When size really does matter

WHEN the University Hospital of North Durham is declared open today, nobody will want to spoil the party by asking awkward questions.

Generous applause will no doubt greet the unveiling of the plaque to mark the opening of North Durham's long-awaited replacement for the old Dryburn Hospital. And no doubt the politicians present will talk about the progress made by the Labour Government in its mission to transform the NHS.

But while politeness will reign today, there remains much tough talking to be done about the future of the new hospital after the dignataries have departed.

Built with too few beds to meet local health demands, the new hospital may soon be absorbed in a split-site merged NHS trust covering the whole of County Durham. This radical plan, drawn up by top London surgeon Professor Ara Darzi at the request of County Durham health chiefs, is aimed at solving two major problems: North Durham hospital's chronic bed shortages which has led to cancelled operations; and uncertainty surrounding the future viability of the even newer £67m Bishop Auckland General Hospital.

The plan sees a new role for Bishop Auckland as the main county-wide centre for routine surgery, freeing up beds in Durham and Darlington for more urgent and acute cases. But this has led to protests about the downgrading of the new Bishop Auckland hospital and fears that people without cars could face serious transport difficulties.

The Durham hospital was also at the centre of a national debate about using private finance to build public sector projects. Academics hired by the trade union Unison concluded that the private finance initiative (PFI) had resulted in fewer beds in the new Durham hospital than there would have been if it had been built with public funds.

Unison still argues that PFI saddles local health authorities with unacceptably high annual fees, which must be paid to the private consortium which built the trust and runs support services. That debate still rages, despite a inconclusive visit to the Durham hospital by members of the House of Commons Health Select Committee last year and staunch Government protestations that PFI represents good value for money.

Health bosses at County Durham and Tees Valley Health Authority believe that it is only by merging hospitals in Durham, Darlington and Bishop Auckland that the ever-increasing demands of the NHS Plan can be met.

But that merger proposal - which must now be referred to Government ministers for a final decision after an objection by South Durham and Weardale Community Health Council - has divided staff, patients and the community at large.

David Woodhead, chief officer of the soon-to-be-abolished North Durham Community Health Council, is grateful to see Dryburn finally replaced by a gleaming 21st Century hospital, but has harsh words for NHS planners.

"Clearly, anything was better than the old Dryburn huts. We desperately needed a new hospital," says Mr Woodhead, who is expected to attend today's opening ceremony. "But I think where we have ended up is a planning disaster."

In what he nostalgically describes as "the good old days", seven or eight years ago, North Durham was served by two general hospitals, Dryburn and Shotley Bridge.

The decision to downgrade Shotley Bridge into a community hospital and concentrate acute facilities at Dryburn led to a steady whittling away of beds for acutely ill patients, he argues.

"There were nearly 800 beds at the Dryburn and Shotley Bridge sites in those days but now we are down to less than 500 at Durham," he says. "We, as a CHC, consistently said during the planning process that the bed numbers in the new hospital were too low. It gives us no satisfaction to be proved right."

While his CHC has not objected to the Darzi rescue plan, Mr Woodhead believes that the authorities should urgently consider extending the new Durham hospital. "I think the case is still there for additional beds at Durham. We will say that in our annual report," says Mr Woodhead.

But he argues that creating extra wards at the UHND should be done as well as forging new links with hospitals in Bishop Auckland and Darlington.

"It would be criminal not to use the investment in Bishop Auckland as effectively as possible. Without the three hospitals working together, they might struggle to survive," he argues. "But whether we needed to bring in the north to solve the problem in the south of the county is debatable."

Despite the headlines about PFI, Mr Woodhead feels that the debate has been something of a red herring. He accepts the argument of North Durham chief executive Steven Mason that the shortage of beds has more to do with planning trends within the NHS, than the demands of private capital.

"Many people seemed to think that we could manage with fewer acute beds and more day case patients, but it hasn't worked out that way," the CHC boss says.

While the North Durham CHC has a number of concerns about the merger plan, Mr Woodhead believes it can be made to work. "We thought that looking backwards is not the way. We have got to come up with a way of using the three main County Durham hospitals more efficiently and effectively."

But that is not the view of the more than 60 consultants from the North Durham trust who signed a joint letter criticising the merger plan as unworkable. Plastic surgeon Brook Berry, who was one of the consultants who put their name to the letter to County Durham health bosses, believes the whole situation is a mess and those responsible for the current crisis should own up.

"The real alternative is for the people responsible to hold their hands up and say we have made a balls-up," says Mr Berry. "They built a hospital that is too small for the population we have got and we need a large extension at North Durham to cope with the demand."

The surgeon has serious reservations about how a single merged NHS trust for County Durham would work in practice. "What they are trying to do is create a trust which has enough beds to do the job. In doing so, they are really throwing the county's hosptals into chaos."

He argues that North Durham has more links with the NHS trust in Sunderland than with its colleagues in Bishop Auckland and Darlington

"It doesn't make any sense. If we need to be more co-operative, we should join with Sunderland." A single County Durham trust would be "dysfunctional" and cause more problems than it would solve, he says.

Mr Berry says bed numbers at the new Durham hospital should be more like 800 to match the local population of around 250,000. Bishop Auckland has 360 beds for only 90,000 people.

Mr Berry is also convinced that a combination of factors, including the increasing insistence of many of the various royal colleges that doctors must be trained in larger hospitals, means that the long-term viability of Bishop Auckland as a general hospital is now in doubt.

"Bishop will close anyway when the present generation of physicians retire. They will not be able to replace them," he predicts.

Meanwhile, Valerie Bryden, chief officer of South Durham and Weardale CHC, argues that Bishop Auckland needs and deserves a fully-fledged district general hospital.

In its 23-page report on the proposals, the CHC claims that the scheme would drastically downgrade the new Bishop Auckland hospital, drive away key staff and offer patients less choice.

Mrs Bryden is particularly concerned at the proposed loss of obstetrics, special care baby unit and paediatric services to Darlington Memorial Hospital.

The varying views about the way forward will collide at County Durham and Tees Valley Health Authority on August 7, when health bosses discuss the Darzi plan. Whatever the outcome, staff at the new hospital can claim credit from a respectable two-star rating in this week's hospital league tables issued by the Department of Health.

North Durham chief executive Steven Mason says he takes "particular pleasure" that patients using the hospital either rated the trust as above average or significantly above average. "This confirms my view that the hard work and efforts of all staff delivering direct patient care are appreciated," he says.

The trust met seven out of nine key targets, but missed out because of cancelled operations and delays in seeing cancer patients.

Ironically, the two-star rating means the trust is unlikely to become one of the new NHS Foundation Trusts which has access to up to £1m of extra capital funds.

That would go a long way to paying for that hospital extension.