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Thursday, 14 April 2011

The controversy over GP use of 0844 telephone numbers develops

GP journal "Pulse" has published an article setting my views against those of the BMA, the Department of Health and Network Europe Group (NEG). I have added a few comments below the article.

To clarify the issue:

My statement, to which Pulse refers, is primarily a link to this publication
I have subsequently published the information detailing call costs with links to published telephone tariff tables separately
I address the issue of some CALLS to geographic numbers (local and national) being more expensive than CALLS to ALL 084 (and some 087) numbers below. This has nothing to do with the false assertion that some particular 084 NUMBERS are not more expensive!
I comment on being set against the views of three sizeable institutions below.
To help the new PCT clusters address the responsibility that the Department of Health has devolved to them without appropriate guidance, I have now published the list of practices again, grouped by PCT cluster - see this posting.

Where geographic calls are more expensive

I have never disputed the fact that some callers pay penalty charges to call geographic numbers, as against regulated low rates for calling 084 numbers. My point is that the NHS is a universal service available to all on the same terms, regardless of their choice of telephone service provider. Perverse factors do lead to some callers paying more to call geographic numbers than the premium charge, which is invariably paid as an inevitable consequence of GPs benefitting from "revenue share", on 084 numbers. This aberration must not be allowed to distort our understanding of the true position.

Where a NHS provider benefits from subsidy to the tune of between 2 and 5 pence per minute on incoming calls and this is paid for by the caller through premium charges - this is a CHARGE FOR ACCESS TO NHS SERVICES. This remains true even though there are cases where some callers would pay even more for calling a geographic number outside the terms of their Call Plan. In general terms the cost of a call to geographic number represents a fair "base price" for the cost of a telephone call. With Call Plans (in which this cost is zero) that cover only limited periods of time, those who make otherwise inclusive calls at different times suffer an "unusual" charge, which cannot be considered as a "base point".

It is important for the BMA and the Department of Health to understand that these exceptions are not a feature of particular 084 numbers. They arise because some callers select a Weekends only or Evenings and Weekends only Call Plan, but then make otherwise inclusive calls during the weekday daytime. In these cases calls to some "Premium Rate Service" 0871/2/3 numbers are also cheaper than the cost of a call to a geographic number.

Hickson vs. NEG, the BMA and the DH

I feel that it is a little unfair to many GPs who believe in the NHS, and to those civil servants who know the truth, for the battle lines to be drawn as they have been in the Pulse article.

Network Europe Group

NEG must understand that I have no problem with its attempt to exploit "enhanced telephony", nor with the use of "Business Rate" and "Premium Rate" numbers in general. Neither type of number is however suitable for those who are unwilling or unable to declare the fact that their financial benefit imposes a charge on the caller. This immediately excludes NHS service providers, because patient access to NHS services cannot be subject to a charge to the benefit of the provider.

Any business must develop products that meet the needs of the market it aims to serve, in function and price. If "Surgery Line" requires the expense of using the features of non-geographic numbers, but this makes it unaffordable for NHS GPs (using 03 numbers), then it cannot have a place in that marketplace, unless a convincing case for supplementary NHS funding could be made and won.

NEG argues strongly that cost is not a major issue for patients in accessing health services, and cites this as a key reason why Ofcom should not proceed with plans to make the cost of calling 084 numbers more transparent. If NEG wishes to stimulate and participate in a genuine argument about the possible partial or total qualification of the principle of "free at the point of need" in the NHS, then this could be an interesting debate. The suggestion that indirect charges should be concealed from patients does not represent a good starting point for such a discussion about an important issue of principle.


Although I suspect that most GP BMA members would hold a different view, the BMA General Practitioners Committee expressed the following opinion in making representation to the Department of Health in response to its 2008/9 consultation on use of 084 numbers in the NHS:

"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 suggestion that NHS providers should be permitted to levy a charge on NHS patients according to the quality of their telephone system is a most radical proposal. The fact that the BMA GPC repeats it in this guidance after the proposal had been rejected by the Department of Health is highly disturbing.

It is also a little mysterious as to why the BMA has now apparently concluded that no such balance is necessary, despite having made a clear point and then lost the argument. It now claims that the communications services being discussed are all accessible at no additional cost! What has happened to the balance that was admittedly required previously, but was rejected?

I cannot accept that any of this represents the balanced and considered view of GPs in England - if it did then they could not possibly be trusted to take a larger role in the administration of the NHS! If their representative body seriously holds the view that the principle of "free at the point of need" has to be qualified according to the quality of service accessed, then they cannot be trusted with any responsibility for commercial decisions relating to the NHS with its existing principles.

The Department of Health

I have plenty of evidence to show that Department of Health is perfectly well aware of the truth about the cost of calling 084 numbers. In forming the regulations as it has, it has not denied this knowledge, as it has given no authorisation whatsoever for use of any number that is seen to be more expensive to call than a geographic number. For reasons that can only be seen as a political defence of its own position, it has failed to actually step forward to provide PCTs with the assistance that they desperately need to do their work effectively.

This does not explain why it has chosen, despite declaring no interest in particular number ranges with a total focus on the cost of calling, to make a meaningless and unhelpful reference to a particular number range. The statement actually makes it more difficult for PCTs to do their work, as it implies a theoretical possibility of which there are no actual examples in practice.

(Strictly speaking, the DH statement provided to Pulse actually has nothing to do with GPs - who are contractors to the NHS, as it refers only to "NHS Bodies".) The GMS contract terms simply state that use of numbers (of whatever type) which cause NHS patients to incur a greater charge than that for calling a geographic number are prohibited. In theory, 09, 07, 087 or 084 numbers could be used if they met this condition. In practice, there are none which do.

Devolved responsibility

Enforcement of the terms of the GMS contract is a local responsibility. As telephone tariffs are set nationally, PCTs could have benefitted from some helpful guidance from the Department of Health. As it is, PCTs have had to contend with a potentially misleading statement from the Department and a failure to confirm or deny unsupported allegations about its position that are made by others and presented to PCTs as if DH policy.

What is most annoying about the Department of Health position is that officers in every one of the PCTs have to go through the same learning curve that officers of the Department of Health will have completed many times over during the years in which it was attempting to get to grips with this issue.

The task facing PCTs

PCTs have to take a view on two key points in establishing whether a practice continuing to use a 084 number is in compliance with the GMS contract (I understand that similar or identical provisions have been applied to PMS contracts):

cIs the number more expensive for patients to call than a geographic number - "having regard to the arrangement as a whole"?
Telephone charges are set by the telephone service provider chosen by the patient. This table (with links to published tariffs to enable objective verification) demonstrates that calls to 084 numbers are more expensive for those calling from Virgin Media landlines, Mobile phones and Public Payphones. For 0844 numbers, one may add those who call under the terms of a BT Call Plan.
cIs the practice able to switch to a number that is no more expensive to call than a geographic number within the terms of existing contracts for local telephone systems and network telephone service?
03 numbers provide the functional benefits of non-geographic numbers, as required by some local systems (e.g. NEG "Surgery Line"), and the potential for continuing provision from the same network telephone service provider. They also offer a guarantee that the cost of calling will be no greater than that of a geographic number - Ofcom now defines 01, 02 and 03 numbers as "Geographic Rate".
This option represents a potential way of "varying the terms of the contract" for telephone service as specified through sub-clause 29B2.2. The contract for the local system is unaffected, given that a non-geographic number continues to be used.

Migration from 084 to 03

All network telephone service providers (e.g. Talk Talk) are known to allow customers to migrate from 08 to 03 numbers at any point within the term of a contract. I am not aware of any case where a request for such a migration has been refused by the provider, or impeded by its agent (e.g. NEG).

The 03 equivalent of the number currently being used, e.g. 0344 477 1799 for 0844 477 1799, is reserved and available to ease the process of migration.

Such a migration would cause the benefit of revenue sharing (derived from higher charges paid by callers) to be lost, so the practice would be required to meet the full cost of their telephone service and any other items that have been funded out of the revenue share (e.g. a local telephone system). This would return the practice to exactly the same position as every NHS GP practice that uses a geographic telephone number and therefore meets the cost of its telephone service in the same way as all other expenses incurred in running a surgery.

Why I have always commended this migration (for those who have reason to use non-geographic numbers)

A proposal I published in January 2009 addressed this matter in the broadest of terms. It is clear that there is no will for the type of engagement indicated there by the parties, however the option of migration has much to commend it. Not least, it is the only way that many GPs could comply with the terms of their NHS contract.

It is possible for every practice to make this change at any time, in order to comply with the GMS contract. (The contract provided a twelve month period which ended on 31 March 2011 for this to be completed. The BMA had a further three months advance notice.)
PCTs must consider any failure to take the action reasonably demanded in the contract seriously.
GP Consortia may find it easier to take on their responsibilities without having members who are known to be charging patients for access to NHS services - in some cases consortium leaders.
The reputation of GPs as focused on patients and able to deal effectively with commercial partners in protecting the principles of the NHS is a key factor in securing public consent to them taking on roles that are presently performed by public servants.
Members of the GP profession may feel happier competing with each other purely on the basis of quality of service.
The NEG proposal that they should openly compete on price of access (to offset costs), with some using 084 numbers and others geographic and 03, may be suitable for a commercial marketplace, but many of us see it as highly unsuitable for the NHS.
The Department of Health was ready to take up this suggestion, but I cannot believe that it did so with a full understanding of the implications.

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