Introduction
The following comments are published in conjunction with various other items in this blog (see "Recent Bloggings" above), as the 31 March 2011 deadline for NHS GPs in England to abandon use of "expensive" telephone numbers approaches.
They are offered as a briefing to those who care for the principle that access to NHS services is "free at the point of need" and wish to see this retained and applied in practice. I urge them to use any material found here to press the necessary truths and understandings on those who are directly engaged in this matter.
I hope that (directly or indirectly) they will help those who are involved in this matter to make correct and proper decisions about what action to take in performance of their duties. I refer to practice managers, executive officers in NHS bodies, those charged with commissioning NHS services, senior NHS executives, officials in the Department of Health, Members of Parliament and Ministers of the Crown.
I will be happy to engage with anyone to provide further information and to hear comments in response. I am particularly keen to address any allegation that any of the information provided below is false.
Contents
| | The present situation | ||
| | The truth | ||
| | NHS Direct | ||
| | Dentists, Ophthalmologists and Pharmacists | ||
| | Confirmation of my personal position | ||
| | Conclusion | ||
The governments' attempt to ban expensive telephone numbers from use in the NHS are being frustrated. On 16 September 2009 the then Minister made a declaration about how the principles of the NHS were to be re-inforced:
"We want to reassure the public that when they contact their local GP or hospital, the cost of their call will be no more expensive than if they had dialled a normal landline number.”
Delivery of this reassurance was to be achieved by:
| • | Directions to NHS Bodies, issued on 21 December 2009, with a deadline for compliance of 21 December 2010. | ||
| • | Revisions to the GMS contract (see clause 29B) which covers most NHS GPs, with a deadline for compliance of 31 March 2011. | ||
At the heart of the failure to deliver this reassurance are mistakes made by the Department of Health. These are manifest in the way it has formed the relevant Directions and GP contract revisions and in the guidance it has issued. There have also been widely circulated and influential comments about its position and authoritative formal guidance on how to interpret its intentions, which it has refused to deny or contradict.
I believe that these errors follow from a failure to recognise and apply the three truths that I state below. In each case, some objective understanding of how telephone services operate in the UK is required, and I fear that the necessary information may have been drawn from highly interested sources and not properly subjected to verification. I am reluctant to suggest that the previous or current government has deliberately set out to allow the principles of the NHS to remain undermined, and I cannot know exactly how mistaken policies came to be formed and mistaken information published. I can only report facts.
I am aware that parties who have openly proposed that NHS patients should pay for access to NHS services have played a significant role in this matter and have celebrated the way in which the Department of Health has acted. I refer to Network Europe Group Ltd. (NEG) and the General Practitioners' Committee of the British Medical Association (BMA). Each of these bodies is fully entitled to suggest alterations to the terms of NHS Constitution and to present subjective opinions on any matter. The Department of Health should note such representations and balance them against the interests of the owners of the NHS, the citizens whom it exists to serve, whilst making its own objective determinations on matters of "fact".
Regardless of how we got to this point, it is now for those directly engaged in this matter, by following and enforcing the terms of the GMS contract and following the (self-enforced) Directions to NHS bodies, to recognise and apply an understanding of the truth in each respect. In the light of the confusion and misunderstanding which currently exists, I believe that they would benefit greatly from central guidance on these matters.
If this is not done, then exploitation of indirect payments by patients to NHS providers as they access NHS services will remain a feature of the English Health Service. (Wales has copied the English mistakes and Scotland is close to doing the same. Although each devolved government is responsible for its own share in the management of our NHS, I believe that the UK government has a duty, at the very least, not to mislead them.)
I offer three simple and highly relevant truths, with an invitation to anyone who questions them to contact me or add a comment below. (Anonymous comments on this blog will be read, but not published.)
These truths are seen to be directly contradicted by the way in the measures intended to deliver the assurance to protect the principles of the NHS are being implemented.
There are no 084 numbers that are not more expensive to call than geographic numbers.
To comply with the terms of the GMS contract and the Directions to NHS bodies (see links above), all use of 084 numbers must cease. This simple point has not been recognised, indeed it has been explicitly contradicted.
In both cases, NHS service providers are required to have regard to "the arrangement as a whole". Because the NHS is a universal service, patients may call from Public Payphones, Contract mobile phones, PAYG mobile phones, Virgin Media landlines or under the terms of the BT Basic package. (NHS services are only provided to individuals, not businesses, so only residential tariffs apply and the cost of VAT cannot be recovered - all prices in this document include VAT.)
In every one of these cases, all calls to all 084 numbers are more expensive than an equivalent call to a geographic number. In the case of 0844 numbers, one may add those who subscribe to BT Calls Plans and comply with the terms of their selected plan.
I urge anyone who doubts the truth of this statement to consult the tariff tables published by the leading call service providers - links are provided in this blog entry.
It is therefore most odd to read the following statement from the current Minister of State (Health Services) in a written answer:
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 statement is utterly worthless, and dangerously misleading, as there are no such cases. Because the condition which qualifies this "freedom" is never seen to apply, there is no such freedom. The only non-geographic number range which meets the condition is 03 - indeed, the stated condition is the very definition of the terms of charging which apply to this range.
If anyone can give me an example of a 084 number which does not cost NHS patients ("as a whole") more to call than the equivalent cost of calling a geographic number, then I will be happy to reconsider the comments published above.
The charge for a telephone call is set by the telephone company that originates the call.
There are some who appear to believe that the total cost of a call is set by the party receiving the call, who is therefore in a position to confirm what it costs the caller. Some even believe that this knowledge also covers what the cost of an equivalent call to a geographic number would be. This is plainly nonsense; however it does help to illustrate the extent of the confusion about how telephone charges work, and the potential for this to be exploited.
Any assurance about the cost of calling any 084 number, as incurred by a NHS patient relative to the cost of an equivalent call to a geographic number, could only be provided if supported by evidence from all potential call originating telephone companies. (I offer an adequate sample of such evidence in support of the points made above.)
The cost of a call to a 084 number is made up of two components: the "Service Charge" which is passed on to the receiving party, and the "Access Charge" which is retained by the telephone company that originates the call. Currently the two are aggregated to present a "bundled" rate.
Calls to geographic numbers from contract landlines and mobiles are generally inclusive with the subscriber's selected package. High penalty charges are normally applied to calls to geographic numbers made outside the terms of packages, as an incentive for the subscriber to select the correct package to reflect their calling pattern.
The complication of penalty charges does not occur with PAYG mobiles and payphones, where calls to 084 numbers are invariably more expensive than geographic numbers at all times for all callers. These therefore provide the clearest examples of the previous "truth"; other examples risk being confused by the false assumption that "penalty charges" are the standard rate.
It is alleged that NEG Ltd, provider of the Surgery Line system, may be able to offer an unqualified and wholly unsupported assurance that the cost of calls to the numbers used by its customers is no higher than that of an equivalent call to a geographic number. It is also alleged that such an assurance would be regarded as sufficient evidence of compliance with the terms of the GMS contract. It is further alleged that in the event of any such assurance being found to be worthless, then the Primary Care Trust would somehow carry a legal liability.
I am reluctant to suggest which of these notions is the most bizarre. They are all found both in this circular letter and this briefing.
The network telephone service provider through whom a call is terminated knows the amount of Service Charge it will receive on every call. This provides it with a guide to the likely minimum charge for the call, because it knows that the originating telephone company will bear this additional cost over that of placing calls to geographic numbers and will probably wish to recover it from the caller. The call terminating telephone company cannot however know the level of Access Charge added by the call originating company in any particular case, or whether an exceptionally high charge would apply to an equivalent geographic call - unless it is also the call originating company.
Talk Talk provides a most useful illustration as it both originates and terminates calls to Surgery Line.
Most Surgery Line customers use network telephone service from Talk Talk, which receives a Service Charge of roughly 5p per minute for each incoming call.
Talk Talk charges its own residential customers 11.14p plus 5.11p per minute for a call to a Surgery Line 0844 number at any time - the "Services G6 Rate" applies. (See Talk Talk call and plan charges.)
Talk Talk invites its customers to "Choose which great value plan suits you best". Those who make (on average) at least one daytime geographic call of any duration per day, or one 10 minute daytime geographic call per week, would be expected to choose the "Anytime Plan". They would therefore pay nothing extra for each daytime geographic call they make. With such modest usage needed to make it worthwhile, this plan will be chosen by most of those who regularly use their landline during the weekday daytime.
Infrequent daytime callers, choosing the "Evening & Weekend Plan", incur a penalty charge of 11.14p plus 6.54p per minute for daytime calls to geographic numbers. (I describe this as a "penalty" charge because Talk Talk's costs in placing these calls are roughly 5p per minute less than those for the type G6 call, whereas it charges more.) Some NHS patients may incur this penalty. There can however be no assurance that those who call geographic numbers regularly during the daytime and choose the "Anytime Plan", avoiding the penalty charges, would not call their NHS GP!
With this knowledge of its own tariffs, Talk Talk could not possibly offer an assurance that calls to Surgery Line numbers are cheaper than equivalent calls to geographic numbers for its own NHS patient customers, even though it actually handles both ends of these calls.
Even though NEG is not itself a provider of network telephone service, and so would have no direct knowledge of telephone call charges, one might think that, as an agent of Talk Talk, it could have access to this information. Like the rest of us, NEG has access to published tariffs.
I must therefore express doubt that the "reassurance" referred to indirectly in this letter would ever be delivered in practice. The BMA however states a belief that such an assurance has been delivered, as confirmed in this briefing. The Department of Health has not sought to deny the implied allegation that it shares this belief.
As a point of fact, I am not aware of any case where such an assurance has actually been provided in respect of a particular number, or even in general. This letter refers to an understanding of the position of the Department of Health with regard to such a "reassurance", quotes the BMA, refers to an erroneous and atypical single call cost example submitted as part of the response to a public consultation and misquotes the Department of Heath response to the public consultation; it does not however provide any specific assurance that covers any particular telephone number.
I hope that nobody is confusing the suggestion that such an assurance could perhaps be issued with the idea that such an assurance is actually on record in respect of any recipient of the letter.
If anyone could explain how such an assurance could be relied upon, with reference to the relative call costs incurred by NHS patients, I would be ready to reconsider the comments made above.
Any user of a 084 telephone number is able to migrate to a 03 number within the term of a contract for telephone service.
It is suggested that to avoid placing additional call costs on patients and to immediately comply with the Directions or GMS contract revisions, NHS users of 084 numbers would need to terminate their contract for telephone service. It is even suggested that some GPs would also need to terminate the contract for their surgery telephone system. This is completely untrue - migration to 03, even the equivalent 034 number, is available as an option for those who do not wish to change their existing arrangements, whilst moving into compliance with the principles of the NHS.
Calls to 03 numbers must (by regulation) be charged at no higher rate than the cost of a call to a geographic (01/02) number. This applies to all types of telephone service and the terms of call inclusive packages. (The regulation has 100% compliance.)
Use of 03 numbers is therefore fully in accord with the terms of the Directions to NHS bodies and the GMS contract. 03 numbers offer exactly the same advanced features to support local systems as 084 numbers. The only difference is that the cost of these features must be carried by the user of the number (the GP), rather than the caller (the patient). In the context of the NHS as presently defined in its Constitution, I cannot see how there can be any room for debate over how these costs must be met, other than by discussing possible changes to the terms of the NHS Constitution.
All registered network telephone service providers offer the facility of migration from a 084 number to provide identical facilities on a 03 number at any point during the term of a contract for the provision of telephone service. This is generally recognised as an industry standard; Talk Talk has explicitly confirmed that it offers this facility.
Any local system connected to the number (e.g. Surgery Line) would not be affected by such a change. Any agent of the registered network telephone service provider (e.g. NEG for Talk Talk) would be expected to advise and respect the policies of its principal.
There is no need for any GP currently using a 084 number to cancel any contract or incur any delay in complying with the terms of the GMS contract. The provisions laid out to cover such a situation are entirely unnecessary.
There is no need to discuss the impact of contract termination penalties or waiting until the term of some contract has expired. All NHS GPs are provided with funding to cover the cost of providing their NHS services. In all cases, this must be used to meet expenses that the practice has chosen to incur.
If anyone can advise me of a case where a request to migrate to a 03 number, in order to comply with the Directions to NHS bodies or revisions to the GMS contract, was refused, I will be happy to investigate the circumstances and correct any falsehood in the above comments.
The NHS Direct NHS Trust was totally exempted from the provisions of the Directions to NHS bodies, due to the possibility of the 111 service coming into use shortly. This total exemption was apparently seen as being the only way to avoid the vast expense of publicising a change to 0845 4647, as the widely promoted number for the "NHS Direct" Health Advice and Information service.
This was also a serious mistake by the Department of Health, for two reasons.
A) In addition to 0845 4647, the NHS Direct NHS Trust also operates 68 other 0845 numbers - used for GP out of hours services and other NHS functions. These are no different to any other expensive number used by any NHS body. 084 numbers used by PCTs for GP out of hours contact centre services from other providers are covered by the Directions.
There is no justification for these numbers being excluded from the "ban".
B) 0345 4647 is already set up and ready for use as an alternative to, operating in parallel with, 0845 4647. There is no reason why this could not be activated and gently, if suitably, promoted as an alternative for use by those who could save up to 41p per minute in call costs. This alternative arrangement, not a complete change of number, should be applied for the short remaining life of the "NHS Direct" Health Advice and Information service.
There may be doubts about whether GP Consortia will wish to subscribe to the 111 service, once the details of its configuration are confirmed, following the review of the pilots that is planned for the coming Autumn. We await resolution of questions about its use for only "urgent" non-emergency enquiries, and the need for co-ordination with urgent access to local authority Social Care services.
I am however prepared to accept that the "NHS Direct" Health Advice and Information service may shortly be withdrawn. Whilst this possibility remains, I would myself argue that no great expense should be incurred in promoting 0345 4647, and promotion of 0845 4647 as the primary number may continue.
This pragmatic approach is only justified due to the particular circumstances of this case. If a decision is made not to withdraw the "NHS Direct" Health Advice and Information service, then the situation must be reviewed. It is possible that once the review of the pilots has been completed and the costs reconsidered, the definition of the 111 service could return to being for "urgent" calls only, rather than being allowed to drift away from this definition, as it has done. In such circumstances it could be decided to retain a NHS telephone advice service to deal with non-urgent enquiries, rather than scrapping it.
0345 4647 must now be made available as an alternative to 0845 4647, to reflect a NHS "free at the point of need".
Dentists, Ophthalmologists and Pharmacists
These other contracted providers of NHS services were omitted from the ban on use of expensive telephone numbers for access to NHS services. Whilst it is acknowledged that their telephone numbers are also used for access to non-NHS services in many cases, the same is also true of GPs and hospitals.
Under the present proposals for reform, it is understood that the role of "outside" providers in delivering NHS services is to be encouraged and extended. If the same NHS services are to be delivered by a wider variety of providers then it is surely more important that common standards covering the essential defining characteristics of the NHS are applied.
The principles of the NHS must surely be applied to all NHS service providers.
Confirmation of my personal position
A) It may be thought that I am opposed to use of 084 telephone numbers. This is untrue - I am fully in support of them being used openly and honestly.
I see no good reason why any telephone user may not recover part of the cost of their telephone service from callers. If they are providing a service to callers over the telephone, there is no fundamental reason why they may not also collect a direct charge for the service itself through the caller's telephone bill.
These two situations are now clearly identified and distinguished in the Ofcom publication - Simplifying Non-Geographic Numbers. The former, including 084 numbers, is designated "Business Rate"; the latter "Premium Rate". Calls to 01/02/03 numbers, which cannot deliver any financial benefit to the recipient, are designated "Geographic Rate".
Ofcom proposes that the level of Service Charge imposed on the caller be clearly declared wherever the number is published, for both "Business Rate" and "Premium Rate". In billing, Ofcom proposes that the Service Charge be "unbundled" from the Access Charge added by the telephone company originating the call. This may appear complex, however is it nothing more than the simplest way of presenting the reality of what is happening at present.
I support these proposals, believing that those who are ready to declare a Service Charge on callers should be allowed to collect it. Telephone companies must also be open about the extent of the Access Charge which they add.
Ofcom detects a significant demand for the "Business Rate" facility, openly declared. I have my doubts; I suspect that if many of those who presently use 084 numbers were required to declare the Service Charge that is currently in place, but hidden in a "bundled rate", they would move away from these ranges. (N.B. BT is uniquely unusual in this respect as it is currently prohibited by regulation from adding an "Access Charge". Its rates are essentially just the "Service Charge".)
Unless the principle of "free at the point of need" is to be formally abandoned, then NHS service providers would have to be at the front of this exodus. I hope that none would wish to wait around for new Ofcom regulations to compel them to do what they should do now.
If the NHS is to be "free at the point of need" in future, NHS service providers cannot be seen to be levying a charge on telephone callers.
B) On the question of what we mean by "free".
There is an important distinction to be drawn between incidental expenses incurred in accessing NHS services and charges imposed by, and to the benefit of, the NHS service provider.
I believe that it is proper for me to be required to pay my bus fare when visiting my NHS GP, or a suitable charge for parking my car when visiting a NHS hospital - according to the availability of public car parking spaces, and prevailing normal parking charges, in the area where the hospital is located. Anything that the NHS provider can reasonably do to help me avoid, or to mitigate, these costs could be a proper use of NHS resources.
I apply the same principle to consideration of the issue of telephone call charges. When I contact the NHS by telephone it is acceptable for me to meet the cost of the telephone instrument, the line rental and the call charge for a "normal" call (that is fairly defined as a Geographic Rate call - i.e to a 01/02/03 number).
In some situations, it may be thought appropriate for the NHS provider to cover the cost of my call, as is the case with 111 and the NPFS. Such a decision must however be based on careful judgement about the proper use of NHS resources. Similar decisions are made in relation to Patient Transport Services and parking for "Blue Badge" holders and outpatients with frequent appointments. These are sensible and proportionate measures that reflect particular circumstances - they have nothing to do with the principle of "free at the point of need".
There can be no justification for addition of a "Service Charge" by an NHS provider, through use of a "Business" or "Premium" rate number.
By "free at the point of need", we mean paid for through general taxation, not through charges to cover the cost of the service as we access it. We do not mean free of all cost or incidental expense.
An exercise which began with the launch of a public consultation on 16 December 2008 should have been completed with the elimination of all expensive numbers from the NHS by 31 March 2011. It is interesting to note that I was engaged in media discussion with representatives of both NEG and the BMA on the day of the launch.
Largely due to powerful efforts by those who openly oppose the principle of the NHS being free at the point of need, this has not come about. I can observe that they had significant involvement with the Department of Health. I cannot comment on how they may have influenced its behaviour, or contributed to its (mis-) understanding of the relevant facts; I can however refer to published materials that are widely used as reference by those engaged in these matters.
Both the BMA and NEG have continually and publicly argued for patients to be required to pay to enable "improved" access to NHS services to be provided. A marketplace in which GPs compete on the basis of cost to the patient vs. quality of service was proposed. Adoption of this proposal, or simply allowing the status quo to remain, turns the NHS patient into a true "consumer" or customer.
This is one "reform" that the present government may have achieved, by doing nothing more than failing to correct mistakes made by its predecessor.
It now falls ultimately to a government committed to "liberating" the NHS from central control to take the necessary action to ensure that the principle of "free at the point of need" is re-instated ... if that is what it wishes to achieve!
