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.

---

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”.

---

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.

---

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.