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Tuesday, 29 November 2011

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.

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.

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).

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.

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.)
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.

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