GPs who "rip off" patients to be given greater freedom. The end of the NHS as we know it?

I add the following comments to those circulated earlier as "A liberated NHS - Free to levy charges on patients? - Advance briefing on Andrew Lansley's announcement 12 July 2010".

Roughly 10% of NHS GPs in England use revenue sharing 0844 telephone numbers to "rip off" their patients, obtaining a subsidy of their costs in providing NHS services, contrary to the principles of the NHS constitution.

(The term "rip off" was used by the Health Minister replying to an adjournment debate in parliament in 2008.)

Today's announcement in the White Paper "Equity and Excellence: Liberating the NHS" suggests that further freedoms are to be given to GPs to run the NHS locally.

In the forward to the White paper the Prime Minister, Deputy Prime Minister and the Secretary of State for Health acknowledge that the longstanding principles of the NHS have had their day as they acknowledge, "free at the point of use and available to everyone based on need, not ability to pay ...". They however go on to say that the principle of quality outcomes must now replace these, stating "... but we believe that it can be so much better – for both patients and professionals". (That "but" is a big word.)

I would argue that the "Equity" represented by the earlier principles is more important than the "Excellence" which is to replace it, however this determination is in line with the conclusions of Darzi. We have for too long taken the principles of the NHS for granted and failed to recognise that they stand in conflict with those of consumerism.

The BMA GPC encourages its members to believe a meaningless, and false, assurance that the 0844 telephone numbers from which they obtain a subsidy are no more expensive to call than an ordinary number. GPs are clearly not experts in telephone charges and so have no reason to question this lie. One wonders how many more well-constructed scams medics will fall subject to when taking on further commercial responsibilities.

If the BMA expects us to accept that GPs can be entrusted with the principles of the NHS, as they take over the role of PCTs, then we must note its policy that patients should pay for access to NHS services according to the quality of the service provided. That is not to say that politicians or quangos have been seen to be any better at dealing with this situation. Furthermore, patients seeking treatment for a pressing condition cannot be expected to invariably choose the cheapest option in order to preserve the principle of "free at the point of use".

This looks like "goodbye to the NHS we have known" and "hello to paying for higher quality". I will continue to fight to defend a NHS that cannot offer any greater quality of service than we are all prepared to pay for through our taxes.

Department of Health Directions fail to ban "expensive" telephone numbers

The Directions from the Department of Health leave it to each NHS body to make its own determination about what is an "expensive" number. There has always been concern that this will not achieve the desired result of eliminating telephone numbers that are "more expensive" from the NHS.

The briefing which is copied below picks up on one particular case, where the objective has clearly not been achieved.

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NHS Devon decides to continue charging patients for access to NHS services by telephone

To: Local and National Media, Local MPs, other concerned parties.

cc: Department of Health - mailbox; Nick Hall - Deputy Director - Department of Health; Simon Burns - Minister of State (Health Services); Claudio Pollack - Director of Consumer Policy - Ofcom; Gareth Davies - Director of Competition Policy - Ofcom

From: David Hickson - campaigner for the NHS

I offer a detailed briefing on this particular case as it is noteworthy of itself. It is also indicative of how the issue of use of 084 telephone numbers is not yet being properly addressed across the NHS; this is in fact my primary concern.

All 084 telephone numbers provide the benefit of revenue sharing to their users at the cost of callers.

The fact that some BT customers pay the revenue sharing surcharge through their package fee, or pay unregulated higher rates for geographic calls, does nothing to change the essential truth of the fact that 084 telephone numbers have no place in the NHS. We all pay for NHS services through our taxes, this removes the need for individual patients to pay towards the cost of providing a NHS service as they access it.

The Department of Health has recognised that "expensive" telephone numbers must not be used. It has however failed to advise local NHS bodies and contractors of which numbers are "expensive", leaving each of them to work this out for themselves. NHS Devon has either got it wrong, or is deliberately trying to mislead.

All telephone tariffs are set nationally, by national providers. NHS patients in Devon pay the same for their calls as do those in Northumbria, where the acute NHS Trust has also got it wrong. Although services are managed locally, we have one National Health Service, for which patients should not be paying as they access its services.

The Department of Health wished to avoid getting into the complex detail of particular telephone number ranges, because of the possibility of future change. It could however have quite simply prohibited use of those ranges on which Ofcom permits revenue sharing, leaving Ofcom to provide the necessary detailed information and advise of changes. There is no reason why it could not now make such a statement as a necessary clarification of its existing Directions.

As things stand, all 084 numbers are used for revenue sharing and will therefore be more expense to call for some, if not all, patients. The Department of Health has chosen not to point out this simple truth, and its significance for a service that is provided to all on the same terms – “free at the point of need”.

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The Story

I have recently provided NHS Devon (and many other NHS bodies) with helpful briefings on this topic. I am therefore most disappointed to find that it has responded (two days after receiving my most recent message) by publishing a misleading statement of its mistaken position - "The use of 0845 numbers in NHS Devon". This includes many errors and propagates some common myths, which are dishonestly used by many to provide false justification for use of 084 numbers. I address these below.

This statement is published at http://www.devonpct.nhs.uk/default.asp?pg=311. I have published an annotated image of this page for reference. I will retain this copy to cover the possibility that efforts may be made to deny the historic fact of its publication, rather than correcting it and offering an apology to the people of Devon and other owners of "our NHS" for having published false and misleading information.

NHS Devon openly declares itself to be in breach of the declared purpose of the Department of Health Directions to NHS bodies, to which it refers.

The determination "NHS Devon will maintain the use of 0845 numbers" is based on a false and unacceptable interpretation of objective facts about the costs of telephone calls and of the principles of the NHS, as reflected in the NHS Constitution and the terms of the particular Department of Health Directions.

Devon is not alone

From contacts with many NHS bodies, it is clear that NHS Devon is not alone. It is however to be thanked for providing us with an open statement of its mistaken position.

The Department of Health must now recognise that local NHS bodies, such as NHS Devon, either do not understand these difficult matters adequately, or are perhaps ready to make false statements knowingly in an attempt to protect an invalid source of subsidy from patients.

Telephone tariffs are set nationally (for the UK), by the telephone companies that provide telephone service to NHS patients. Contrary to what some dishonestly allege or mistakenly believe, call charges are not set by those who use 084 numbers. "Considering the arrangement as a whole", calls to 084 numbers are invariably more expensive than equivalent calls to geographic numbers for NHS patients anywhere in England (indeed throughout the UK, even including the special case of Kingston-upon-Hull).

This example is but one of many which prove that the Department of Health is unable to leave the difficult task of determining the relative costs of calling different types of numbers to be undertaken locally. There are no different local factors. The same work is being repeated many hundreds of times over. This inevitably leads to both a waste of effort and, as is seen in this case amongst others, the possibility of error.

The Department of Health must now put the record straight by providing clear and accurate guidance on the relevant issues to all those who serve the NHS.

Summary of my points on the NHS Devon statement

1. It is falsely suggested that the cost of calls to 0845 numbers is generally regulated and that the cost of "local" calls is distinct from that of "national" calls.
   
   
2. It is falsely suggested that BT offers "free" calls to 0845 numbers during the day. It is falsely suggested that because BT originates nearly 25% of all telephone calls, its uniquely partially regulated tariffs, and the perverse effects thereby produced, provide a sound basis for determining policy for the universally provided NHS.
   
   
3. It is falsely suggested that the charge for a geographic telephone call within the UK varies according to the respective locations of the two parties.
   
   
4. It is suggested that patients can be expected to understand the facts about the cost of calling 0845 numbers when NHS Devon itself either does not, or it deliberately seeks to mislead. This is not an acceptable response to the Directions from the Department of Health, nor does it meet the explicit terms of those Directions.
   
   
5. The word "profit" is perhaps used to imply that NHS Devon gains no financial benefit from use of 0845 numbers. This is false; we can argue about whether the word "profit" is suitable for describing a financial benefit, if we must. Alternatively, the statement includes a serious accusation, or admission, of financial impropriety on the part of NHS Devon.
   
   
6. It is suggested that a switch to 03 numbers would cause new costs to be incurred. This is false; if such a switch were appropriate it would simply transfer the same cost incurred in providing a NHS service from the patient accessing the service to the provider. We all meet the costs of providing NHS services through our taxation, not individually as we access them.
   
   

The detail of this complex issue is difficult and widely misrepresented by those offering telephone systems. NHS bodies may therefore themselves propagate misrepresentations, either deliberately or through lack of care. Because the vital issue of the NHS being "free at the point of need" is at stake, we cannot tolerate abuse and misrepresentation.

Please contact me for clarification and further comment on this matter.

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Detailed comments

I will quote and address the false and misleading statements in turn. I have to explain the assertions made above fully and I urge objective verification of all my comments. As well as the Department of Health, I believe that Ofcom also has a duty to provide clear and truthful authoritative public statements to help with a proper understanding of this important and contentious issue.

1. "A patient’s call to a 0845 number should not cost more than a local call"

There is no "should", that can be expressed in this way, unless this is just the expression of an aspiration by NHS Devon. The only objective “should” would in fact state the opposite.

Charges for 0845 calls from BT (where these apply) are regulated in absolute terms, whilst those from all other providers are not. BT rates for local and national geographic calls and for call-inclusive packages are not regulated. In common with all other telephone companies, BT complies with the regulations that exist; there is no area of doubt or breach of regulations to warrant use of the word "should". There is no regulation whatsoever that establishes a relationship between the cost of a call to a 0845 number and that to a "local" number.

Reference to a "local call" in the context of charging is unhelpful and confusing. The vast majority of residential telephone subscribers, including all those using mobile phones, pay at the same rate for a national call as a "local call". (This changed for landlines on 1 July 2004!)

BT is regulated to charge low rates for 0845 calls, and a few other landline providers follow this example on some tariffs. The actual general situation, which covers the remainder, including VirginMedia Orange and O2, is that surcharges are applied to 0845 calls in order to recover the cost of the revenue share which is paid on to the receiver of the call.

Because of the revenue sharing, calls to 0845 numbers "should" be more expensive than (local and national) geographic calls. This is indeed generally the case; whatever NHS Devon may wish for, calls to a 0845 number do cost more than a local call (or indeed any geographic call), as they should.

2. "The largest call provider, BT, now offers free calls to 0845 numbers during the day"

The reference to "free" calls is untrue. Those with the most expensive BT "Unlimited Anytime" package choose to pay through their package fee for calls to 01/02/03, 0845 and 0870 numbers at any time. All other BT subscribers pay for all their weekday daytime calls to these numbers at a (non-zero) rate for each call.

BT is the largest call provider, originating nearly 25% of UK calls. Around 10% of its residential customers subscribe to the "Unlimited Anytime" package. This means that BT customers represent a sizeable minority of callers, probably the largest single group.

The NHS is a universal service, available to all, regardless of their choice of telephone tariff. The needs of all minorities must be properly considered, as the principles of the NHS, and the terms of its Constitution, apply to every patient. Services cannot be configured to serve the needs of a particular group, whilst the principles of the NHS are being breached in other cases.

This point is made very clear in the Department of Health Directions which require consideration to be given "having regard to the arrangement as a whole", rather than simply by looking at one group of patients. 0845 numbers could not be used even if it was only a small minority that suffered a surcharge.

3. "... a geographical area where non-local rates might apply to the calling of 01 numbers"

This supposed justification for use of a 0845 number is utterly spurious, being based on a mistaken long out-dated assumption. As stated above, this is going back to the situation that existed before 2004. For the vast majority of NHS patients there is no distinct "local" as against "non-local" rate. Furthermore, the rate for calling a 0845 number is generally greater anyway; location is irrelevant.

4. "We will also publish local numbers, so the caller can make the decision about which number to use"

There is no good reason offered as to why anyone should incur the many costs and suffer the confusion of there being two numbers for access to the same service.

The Directions from the Department of Health rightly do not allow this use of multiple numbers to be used as a get-out for retaining the subsidy obtained through use of revenue sharing numbers (if only on some calls). Given that NHS Devon itself cannot understand the issue, and furthermore publishes inaccurate and misleading advice to its patients, it is unreasonable to expect that callers are able to make a proper decision about which number to call.ealthgHe

NHS Devon may think that it can get away with passing the responsibility to the patient, so that anyone suffering a surcharge to its benefit can be told that it was their free choice. This is untrue, we take great care to protect the principles of the NHS by not even allowing patients to pay for NHS services when they clearly wish to. The Department of Health rightly does not allow them to be able to do so through ignorance.

These 0845 numbers may be retained for a period of transition, but all 084 numbers must be taken out of use in the NHS.

5. " NHS Devon does not make a profit from the use of 0845 numbers"

If this is not simply playing with words, then it is a very serious accusation, or admission, of impropriety on the part of those who procure telephone services for NHS Devon. Its telephone service provider is receiving a share of the revenue from every call made to the 0845 numbers. This would normally be reflected in a discounted, or waived, charge for services, or in some form of "cashback". NHS bodies would be expected to take advantage of this facility in some way.

If this statement is intended to suggest, or admit, that NHS Devon is gifting this benefit back to that company or on to someone else, rather than taking the benefit itself, then this allegation, or admission, of impropriety on the part of NHS Devon warrants serious investigation.

In fact, I suspect that the statement is simply playing with words, suggesting that a subsidy towards the costs of providing its telephone services is not the same as a "profit". We are familiar with this type of semantic nonsense from those who seek to rip-off the NHS and its patients; I am most disappointed to see it being used to mislead by a NHS body.

6. " NHS Devon has not implemented 03 numbers as these would incur costs for the Trust and in addition would not necessarily be free of charge to end users"

The costs which the Trust would incur by using 03 numbers are exactly the same costs as those being covered by the revenue share on 0845 numbers, and thereby being indirectly met by callers.

Telephone companies levy their own charges for calls to 03 numbers, although by regulation this cannot be greater than that for a normal national or local call. Also by regulation, revenue sharing is prohibited on 03 numbers. 03 numbers would not be free to call, although they would leave callers free of the sur-charge currently being applied to the benefit of NHS Devon.

There is no justification offered for either patients or NHS Devon incurring the cost of non-geographic numbers, so one cannot see why 03 numbers need to be considered.

The Department of Health Directions

By its apparently ill-founded determination to retain the 0845 numbers, NHS Devon is in breach of the Directions to NHS Bodies issued by the Department of Health on 21 December 2009 (as referred to in the statement).

These only permit arrangements whereby "persons will not pay more to make relevant calls to the NHS body than they would to make equivalent calls to a geographic number".

"Persons" with telephone service from VirginMedia, Orange and O2, as well as users of public payphones, other mobile services and most other landline services invariably pay more to call the 0845 numbers used by NHS Devon (or indeed anyone else) than they would to make equivalent calls to a geographic number.

The Directions also demand consideration of "the arrangement as a whole". It is therefore vital to remember that the NHS is a universal service provided "free at the point of need" to all. There can therefore be no basis for considering only a particular group of patients, e.g. those using BT landlines. The fact that some patients may be able to evade the surcharges generally applied on calls to 0845 numbers does nothing whatsoever to make their use permissible in the NHS.

The points of principle in the NHS Constitution

By its action, NHS Devon is also in breach of the terms of the Health Act 2009, which demands that regard be shown to the NHS Constitution.

The first of the rights under that Constitution prohibit charges for NHS services, except where explicitly sanctioned by parliament. Examination and consideration of the NHS Constitution show it to refer to a prohibition of any charge to the benefit of a provider of a NHS service which is necessarily incurred in using that service.

The incidental cost of a normal telephone call, to the benefit only of the telephone service provider, is not a charge levied by a NHS provider. Like the bus fare to attend a surgery or clinic, or the cost of a computer and broadband when using an online service, it is not a charge for the NHS service.

It is the inevitable surcharge on a call to a revenue sharing number that has been selected by a NHS service provider, to the benefit of the NHS provider, which is prohibited. This abuse of the principles of the NHS can only be removed by ceasing all use of 084 numbers by the NHS.

Offering patients a choice of number, so that they may be deemed to have voluntarily chosen to incur a surcharge, should they perhaps complain, is no answer. Great care is taken to protect the principles of the NHS by even denying patients the opportunity to pay for NHS services when they wish to do so.

Action required

I have long been calling for the Department of Health to issue proper and much needed guidance on these issues, as they are widely misunderstood. Regrettably, this misunderstanding has even been seen to extend into the Department itself. At least one officer in the Department seems to hold the mistaken belief that it is possible to use a 084 number without patients being charged more than the cost of calling a geographic number. Even though the decision is passed down to the local NHS body, it is unhelpful to suggest a possibility that none will be able to find, if they do their job properly.

This does not entirely excuse NHS Devon for having formed a mistaken view and certainly not for having chosen to issue a misleading public statement. Now that both are in the public domain, the Department of Health must act swiftly to correct the situation.

I will be happy to help anyone with further information and comment.

Ofcom joins the party late - my response to a preliminary consultation

In the Autumn of 2010, Ofcom will issue proposals for the revisions of the regulations covering what it now calls Non-Geographic Call Services.

This will cover, most contentiously, 084 numbers. It will however also cover all of the numbers used for Premium Rate Services. The clarity which will emerge from this exercise may provided belated assistance to the understanding of the need for a complete ban on use of 084 numbers in the NHS. If this work had been undertaken a year or more ago, the present confusion would undoubtedly have been avoided.

As a preliminary, Ofcom has just completed a consultation inviting input of ideas to a process that will address many issues well beyond the scope of the campaign being covered here. From my broader engagement in these issues I have contributed a response to the consultation.

This may be be viewed here - Input to Ofcom Review of non geographic calls services

To: Chief Executives of all PCTs in England

cc: Other interested parties (for information)

From: David Hickson - campaigner for the NHS

Implementation of Ban on use of "expensive" telephone numbers by NHS GPs

You will be aware of the recent revisions to the GMS contract which impose a ban on use of "expensive" telephone numbers by NHS GPs.

These mean that GPs must now join NHS bodies and other contracted providers in ceasing use of all telephone numbers beginning 084.

The revisions are published by the Department of Health here - DRAFT Standard GMS Contract Variation Notice – April 2010. I understand that identical variations to the PMS contract are also in hand.

I trust that you are now in the process of issuing the variation notice to your contracted GPs.

In the absence of a full briefing from the government, I offer the following guidance on interpretation of the new contractual requirements and my comments on their enforcement.

Summary

• With reference to the various sub-clauses of clause 29B - ALL numbers beginning 084 fall within the category of those which "persons pay more to make relevant calls than they would to make equivalent calls to a geographical number". Whilst some callers may at some times be subject to greater surcharges for calling geographic numbers, there are NO 084 numbers which are exempt from prohibition under the terms of this provision.
  
• With reference to sub-clause 29B.3 - the relevant contract is that for supply of network telephone service, which must be with an authorised provider. Such providers allow migration from a 084 number to the equivalent 034 number within the term of the contract.
  
• I see there as being no case where the fall back provisions under sub-clause 29B.4 will need to be invoked. All relevant arrangements may be modified satisfactorily, given the will to do so.
  

This issue has a long (and continuing) history of misrepresentation and confusion. I strongly urge you to verify all information provided with great care. I deeply regret the fact that this responsibility has been passed down to many local organisations when all telephone tariffs are set nationally. I will continue to do all I can to ease this burden on your staff.

What is "more expensive"

Put simply, for those using Virgin Media landlines, Contract or PAYG mobiles or Public Payphones, calling any 084 number is always more expensive than an equivalent call to a geographic number.

There are many other cases where this is true, however these depend on various factors.

This confident assertion is often disputed, so whilst urging you to verify it, I will attempt to explain further.

My previous briefing on this topic advised that all 084 telephone numbers are generally more expensive to call than ordinary "geographic" numbers because part of the price paid by the caller is invariably shared with the receiving party's telephone service provider, thereby providing a subsidy to the GP's costs at the expense of patients. The only cases where calls to 084 numbers are not more expensive than those to geographic numbers are due to the perverse effects of partial regulation of BT charges.

This effect applies to some telephone tariffs that may be used by patients, including some, but not all from BT. The tariff which applies to each patient and the rates charged by their chosen telephone service provider are totally beyond the control of GPs, their telephone system providers and their telephone network providers. A share of the revenue derived from the caller is invariably passed on through these companies to benefit all users of 084 numbers. Various factors may cause some patients to be perversely shielded from paying the consequent surcharge directly, however this must not be allowed to confuse the true and general position.

Please refer to this briefing and the material in the many links provided there, which describe the situation and the reasons for it in more detail.

Provisions introduced by Directions to NHS Bodies issued in December 2009 and affecting their sub-contractors are now, by these GMS contract variations, explicitly extended to one group of sub-contractors. It must be noted that, as confirmed by their duties under the Health Act 2009 with reference to the NHS Constitution, all NHS bodies must apply the same principles to the terms of all other contracts. This means that NHS bodies are required to subject other contracted bodies providing NHS services accessed by telephone, e.g. Dentists, Pharmacists and Ophthalmologists, as well as out of hours GP service providers, to the same requirements.

Any GP who has been told that any 084 telephone number is not more expensive to call than a geographic number has been deceived (unless there is a qualification limiting this statement to a few telephone providers and tariffs, so that it applies only to some patients). I suggest that any such claim must be supported by evidence of the telephone tariffs used by all patients and details of the relative costs. I am confident that this cannot include any patient using the telephone services listed above.

In theory, it could perhaps be shown that everyone who may call a particular 084 number is using one of the few particular telephone tariffs which make that number no more expensive to call than a geographic number. In such a hypothetical case, then one would have to permit its use. I am personally prepared to dismiss the possibility of this being achieved in practice.

I present this briefing with total confidence. I must urge you to verify this information with authoritative sources.

GPs requiring special telephone numbers

Whilst all 084 numbers provide the financial benefit of revenue sharing to the user, there are also some technical benefits that can be derived from use of any "non-geographic" number.

Ofcom recently introduced the range of numbers beginning 03 (see its publication - "The 03 alternative"). 03 numbers are for use by those who wish to utilise the technical features of non-geographic numbers, but do not wish callers to pay for them.

All telephone service operators are required by regulation to charge for calls to 03 numbers on the same (or better) terms than for calls to geographic (01/02) numbers. This applies to landlines, mobiles and payphones and to the terms of call inclusive packages. Extensive research shows 100% compliance with this regulation.

The technical benefits available with 03 numbers are identical to those available with 084 numbers. The only difference is the lack of a financial benefit to the user at the expense of callers.

In framing its rulings on telephone numbers, the Department of Health was reluctant to specify particular number ranges, having got such provisions badly wrong in the past (see below). It could have simply said that 084 (and other previously banned ranges such as 087, 070, 09 etc., as well as 080 when not subject to special arrangements) are unacceptable, whereas only 01, 02 and 03 are acceptable. This is precisely what the requirement for the cost of a call to be no greater than that of calling a geographic number means in practice.

GPs, NHS bodies and other contractors wishing to apply the technical benefits of non-geographic numbers must now use only 03 numbers, so as to avoid taking subsidy from patients. The principles of the NHS rightly deny them the opportunity to take advantage of the financial benefits of 084 and other revenue sharing numbers. It is acceptable for a NHS patient to incur the incidental third party cost of an "ordinary" telephone call at the particular rate charged by their telephone company, but not for them to incur a surcharge that provides an indirect subsidy to the benefit of the NHS service provider.

It is important to understand that the financial benefit of use of revenue sharing 084 numbers is rarely seen in the form of a cash payment. It is generally applied as a discount against of the cost of telephone services, or retained in place of a charge being levied on the user. Those who deny "profit" or "income" cannot honestly deny financial benefit and are simply playing with words to create a misleading impression.

GPs with long term contracts for provision of telephone service

The GMS contract revisions recognise the fact that some GPs are using expensive numbers in connection with the use of systems to which they have a long term contractual commitment. Indeed, their contract for the supply of network telephone service may also have some period to run. When considering such cases, it is important to understand the following points:

• Regulations limit the provision of telephone network service to certain authorised operators, such as The Talk Talk Group, the company most involved in this provision of service on 084 numbers to NHS GPs.
  
• Arrangements for the provision of network telephone service on a particular type of number may be closely related to the provision of local switchboard equipment and systems, however the two need to be considered separately. This applies where the equipment and system provider has also acted as a sales agent for the network telephone service provider.
  
• Providers of telephone network service on non-geographic numbers (including the Talk Talk Group) permit, and where appropriate encourage, migration from one type of number to another within the term of a contract.
  

Whatever may be the contractual terms for any switchboard or call handling system, it is the contract for provision of network telephone service that is relevant to the number used. This can only be with an authorised provider of such service as the principal. A sales agent and system provider may be keen to retain the benefits of revenue sharing at the expense of patients, and a GP may be keen to avoid incurring costs that have so far been met by patients. It is therefore possible that the position of the network service provider on the issue of migration from 084 to 034 may be misrepresented.

Migration from 084 to 034

Those currently using revenue sharing 084 numbers have the equivalent 034 number reserved for their use, should they wish to migrate. Network telephone service providers (i.e. those who provide the actual network connection and the numbers) support and encourage such migration within the term of a contract. The Talk Talk Group (trading as Opal Telecom) is the major player in this area, providing well over 90% of the service on expensive numbers used by NHS GPs - I cover its policy on this matter in my briefing "NHS GPs using 0844 numbers can change to 0344". Other similar providers apply similar policies.

Some switchboard systems, notably "Surgery Line", rely on use of non-geographic numbers. This is allegedly for the technical, rather than financial, benefits that these provide (although there are grounds for challenging this allegation). There is however no sound reason why those who are contractually required (or perhaps simply wish) to continue using this type of system could not migrate to the equivalent 034 number so as to retain their telephone system, whilst complying with the terms of the revised GMS contract.

I suggest that any GP claiming that their network telephone service provider (e.g. Talk Talk) will not allow them to migrate to a 03 number within the term of their contract for provision of network telephone service should be asked to provide confirmation of this from that provider. It is important that such confirmation is provided by the actual network telephone service provider - not their sales agent, the system provider, whose interests may suffer as a result of such migration.

You may find this TV clip informative in relation to the degree of enthusiasm about the potential for migration to 03 shown by providers of surgery telephone systems - the position has not changed since this recording made on 16 December 2008.

"Having regard to the arrangement as a whole …"

Because there may be cases where some patients do not pay more to call a 084 number, it is possible that some may seek to invoke the quoted provision to suggest that those who pay more can be disregarded as an insignificant minority. A detailed survey of the specific telephone tariffs applicable to all those who call the number in question (as well as the day of the week and time of day when they call) would be necessary to establish whether there could be any truth in such a suggestion.

I suggest that engaging in any such exercise, or entertaining such a suggestion, would be to miss the point about the NHS. The NHS is a UNIVERSAL service available to all; it is not a consumer commodity where the purpose is to achieve the maximum level of aggregated customer satisfaction. Any arrangement for provision of a NHS service "as a whole" must fully INCLUDE every minority interest.

In principle, having just one patient who may need to call the surgery from a public payphone when their home phone is out of order should be sufficient to demand that a 084 number be determined to be more expensive. In practice, one will find that it does not come down to such an extreme situation, however that would be sufficient.

I trust that you will understand the situation where perhaps 80% of registered patients have BT landlines on tariffs without inclusive daytime calls and may therefore not pay more to call some 084 numbers, whereas 20% have PAYG mobiles and consequently pay twice as much to call 084 numbers. I could go on to say that the 80% may be more eloquent in pressing their interests, however I trust that my point has been taken.

Implementation of the ban

The terms of the GMS contract revisions place the responsibility to acquire the necessary understanding of telephone tariffs on the GP. The BMA GPC suggests in its guidance that this information should be obtained from the GP's own telephone system provider (see GPC Guidance: use of 084 numbers in the NHS). The BMA however totally undermines this unsatisfactory suggestion by referring to a totally false assurance given by one such system provider, who cannot be expected to have any competence in this matter. The company in question is not a network telephone service provider; it is indeed an agent for Talk Talk, which invariably charges all of its customers more than the cost of a normal call to call the 0844 Talk Talk numbers used by the agent.

The BMA initially argued that patients should be allowed to be charged for access to "higher quality" services. This is confirmed in its guidance notes. After having lost that argument, it now changes its tune to implying that expensive numbers are not more expensive. (On a personal basis, I am dismayed to see the BMA firstly opposing the principles of the NHS and then switching to endorse a false statement and encouraging its members to be misled. I doubt that these positions truly represent the general view of its membership. Points from our respective positions were brought out in this Radio 4 Today Programme discussion.)

When enforcing compliance with the terms of the GMS contract the PCT has a duty to ensure that any determination made by GPs regarding the relative cost to patients of calling different types of telephone number is sensible and reasonable. There is quite sufficient evidence available to show that any 084 number is more expensive than a geographic number in general. Any exceptions are for particular patient's tariffs, not for particular 084 numbers.

Those who benefit financially from the revenue share that is provided on every call to a 084 number have long sought to pretend otherwise. In 2005, they were successful in totally misleading the Department of Health into the totally false belief that 084 numbers offered "a guaranteed low rate call" (see Hutton rings the changes on NHS telephone numbers).

The Department of Health has now retreated to a position of uncertainty, as it is no longer prepared to offer any specific guidance. Despite the fact that telephone tariffs are set nationally for each type of number, responsibility for ensuring that each GP is acting properly in this respect has been passed down to PCTs.

I draw your attention to the positions seen to be taken by the various parties, so as to help you understand how we got to where we are and to enable you to appreciate the type of representations that you may be receiving. It is of course for you to make your own determinations and judgements as you serve us in administering "our NHS".

(I will of course be making representations to the new ministerial team at the Department of Health in the hope of getting more solid guidance issued. There may now be a greater willingness to acknowledge a serious error made by an earlier minister than was the case a few weeks ago!)

My position and role

My only interest in this matter is as a patient and part-owner of "our NHS". I have no personal, Political or commercial interests in this, or any related, matter. I am deeply concerned for the principles of our NHS and have conducted extensive research into all of the relevant issues to gain an understanding of the problem and to be sure that there is a fair and workable solution.

"Our NHS" is funded through taxation, supplemented by specific additional charges sanctioned by parliament at set rates and subject to exemptions. Providers cannot be permitted to obtain funding from patients through charges as they use NHS services, either directly or indirectly. This is the vital point of principle which I am fighting to defend.

(Other issues are raised in relation to contributions by patients where spare NHS land is used to provide income from car parking and retail concessions - however these are more complex as they involve the provision of additional non-NHS services.)

In progressing the matter of expensive telephone numbers, I am happy to provide my informal assistance to PCTs. If invited to collate and provide formal evidence about telephone charges in a formal capacity that may be regarded as being authoritative, e.g. through some agency such as NHS Primary Care Commissioning, I would be delighted to assist.

Please feel free to contact me for further information and advice.

The end of rip-off GP telephone numbers - contract revisions now issued

A media release has been issued, drawing attention to the fact that the revisions to the GP Contracts have now been issued to PCTs by the DH. PCTs will formally notify GPs of their revised obligations.

GPs have until 1 April 2011 to get off "expensive" telephone numbers (i.e. all those beginning 084).

There are two important points to note.

• Assurances from system providers about the cost of calling 084 numbers are known to be misleading. They are entirely worthless as these providers have no control over the price that callers pay, unless they themselves happen to provide the callers' telephone service.

• Migration from a revenue sharing number to another number, within the term of a contract, is a perfectly normal option. There is no need for NHS providers to suffer contract  termination penalties in order to move back to compliance with the principles of the NHS.

GENERAL ELECTION ISSUE - Will the NHS remain free at the point of need?

Efforts by campaigners to stop GPs, Hospitals and other NHS service providers from obtaining clear subsidy from patients by use of expensive "revenue sharing" 084 telephone numbers were thought to have succeeded. [see petition]. On 14 September 2009 it was announced that use of these numbers was to be banned. [see DH press release]

Directions to NHS bodies, to this effect, were issued on 21 December 2009. [see statutory document] These however excluded all services provided by the NHS Direct NHS Trust, and have not been applied by the many Hospitals and other NHS bodies that continue to use 084 numbers [see my list).

Similar revisions to the terms of GPs' contracts, intended to come into effect on 1 April 2010, were also published. The relevant Statutory Instrument was however presented to parliament too late to complete its processing prior to dissolution, and no action has been taken to implement these changes. [see SI 2010/578]

 

Notwithstanding the preparatory work done so far, it will now fall to the government that emerges from the new parliament to take positive action to preserve the principles of the NHS.

In the absence of any indication of how NHS budgets will be protected when public spending is under pressure, we may wonder if payment by patients could be used as a way of achieving this.

• Talk of a "National Care Service", as part of the NHS, where the principle of payments by users is not ruled out, suggests the danger of a broader weakening of the principle of the NHS being exclusively funded by taxation.
• The "Big Society" appears to imply that people take care of themselves, making their own commercial arrangements with local providers, rather than relying on the government always footing the bill, or telling providers what to charge.
• Some would say that "fairness" is best achieved by patients making some financial contribution towards their treatment, or at least the associated administrative costs, rather than having these paid by others.

 

A few pence (or in some cases, pounds) on a telephone bill may not be the biggest issue in itself. It is however a clear manifestation of a principle that many hold dear being breached.

We are aware of NHS fees for prescriptions, eye tests and dental services. These are clearly stated, set nationally, explicitly sanctioned by parliament, and subject to exemptions loosely on the basis of need and ability to pay.

NHS service providers cannot be permitted to levy charges themselves (indirectly through use of revenue sharing telephone numbers in this case) under the terms of the NHS Constitution currently in force. One wonders if new circumstances and a possible new government will cause the fundamental principles of an aging institution to finally be formally abandoned in its 62^nd year.

 

I propose a question to those seeking to take on the management of our NHS as members of the next parliament, and the government that emerges from it.
"How far will payments by patients be used to enable NHS budgets to be maintained in the context of public spending cuts?"

Any answer that falls short of a clear denial and an assurance that firm action will be taken to eliminate the existing examples of this practice must be taken as a commitment that sacrificing the principles of the NHS is a price worth paying for whatever else is to be done with public money.

Will the BMA be able to beat the government by enabling GPs to continue using expensive telephone numbers?

The formal announcement of changes to the GP contracts to be applied from 1 April is imminent. In readiness for this, I pose a question, offer a briefing in 6 numbered points and propose action.

1. On 14 September 2009 the government announced:

"phone numbers that charge the public or patients a premium rate to contact the NHS are to be banned in England

"We want to reassure the public that when they contact their local GP or hospital, the cost of their call will be no more expensive than if they had dialled a normal landline number.

"The Department of Health will work with the British Medical Association's GP Committee over the coming months to integrate the legislative changes into the GP contracts.".

2. The GP contract revisions have been drafted and submitted for approval by parliament - they can be seen at items 6 and 10 of SI 2010/578. They will come into effect from 1 April and will be announced and issued formally before that date.

The "ban" applies to all numbers that cost more than "equivalent calls to a geographical number". The government has not offered any guidance on which numbers these are, effectively requiring each and every PCT to refer to all of the nationally published tariffs of telephone service providers for those services known to be used by NHS patients. (I have attempted to assist with a briefing - Telephone Tariffs used by NHS Patients.)

3. Although the terms of the ban are not yet formally published, nor in effect, the BMA GP Committee has already issued Guidance to its members restating its policy of opposition to the ban and offering advice on how it may be avoided.

a. This confirms that it is BMA policy for patients to be charged for access to NHS services according to the "quality of the service that patients are accessing". (I address this radical approach to the principles of the NHS in noting the BMA response to the recent DH consultation, and also in my "Today" programme discussion with Dr Richard Vautrey, deputy chairman of the BMA GP Committee.)

Whilst I must focus here on the means by which the BMA seeks for its members to avoid the ban on use of expensive telephone numbers, my underlying concern is out of care for the principles of the NHS. If the BMA is seen to be opposed to those principles then it must state its position and be ready to withdraw its support from the March and Rally in defence of the Welfare State on 10 April.

b. On the terms of the new contract itself, which expressly prohibit such charging through use of revenue sharing telephone numbers, the BMA advises members that they will be in compliance with its terms if they "obtain written confirmation from their phone service supplier that the charge for a call to their number is no more expensive than making an equivalent local call". NEG is confirmed to have issued such an assurance covering the 0844 numbers used to subsidise the cost of its "Surgery Line" system, as used by Dr Vautrey and around 1,000 other practices in England.

The guidance states without equivocation "As long as the tariff is equivalent to local rates, and the practice obtains a written guarantee from their phone supplier (usually NEG) that they are charging rates in line with local geographic calls, then they will be deemed to have fulfilled their medical services contract".

The simple truth of the matter is that NEG is in no position to offer any such assurance as it does not set the charges. The tariff of charges incurred by the NHS Patient calling the surgery number is set by their own telephone service provider. NEG only arranges the provision of telephone service to the GP, as an agent for the Talk Talk Group, which is the actual registered telephone service provider involved here.

Furthermore, the information provided by NEG is factually inaccurate. The Talk Talk Group, along with Virgin Media and all mobile and public payphone providers invariably charge more than the cost of a local (or indeed any geographic) call to call Dr Vautrey's surgery and all others that use the 0844 Surgery Line numbers. (see my briefing on Telephone Tariffs used by NHS Patients)

Confusion may be generated because the unregulated penalty charges imposed by BT for making geographic calls, which would be covered by a package, when made outside the times when the selected package is in effect are seen to be perversely expensive when compared with its regulated charges for calling 084 numbers. (BT is alone in being subject to regulation that prohibits it from making a normal margin when placing calls to 084 numbers. Other providers are free to levy a surcharge to cover the additional cost of revenue sharing).

This is one of a number of cases where regulation that applies only to BT make the following statement accurate and relevant -

"Calls to 0844 Surgery Line numbers are always more expensive than calls to geographic numbers (BT charges may vary)".

(For an explanation of this perverse effect, see my briefing BT charges may vary from others. I offer no apology for introducing this complicated point. I merely seek to show how a complicated situation is being exploited by those who adopt a position of opposition to the principles of “our NHS”.)

4. Although the new contract terms have not yet come into effect, the BMA Guidance has been referred to in correspondence with a patient of a practice in Chelmsford that adopted Surgery Line and a 0844 number in November 2009.

The patient now pays 10p + 6p per minute to call the surgery from his Virgin Media landline, when a call to the previous local number was included without charge. He has rightly pointed out that he is paying more than the cost of an equivalent geographic call. The practice has responded, after taking advice from NEG and enclosing a copy of the BMA Guidance, stating "we are confident that the written undertakings we have received from NEG fully meet the requirements".

If practices are able to counter clearly demonstrated evidence of a breach of the terms of the contractual requirement with essentially worthless undertakings, then the BMA will be successful in giving effect to its policy of charging for access to NHS services.

5. I have made enquiries of a number of Primary Care Trusts about their ability to enforce the revised contractual terms when they come into effect. I understand that this will not be easy for them, especially in the absence of a clear understanding that the assurance provided by NEG is totally worthless.

6. The solution, offered by the terms of the contract revision, is relatively straightforward. Practices tied into long-term contracts for supply of network telephone service that are currently using an expensive number have 12 months in which to "vary the terms of the contract or arrangement". In most cases, including those who have telephone service from the Talk Talk Group, they will be able to do this by migrating their number from 084 to the equivalent 034 number. (see my briefing - NHS GPs using 0844 numbers can change to 0344.)

03 numbers were introduced 3 years ago for those who wish to use the technical benefits readily available with non-geographic numbers, but do not wish callers to incur the additional cost that is inevitably incurred when revenue sharing numbers are used. Charges for calling 03 numbers cannot, by regulation, exceed those for calling geographic numbers.

Surgery Line requires the technical benefits of non-geographic numbers, notwithstanding the financial benefits of using revenue sharing numbers. There seems to have been a reluctance to explore this option. This started with a discussion I had with a representative of NEG on BBC Breakfast TV. It seems that the time to address use of 03 numbers has still not arrived!

7. The purpose of the Minister of State in introducing these contract revisions was made very clear in parliament by the answer to an oral question about use of 0844 numbers by GPs on 12 January 2010.

The detail is a little confused, as the dates referred to are those which apply to NHS Bodies under the terms of Directions that apply to them also covering contracts that they negotiate, rather than the complementary changes to the terms of the GMS and PMS contracts. For NHS GPs the year in which to change the arrangements begins on 1 April 2010, whereas it began for NHS Bodies themselves on 21 December 2009. The bracketed words in the quotation below should be understood to mean “a” year and 1 April 2011 respectively.

The essence of Mr O’Brien’s comments were:

“GPs will have [this] year to end the practice completely .... some of the companies involved ... have said they are prepared to negotiate equitable arrangements with the GPs ... They have all got to be out by [21 December], but we want them to be out now, or as soon as they possibly can be”

The Hansard reference is 12 Jan 2010 : Column 547.

The strength of Mike O’Brien’s determination can be seen in the video clip available here.

It is important to understand that the necessary changes are only in relation to the telephone number used; systems such as “Surgery Line” will be able to work in exactly the same way as they do at present on 03 numbers. The contract referred to is that for provision of network telephone service, which must be with a registered provider, not that for associated leased locally installed equipment, which is presently being partially paid for out of the proceeds of the revenue share, i.e. by patients.

Summary and action required

• The BMA must explain its policy regarding charging for access to NHS services. If it opposes the principles of the NHS, it must say so clearly.
• The "assurance" from NEG about the cost of calling Surgery Line numbers must be exposed for what it is.
• Primary Care Trusts must be given complete and authoritative relevant guidance about the costs that patients incur in calling particular types of telephone numbers.
• The Talk Talk Group and other telephone service providers (NEG is just an agent) must become engaged in helping their customers comply with their contractual duties.
• All those wishing to form a government during the time when the bans on use of expensive telephone numbers in the NHS will be implemented may wish to declare what additional action they will take to ensure that it is effective.
  

  NHS Bodies, although excluding all services provided by the NHS Direct NHS Trust, have 12 months from 21 December 2009 to cease use of expensive telephone numbers. We await news of revisions to the contracts held by providers of NHS Dentistry, Pharmacy and Ophthalmology.

  We also wait to hear why NHS Direct is able to retain subsidy from its provision of local GP out of hours services by using expensive numbers, whereas other providers are not. It is reasonable not to put patients through the confusion of a change to the main 0845 4647 NHS Direct number whilst it is still possible that this may shortly change again to 111. There is however no reason why the 0345 4647 alternative, which is already set up for use, could not be quietly run in parallel for the sake of those who incur premium rates when calling 0845 numbers.

  Similar action is required in respect of other expensive telephone numbers used in the delivery of public services. Retaining, or even extending, charges for access to public services is one way of dealing with "the deficit". It is however highly regressive and therefore likely to appeal only to those of a particularly extreme political persuasion.

  If a premium of 40p per minute is acceptable for financially disadvantaged users of PAYG mobiles to contact NHS Direct, JobCentre Plus or HMRC, then why not £1 per minute for wealthy landline users? ... No - neither is acceptable.

Why are calls to 084 numbers more expensive, but not from BT?

These comments provide an explanation for information released about the cost of calling NHS Direct. The comments apply to calls to all 084 numbers.

Summary

Some of the revenue derived from all calls to 084 numbers is "shared" between the two telephone companies involved. This effectively provides a benefit to the call recipient at the expense of the caller, as the respective telephone companies pass this on to their customers in some way.

BT is regulated in its charges for calls to 084 numbers, but not for 01/02/03 numbers. Despite the fact that revenue sharing is taking place, BT's tariffs currently create the perverse effect of 084 calls being cheaper overall.

084 calls are not cheaper for those who call under the terms of a BT call inclusive package. Whilst it may be fairly assumed that many calls are made outside the terms of these packages, the overall perverse effect will continue to be seen.

Revenue sharing

On every telephone call a "termination fee" is paid by the Originating Communications Provider (OCP - the caller's telephone company) to the Terminating Communications Provider (TCP - the recipient's telephone company).

The level of the fee is set to cover the following costs incurred by the TCP:

• Geographic numbers (01/02) - work done within the telephone network in connecting the call.
• Revenue sharing numbers (084) - as above, plus an addition to perhaps cover the cost of additional features provided to the call recipient.
• Premium Rate Service numbers (087 / 09 etc.) - as above, plus a guaranteed income to the recipient.
• UK rate (03) - nothing more than the work done within the telephone network in connecting the call. The recipient must meet the full cost of additional features provided to handle calls beyond the network.

Benefit to the recipient

• For 01/02 and 03 calls there is no financial benefit to the recipient. The cost of their incoming telephone service is simply paid for in full.
  
  
• Premium Rate Services earn income for the recipient.
  
  
• There are three ways in which a recipient may benefit from revenue sharing on 084 numbers:

1. Indirectly - incoming call services are provided at a discounted cost, which the TCP makes up from the enhanced termination fees received.
   
   
2. Directly - the recipient pays the full cost for incoming call services, but receives a cash-back from the enhanced termination fee, according to the number of calls received.
   
   
3. Some complex arrangement involving a combination of the two.

Government guidance to public bodies, through the Central Office of Information (COI), urges use of the first of these as it "appears" more proper than the second. Any public body that is paying the full cost for its incoming call services on a 084 number, without deriving any benefit, is gifting money to its telephone service provider.

Exactly what happens at this end of the line makes no difference whatsoever to the cost to the caller.

The benefit gained by NHS Direct

NHS Direct is served by BT Global Services. The differential that it receives in termination fees for a 0845 call over a 03 call is at least 2.1 pence per minute (see note below). For an average 528 second call, that amounts to around 18.5 pence.

In correspondence with myself, and in a written answer provided by the Minister of State for Health (19 Jan 2009 Column 1201W), NHS Direct alleges that it allows BT Global services to keep this money, as it claims that neither of the options referred to above apply.

"NHS Direct does not directly or indirectly receive revenue for the use of any 0845 numbers".

(One may play with definitions of the term "revenue". I will take the reference to "no indirect revenue" to mean no subsidy of its costs for receiving telephone calls, which is a "revenue", as opposed to "capital", expense.)

Note: BT Wholesale publishes the termination fees paid and received by BT in The BT Wholesale Carrier Price List (CPL). The respective figures for 0845 and 03 calls terminated by BT are 2.6654 pence per minute and 0.5600 pence per minute. These are found in tables 1.6.3.2 and 1.6.13.1 of section B1 of the CPL. In some cases the rate for 0845 calls increased considerably after 1 November 2009.

Cost to the caller

The cost of calls to 03 numbers is compelled by regulation to be no greater than the cost of calling 01/02 numbers. This applies to all telephone service providers, including the terms of inclusive packages. There are no known cases of non-compliance.

The OCP will (in some way) recover the cost of the enhanced termination fees from callers. This is typically seen by exclusion of revenue sharing and PRS numbers from inclusive packages and the imposition of higher rates. As the rate for calls to 01/02/03 numbers is highly visible in a competitive market, there is downward pressure on this rate, which does not apply to the rates for calls to 084 revenue sharing and PRS numbers.

The differential may therefore be seen as being disproportionate to the actual cost. Extended differentials may also be seen due to the many different classes of revenue sharing numbers being grouped together in a single rate.

In general therefore, calls to 084 numbers are more expensive, but we have an anomaly ...

The BT anomaly

At one time, all BT charges were regulated by Ofcom. This included fixing the pence per minute element of the charge for calls to 0844 numbers and denying BT the ability to make a full margin on calls to 0845 and other NTS numbers.

Other restrictions on BT charges have now been lifted, however those stated above remain.

BT now applies a heavy call setup fee to all calls where a call charge applies. This covers 0844 calls at all times and 01/02/03 and 0845 calls made outside the period covered by an inclusive package. This setup fee and the rates for calling 01/02/03 numbers, where these apply, are currently being increased at the fairly constant rate of 30% per annum through successive price changes. This is all seen to be part of a policy to encourage subscription to inclusive packages covering all times when calls may be made.

BT cannot increase the pence per minute rates for 0844 and 0845 numbers. It has even found it possible to include 0845 calls within packages without having to increase the package fee by an intolerable amount.

Although BT's pricing policy is strongly geared to most calls being made under the terms of an inclusive package, it is assumed that very many calls are being made at its chargeable rates. Where it can, BT imposes a penalty charge on such calls, i.e. the unregulated charges for calling 01/02/03 numbers. It cannot however impose the same penalty charge in respect of calls to 084 numbers.

This anomalous position will be addressed by Ofcom in a forthcoming review.

Further comment

I have already published comments on BT charges may vary from others, explaining why the suggestion that "other providers' charges may vary" when quoting a BT rate is perhaps addressing the issue from the wrong side.

I will comment further as the forthcoming Ofcom review gets under way.

For now it is sufficient to understand that

084 CALLS COST MORE - BT CHARGES MAY VARY FROM ALL OTHERS.

Comments on the Daily Mail item - Millions of patients pay 40p a minute to phone their GP

The Daily Mail reports reports a claim by Network Europe Group that “Up to 200 doctors' practices have switched to the controversial 0844 numbers in the past six months”.

I have issued a briefing and media release in response to this news:

Government efforts to prevent NHS GPs ripping off patients through use of revenue sharing telephone numbers have failed - this must now change!

"Ban" on use of expensive (revenue sharing) telephone numbers - Briefing to all PCTs and SHAs

This posting is for a general briefing, however it contains the essence of a message distributed to the Chief Executives of ALL PCTs and SHAs in England.

An earlier message from me on this subject and the related briefing material covers, and provides more detail on, some of the points made below.

These comments are prepared in the light of recent comments published by

• the BMA
• and NEG Ltd
• and answers to questions in parliament given by the Minister of State (Health Services).

There could be a cloud of confusion that needs to be dispelled. I offer my assistance and urge verification of my comments.

The Directions to NHS bodies concerning the cost of telephone calls issued on 21 December 2009
must be considered, in effect, to represent
a ban on the use of 084 telephone numbers in the provision of NHS services.

As there is no general regulation of the cost of calling particular telephone number ranges, the Department of Health requires that attention be given to the actual costs incurred by patients. It has however (so far) failed to understand the effect that revenue sharing, which applies to all 084 numbers, has on unregulated charges in the market.

Regardless of undertakings by GP system providers and the perverse effects seen in some telephone tariffs (under some circumstances as a result of legacy regulations that apply only to BT), the cost of paying the revenue share that provides financial benefits to all users of 084 numbers is generally passed on to callers.

The Minister and the Department of Health are quite correct to declare that in a NHS "free at the point of need" NO PATIENT should be required to pay for access to NHS services, even if the money is collected, and the financial benefit is received, indirectly.

System providers to GPs and others can issue any personal undertaking they wish about the cost of calling, it has no meaning. The cost of a telephone call is set by whoever provides telephone service to the patient. Some may have been totally misled on this point, or led to accept a false belief that charges to callers are set by agreement with the called party.

This briefing document shows that those who pay more to call any 084 number than the equivalent cost of a call to a normal ("geographic") number include all users of:

Public Payphones, all Virgin Media landlines, all Contract and PAYG Mobiles.

If any NHS provider could be sure that no patient would call using these (or some other) services, then it could continue using a 084 number. Unlike 084x, 03xx numbers are subject to general regulation; this requires that the cost of calling may be no more than that of calling a geographic number.

I have invited recipients of my message to verify my comments with those having the relevant authority and let me know if they are challenged. I have also asked to be advised if there is any known situation where there are no patients who would call under the terms of the types of tariff listed above.

I must urge anyone reading this briefing who can identify any factual errors here, or in the any of the supportive material, to please submit a comment or contact me.

Advice to NHS Bodies 1 - Introduction and Summary

Advice to NHS Bodies concerning the cost of telephone calls

1 - Introduction and Summary

In support of the Directions to NHS bodies concerning the cost of telephone calls issued by the Department of Health on 21 December 2009, I offer some supportive advice.

The "Dear Colleague" letter accompanying the Directions makes it clear that these directions do not explicitly represent a prohibition on use of 084x numbers. Each NHS body is left to draw its own conclusions about which "contact telephone numbers have the effect of the patient paying a premium above the cost of a call to a geographical number". Given that telephone tariffs are set nationally, this means that the same work has to be done time and time again.

To perhaps help avoid some unnecessary effort and possible error I offer this advice to all NHS bodies. My authority to do so derives from many months of engagement in the issue and appropriate research and study. I must urge verification of all that I say with Ofcom and, as necessary, with all of the 200 or so registered providers of telephone service in the UK.

PLEASE ADVISE ME OF ANY ERRORS in the general comments I make or the detailed information I provide, as I seek to be wholly objective and would wish to immediately correct any false or misleading information.

The advice offered

Apart from the comments made below, I present this advice in two separate publications.

Firstly, I offer some general comments on a number of relevant issues.

These are intended to help correct some common false assumptions and misunderstandings.

Secondly, I address what is demanded of NHS bodies by the Directions.

The determination demanded by the DoH Directions requires knowledge of which telephone tariffs apply to patients who may call numbers used in the delivery of NHS services. Most tariffs pass on the cost of the revenue sharing associated with all 084x numbers to callers, thereby making these calls more expensive. There are however cases where calls to geographic numbers are subject to a greater premium charge (e.g. the penalty charge imposed for calling outside the time period during which an inclusive package is in effect), thereby exceptionally making an equivalent geographic call more expensive.

To comply with the Directions it would only be possible to use a 084x number if it could be established that the only tariffs applying to patients likely to call it were those which had this perverse effect in place.

To help with this determination, I therefore present lists of published current residential telephone tariffs classified according to the relative cost of weekday daytime calls to relevant types of number. If any patient could perhaps call under the terms of a tariff on the first of these lists then 084x numbers may not be used in the delivery of NHS services.

Conclusions

It may be noted that this first list list includes the tariff for BT Public Payphones, all tariffs offered by Virgin Media and all the Contract and PAYG tariffs offered by the major mobile providers.

As the inevitable conclusion would therefore appear to be that 084x numbers cannot be used in the provision of NHS services, it is perhaps strange that the Department of Health was unable to come to this conclusion itself and act accordingly, thereby saving a lot of possibly unnecessary work.

I must therefore urge anyone who can offer an alternative conclusion to contact me and point out the possible flaws in my information and thinking. Given the amount of time that the DoH has dedicated to this issue and the amount of good advice that it has received in the process, it is difficult to believe that it could have got things so wrong.

I would be delighted to hear of a situation where a NHS body has found that it can comply with the Directions and continue to use a 084x number.

(I have advised of this publication in a message published here)

Advice to NHS Bodies 2 - Useful information

Advice to NHS Bodies concerning the cost of telephone calls

2 - Useful information

To support advice being provided with reference to the recently published Directions to NHS bodies concerning the cost of telephone calls, I provide some useful additional general information that may help correct some common false assumptions.

I must urge verification of these comments to be made with Ofcom and all relevant telephone companies.

Contents 

Who sets charges?
What is revenue sharing?
What is "local" rate?
What is a geographic number?
What is premium rate?
Are calls to 084x numbers ever cheaper than calls to geographic numbers?

(Details in support of the final item may be found here)

Who sets charges?

The charge for calling a particular type of number is set by each provider of telephone service as part of their contract with their customer. There is nothing that the body renting the number, nor their telephone service provider, can do to change this. They can only select the type of number that best meets their needs, noting the relevant terms of the tariffs of the various companies providing telephone service to their callers.

Different ranges of non-geographic numbers have different charging characteristics.

• It is only the 03xx range that is subject to charge regulation for all providers. Charges must be no greater than that for calling a geographic number. This covers landlines, mobiles and payphones, extending to the terms associated with pre-paid and "unlimited" packages also.
• BT alone is subject to regulation of its charges for calling all other non-geographic (landline) numbers. Those who choose non-geographic numbers therefore can be assured of what BT will have to charge its customers.
• This control however only covers BT and it has no bearing on which calls are included in any packages, nor on call setup fees. Any influence that BT's rates may have on the market for calls from landlines does not apply to calls from mobiles as BT no longer participates in this market.
• BT is not regulated in its charges for calls to geographic numbers, nor its policy regarding inclusion in packages.
• Barring the perverse effect of the regulation on BT, and the impact this has on the market, one would expect telephone providers to pass the cost of the termination fees incurred on calls to 084x and other ranges, to callers. Indeed, this is generally what is found. In cases where these costs are not carried by callers to the numbers on which the fees are imposed, they will be reflected elsewhere in the overall charging structure.

What is revenue sharing?

Calls to all non-geographic numbers, including all 084x numbers, but excluding all 03xx and in reverse for 080x, are subject to revenue sharing. Part of the revenue earned by the "Originating Communications Provider" (OCP) is shared with the "Terminating Communications Provider" (TCP). This is achieved through the payment of a termination fee between the respective telephone companies. The rate of the termination fee is set (per call minute) according to the number called.

This mechanism is used for calls to mobiles, as addressed by the "Terminate the Rate" campaign. It provides the basis for the provision of Premium Rate Services and operates in the same way, although on a lesser scale, for all 084x numbers.

There is nothing that the caller can do to affect the way this operates. Neither can the call recipient effect any change to the arrangement, after having selected a number from a particular range.

It would normally be seen that where revenue sharing is in effect this would provide a financial benefit to the call recipient and cause a cost to be incurred by the caller.

In the case of Premium Rate Services the benefit is very clear, as it covers the cost of providing the service as well as a profit margin. It is generally assumed that mobile users benefit from the fact that their provider receives income from their incoming calls, so as to enable them to receive incoming calls at a minimal or zero cost. Users of 084x numbers benefit, perhaps in cash payments from incoming calls, but always from the fact that the charge for their service would (all things being equal) be greater were it not for the termination fee payments received by their provider.

The cost to callers is clearly visible in the first two cases. In the latter case there is confusion. Some of this is caused by the effect of the regulation on BT, which denies BT a proper margin when originating these calls, thereby artificially suppressing the relative total charge. As no other provider is subject to this constraint, any suggestion that BT charges are typical, whilst others "may" vary is clearly absurd. In some cases telephone companies fail to reflect the refinement of the many different categories of number, and charge an excessive premium based on the worst case. The fact that there is heavy competition based on the rates for calling geographic numbers tends to force these down, exacerbating the differential.

What is "local" rate?

Historically there was a distinction between the charges for "local" and "national" calls from landlines, although never from mobiles (which cannot have a locality by definition). Whilst the distinction between local and national calls does still exist, since 2004 the vast majority of residential tariffs have offered both at a common rate.

This change is recognised by the ASA and by most trading standards bodies, who have taken action against those using the term "local rate" when describing the cost of telephone calls.

There are a very small number of callers for whom the distinction makes a difference (e.g. subscribers to Kingston Communications, T/A Karoo, in Hull). It is however now generally accepted that the base point to use when referring to the cost of a telephone call is that of a call to a geographic number (Ofcom uses the term "UK rate").

The connection between the charge for calling 0845 numbers and "local rate" was once a key feature of the telephone calls market, but this no longer exists, neither in regulation nor in practice. It sadly remains as a suggestion in the naming of some rates, but this does not imply that the actual connection in charging remains.

The term "lo-call" has been coined to refer to those number ranges which are subject to relatively low premium charges. The phonetic similarity with "local" is perhaps deliberately misleading. This term is now, as it has always been, nothing more than marketing hype.

What is a geographic number?

With the exception of a few such numbers used by Internet Service Providers, a geographic number is any number commencing 01 or 02. Calls to numbers beginning 03 must (by regulation) be charged at the same or a lesser rate. Since the distinction between "local" and "national" rate was abolished, it is the rate for calling a geographic number that represents the base point for UK telephone call charging - a "normal" call.

What is premium rate?

Any rate that includes a premium charge, such as that applied to fund a revenue share, may fairly be referred to as a "premium rate". There is however the danger of confusion with a specific technical term defined in the Communications Act of 2003 - "Premium Rate Service" (PRS).

Those using numbers in ranges deemed by Ofcom as being for PRS are classified as providers of telecommunications services and thereby fall within the terms of special regulations administered on behalf of Ofcom by PhonePay Plus. Ofcom has recently extended the list of number ranges covered by the PRS regulations to include those beginning 0871/2/3.

One must be careful to understand that simply because a number is not classified as being for use in the provision of "Premium Rate Services", calls to it may nonetheless be subject to a "premium rate".

Ofcom will shortly be reviewing the situation regarding 084x numbers. One of many options open to it is to also add some or all of them to those covered by the formal classification of PRS.

Are calls to 084x numbers ever cheaper than calls to geographic numbers?

Every telephone service provider (OCP) must cover the cost of the revenue share incurred when placing calls to 084x number somehow. One would therefore expect such calls to always be more expensive than calls to geographic numbers. Whilst this is generally true, it is not always the case.

BT encourages its customers to subscribe to inclusive packages and markets its call plans on the basis that customers will select a plan to be in effect during the times when they make calls. Cheaper plans are offered for those who do not make calls during the working day or during the working week. Over recent years this has produced two interesting effects in respect of the differential. Both of these derive from the fact the regulation of BT's charges for calls to 084x numbers limit the margin it may take on such calls to deny any profit.

Firstly, BT has been steadily increasing the charge for calling geographic numbers, when outside the period covered by the inclusive package, at the rate of 30% per annum. This has led to the situation where the unregulated rate for calling geographic numbers (outside the terms of a package) has now overtaken even the highest regulated rate for calling 084x numbers. In effect, the penalty premium charge for calling outside the terms of a package exceeds the premium to cover the revenue share.

Secondly, because the rate of the termination fee on 0845 calls is relatively low and BT is limited to the most miniscule margin on these calls anyway, it has been able to make these (but not 0844, on which the termination fee is much greater) calls inclusive in packages whilst only making a relatively modest increase to the cost of the package.

As BT has to make a fair return on its business overall, it is perhaps reasonable to assume that the sharp increases in per minute rates for non-inclusive calls to geographic numbers and the now heavy "call set up fee" of 9.05 pence, which applies to all non-inclusive calls, are effectively cross-subsidising the cost of inclusive 0845 calls and the comparatively cheap rates charged for all 084x calls (0845 when non-inclusive, 0844 is never inclusive).

BT's strong market position in landline call provision has led some others to copy its structure. As their rates for 084x calls are not forced low by regulation, they can only match BT by cross-subsidy.

Details of the which tariffs this does and does not apply to are found here.

Comments

Please advise me if any of the information given above is found to be false or misleading.

David Hickson
Tuesday, 05 January 2010

Advice to NHS Bodies 3 - Telephone tariffs used by NHS Patients

Advice to NHS Bodies concerning the cost of telephone calls

3 - Telephone tariffs used by NHS Patients

The recently issued Directions to NHS bodies concerning the cost of telephone calls requires those bodies to determine whether "persons will not pay more ... than they would to make an equivalent call to a geographic number" if choosing to use a non-geographic telephone number for the delivery of NHS services.

As use of 087x, 09xx and 070x numbers has already been banned, and 03xx numbers are guaranteed to meet this condition by regulation, the point at issue is 084x numbers. As different telephone service providers operate different tariffs the necessary determination of whether "persons will not pay more" can only be made based on the tariffs applicable to those persons - "those to whom the health services are being or may be provided".

It appears therefore that the Department of Health requires NHS bodies to survey all current and potential recipients of their services to discover if a current or proposed 084x telephone number can be retained or newly adopted.

Assistance with resolution of this matter

I follow with three lists that classify a large number of current residential telephone tariffs with respect to the cost of calls to 0845 and 0844 (call type "g6") numbers relative to that for geographic numbers.

For simplicity I refer only to weekday daytime calls, as defined by the respective provider - those taking calls in the evening and weekends will find it less easy to use 084x numbers. As there are 34 different rates associated with the 0844 prefix I use that most commonly adopted - in general the same would be true of most other 0844 rates, however there may be a tiny number of exceptional cases.

The three lists

The first list identifies those on which a caller would pay more to call either a 0845 or 0844 number than an equivalent call to a geographic number.

The second is of those for which this applies to a 0844 but not a 0845 number.

If any "user of health services" could be expected to call under the terms of any one of these tariffs then use of the number must be considered to be prohibited.

The third list is offered for completeness to show the extent of my research and to place claims about the cost of calling 0845 and 0844 numbers in a proper context, as they may relate only to those tariffs. It lists those tariffs on which a caller would pay the same or less to call the 0845 or 0844 number. Those who promote use of 084x numbers are known to quote examples from these tariffs, under the false pretence that they are typical or even universal, to sustain the argument that use of 084x numbers is acceptable.

This would, of course, only be true if all callers were calling under the terms of these packages. I am not sure if it would be proper for an NHS body to urge or advise patients to change their telephone service provider or tariff so that it may comply with Department of Health directions!

Further considerations

The Directions demand consideration of "the arrangement as a whole", so it may be necessary to verify that the classification of tariffs on the second and third list would remain valid for the duration of the contract for supply of telephone service on a 084x number. In this regard it should be noted that Ofcom will shortly be considering whether or not to retain the regulatory control on BT pricing, which is the primary reason for there being any tariffs on these lists.

Given the nature of the principles of the NHS, I am sure that there could be no question of tolerating some patients paying for NHS services because others can gain access at a saving against the normal costs that they would be expected to incur.

Notes are appended below the lists.

List 1 - Telephone tariffs where the cost of a daytime call to a 0845 or 0844 number is greater than that of an equivalent call to a geographic number (see notes and comments).

• BT - Public Payphones
• Virgin Media - Talk Weekends
• Virgin Media - Talk Evenings and Weekends
• Virgin Media - Talk Anytime
• Vodafone - £10 - Contract
• Vodafone - £15 - Contract
• Vodafone - £20 - Contract
• Vodafone - £25 - Contract
• Vodafone - £30 - Contract
• Vodafone - £35 - Contract
• Vodafone - £40 - Contract
• Vodafone - £75 - Contract
• Vodafone - Simply - PAYG
• O2 - Pay Monthly
• O2 - Pay&Go
• Orange - Racoon - PAYG or Contract
• Orange - Dolphin - PAYG or Contract
• Orange - Panther - Contract
• Orange - Monkey - PAYG
• Orange - Canary - PAYG
• Orange - Camel - PAYG
• T-Mobile - Combi - Contract
• T-Mobile - Flext - Contract
• T-Mobile - Solo - Contract
• T-Mobile - PAYG
• 3 - Texter - Contract
• 3 - Internet Texter - Contract
• 3 - Mix & Match - Contract
• 3 - Pay as you go
• Virgin Mobile - Pay Monthly - Contract
• Virgin Mobile - Liberty SIM - Contract
• First: - Anytime
• First: - eve&weekend
• Phone co-op - Evenings & Weekends
• Phone co-op - Pay as you use
• Pipex - Anytime
• Pipex - Saver
• Pipex - Leisure
• Saga - Hourtime
• Saga - Standard
• Sky Talk - Unlimited
• Tesco - HomePhone - Talk 3

List 2 - Telephone tariffs where the cost of a daytime call to a 0844 number is greater than that of an equivalent call to a geographic number, whereas that to a 0845 is the same or less (see notes and comments).

• BT - Calling Plan - Unlimited Anytime Plan
• BT - Calls and Broadband package - Unlimited
• Karoo - KC Talk1
• Karoo - KC Talk2
• Karoo - KC Talk3
• Karoo - KC Talk4
• Talk Talk - UK Evening and Weekend
• Talk Talk - UK Anytime
• Pipex - Hometime
• Pipex - Everytime
• Post Office - Home Phone
• Tesco - HomePhone - Talk 1
• Tesco - HomePhone - Talk 2
• Utility Warehouse - Home Phone

List 3 - Telephone tariffs where the cost of a daytime call to a 0845 or 0844 number is the same as or less than that of an equivalent call a geographic number (see notes and comments).

• BT - Calling Plan - Unlimited Evenings and Weekends Plan
• BT - Calling Plan - UnlimitedWeekends Plan
• BT - Calls and Broadband package - Get Connected
• BT - Calls and Broadband package - Home & away
• BT - BT Basic
• Virgin Mobile - Addict - PAYG

Notes

• The tariffs listed are those currently available and with details published on the internet. Details of previous tariffs and others that may still be in use are not always published. It is imperative that the relevant information be confirmed with the companies listed here. I must urge confirmation of this information with all relevant providers. Published information is often obtuse and difficult to access.
  
• It may also be necessary to consult any other providers of telephone service to patients likely to call any 084x number that may be proposed for use in the provision of NHS services.
• The above classification takes account of the penalty charges applied to landline tariffs when calls are made outside the terms of an inclusive package, which is limited by time and day.
• The classification does not necessarily take account of the fact that some contract mobile tariffs apply a penalty on calls to geographic numbers when the number of inclusive minutes selected has been consumed. This may cause them to cease to be cheaper than calls to 0844 and / or 0845 numbers, under those circumstances. (I believe that this represents a fair approach. One could never be assured that calls to numbers used to provide NHS services would only be made after inclusive minutes had been consumed.)
• There are no business tariffs listed, as NHS services are only available to individuals.
  
• If anyone notices any significant errors in or omissions from any of the lists I would be most grateful to be advised, so that this information may be corrected as necessary.