington Acute Hospitals NHS Trust, knows only too well about the controversy which has raged around the shortage of beds at the new Durham hospital.

Built with fewer beds than the old Dryburn Hospital it replaced, the University Hospital of North Durham has struggled to cope with the demands placed upon it, leading to cancelled operations due to the sheer scale of emergency admissions.

While Mr Saxby says the issue of building an extra ward block at the University Hospital of North Durham is still "a live issue" it is likely to be years rather than months before the capacity issue at Durham can be tackled. So what is to be done in the short term?

For too long, according to Mr Saxby, the emphasis has been on what happens inside hospitals. Now the former South Durham trust boss wants to see a greater emphasis on admissions and discharges.

"We have focused on streamlining inside the hospital but what we have never done is bring the hospital out to primary care. Before the patient leaves home we need to have a discussion with social services and primary care about whether the only place this person needs to go is hospital," he says. "It may be we could have someone sit with a patient while we work out what is the best approach to managing his or her condition."

In many cases, that might involve treatment and nursing in the patient's own home rather than admission. "Otherwise we admit them to an acute ward and within 24 hours many of the elderly are semi-institutionalised," says Mr Saxby.

The same rule applies at the other end of the hospital process, where there have been serious problems with delayed discharges throughout the UK, often caused by lack of social services funding to provide a residential or nursing home place. "We need to establish community-based teams so the patient can actually get home quicker," says Mr Saxby.

Currently, most patients who have major joint replacements stay in hospital for nine or ten days. Mr Saxby believes this could be reduced to four of five days, providing resources are in place in the community to support patients in their own homes.

"We want patients who are mobile and clinically fit to be at home. To do that requires good infrastructure out in the community," he adds. "The evidence is that people thrive better when they are in familiar surroundings but they need to be supported in their own homes."

This means more community nurses, more community physiotherapists, more community occupational therapists.

The idea of nurses providing an overnight "hospital-at-home" service is still novel in the NHS, although it has been piloted successfully around the UK.

Mr Saxby accepts that much work remains to be done but says he is determined to try to make better and more appropriate use of County Durham's hospital beds. "Until you try to turn the tap off, there's no point thinking that the only solution is to have a bigger bath," he says.

But in the long term, a combination of factors, including the ageing of the population and increasingly demanding NHS targets, mean that the bed capacity at the "new Dryburn" will have to be increased, he says.

If necessary, says Mr Saxby, an extension could be build under the Government's controversial private finance initiative (PFI).

"If that is the only way to get it built, so be it," he adds.