A top NHS expert has suggested sweeping changes in the way the health service is run in County Durham. Health Correspondent Barry Nelson examines the way ahead.

TONY Blair beamed as he unveiled the foundation stone of the new £67m Bishop Auckland General Hospital back in July, 2000. As a large crowd of hospital workers and VIPs milled around, the Prime Minister said: "We have a real chance of rebuilding the health service in the way we all want."

At the ceremony, Bishop Auckland MP Derek Foster said the campaign to replace the town's outdated hospital may have taken more than 25 years, but he was proud that a Labour Government had allowed the scheme to go ahead.

More than a year later, the new privately-financed hospital is at the centre of a hastily put together plan designed to ensure that County Durham's health care system is ready to meet the challenges contained in the Government's NHS Plan.

Professor Ara Darzi, the Department of Health's advisor on surgery, was called in because of severe bed capacity problems at the new privately-financed University Hospital of North Durham. He spent eight weeks talking to hospital managers, consultants and GPs about the problems facing County Durham's health service.

Despite the opening of a superbly-equipped new hospital in Durham last year, staff found themselves fighting a losing battle to cope with a huge surge in patients. Figures showed a 131 per cent increase in the number of emergency medical admissions at the Durham site.

Fears that the hospital would not be able to meet tough national waiting list figures - and an awareness that the NHS as a whole is being asked to go up a gear in the near future - prompted health bosses to bring in Prof Darzi to find a way out of the dilemma.

Stephen Mason, chief executive of North Durham Health Care NHS Trust, still believes the ultimate answer is to extend the PFI-funded hospital, either by bringing in more private finance or funding it through the NHS. But that could take too long.

Prof Darzi was asked to come up with a quick fix which could turn things around as soon as possible. His solution, after doing the rounds of County Durham's health establishment, is to recommend a two-tier hospital system. Instead of three district general hospitals, each doing its share of acute, emergency and planned medical and surgical work, he believes there should be a division of labour.

The idea is to transform the almost-complete Bishop Auckland District Hospital into a kind of "surgical factory", where the majority of routine, non-emergency operations can be carried out without the fear that a sudden influx of acutely-ill medical patients will swamp the available beds and lead to cancelled operations.

Freed from the burden of carrying out thousands of routine hip and knee operations, the two, mainly acute, hospitals in Durham and Darlington will be able to develop more specialised services - such as the new vascular surgery service Prof Darzi would like to see established at the Durham site.

Prof Darzi argues that the need to perform up to an extra 10,000 operations in County Durham every year to meet Government NHS guidelines means that normal working practices need to be scrapped.

Instead of most hospital consultants sticking rigidly to their own backyard, he wants to see surgeons and physicians showing more willingness to travel between the three hospital sites.

His report concedes that this may be one of the main barriers to successfully implementing his master plan. "The surgical community needs to embrace these changes and develop the new models of working to support them. Surgeons must be ready to travel just as much as patients are to ensure they get faster access to high quality care," says Prof Darzi.

The downside of this vision means that, when the new Bishop Auckland hospital opens this summer, it will not be the replacement general hospital that local people have dreamed of for decades. Instead, Bishop Auckland's main role will be as an elective surgery unit for County Durham and Darlington.

Local people will increasingly have to travel down the road to Darlington, or up the road to Durham, if they have an acute medical or surgical problem.

A limited accident and emergency service will remain, but the hospital is set to lose its emergency gynaecology and obstetric cover in its maternity department. While a 9am to 9pm midwife-led maternity unit will continue, the long-established Special Care Baby Unit at the hospital will close and staff will transfer to Darlington.

At the other end of the county, the plan is likely to run into opposition in places like Derwentside, which had to endure the downgrading of the former Shotley Bridge General Hospital into a community hospital a few years ago.

The brand new general hospital in Durham - replacing the clapped-out Dryburn Hospital facilities - was meant to be some compensation for people in the Consett area. But the reality was very different. From the day it opened to patients, it was bursting at the seams.

Opponents of the Government's Private Finance Initiative blamed the lack of beds on the financial arrangements agreed with the private backers, but the new hospital's chief executive, Stephen Mason, argued that it was down to changing fashions in medicine and a failure to realise that the ageing population would place increasing burdens on hospitals. He said it also failed to bargain for the Government's drive to increase the number of operations carried out in NHS hospitals.

Kevin Earley, the former chairman of the North Durham Health Care trust, takes a tough and, in some quarters, very unwelcome line on the Bishop Auckland hospital.

He says: "People will say, why on earth was Bishop Auckland treated differently to Shotley Bridge. The money spent on the new Bishop Auckland hospital should have gone on a community hospital and the rest should have gone on acute services in Durham and Darlington."

He argues that the relatively small catchment area in Bishop Auckland could never support a viable modern district general hospital.

Bearing in mind the withdrawal of support for medical training by the Royal College of Surgeons several years ago, the writing was on the wall for Bishop Auckland, says Mr Earley.

In a way, the plan by Prof Darzi acknowledges that a new role must be found for the impressive new Bishop Auckland complex. Whether he would agree with Mr Earley's previous description of the Bishop Auckland hospital as a "white elephant" is another matter, but, short of putting the hospital on wheels and moving it to where it is wanted, Prof Darzi is suggesting that the new hospital should become a county-wide asset.

The willingness of patients from Darlington in the south and Derwentside in the north to travel to Bishop Auckland for routine operations will be the acid test.

But, as Ken Jarrold, chief executive of County Durham and Darlington Health Authority points out, if patients in the South-East of England are willing to jump on a Eurostar to Lille in France to get treatment, shouldn't we all become more flexible?