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.