Local campaigners publish geographic numbers for 0844 surgery

After failing to get the local PCT - West Berkshire (clustered with East Berkshire under Chief Executive Charles Waddicor) to do its job by enforcing the terms of the NHS GP contract, the Neighbourhood Action Group for the district of Earley, near Reading, has adopted a tactic that could be used by similar groups elsewhere.

After securing coverage of the issue in local newspapers, members of the group are now distributing the poster shown below around local shops, community centres and other places where patients of the particular large practice that serves this whole area may see it.

Action like this is not "the solution" to the problem of GPs using expensive telephone numbers, however it is a worthwhile exercise. Those patients who get to hear of the alternative numbers, and recognise that they are cheaper for them to call, may be saved considerable sums of improper expenditure. The consequent loss of subsidy to the practice, because the number of calls to the 0844 number is reduced, may perhaps cause it to wonder whether it makes sense to continue in breach of its contract with the risk of suffering action, for the sake of a relatively small financial benefit.

For myself, I would rather that the practice and the PCT respected the principles of the NHS, on all matters, and behaved accordingly.

Your NHS GP practices using 084 telephone numbers (message to PCTs and MPs)

The draft which follows is of a circular message sent today to each NHS PCT Cluster Chief Executive, with copies to the MPs representing the affected patients.

The circulation and the variable data added to each message is published here.

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To:         <<to>>

Cc:         <<cc>>

From:    David Hickson - campaigner for the NHS

Use of 084 telephone numbers by GP practices

I ask you to review the information provided via the link given below. This lists <<surgeries>> GP surgeries in breach of the GMS / PMS contracts that it is your duty to enforce.

The link provides a formatted view of a section of a database, derived from NHS Choices. (If not properly formatted - please press the green button presented for a full screen view.)

Click here to link to a list of 084-using surgeries serving <<cluster>> <<listurl>>

The relevant GMS / PMS contracts prohibit use of a telephone number for which "persons pay more to make relevant calls than they would to make equivalent calls to a geographical number". All of the numbers listed fall within the terms of that prohibition.

I would be grateful if you would provide me (and the MPs listed above, who represent the affected patients) with an explanation for why these breaches of contract are still occurring.

These breaches of contract undermine the principles of the NHS and imply that your role, as it will continue beyond the present NHS reforms, is ineffective.

You, and the MPs, may wish to review the following briefing, including links to published material. I cover your duties in respect of the requirements, some common myths and the action demanded of practices.

In my Conclusion, I request sight of two specific items of evidence which would be most helpful at this stage, as they would seem to be essential to justify your current position.

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The requirements you are required to enforce

The terms of the contractual requirements are clear. Department of Health Ministers have confirmed both the clarity of the terms and the fact that it is the exclusive responsibility of Primary Care Trusts to ensure that they are enforced.

I do hope that your duties have been made sufficiently clear to you, and trust you understand that no further formal guidance may be issued to vary the terms of a contract now in force.

Your duties include a specific statutory requirement to "have regard to the NHS Constitution". The "guiding principles of the NHS", as defined by the NHS Constitution, include the following:

•	"The NHS provides a comprehensive service, available to all ...
•	"...  It has a duty to each and every individual that it serves ...
•	"... we use our resources for the benefit of the whole community, and make sure nobody is excluded or left behind"

You may have been advised that there may be some callers who do not pay more to call a particular number, whereas others do. I do hope that, in forming your policy to address this matter, you have given due regard to the principles of the NHS and also the confirmation of the detail of the relevant specific contractual terms recently provided from parliament: "It is absolutely clear that there is no distinction between landlines, mobiles or payphones".

It is ALL PATIENTS ("persons") who have to be considered, when possibly making a determination that persons do not pay more. "Relevant calls" are defined as including those made by "patients to the practice". The terms of the contract specifically state "having regard to the arrangement as a whole", thereby expressly precluding the possibility of considering only a particular selected group of callers, or taking some other view that is not fully inclusive.

I trust that you have paid no heed to comments from the BMA, which remains opposed to these provisions, re-stating its alternative view - "calls to NHS services should incur as low a charge as possible, but that this must be balanced by the quality of communications service that the patients are accessing".

The NHS, as currently defined in its Constitution, does not balance the cost to the patient according to the quality of service accessed. No such radical proposal has even been formally presented for serious consideration by the owners of the NHS.

By re-stating its position of opposition, after it had failed to sway the policy decision reflected in the contract revisions, the BMA shows itself to be seeking to achieve an objective other than that reflected in the contract revisions, as expressed in terms approved by parliament. The BMA is entitled to this opinion, which reflects the financial interests of its members as against those of their patients, and to advise its members in any way it chooses. I hope that officers of the NHS seek to apply the principles of the NHS and to further the interests of those whom they serve, in accordance with directions from parliament, regardless of the alternative views advanced by representatives of those who may be reluctant to see their competing interests damaged by complying with these principles and their specific contractual obligations.

Addressing some common myths about relative call costs

Under the present regulatory conditions and the terms of commonly used telephone tariffs, there is no 084 number which meets the requirement not to cause many persons to "pay more ...
to make relevant calls than they would to make equivalent calls to a geographical number".

The cost of a telephone call is set by the provider of telephone service to the caller, not by that to the person called. See a summary of current costs from major providers.

Some callers incur a penalty charge if calling a geographic number outside the terms of their selected call plan, which may be greater than the premium rate charged for calling a 084 number. This fact may be noted, but it is irrelevant, unless it can be shown that these perverse conditions apply to all callers. Every telephone company incurs greater costs when originating calls to 084 numbers than to geographic numbers; it is only under the unusual circumstances which apply to certain call originators (BT and its competitors) that this fact is not reflected in the charge to the caller. The GMS / PMS contracts specifically demand consideration of "the arrangement as a whole". Especially in the context of the NHS as a universal service, it is not sufficient to consider only a selected group of callers who are subject to perverse conditions, when required to consider "the whole".

Some suggest that there may be some significance in the regulated low rates charged by BT for calls to 084 numbers; it is uniquely subject to regulation which prohibits it from taking any margin on originating such calls. All rates for calling geographic numbers (including those of BT) are not regulated. This is how perverse situations can arise with some 084 numbers on some BT tariffs.

If choosing to look at BT, it should be noted that BT originates less than 25% of non-business telephone calls. All residential BT customers are assigned to a package (known as a "Call Plan") of some sort - "BT Standard" no longer applies to any of its residential customers. Whilst the regulation uniquely applied to BT enables it to include 0845 calls in packages whilst maintaining competitive package prices at no exceptional cost to itself, it is unable to do so for 0844 calls. The most widely used BT Call Plan is "Unlimited Anytime", under which calls to geographic numbers are free of charge at all times.

If reference to BT is of any value in this matter, it may be used to indicate that no 0844 number may meet the requirements. Those who subscribe to its most widely used arrangement for residential customers pay no call charge to call a geographic number, whereas they pay a call set up fee and various per minute rates to call 0844 numbers. For 0845 numbers, one has to look a little further, unless it can be established that BT is the provider to every caller to the practice.

The requirement to vary arrangements

For those practices which were not using non-geographic numbers in April 2010, the situation is crystal clear; they should not have adopted 084 numbers. If requiring use of a non-geographic number, the only type of number which provides the assurance that "persons will not pay more to make relevant calls to the practice than they would to make equivalent calls to a geographical number" is one from the 03 range, where all telephone service providers are compelled to charge no more, by regulation. Those who have subsequently adopted 084 numbers, in breach of their contract, may remedy the situation by following the course open to those who were already breaching the principles of the NHS, if not the specific terms of their contract.

Those with 084 numbers in use on 1 April 2010 are required to " take all reasonable steps ... to ensure that, having regard to the arrangement as a whole, persons will not pay more to make relevant calls than they would to make equivalent calls to a geographical number". These include considering "varying the terms of the contract or arrangement".

If wishing, or contractually obliged, to continue using a non-geographic number, practices are able to consider "migrating" to the equivalent 034 number. It is standard industry practice to allow such migration at any point within the term of a telephone service provision arrangement, without penalty. Ofcom has regulations in force covering the cost of calls to 03 numbers which offer precisely the assurance that "persons will not pay more to make relevant calls than they would to make equivalent calls to a geographical number". Migrating to 03 is one clear way of ensuring that the relevant conditions are satisfied.

GPs may have presented evidence to show that, having considered this option, they were faced with "unreasonable" terms and it therefore has not been possible to achieve the intended position. I can see no other justification for continued use of a 084 number by a NHS GP, which complies with the requirements now in force.

It is therefore most important that this evidence is placed in the public domain. If some telephone service providers are not following the standard industry practice, and thereby forcing additional costs upon NHS patients to the benefit of NHS GPs, then their role in setting the terms of the NHS needs to be clearly understood. It may be noted that some contributors to the public consultation on this issue joined the BMA in arguing that NHS patients should subsidise the costs of NHS GP telephone systems. Whilst the contract revisions applied serve to prohibit this, one means of achieving this political objective is to discourage or prevent practices from migrating from 084 to 03 numbers.

It could be that GPs have more directly claimed that it is "unreasonable" for them to meet the full cost of a telephone system to which they have contracted, without the benefit of subsidy at the expense of callers. The effect of migration to a 03 number is to effectively transfer the cost of facilities that is met out of the revenue share income from 084 numbers to the user of the number.

Whilst the BMA encourages its members to argue this point, I trust that any PCT would have affirmed that it is for GPs to make their own decisions about how they meet the costs they incur in providing NHS services, without relying on subsidy at the expense of patients. This is the entire basis of the relationship between GPs and the NHS and thereby must be considered "reasonable". If the terms of the arrangement between the GP and its telephone service provider are thought "unreasonable", then that is a matter between those parties, not a matter for which NHS patients should be required to pay.

For those who had failed to note this point, it was helpfully covered by the Minister speaking in parliament on 12 July:

"There are a number of options open to GPs who already have such telephone contracts, such as calling patients back, altering the contract arrangements or, indeed, paying the costs themselves." The minister could have added that only if the option to alter the contract arrangements so as to pay the costs themselves (GMS clauses 29B.2.2 and 29B.3) is found to be impossible then must alternatives such as calling patients back be considered (29B.2.4).

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In Conclusion

After consideration of these points, I would be most grateful if you assist me and the MPs involved with an explanation of why the PCTs for which you are the accountable officer are allowing their contractors to breach both the principles of the NHS and the specific terms of their contracts. (There may be evidence to show that only the former breach is being forced on them by their telephone service provider.)

In addition to your general explanation, there are two specific items of relevant evidence which, if held by the PCT, I would be most keen to see. In both cases, if there is any such evidence held, then please consider this message as a formal request for it to be released to me under the terms of the Freedom of Information Act. If no such evidence is held, then I believe that you will have great difficulty in explaining why the use of 084 telephone numbers is continuing, and will doubtless wish to re-consider your present policy on this matter.

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I repeatedly assert that "there is no 084 number which meets the requirement not to cause many persons to pay more". I would be most grateful if you would share with me any evidence that shows this assertion to be untrue. I refer to relevant evidence, i.e. that which has regard to the arrangement as a whole and is based on what persons actually pay to call the practice, relative to the cost of an equivalent call to a geographic number. (You should note that the reference to the potential for continued use of 084 numbers by a Department of Health official was qualified by this requirement.)

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It is standard industry practice for telephone service providers to allow migration from a 084 number to a 03 number, at any time during the term of a contract, without penalty. (Talk Talk is known to be amongst those who offer this facility as standard.) Such migration, including taking on the full cost of the practice's selected telephone system, must be regarded as a reasonable step open to every NHS practice with a 084 number. I am very keen to see any specific evidence you hold to show that any particular telephone service provider does not permit such migration on reasonable terms.

I look forward to your reply. Please contact me if I can help with any further information.

Contribution to a Which? conversation

In a Which? "conversation" "GPs – stop using expensive phone numbers", I have been asked to provide statements confirming that

"0344 provides the same functionality for the surgery as 0844"

I regret that I cannot provide a link to the specific comment to which I reply, nor has it been possible to add the comments that follow to the "conversation".

I can offer the following (hyperlinks are supported by page references where necessary):

1. From Daisy Group / NEG

This may be the most suitable, although I cannot confirm this. It is from a company called NEG, now part of The Daisy Group. It claims to be "the market leader in the provision of enhanced telephony services to NHS Primary Care".

Identical functionality can be provided to organisations
through 084 and 03 numbers

This is found on page 10/75, labelled "Page 4" of this pdf document, authored by NEG and published by Ofcom.

There is much else in this document, on which I comment in this blog posting.

It is likely, but not confirmed, that the Daisy Surgery Line system is used by the only GP in Hadleigh shown on this map.

2. Ofcom

Some basic information about 03 is published by Ofcom in this press release.

3. The Department of Health

The Department of Health Consultation document - The use of 084 telephone numbers in the NHS included (on page 5/16) the following statement:

03 numbers offer the same extra functions as 084 numbers
but are charged at the same rate as a call to a local number

General Comment

It is taken as given that all non-geographic numbers provide the same potential for use of "Enhanced Telephony" features because, unlike geographic numbers, they terminate at the same type of equipment - an "intelligent switch" - from where calls are distributed as appropriate.

Similar facilities may be provided on some (or perhaps all) geographic numbers, however this is said to be less convenient and may cause greater costs to be incurred.

References to comments made in the conversation

There can be no instruction more specific than the terms of the contract between the practice and the PCT. This was approved by parliament, and the Department of Health cannot vary these terms by issuing its own instructions.

Ministers of the Department have commented that the requirement to consider call costs applies to all types of telephone service and tariff. This only draws attention back to the terms themselves, and away from misleading guidance issued by certain parties.

If the practice believes that "having regard to the arrangement as a whole", persons do not pay more to call its 0844 number than for an equivalent call to a geographic number then it is shutting its eyes to obvious facts.

It is perhaps relying on guidance based on the situation as it relates to a selected group of potential callers, who incur penalty charges for calling geographic numbers outside the terms of their chosen call plan. Unlike all others, this select group may not pay more.

No matter how convincing and reassuring that guidance may be, it is partial in two senses. Firstly, it comes from a pair of organisations working together and known to be opposed to the objective of prohibiting use of numbers that cost more than the cost of a geographic call. Secondly it admittedly addresses only some callers, rather than "the arrangement as a whole".

The NHS is universal, the rights and principles outlined in its Constitution apply to everybody, arrangements relating to the provision of NHS services cannot be made with regard only to a group which conveniently allows the objective of GPs continuing to benefit from revenue sharing at the expense of patients to be achieved.

References to published comments from the practice

The benefit from revenue sharing is used to subsidise the cost of the GP's chosen telephone system. The full cost should be carried by the practice. "The practice profits" by using a revenue sharing telephone number, not by "providing an advanced telephone system".

The term "local rate", when applied to a 0844 telephone number, represents a "serious factual inaccuracy".

Daisy Surgery Line and "Enhanced Telephony"

There is keen public debate over the still unresolved issue of NHS GPs using 084 telephone numbers to gain subsidy of their costs at the expense of patients. As a contribution to this debate, Daisy Group, the provider of the Surgery Line system used by many NHS GPs, has issued a helpful leaflet -

•    Enhanced Telephony - THE FACTS

Noting this useful contribution to the debate, I have published two documents:

•    Daisy Surgery Line - The Facts

This addresses some omissions from the Daisy Group document in an attempt to further public understanding of the issues.

In particular, it highlights the fact that no NHS GP using a 084 number can be assured of compliance with the principles of the NHS and the specific terms of their NHS contract. In truth, it is only under inconceivable circumstances that a 084 number could be used.

•    How to use Enhanced Telephony as a NHS GP

This refers to the specific options available to NHS GPs who wish to use Enhanced Telephony whilst remaining in compliance with their NHS contract.

In particular, it refers to the option for existing and committed users of non-geographic numbers to migrate to 03 numbers so as to be assured of compliance with the principles of the NHS and the specific terms of their NHS contract. It highlights the need for identification of the telephone service providers who are alleged to be deviating from the standard industry practice by preventing such migration.

Whilst there are many opinions about the way in which the NHS should develop, it is vital that public discussion is conducted on the basis of truth. I will be pleased to engage in debate on the former, but must urge any alleged inaccuracies in any of my comments to be brought to my attention immediately.

References

For the sake of simplicity, neither of my documents contains detailed references to relevant materials. I list the specific materials referred to, and from which quotations are taken, along with other relevant items.

Key documents

→    Calling costs
A summary from the most commonly used tariffs giving the costs of calling 084 and geographic numbers. This document provides links to the relevant published tariffs, which can be the only relevant source of information for those wishing to be assured about the costs that will actually be incurred by callers.

→    Statements from Ofcom
This series of formal statements issued by Ofcom covering relevant issues should be of interest to those who wish to review an objective presentation of the relevant facts. This key document is also presented embedded below.

→    The 03 alternative
A media release from Ofcom confirming the benefits of use of 03 numbers as an alternative to "the service provider generating revenue from those making the calls to offset the cost of equipment to the organisation".

Department of Health material

→    Revisions to the NHS GP contracts
the Statutory Instrument passed by parliament to provide the revised terms of the GP contracts.

→    The use of 084 Numbers
a letter from Nick Hall of the Department of Health confirming the basis for possible continuing use of 084 numbers - "… providing that patients are not charged more than the equivalent cost of calling a geographical number to do so".

→    Hutton rings the changes
an announcement by the Department of Health in February 2005 including the false advice that 084 numbers "offer patients a guaranteed low rate call". There never was any such "guarantee", Mr Hutton was mistaken or misinformed.

→    Clarification of the terms of the requirements placed on GPs
an exchange in parliament on 12 July 2011 providing clarification of the meaning of the terms of the contractual terms, including "It is absolutely clear that there is no distinction between landlines, mobiles or payphones".

Other material

→    Surgery Line is "co-funded"
Confirmation that a key feature of Daisy Surgery Line is the fact that users benefit from revenue sharing - "The revolutionary co-funded enhanced telephony service, designed specifically for GP surgeries. "

→    BMA Guidance vn 1
Indicating a clear position of continuing opposition to the objectives of the contract revisions - "calls to NHS services should incur as low a charge as possible, but that this must be balanced by the quality of communications service that the patients are accessing". It is use of numbers on which a premium charge is applied to achieve the "balance" which is now explicitly prohibited for the NHS.

→    BMA Guidance vn 2
This alleges that some telephone services providers are not allowing GPs to vary their arrangements by migrating to 03 numbers, so as to retain the benefits of Enhanced Telephony whilst complying with the principles of the NHS and the terms of their NHS contracts - "many GP practices have signed multi-year contracts with telephone services providers which cannot be varied, renegotiated or terminated without substantial financial penalty". Any company which is preventing migration to 03 by imposing unreasonable penalties, contrary to Standard Industry Practice, needs to explain the reasons for this unusual conduct.

→    Example of call cost statement
This is a typical example of a practice indicating that the "5p per minute" revenue share charge (as levied by BT) is used to pay for the enhanced telephony it uses, not to provide income to the practice. Despite being proud to "offer NHS Services", the practice appears to forget that the payments it receives for providing these services are intended to be used to cover the costs of telephony. "lo-call" means that the premium rates charged for calling revenue sharing 084 numbers are generally lower than those for calling numbers used for "Premium Rate Services", which can attract much higher premiums.

→    Example of surgery letter to patients
This example shows how a practice and its patients are benefitting from the use of "Enhanced Telephony". Unfortunately this practice has failed to "have regard to the arrangement as a whole" by only considering a claim about rates charged by their "own phone supplier". I have no evidence, but I suspect that the company in question does not provide telephone service to even one of the practice's patients, and so the "written guarantee" about the charges it makes is worthless. (The reference to "guidance of The Department of Health" is utterly spurious. There is no "OFCOM regulated rate for, or related to that for, "local geographic calls", other than the regulation covering 03 numbers, which applies to all providers. I have no idea of what could possibly be meant by "a standard BT tariff", it is certainly not that most commonly used by BT residential customers.)

Under the terms of the most commonly used BT residential tariff (the "Unlimited Anytime" Call Plan), a geographic call costs zero whereas a call to a 0844 "g11" or "g6" number, as used by Surgery Line users, costs 4p or 5p per minute to the benefit of the practice, plus a call setup fee to the benefit of BT.

NHS Bodies in Breach of Directions to uphold the principles of the NHS

On 21 December 2009, the Department of Health imposed "Directions to NHS Bodies concerning the cost of telephone calls".

The Directions

The Directions covered the costs incurred by callers contacting the NHS, which are set by their respective telephone company. All telephone companies have to pay on a "revenue share" when connecting calls to all 084, 087 and 09 numbers. They pass this cost on to callers.

The Directions required that:
"having regard to the arrangement as a whole,
persons will not pay more to make relevant calls to the NHS body
than they would to make equivalent calls to a geographic number".

The terms are defined to apply to all NHS patients, with no exclusion from NHS entitlements for those who do not have a landline telephone or are on the social tariff "BT Basic". It is well known and understood that landline providers charge more for calls to 084 numbers than to geographic numbers, for the reason given above.

Because NHS bodies do not themselves provide telephone service to those who call them, the only way that they can comply is by ensuring that the number they choose is never subject to additional charges from telephone service providers.

The Implications in practice

There are some perverse situations where the penalty charge for calling a geographic number outside the terms of a Call Plan exceeds the premium paid to fund the revenue share to the benefit of the receiving party on 084 calls. Exceptional marketing practices, enabled by special regulations which apply only to BT, create further perverse effects with 0845 numbers. These distort the natural situation for some BT customers, but not those on its social tariff "BT Basic".

There is however no doubt whatsoever that all calls from Virgin Media landlines, mobile phones and public payphones to 084 numbers are more expensive than those to geographic numbers. The situation with other providers may be mixed.

The statement "having regard to the arrangement as a whole" can only refer to the fact that NHS services are provided on a UNIVERSAL basis. Entitlement to access NHS services under the terms of the NHS Constitution (i.e. without charge from the service provider) and as specified in these Directions cannot be sacrificed as a result of not calling under certain specific and unusual terms from a particular type of telephone service provider.

Unless the assertions made above can be shown to be false,
THE DIRECTIONS AMOUNT TO A PROHIBITION OF THE USE OF ALL 084 NUMBERS.

The above comments relate to the situation as it is today, has been since 19 December 2009 and is likely to continue (with some of the perverse exceptions likely to be removed) in future. Potential regulatory changes anticipated by the comment "Organisations remain free to use non-geographical number ranges such as 084, providing that patients are not charged more than the equivalent cost of calling a geographical number to do so" HAVE NOT OCCURRED, indeed Ofcom has taken a totally different direction from that which some anticipated. As things have remained, and are likely to continue, there are no 084 ranges or numbers that meet the stated conditions.

For those reluctant to verify the truth of the matter for themselves, I can offer a quotation from a formal Ofcom statement on this matter:

"Only 03 is charged precisely the same as 01 and 02 numbers by all telephone companies.

"084 numbers are frequently charged at a higher rate than a 01, 02 or 03 number. Where they are not charged at a rate above a 01/02/03 number they are, however, frequently not included in a calling plan, thus callers will pay an additional charge for the call."

If anyone wishes to challenge these assertions, I would be most grateful if they would contact me, so that I may consider revising these comments, and attempt to persuade Ofcom to change its position also.

Implementation

The Directions imposed a deadline of 21 December 2010, by which those already using numbers which cause a greater expense to be incurred must, notwithstanding other possibilities, "vary the terms of the contract or other arrangement". As all telephone companies allow migration from a 084 number to the equivalent 034 number at any point during a contract, there can be no case where the NHS body was unable to comply with this requirement. (Calls to all 03 numbers are charged on the same basis as calls to geographic numbers.)

If anyone wishes to challenge my assertion, with evidence of a case where a request to migrate from 084 to 034 was refused, I would be most grateful if they would contact me, so that I may consider revising these comments.

Many of those listed from research undertaken some years ago have now moved into compliance with Directions. (My publication - NHS bodies using revenue sharing telephone numbers - is now OUT OF DATE.)

There are however many other NHS bodies which are both

    •    defying these explicit Directions, and

    •    continuing to breach their duty under the Health Act 2009 to "have regard to the NHS Constitution".

By benefitting from the subsidy provided by use of revenue sharing telephone numbers, at the expense of patients, they are effectively imposing a charge for accessing NHS services which is not "sanctioned by parliament".

NHS Bodies in breach

I list those seen to be in breach below, along with the name and position of the senior officer responsible, to whom I have written.

Cases where an alternative geographic number is advised alongside the 084 number are annotated "*". Unless it could be shown that sufficient advice is provided to ensure that nobody would ever call the 084 number in error, then the breach remains uncorrected by advice of an alternative number. (I have excluded cases where two numbers are published simply to cover a period of transition.)

Barking, Havering and Redbridge Hospitals NHS Trust	0845 130 4204 *	Averil Dongworth - Chief Executive
Barnet and Chase Farm Hospitals NHS Trust	0845 111 4000 *	Mark Easton - Chief Executive
Basildon & Thurrock University Hospitals NHS Foundation Trust	0845 155 3111 *	Alan Whittle - Chief Executive
Calderdale and Huddersfield NHS Foundation Trust	0844 8110101 *	Diane Whittingham - Chief Executive
Gloucestershire Hospitals NHS Foundation Trust	08454 222 222	Frank Harsent - Chief Executive
Luton and Dunstable Hospital NHS Foundation Trust	0845 127 0 127	Pauline Philip - Chief Executive
Maidstone and Tunbridge Wells NHS Trust	0845 155 1000	Glenn Douglas - Chief Executive
Mid Yorkshire Hospitals NHS Trust	0844 811 8110	Julia Squire - Chief Executive
Northumbria Healthcare NHS Trust	0844 811 8111	Jim Mackey - Chief Executive
Plymouth Hospitals NHS Trust	0845 155 8155 *	Helen O'Shea - Acting Chief Executive
University College London Hospitals NHS Foundation Trust	0845 155 5000 *	Robert Naylor - Chief Executive
East Kent Hospitals University NHS Foundation Trust       (Patient Service Centre)	0845 084 0500	Stuart Bain - Chief Executive
Blackpool Teaching Hospitals NHS Foundation Trust       (National Artificial Eye Service)	0845 60 50 561	Aidan Kehoe - Chief Executive
North East London NHS Foundation Trust	0844 600 1200 *	John Brouder - Chief Executive
Northumberland, Tyne and Wear NHS Trust	0844 811 5522	Gillian Fairfield - Chief Executive
Marie Stopes International      (many centres - providing NHS services)	0845 300 3740	Di Hendry - Head of Marketing
Spire Parkway Hospital, Solihull      (providing NHS services)	0845 850 1451	Will Knights - Hospital Director
Bradford and Airedale Teaching Primary Care Trust	0845 111 5000 *	Matt Neligan - Acting Chief Executive
Gloucestershire Primary Care Trust	08454 221500	Jan Stubbings - Chief Executive
North Staffordshire Primary Care Trust	0845 602 6772	Graham Urwin - Chief Executive
NHS Direct NHS Trust; Health Advice and Information Line	0845 4647	Nick Chapman - Chief Executive

Note on NHS Direct

The NHS Direct Health Advice and Information service is to be withdrawn in the near future, once the mandate for the Urgent-Only NHS access 111 service has been enforced in all localities. It is therefore reasonable not to incur the expense and confusion of a complete number change for the Advice and Information service, which now has less than two years of operation left. The alternative number - 0345 4647 - (charged at the same rate as a call to a geographic number for all callers) has however been configured ready for use in parallel.

There is no justification for the decision to continue to totally withhold availability of this alternative number for the remaining life of the service. The total exemption from the terms of the Directions, which applies to all telephone services provided by the NHS Direct NHS Trust, was totally unnecessary. It being ruthlessly exploited by the NHS Direct NHS Trust and the many NHS bodies which use it as an agency to deliver their services, covering many other numbers not listed above, in disregard of the clear duty under the Health Act 2009.

Comment on Sheffield Star article - GP phone numbers switch

I added the following comments to an article published by the Sheffield Star - GP phone numbers switch.

As the comment item was published as an unbroken string of characters, it may be more easily read below:

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The work being undertaken by NHS Sheffield is to be commended.

Both it and the practices should however be aware that switching to a geographic or 03 number is the ONLY way of achieving the compliance with the terms of the contract, which was demanded by 1 April 2011.

GP contracts covering leasing of equipment and use of a particular system cannot preclude use of a legitimate telephone number. Migration to a 03 number is an option available to every practice.

The revisions to the contractual terms were applied in April 2010. Practices have had plenty of time to make the necessary arrangements.

NHS Rotheram has no need to continue to "review its policy"; its duty to enforce the terms of the contract has been unchanged since these revisions were applied 16 MONTHS AGO.

Along with the other PCTs, NHS Rotheram is set to be abolished in 20 months time.This behaviour does not help those of us who are campaigning to defend the NHS and the public servants who are charged with uploading its values.

NHS Doncaster and its practices should take a little trouble to check what patients are actually paying to call their GPs. When one looks at the facts it may be seen that the providers to the practices were mistaken in their assurances!

The implication that those calling from a BT line do not pay more to call 084 numbers than for an equivalent call to a geographic number is incorrect.

Whilst BT itself includes calls to 0845 numbers in the consequently inflated cost of its Call Plans, other call providers who may be used by those with BT lines do not.BT does not include calls to 0845 number in its "social tariff" - BT Basic. Nobody includes calls to 0844 numbers in their standard packages, so these invariably cause callers to incur a premium charge.

The expense of a "call back" system that prevents those wishing to speak with their surgery from incurring illegal surcharges is a ridiculous waste of money. Every practice is readily able to move swiftly into compliance - the call back idea is pure nonsense.

Example of how PCTs are failing

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UPDATE - This matter was discussed on the Ronnie Barbour Show on BBC Three Counties Radio - Listen here.

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A good example of how the ban on use of expensive telephone numbers is failing to be enforced is highlighted by an article published by Bedfordshire PCT - 22 July 2011 : Dr Cakebread and Partners to get ‘local code’ phone number.

I quote below the text of an email message I have sent, circulated to various interested parties, but aimed directly at the key players:

•    Paul Cooper – Press Officer – NHS Bedfordshire

•    Tony Medwell - Head of Primary Care Commissioning - NHS Bedfordshire

•    Vivien Kinch-Jameson - Managing Partner - Dr Cakebread and Partners

•    Lynnette Brennan - Practice Manager - Dr Cakebread and Partners

The text of my email message follows:

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[The article] includes some errors and a notable omission. As a national campaigner for the NHS, with extensive engagement in this issue, I point these out and comment.

Any belief that a 0844 number may be called “for the cost of a local call” has always been, and remains, false. Under the terms of contractual requirements introduced in April 2010, NHS GPs have a duty to determine whether the cost of calling a non-geographic number may, having regard to the arrangement as a whole, is greater than that of an equivalent call to a geographic number.

By its failure to make a proper determination, the practice was directly in breach of its contract by adopting this number.

As for the allegation that no money was made from this choice of number – this is at best misleading (one hopes that it is false). All 084 numbers are subject to revenue sharing – the call originating telephone company has to pass on part of its call charge to the call terminating company, the provider to the practice. That is why these numbers are more expensive to call.

This financial benefit is normally passed on, by being reflected as a reduction in the cost to the practice of the services provided. If not, then the practice was being “ripped-off”. If the practice did not make any money, as alleged, then it was doubly at fault (or perhaps commercially naive) by allowing its telephone service provider to profit at the expense of its patients.

It should be noted that all of the technical features available on a 0844 number are available on every other non-geographic number. It is only the 03 range which enables these to be utilised “for the cost of a call to a local or other geographic number”. It is the commercial benefit of revenue sharing which is available on 0844, but not 03, numbers. On discovering its error, the practice could have retained all of the same features by migrating to a 03, even the equivalent 0344, number. One suspects that is was on seeing the true cost of these features (which was being borne by patients) that the practice decided to abandon them in favour of a new system.

Ms Brennan may care to note that in the NHS the interests of patients are protected by principles, such as the right to access NHS services without charge to the benefit of the provider. This is not a “view” which they have to articulate. Had some patients expressed a view that they would like to pay the practice for improved services, this request would have had to be denied. It is the PCT, not the body of patients, which is responsible for ensuring that a contracted practice follows the principles of the NHS and respects the rights declared in the NHS Constitution. (The practice itself also carries this statutory duty.)

When Mr Medwell expresses his “strong feelings” he is doing nothing more than reflecting the terms of the contractual obligations which he is required to enforce, although he is clearly failing to do so. According to NHS Choices, NHS Bedfordshire has 8 GP surgeries (6 practices) using 0844 numbers in breach of the terms of their contracts, which demanded compliance (for those with such numbers in place in April 2010) by 31 March 2011.

A list of these surgeries is published at this link.

It is fair to note that Mr Medwell’s failure is echoed in neighbouring PCTs and across England and Wales. More information is available via this link.

I am naturally delighted that this practice has discovered its error and taken the necessary action. I am however disturbed that this was done for the wrong reasons and that the full nature of the mistake has not been acknowledged. Yet more disturbing is the fact that the PCT appears to be totally unaware of its proper responsibilities. If the PCT had discharged those responsibilities properly in respect of the other practices, then it is likely that this mistake would never have been made.

As all parties look to take this matter forward, I would be delighted to assist in any way.

PCTs failing to understand DH Guidance

... on use of expensive telephone numbers to contact NHS providers

Introduction

Contrary to the understanding of many PCTs, the Department of Health position on the topic of use of expensive telephone numbers to contact NHS providers is very clear, simple and unqualified.

It is specified in the wording of Directions to NHS bodies [Directions] and revisions to the GMS contract [GMS] - NOTHING MORE.

Additional clarification of the Directions was provided in a "Dear Colleague" [letter]. No further guidance has been issued by the Department. This position has been confirmed in many written answers (see below).

The requirement is very simple, it amounts to -

prohibition of the use of telephone numbers which can cost
NHS Patients more than equivalent calls to a geographic number

Despite the clarity of the statement, there is a widespread mistaken assumption that the requirement is much more complex. In particular, there is a failure to recognise that the NHS is a universal service, with rights that extend to all patients, not just to a select group, even if that represents a majority.

For the record, and with apologies for the necessary repetition, I will quote all of the relevant references from the publications referred to above. Some quotations cover what is permitted, others what is prohibited (please use the respective links given above to confirm the context):

"... having regard to the arrangement as a whole, persons will not pay more to make relevant calls to the practice than they would to make equivalent calls to a geographical number." - GMS 29B

"... having regard to the arrangement as a whole, persons pay more to make relevant calls than they would to make equivalent calls to a geographical number ... " - GMS 29B.2.1

"... having regard to the arrangement as a whole, persons will not pay more to make relevant calls than they would to make equivalent calls to a geographical number ..." - GMS 29B2.2

"... having regard to the arrangement as a whole, persons will not pay more to make relevant calls to the NHS body than they would to make equivalent calls to a geographical number." - Directions 2(1)

"... having regard to the arrangement as a whole, persons pay more to make relevant calls than they would to make equivalent calls to a geographical number ... " - Directions 2(3)(a)

"... having regard to the arrangement as a whole, persons will not pay more to make relevant calls than they would to make equivalent calls to a geographical number ..." - Directions 2(3)(b)

"... prohibiting the use of telephone numbers which charged the patient more than the equivalent cost of calling a geographical number to contact the NHS." - Letter para 1.

"... contact telephone numbers which have the effect of the patient paying a premium above the cost of a call to a geographical number." - Letter para 2.

"These Directions do not prohibit an organisation from using specific number ranges for the purpose of contacting NHS services. Organisations remain free to use non-geographical number ranges such as 084, providing that patients are not charged more than the equivalent cost of calling a geographical number to do so." - Letter para 3.

Could it be any clearer?

Possible Omission

The only clarification that may have been omitted is the possible need for PCTs to understand that in the UK we purchase telephone call services from telephone call service providers, not from the person we are calling.

The person called may receive a financial benefit, but they do not determine the charge we pay, relative to the cost of an equivalent call to a geographic number. Obviously callers can expect to incur the cost of this benefit, however neither the person called, nor any agent of theirs, can control any further additional cost we may incur, simply due to the existence of "revenue sharing" on the call. (In some cases a benefit of 2p per minute, causes callers to incur an additional cost of 41p per minute).

We pay the charges set by our chosen provider under the terms of our chosen tariff. These are subject only to the charge regulations that are currently in force - not the regulations which some may wish to see, or mistakenly believe to be in effect. We pay the charges which are set, not those which some may argue "should be charged".

All telephone call service providers set rates for the UK as whole. Certain services are only provided to residents of the Kingston-upon-Hull area and other services are not available in all areas - there are however no local price differences.

Telephone call service providers publish their various tariffs, so these are available for inspection by GPs, telephone system providers to GPs, PCTs and all other persons. All parties may wish to determine the cost of calling particular numbers as against the cost of an equivalent call to a geographic number. NHS providers have a duty to make themselves aware of whether or not any caller pays more than the cost of an equivalent call to a geographic number to call their number.

I have prepared a summary of relevant charges from widely used providers, with links to their published tariffs for verification - a regularly updated version may be viewed here.

It would have been helpful for the Department of Health to have done something similar to save the cost of the same exercise being repeated by each practice and PCT, not to mention the danger of it being done ineffectively or not at all, however it chose not to do so.

A further Omission

It would perhaps have been helpful of the Department of Health to advise that those who are committed to a long term contract for systems which require the features of a non-geographic telephone number are able to migrate to a 03 number at any point during their telephone service contract without penalty.

Migration to 03 guarantees compliance with the terms of the Directions and Contract Revisions because all telephone service providers (under regulation) charge no more for calls to 03 numbers than for equivalent calls to geographic numbers.

The contract renewal, contract termination and "call back" provisions in the Directions and Contract Revisions are totally unnecessary, because this change to the arrangements for telephone service can be made in every case and at any time. Lease contracts on surgery telephone equipment and service contracts for telephone system software may be maintained notwithstanding revisions to a contract for provision of network telephone service. The possibility of premature termination of such contracts is of no direct relevance to the issue of use of expensive telephone numbers.

It is deeply regrettable that many practices and PCTs are unaware of this fact. Much energy is being wasted on the issues of contract termination, non-renewal and arranging to call back to patients.

The current position

The deadline for compliance with the requirements was 31 March 2011. This listing shows the PCTs with GPs in breach - cases are listed and shown on a map.

The Department of Health was, and remains, correct to say that "Organisations remain free to use non-geographical number ranges such as 084, providing that patients are not charged more than the equivalent cost of calling a geographical number to do so."

The Department clearly wished to cover the possibility of forthcoming changes to telephone charges, as Ofcom had indicated the imminent possibility of regulatory changes affecting 084 numbers (0845 in particular). The regulations cover the reality of what callers actually pay, which is potentially subject to change. I address the current position in the following statement.

For a large number of commonly used tariffs 1, i.e.

BT Anytime 2, BT Basic, ALL Virgin Media landline tariffs 3,

ALL commonly used Mobile contract and Mobile PAYG tariffs

and the tariff for public payphones,

weekday daytime calls to 084 numbers cost more

than an equivalent call to a geographic number.

Notes: 1 Adherence to the terms of the tariff is assumed. 2 BT Anytime exceptionally includes calls to 0845 numbers. 3 Some Virgin Media tariffs offer cheaper calls to some 0844/3 numbers under some circumstances.

Unless it can be shown that no "person" would ever call under the terms of the tariffs listed then no 084 number can be used.

There are tariffs and circumstances under which unregulated penalty charges imposed for calling geographic numbers outside the terms of the Call Plan in effect exceed the regulated charge for calling 084 numbers. These perverse and anomalous cases are likely to disappear if the current Ofcom proposals for revised regulation are taken forward to meet the declared objective of simplification.

(These new Ofcom proposals will enable BT to join its competitors by being able to raise an "access charge" on calls to all 084 numbers and require the "service charge" element of currently bundled rates to be declared by users. The expectation, by the Department of Health and others, that revenue sharing would be removed from 0845 was not met. Further announcements from Ofcom are expected in the Autumn of 2011.)

To maintain that use of any particular 084 number is compliant one must disregard the possibility of any call being made under the terms of one of the tariffs listed above.

By permitting use of a 084 number, a PCT excludes those subject to any of these tariffs from the meaning of a "person" in the terms of the Directions and Contract Revisions.

Misrepresentation

The Guidance issued by the Department of Health is the Guidance issued by the Department of Health. Certain parties may have their own ideas about the Guidance which they would have wished the Department to have issued. They are entitled to their opinions, but they cannot claim that the DH Guidance is anything other than what is actually published by the DH. Any definitive statement about the Guidance issued by the Department, or its policy position, must include the appropriate references if it is to carry any authority.

Sadly, there are materials in circulation which make allegations about Guidance from the Department of Health, and its position on relevant issues, which cannot be sustained in the way that they have been understood. From the quotations in the following section of this briefing it would appear that some have been misled into believing that what is stated below represents the position of the Department of Health.

I offer quotes, highlighting key phrases and adding brief comments:

From - "GPC GUIDANCE: USE OF 084 NUMBERS IN THE NHS" January 2010, issued by the BMA and published here.

"GP practices (and all others bodies within the NHS using 084 numbers) should 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. The DH has been assured by the main phone service supplier, NEG (Network Europe Group, a national provider of telephony services such as Surgery Line), that this is the case."

The competence of a particular "phone service supplier" to consult the tariff tables published by the various suppliers to callers is no greater than that of any other party. The idea that NEG is in any better position to provide the necessary assurance about the charges levied on callers than any other person is mistaken. NEG cannot be accountable for anything other than the accuracy of its reading of information published by others, and ensuring that the extent of its research is sufficiently comprehensive to cover all those who may call the practice.

There is no basis for an apparent claim that the Department of Health believes NEG to have privileged access to the tariffs of telephone companies, knowledge of which tariffs apply to callers, or particular skill in reading and interpreting publicly available documents.

Whilst NEG may have sent a document offering an "assurance" to the DH, there is no evidence that the DH has accepted it as such. It is likely that the DH will recognise that because NEG has an interest in the matter, as the reseller of Talk Talk numbers, it may have difficulty in approaching the task of investigating competitors' call charges with the necessary objectivity.

"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."

Rates charged by NEG (or any other supplier of surgery switchboard systems) to unspecified persons are of no relevance whatsoever to compliance with the relevant Directions and Contract Revisions. It is the charges imposed on callers by their telephone call service provider which are relevant. (See also the comment below the next quotation.)

There is no indication that "will be deemed" represents anything more than an opinion held by the BMA. There is no evidence whatsoever to show that the DH or anyone else would share the rather odd view that some unspecified charge levied by NEG had anything to do with compliance with the relevant contractual requirements.

"Practices can also ask their supplier to provide the information necessary to demonstrate that their call charges are in line with geographic call charges, as required by the new legislation."

This comment touches on the Omission from the guidance highlighted above. It falsely implies that it is charges imposed by the practice's telephone system provider ("their call charges") rather than those incurred by callers which are covered by the Directions and Contract Revisions.

In drafting the Directions and Contract Revisions, the Department refers only to the cost incurred by callers, whether they take service from NEG or any other provider. In fact, NEG does not provide network telephone service to private individuals, so no NHS patient pays charges set by this company.

From - Circular letter "Dear Surgery Line User" issued by NEG - 19 January 2010, copied and distributed by many Surgery Line Users - copy published here.

"The Government recognised that some telecoms providers (e.g. NEG) 'have chosen to charge no more for an 084 call than a call to a geographic number when dialing from a fixed line'"

Although it has failed to address this point in its Guidance, one must assume that the Department of Health is aware that NEG does not set the costs which callers incur (relative to that of an equivalent call to a geographic number) when calling NHS providers. The original reference was to the telephone company (BT) that chooses to impose unregulated "penalty charges" for 'out of contract' calls to geographic numbers, which exceed the regulated charge for calling 084 numbers, and those others who mirror its charges.

The Directions and Contract Revisions make no reference to "dialing from a fixed line". If this qualification applies to subsequent comments from NEG, then it is not stated.

"The Directions from the Secretary of State make clear that any NHS organisation is free to choose to continue with an 084 number. All that is required is for the NHS organisation to satisfy itself that the cost of calls to the NHS body is no higher than equivalent calls to geographical number.

"Having held many meetings with the Department of Health over the past year, we understand that the Department of Health would be happy for an NHS body such as yours to get this reassurance in the form of this letter from NEG to you confirming that the cost of calls via the Surgery Line solution is no higher."

There is no evidence to show that the Department of Heath regards all Surgery Line users, including GMS contractors, as "NHS organisations" or "NHS bodies".

There is no reason why NEG could not consult the relevant telephone tariffs so as to establish the relative cost incurred in calling any particular number to which the Surgery Line system is connected, as against that of an equivalent call to a geographic number. If somehow reaching the false conclusion that the cost was no greater, then there is no reason why NEG could not provide the reassurance which it wishes to offer with reference to the actual requirement stated by the Department of Health.

There is however no evidence to show that the Department of Health would be happy with such a reassurance if it were ill founded. As NEG offers no indication of the extent of its research into telephone tariffs, nor the period for which this is thought to be valid, one must have cause to question the reliability of its reassurance.

"During the consultation period, we provided evidence to the Department showing the comparative cost of calls to NEG Surgery Line under your existing contract compared with the OFCOM regulated tariff cost of calling a geographic number. The Department accepted our evidence, ..."

Ofcom does not regulate the cost of calling geographic numbers. BT is the only telephone service provider subject to absolute regulation of some of its charges - this does not include any of its charges for calling geographic numbers. There is no evidence that the Department of Health accepted this simple falsehood. This apparent misunderstanding (or deliberate misrepresentation) of the nature of telephone charge regulation should give any reader cause for concern.

The actual evidence submitted by NEG was flawed in a number of respects, not least because it only covered only one provider and only one of its tariffs, whilst claiming to make a universal point. The actual figures given were even incorrect with reference to that tariff, to the point where they inverted the proper conclusion. I covered this at length at the time - see this commentary.

There is no evidence to show that the Department of Health did anything more than acknowledge receipt of this submission. It may have accepted the document, this does not mean that it accepted the arguments advanced on this point! (At a different point in its submission NEG argues that patients are prepared to pay more if this means that they can thereby enjoy a better telephone service from their GP!)

"your decision to continue to deliver excellent services for your patients using NEG Surgery Line has the full support of the Department of Health"

The Department of Health may well support use of the Surgery Line system - that is not the point at issue. Given that the letter addresses only the regulations covering use of expensive telephone numbers as a means of funding the system, it would not be unreasonable for the reader to wrongly infer that this represents an allegation of Department of Health support for the funding arrangements.

Misunderstandings

I quote below extracts from recent communications from Primary Care Trusts, indicating how they are interpreting their duty to enforce the terms of the Directions and GMS Contract Revisions. In many cases they seem to believe that the additional qualifications which they have applied to the strictly drafted terms reflect DH Guidance and policy.

Every one of these statements indicates some degree of failure to understand the simply drafted terms of the Directions and Contract Revisions and a failure to recognise the option for re-arrangement which is available to every user of 084 numbers.

I quote extracts from various statements below. These were generally provided in response to being challenged over a failure to enforce the terms of the Directions and Contract Variations. In each case, I will be happy to provide full references and copies of the entire item from which I quote.

I have underlined key phrases. Please read these comments recalling that the significant, unqualified guidance from the Department of Health is expressed in the phrase "persons will not pay more".

From Berkshire West PCT (updated 19 Jul)

"The advice given by the Department of Health was that the cost of calling the 0844 numbers should be in comparison to the cost of using a fixed line to call a geographical number at the local BT rate."

From Surrey PCT

"... some telephone packages mean that patients don’t have to pay for daytime phone calls, but the 0844 might not be included in this and therefore they will be charged for these numbers.  If this is at a local call rate – patients should still be expected to pay. ... if practices are meeting the terms of the Department of Health directive we are unable to influence this."

From West Kent PCT

"Generally calls made to NHS contractors using 0844 number should be charged at a local rate if calls are made from callers with a BT Standard Rate Tariff only. However if a customer is not on a Standard Rate Tariff their Service Provider can charge more for the call, if that is the case the customer should follow this up with their Service Provider as customers are informed of the T & C their Service Provider offer and this is so as there is freedom of choice as to which Service Provider a person signs up to for their phone service"

From East Berkshire PCT

"GP practices across east Berkshire are committed to ensuring patients pay no more than they need to when contacting their local surgery. The PCT is encouraging practices to fully explore all options when current contracts are up for renewal."

From Dorset PCT

"We can confirm that we have three practices in Dorset which use 084 numbers. These practices comply with the regulations, which means a call to them would cost no more than a call to a geographically equivalent number."

From Norfolk PCT

"We are working with practices to make sure they put in place arrangements which are convenient to patients and consistent with contractual requirements."

From Bournemouth and Poole PCT

"Within the NHS Bournemouth and Poole area there are nine practices using an 084 number, all of which report to be charging local rates. We have requested that a contract variation is signed which commits practices to reviewing call costs to ensure they are in line with guidance so that calls to their 084 number are charged at a local rate for fixed lines."

From Warwickshire PCT

"Primary Care Trust NHS Warwickshire said it was happy that no surgeries broke rules"

From Rotherham PCT

"The majority of our practices use the 0844 numbers or a local number. Calls to 0844 numbers are charged at the same rate as a local call when dialed from a landline."

From Barnsley PCT

"While for some it is still possible to be charged more than the cost of a landline call when phoning from a mobile, we are committed to supporting those GPs that operate 084 numbers to make changes"

From Leicester City and Leicester County and Rutland PCTs

"We do recognise the use of this number is a problem for patients"

"if practices were unable to renegotiate or terminate contracts they should consider a system where a patient can ask for a call back from the surgery"

From Suffolk PCT (Added 30 July 2011)

"We are in discussion with the practices and the provider to try and find a way of exiting earlier from the contracts."

From Bedfordshire PCT (Added 31 July 2011)

"We have been assured by the GP practices using 0844 numbers that their phone providers do not charge patients more than the cost of calling a local geographical number. However, neither NHS Bedfordshire nor the practices have access to details regarding the cost levied by patients’ own telephone providers for calling these numbers."

The accountable officers of these PCTs (and others) must be made to recognise that they are deciding to limit the scope of the simply drafted requirements for themselves. They are not guided, directed or bound by the Department of Health to apply any qualification to the simple phrase "persons will not pay more".

ALL patients must be able to access NHS services without charge from the provider, as the first of their rights under the terms of the NHS Constitution. The Health Act 2009 places PCTs under a statutory obligation to have regard to these rights.

Confirmation of the duty of PCTs

Many written ministerial answers from the Department of Health have confirmed the position. The most recent was on 14 June 2011, as follows:

"The Department issued guidance and directions to national health service bodies in December 2009 on the cost of telephone calls, which prohibit the use of telephone numbers which charge the patient more than the equivalent cost of calling a geographical number to contact the NHS. It is currently the responsibility of primary care trusts to ensure that local practices are compliant with the directions and guidance."

One may also read the same essential point being made as follows:

9 June 2011

8 June 2011 (again)

8 June 2011

5 May 2011

11 February 2011

25 January 2011

At the time of publishing this blog entry I am hoping that further clarification will emerge when this matter is raised in Questions to the Secretary of State for Health on Tuesday 12 July 2011.

PCT Cluster Chief Executives asked to remove "co-payment" from the NHS

The following text is of a message I have distributed to all 51 NHS PCT Cluster Chief Executives, as advised by their respective SHAs. One of them is shortly to be out of a job, as Sir David Nicholson confirms, in the article referred to, that there are only 50 such positions recognised by the Department of Health.

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You will have learned from Sir David Nicholson ("The Month" - 20 June 2011) that the bodies which you head will now have a future in the NHS, beyond 2013, as the "arms" of the National Commissioning Board, commissioning Primary Care services and overseeing the work of Clinical Commissioning Groups. As such, you will retain the vital role of ensuring that the principles of our National Health Service are maintained, as GPs focus on the needs of their particular patients and commissioning the services to meet them.

The core principle of the NHS is that providers are funded from the public purse, and cannot seek or receive payment from patients for NHS services. There are many who believe that this principle will not be maintained for long, due to increasing demand for services that the NHS "cannot afford". Patients will insist on their "right" to exercise choice, and so the principle of co-payment will have to be accepted. We have not yet formally reached that point, however there is one relatively small example of where this is happening. Many GPs are now breaching the terms of their NHS contracts, allegedly because they have chosen to acquire telephone systems that they cannot afford to pay for.

All use of 084 telephone numbers invokes a revenue sharing mechanism between the call originating telephone company and the company providing service on the number. The value of the "supplementary termination fee" is between 2p and 5p per minute, depending on the range within which the number falls. In effect, this is the amount of money transferred between the caller and the person called. Notwithstanding the vagaries of some unusual (if common) tariffs, this represents a "service charge" added to the call charge and applied to the financial benefit of the call recipient in some form. When a patient is calling their NHS GP on such a number, they are effectively incurring a charge for access to a NHS service (albeit that this is collected and distributed through third parties). This is nothing other than indirect co-payment.

In response to the DH consultation on use of 084 telephone numbers, the BMA GPC argued that "calls to NHS services should incur as low a charge as possible, but that this must be balanced by the quality of communications service that the patients are accessing". This argument in favour of co-payment for access to NHS services was rejected by the Department of Health. Directions and contract revisions were issued prohibiting use of telephone numbers that caused any patient to incur a greater cost than that of an equivalent call to a geographic number.

In its subsequent Guidance to members, the BMA GPC repeated the argument that had been rejected and advised its members on how they may circumvent the intention of the regulations. Practices were encouraged to offer a meaningless assurance from a highly interested party, who has no influence over the telephone tariffs of any provider, as if this represented evidence that the telephone number used by the practice somehow caused no patient to incur a greater charge - i.e. that it complied with the requirement.

A simple inspection of the tariffs of any provider of telephone services to patients shows that this assurance is simply false with respect to the actual terms of the requirement. A variety of different interpretations of the terms of the contract revisions have however been suggested, commonly with the false claim that they represent the view of the Department of Health. These generally suggest that there are additional qualifications that need to be applied to the simple drafting of the requirement, e.g. that it does not apply to calls from mobile phones or callers subscribed to call inclusive packages. The Department of Health has made it very clear that there are no additional qualifications in the standard terms approved by parliament.

One common suggestion is that the requirement applies only to those cases where the practice or its telephone system provider has direct control over the relative cost of calls to its 084 number as against that of an equivalent call to a geographic number. This suggestion is complete nonsense, there is no such case - the cost of all calls is set by the telephone company that originates the call. Some of BT's charges to particular ranges are regulated in absolute terms, but this regulation does not cover the relative cost of calls to geographic numbers, nor does it permit any variation in charging to be made by the user of the number or their agents.

I understand that many practices have followed the BMA advice. Some have claimed that the Department of Health has endorsed one particular provider of telephone systems to GPs as an authoritative source of information on the relative cost incurred by patients when calling 084 and geographic telephone numbers. Such an assertion is untrue. The BMA may believe whoever it wishes to believe, indeed the Department of Health has shown itself to have been misled on some points. No PCT can however be required to accept an obvious falsehood as the truth; it must make its own determination.

I understand that many primary care commissioning teams have been taken in by this deceit, denying the clear objective truth of published telephone tariffs in favour of a wholly unreliable statement by a highly interested commercial party to the arrangement. The BMA itself even points out to its members that the author cannot be held to account for its false claims about matters over which it has no control. In the GPC Guidance (foot of page 1) it suggests that the PCT would carry legal liability for failing to verify that a meaningless assurance had been used to indicate compliance, whereas the practice could plead ignorance. I cannot myself comment on the legal position, however this would seem to be a clear indication that the alleged "guarantee" is worthless.

The fact that there are still (at the time of writing) 1,262 GP surgeries in England using 084 telephone numbers long after the deadlines of 21 December 2010 and 31 March 2011, demonstrates a significant degree of failure on the part of PCTs. Some practices have even adopted new 084 numbers after receiving the contract variation notices.

I also understand that many PCTs have failed to recognise that every user of a 084 number has the simple option of migrating to a 03 number at any point during a contract for telephone service. This means that once it has been established that the number used is more expensive to call than an equivalent call to a geographic number, every practice has the option of changing its arrangements with its network telephone provider by migrating to a 03 number.

In many cases this is necessary so as to retain use of a local telephone system that relies on use of a non-geographic number. Such local systems are commonly funded through a seven year lease arrangement and need to be retained so as to avoid heavy early termination penalties. It is important to understand that any non-geographic number (03/080/084/087/09) would support the features of these systems equally well - all bar the first are prohibited from use by NHS providers. 03 is the only non-geographic range for which the cost of calling can be assured to be no greater than the cost of an equivalent call to a geographic number. (All 080 880 numbers, and 0800 numbers subject to special “free of charge” arrangements, may also be used – and the NHS Direct Special NHS Trust has been exceptionally allowed to continue its use of co-payment, despite the fact that it has the specially configured 0345 4647 number standing ready for use as an alternative.)

Since my last circular message, I have revised my database of cases to reflect the fact that primary care commissioning is still generally being undertaken at the PCT level, rather than for a Cluster. A table by PCT, with links to the detail and the relevant section of a map, is found here. A general description of the database, with links to other relevant briefings is found here. (A supplementary summary by Cluster is published here.)

Given that the core and remaining role of the organisation which you head is now confirmed as being that of maintaining the principles of the NHS, I am anxious to know what action you are taking, if belatedly, to ensure that the revised terms of the GMS contract and the Directions to NHS bodies are enforced.

If false and unverified assurances about the cost of calling have been accepted in the past, I must ask you to ensure that inadequate efforts to address the relevant requirements are now rejected as evidence of compliance. A practice can have no valid reason for retaining a 084 number, unless can show that genuine efforts to arrange immediate migration to a 03 number have failed - other than due to an unwillingness by the practice to bear the cost of its own telephone line and system. The issue of contract termination penalties does not arise. Talk Talk, the company responsible for the service to the vast majority of cases in my database, is known to allow such migration at any time during the term of a contract (without penalty) and the other providers are believed to follow similar policies.

Should you come upon cases where you believe that use of 084 numbers may be continued under the terms of the Directions and contract revisions, then please let me know. I do not believe that we are yet ready to accept sanctioned, provider-controlled co-payment in the NHS. If you believe that the present regulatory structure requires, or permits, you to allow continuing use of 084 numbers then this must be clearly made known to those whom you serve.

Under the NHS Constitution, they have the right to access NHS services without charge, except where such charge is explicitly sanctioned by parliament. Under the terms of the Health Act 2009, you (and your contractors) have a duty to have regard to the rights under the NHS Constitution. Public notification that these rights cannot be upheld would be a minimal response in the event of a decision to permit continuing use of 084 numbers. It would then be for parliament to decide whether to sanction co-payment, or perhaps approve further contract revisions that would require you to prohibit it, if you feel unable to do so under the current terms.

I understand that you will have much work to do through the continuing period of transition. Now that it has been confirmed that you will remain as the guardians of the principles of the NHS, when accessed through primary care, through and beyond the transition, I hope you will be keen to show that you treat this responsibility with the importance that it deserves.

My engagement in this issue has been purely in an attempt to ensure that the principle of universal and equitable access to NHS services "free at the point of need" is not undermined by the consumerist pressures that threaten to destroy the NHS. A difficult and widely misunderstood issue is readily open to exploitation if the necessary care is not engaged to counter blatant misrepresentations of the truth. I hope you will be ready to declare your refusal to sanction co-payment on access to NHS services under your control, and direct the action necessary to remove it.

Please be assured of my readiness to assist in any way I can.