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Friday, 24 June 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.

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.

Wednesday, 15 June 2011

Enforcement of the principle of "free at the point of need" in the NHS

The text which follows is that of a message sent to the Chief Executives of a number of PCTs - see list below.

To: Chief Executives of PCTs in the “TOP 20” of those who have not yet eliminated use of 084 telephone numbers by GPs

From: David Hickson – campaigner for the NHS


You and your predecessors have received many briefing messages from me on the topic of GPs using "expensive" 084 telephone numbers. As a lover and part-owner of "our NHS" I am campaigning, as a "concerned citizen", for the principle of "free at the point of need" to be properly enforced.

For those who understand these matters, use of any 084 telephone number represents a breach of this principle because of the revenue sharing that is involved. Contrary to misleading advice from certain quarters, EVERY call to EVERY 084 number involves a transfer of funds from the caller to the recipient (albeit heavily disguised in some cases).

You have a statutory duty, under the terms of the Health Act 2009, to have regard to the rights declared in the NHS Constitution. If you are properly aware of the situation and un-swayed by those who argue for co-payment, you will have no option other than to ensure that use of 084 numbers is eliminated from the NHS.

GPs who are GMS contractors are in breach of the revised terms of the GMS contract (clause 29B) issued around April 2010, with a deadline for compliance of 31 March 2011. PMS contractors are in defiance of the Directions to NHS bodies issued by the Department of Health on 21 December 2009, with a deadline for compliance of 21 December 2010.

These specific directions and contract revisions, if properly understood and applied, provide you with a clear basis for taking action against those who fail to comply.

This briefing

To support my campaigning efforts I have now prepared a further database of cases of non-compliance, based on the information published by "NHS Choices". This includes "Top 20" lists of PCTs, and the equivalent bodies in Wales and Scotland, who are clearly having the greatest difficulty in achieving compliance. This may be due to a failure to properly understand their duties or due to them having adopted a policy of permitting the principle of co-payment to apply for those they serve.

This message is circulated to the Chief Executives of these PCTs, listed in sequence according to the position on the lists by number of cases or proportion. As the question of a policy of permitting co-payment is involved I believe that this demands your attention. The detail is however a matter for the appropriate officers - I hope this message will be passed to them.


Please follow this link to see your place on the “Top 20” lists and to follow a further link (on the name of the PCT) for a list of the cases.

This blog entry describes the database of cases, what it represents and the manner in which it has been prepared.

You may find a further briefing - Resistance to the ban on use of 084 numbers by NHS GPs - to be of value. This covers the terms of the contract variations in detail and addresses some of the devices used by those who seek to evade their duty under the terms of their contract. This briefing expands on, and gives references for, many of the comments in this message.

Action to follow

I will be delighted to offer you any assistance in performing your duty to ensure compliance, if somewhat belated.

If you are not proposing to take immediate action against practices who continue to use 084 telephone numbers, then I would be most grateful to be advised of this decision.

Some who fear that the "NHS reforms" already underway may not achieve the intended cost savings see it as inevitable that co-payment will become a major feature of public health provision in England in the coming years.

I will be most interested to note any areas of the country where co-payment is already officially sanctioned in access to primary care, allegedly under the terms of the NHS. A policy of failing to eliminate use of 084 telephone numbers amounts to such sanction, even if only as a result of ignorance.

This sanction of co-payment may be on the relatively modest scale involved through use of revenue sharing telephone numbers and may have been achieved through misrepresentation and incompetence. These features, even if there are the true explanation, will not be used as the way of explaining it to those whom you serve! The general principle, outlined by the BMA, that the cost of accessing NHS services should be dependent on the quality of service received, will doubtless be used.

Please let me know where you stand on this - your policy and how it is being applied to this matter.

Further comments

It is fair for me to add that I deplore the decision of the Department of Health to leave it to each PCT to work out that calls to all 084 numbers are more expensive for patients than equivalent calls to geographic numbers. This applies to all of the UK; there are NO LOCAL VARIATIONS, neither by locality nor for specific numbers. Actual call costs vary enormously, but we are only concerned with the question of whether a call to a 084 number is more expensive than the cost of an equivalent call to a geographic number. Any call to a 084 number is more expensive than an equivalent call to a geographic number. The only exceptions apply to particular patients who incur penalty charges for calling geographic numbers outside the terms of their Call Plan, which may exceed the premium added for calling a revenue sharing number. This exception is for a CALLER, not a NUMBER.

The BMA declares its position in favour of co-payment openly. It nevertheless urges its members to seek to pretend that there are local variations in the cost of calling 084 numbers. It also encourages them to engage the services of a much stronger advocate of co-payment as the basis for encouraging competition between GPs. This company, which also happens to have a direct commercial interest in this matter, not only supports this false assertion but also offers to make an absurd declaration allegedly covering the tariffs of up to 200 telephone companies. This assertion is readily shown to be untrue by looking at only a handful of tariffs, including that of the network telephone service provider for which it is an agent!

The Department has failed to point out the truth of the matter, refusing even to comment on misrepresentations of its own position. It is therefore for each PCT to plough its way through clouds of misinformation before being able to make a clear decision about whether or not to support the BMA by permitting co-payment. The Department has also failed to advise that every practice committed to a long term telephone system contract which requires a non-geographic number has a perfectly simple and straightforward option for re-arranging their provision of network telephone service so as to comply with the terms of the Directions and contract revisions at any time. References to awaiting the renewal of contracts or considering termination are totally pointless – there is no need to wait.

In my view, the DH decision to devolve this issue of fundamental policy to a PCT, when there are no issues of local variation, denies the essence of a National Health Service. That however is the position. I would be most interested to know if you have made a positive decision to allow co-payment, or if perhaps you would welcome further assistance in eliminating it, albeit some months after the deadline has passed.


Ian Atkinson - Interim Chief Executive - Sheffield PCT
Andy Buck - Chief Executive - Rotherham PCT
Andrew Donald - Chief Executive - Birmingham East and North PCT
Catherine Griffiths - Chief Executive - Leicester City PCT
Catherine Griffiths - Chief Executive - Leicestershire County and Rutland PCT
Denise McLellan - Chief Executive - Heart Of Birmingham Teaching PCT
Ailsa Claire - Chief Executive - Barnsley PCT
John Lawlor - Chief Executive - Leeds PCT
Mike Potts - Chief Executive - Wakefield District PCT
Allison Cooke - Chief Executive - North Lincolnshire PCT
Amanda Fadero - Chief Executive - West Sussex PCT
Kevin Flynn - Chief Executive - Isle Of Wight NHS PCT
David Sharp - Chief Executive - Derbyshire County PCT
Tracy Sanders - Chief Executive - Portsmouth City Teaching PCT
Mike Potts - Chief Executive - Calderdale PCT
Jane Halpin - Interim Chief Executive - Hertfordshire PCT
Robert Bacon - Chief Executive - Walsall Teaching PCT
Debbie Fleming - Chief Executive - Hampshire PCT
Anne Walker - Chief Executive - Surrey PCT
Ann Sutton - Chief Executive - Eastern and Coastal Kent PCT
John Parkes - Chief Executive - Milton Keynes PCT
Jan Stubbings - Chief Executive - Gloucestershire PCT
John McIvor - Chief Executive - Lincolnshire Teaching PCT
Robert Bacon - Chief Executive - Sandwell PCT
Mike Potts - Chief Executive - Kirklees PCT
Simon Morritt - Chief Executive - Bradford and Airedale Teaching PCT
Christine Willis - Chief Executive - Middlesbrough PCT

Monday, 13 June 2011

How will NHS reforms meet the funding gap?

Andrew Lansley has stated that the NHS faces a funding gap of nearly £20 billion a year by 2015, and its costs will double by 2030. Efficiency savings with short term costs and disruption may produce some long term savings. Only a change in the level of NHS provision, or the means of funding, will address this problem.

More patient choice and competition only on quality will not save one penny, it can only cost more. Patients are already making small payments indirectly through use of revenue sharing telephone numbers, excessive car parking fees and premium rates at retail concessions in hospitals. These are however tiny.

What else we will have to pay for if the reforms are to meet their declared objective?

What is it that will have to be cut out of the scope of the NHS?

Where is the secret agenda that balances the reform proposals with their alleged objective?

Wednesday, 8 June 2011

NHS GPs using expensive telephone numbers - new database

(Updated - Thursday, 24 November 2011)

These notes accompany my database listing the GP surgeries using 084 numbers throughout the UK
(1,402 cases at the time of this update). I cover:

•    Why use of 084 telephone numbers is a breach of the principles of the NHS

•    The database

•    The mapped rendering of the database

•    Other relevant bloggings

084 telephone numbers used by NHS providers

These numbers provide financial subsidy to a NHS provider at the expense of patients (via the respective telephone companies at each end of the call).

ALL 084 numbers are subject to "revenue sharing" at rates which vary between around 1.5p per minute to around 5p per minute (including VAT). This is reflected in the "Termination Rate" paid by the call originating telephone company to the call terminating telephone company.

The manner in which the financial benefit is achieved by the call recipient may vary. It could be through reduced charges for telephone services, payment for a local switchboard system from an independent provider or as cashback.

It is for accountants and economists to determine whether such financial benefit is properly described as "income", "profit", "subsidy" or whatever. There can be no dispute that financial benefit is achieved in some way. (Claims by some NHS bodies that they allow their telephone company to retain this benefit without any consideration demand investigation.)

The way in which the cost of the revenue share is carried by the caller may also vary. Generally a telephone company will add the additional cost to the rate charged for a call to a non-revenue sharing number. Telephone tariffs are rarely that simple, but the telephone company originating the call will not hand over the revenue share as a "gift".

Apart from some perverse exceptions, the caller will pay more to call a 084 number than a "Geographic Rate" (01/02/03) number. These exceptions are cases where the caller suffers a "penalty charge" for calling geographic rate numbers outside the terms of their selected "Calling Plan". These cases are "perverse" because it is invariably cheaper for a telephone company to place a call to a Geographic Rate number than a 084 number.

Unless it can be shown that all those who call a particular surgery are subject to these exceptions and incur "penalty charges", then there can be no dispute that additional costs are incurred by patients as a result of the choice to use a 084 number.

The database includes a "Table of Call Costs" covering the major call providers in the UK.

The Database

The source data in the database was obtained from the information published on the internet by the respective NHS bodies. Each case has a link to the individual webpage published or referenced by the NHS body.

Each entry also identifies the constituency in which the surgery falls and provides a link to the respective MP / MSP / AM / MLA contact details.

The data is arranged by the responsible NHS Organisation - PCTs (Clustered) in England, Health Boards in Scotland and Wales and the single board for Northern Ireland. It is also grouped and totalled within the "Regions" of the UK - the nations of Scotland, Wales and Northern Ireland and the Clustered Strategic Health Authority areas of England.

Summary information is provided by "Region" and "Organisation".

For interest, the number of cases by Organisation, Call Type and Provider are used to provide "Top 20" tables.

A further summary shows the number of cases in each English parliamentary constituency, ranked by the number of cases and giving details of the MPs.

As the data is assembled using Google Spreadsheets, all may be readily copied and downloaded for additional custom analysis.

The "List view" feature of Google Spreadsheets may be used online to sort and filter the data.

The linked MAP

ZeeMaps is used to provide a mapped rendering of the same data. (N.B. ZeeMaps are supported by Google advertising to the benefit of Zee Source. My use of free online facilities is without sponsorship nor benefit.)

Each case is represented by marker, which when clicked shows a "bubble" giving the information as shown in the database, including the hyperlinks.

Isolating cases on the Map

The Region and Organisation sections of the database provide map views zoomed and centred for the item in question. Other cases within the scope of the view are however shown.

To show only the markers for a particular data value, the View/Search feature may be used. (N.B. For technical reasons the "Region" is known as "City", other criteria may produce unexpected results - search does not change the zoom and pan settings.)

To show only those cases in a constituency: - Use MP/MSP/AM/MLAs contains {constituency name}

To show only those cases for a PCT Cluster / Health Board: - Use Organisation contains {Cluster / Board name}

A more unusual case is demonstrated by the example which follows:

Other relevant bloggings

•    NHS Direct has caught up with mobile apps - but not mobile voice calls!

•    Resistance to the ban on use of 084 numbers by NHS GPs

•    NHS Reforms - Government says "PCTs must carry on with their work"!

•    084 calls more expensive than geographic calls for NHS patients

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