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Sunday, 29 January 2012

Open message in response to the letter to the Telegraph - "NHS in peril"

Dr Gordon

I am interested to note your letter to the Telegraph, which has been taken as support for the efforts of the Government to eventually replace our National Health Service, funded exclusively from taxation, with a patient-focussed English Health Service, funded by patients with some central government support. Articles such as this Daily Telegraph piece have presented you and your colleagues as opposing efforts to encourage parliament to reject the bill that would enable this to come about.

I see that 5 of your co-signatories are not currently in general practice, however it is 8 of the remaining 50 that cause me most concern.

I refer to:

Dr Andy HarrisDr Amit BhargavaDr Kamal BishaiDr Stephen Madgwick
Dr Vaishali NandaDr Stewart FindlayCharles BroomheadDavid Eyre-Brook

With the exception of the latter, all serve in practices which use 084 telephone numbers, in breach of the revisions to the respective NHS contracts, which were introduced in 2010.

Dr Eyre-Brook's practice is used as a case study for the most widely used surgery telephone system that is allegedly funded exclusively by patients, and provides an additional 2p of income for the surgery - see "Surgery Line sounds too good to be true".

I raise two points with respect to this matter and these individuals, given that the replacement of the NHS referred to above has not yet occurred.

•    If these individuals are thereby seen not to be personally committed to the principles of "our NHS", as they stand and will remain, then one must question their suitability to have a leading role in procuring NHS services.

•    If, as some have alleged, those who procured these telephone systems for NHS surgeries were not aware that they would be funded by patients, then one must question their competence to lead bodies concerned with commercial matters.

It is vital that NHS money is spent wisely and that current clinical experience, derived from engagement with patients in general practice, is deployed to ensure this.

We cannot however have decisions made within the NHS led by those who are content to disregard its principles, because they support an alternative system for healthcare in England, or who are ready to believe sales pitches that are "too good to be true".

It is my personal view that GPs are better able to serve the NHS from outside its structures, rather than taking on the responsibilities of a public servant. I see their professional focus and skills as continuing to be best focussed on meeting the clinical needs of their patients, regardless of cost to the public purse. Responsibility for the effective, equitable and accountable management of public resources is an onerous and quite separate duty. I accept that we must differ on that point, or alternatively you believe that the NHS will have effectively ended in England from the point when CCGs acquire their authority.

If the latter were to be true, then those who accept the responsibility of public servants would no longer be required to ensure that publicly funded health services were only delivered "free at the point of need". The leaders of CCGs would thereby be able to focus exclusively on patients, without having to be concerned about the wider public interest and nationally set principles.

I would be pleased to hear any response from yourself and from the individuals who I have identified and copied.

If the practices in question may believe that they are not in breach of their contracts, because all callers subscribe to the few telephone tariffs that cause them not to pay more than the cost of an equivalent call to a geographic number to call a 084 number, then I must draw their attention to an appeal from Simon Burns, Minister of State (Health Services).

Responding to a debate in parliament on this matter last Tuesday (Hansard Column 54WH 24 Jan 2012), Mr Burns said "... we need the evidence. We do not need anecdote or the 'friend of a friend', who has said this or that. We need precise, concrete evidence, to be able to pursue this matter" ... "I say to the right hon. Gentleman, and to anyone else who has an interest in this important subject, ‘Please send us the evidence’".

If these practices have complied with the contractual requirement to "consider whether, 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", then this evidence will be readily available. If your colleagues wish to show themselves to be keen to protect the NHS from the perils of "co-funding" then I am sure that they would wish to clearly demonstrate that they and their practices reject this and are compliant with their contractual obligations.

I would also be very interested to see a copy of any such evidence myself, as I cannot see how it could possibly have been assembled.

Wednesday, 25 January 2012

Please Help to Save the NHS - a Request from Simon Burns

For the NHS to be preserved as "free at the point of need", patients cannot be allowed to provide financial subsidy to GPs and NHS bodies by calling 084 telephone numbers to access NHS services.

Since 1 April 2011 all NHS GP practices in England have been under a contractual duty to ensure that "persons will not pay more to make relevant calls to the practice than they would to make equivalent calls to a geographical number".

The clip below shows that the responsible minister in the UK government has been unable to identify any of the nearly 1,300 surgeries listed on NHS Choices where this requirement is still being breached. He appeals for help.

The relevant Hansard record is at column 56WH for 24 January 2012.


You can contact Mr Burns at this email address, according to the latest Cabinet Office publication of Government ministers and responsibilities.

If you are aware of any cases, please give the details very carefully. In a briefing to MPs and others, I provided a link to my database summarising and listing nearly 1,300 NHS GP surgeries in England. Mr Burns was unable to recognise that any cases were identified, even though every case is taken from NHS Choices and linked back to the published entry.

The list is also available directly at this link. This includes a link to a table of call costs under the terms of commonly used tariffs for the different types of numbers on the list.

A longer video clip is available - this includes a reference to the absence of detail from my briefing, and repetitions of the request for evidence.

Some comments on Government policy, as revealed on debating 084 telephone numbers in the NHS

I comment on remarks made in the Westminster Hall debate yesterday on "084 telephone numbers in the NHS". I pick out specific points with reference to government policy for comment. This note does not intend to convey the general thrust of the arguments, nor present a comprehensive summary. In each case, I quote the relevant text from the remark, covered by a link to the Hansard text for context.

At the moment, the Minister is trying to convey to the House that the NHS will not be made unaccountable through his health Bill, and it would really help his argument if he made an effort to show that he is prepared to make the NHS accountable, as it currently is.

This point neatly draws in the wider political context.

The Government’s position is extremely clear—when patients contact their GP or anyone else in the NHS, they should not be charged more than they would be to call their next-door neighbour’s landline. Those are the rules. ... [there is] a contractual requirement for GP surgeries to ensure that that is the case.

This appears to be an unequivocal statement about "the rules". (The catch comes later.)

If they found that patients were being charged more than a standard local landline call, they had one year to take all reasonable steps, which could include varying the terms of their telephony contract, cancelling the contract, or offering an alternative number to call, such as an 03 number, which charges callers at a local rate.

There are two small points of confusion here. Firstly here, as should be said throughout, the point of comparison is with a "geographical call", not a "local call" - there is no longer a distinct "local rate".

Secondly, use of a 03 number arises as an option for varying the terms of the telephony contract (to replace the 084 number). There is no provision in the terms of the regulations or contract revisions to cover publication of alternative numbers alongside those which are "banned".

We must also be clear that the additional services can also be offered on other number ranges—such as 01, 02 and 03—and GP practices should feel able to choose the number that is most suitable for their patients, provided that it does not cost them any more to call.

This expresses the position very clearly.

I fear that banning 084 numbers would not be the panacea that Opposition Members might believe it to be. ... The 2010 regulations make it clear that patients must not be charged more to contact their GP than they would be if they called a local number.

The Minster fails to recognise that the requirements that have been imposed do effectively amount to a ban on use of all 084 numbers, under present conditions. There is no 084 number which does not cause, at least some, patients to be charged "more", by their telephone service provider.

The legislation is absolutely clear that if a person calls a GP surgery with an 084 number from a mobile, landline or payphone, they should not pay more than they would if they called a local landline number from the same phone.

This is nonsense. The regulations cannot address what telephone service providers charge for calls to 084 numbers, neither do GPs or their telephone providers have any control over this. It is because callers do pay more that 084 numbers cannot be used by GPs.

GP practices and their PCTs should look at evidence of call costs to determine whether their patients are being charged more than they should be. Such evidence could include cost-per-call information from providers, such as O2, Vodafone and BT. A suitable sample should be considered, bearing in mind the different contracts that patients can choose to sign up to.

It is not for GPs or PCTs to determine whether customers of telephone companies are being "charged more than they should be". They must consider only what they are paying to call the GP, relative to the cost of a call to a geographic number.

Evidence of the relative call costs incurred under the terms of commonly used tariffs has been published and drawn to the attention of all PCTs and the Minister. (It is available at this link.)

People say that there are 1,300 GP practices that charge more than they should; what they do not say is which practices they are, and they do not provide the robust proof that overcharging is happening

This is most likely a reference to a briefing document that I issued prior to the debate; it is however misrepresented.

I refer to "nearly 1,300 NHS GP surgeries in England". This text is covered by a link to a summary by nation and region, in turn linked to lists and maps containing the details of 1,292 cases (some of which are pending removal, so the actual number is a little smaller). These are "surgeries" not "practices", so the number of practices is yet smaller.

I have never implied that it is the practices which impose the charges on callers or that the charges made are improper. The practice only has a duty to determine what callers pay, relative to the cost of an equivalent call to a geographic number.

... overcharging ... overcharging ... overcharging ....

This is not about "overcharging". Telephone call charges are set by telephone companies. It is perfectly reasonable for a telephone service provider to recover the cost of the revenue share that is paid on to the benefit of the user of a 084 number.

GPs only have a duty to ensure that "persons will not pay more to make relevant calls to the practice than they would to make equivalent calls to a geographical number". They can only do this by using a number that is assured not to be charged at more than the cost of a call to a geographic number.

We do not need anecdote or the "friend of a friend", who has said this or that. We need precise, concrete evidence, to be able to pursue this matter.

It is regrettable that PCTs have indeed, as the Minister says, failed to obtain precise concrete evidence of compliance from GPs. The assurances which they have provided are based on a single "anecdotal" case, which was presented to the Department of Health in the course of the public consultation.

The relative call cost information used by GPs has been obtained not from some authoritative source but precisely from "a friend of a friend". The BMA has commended use of advice from the very provider of the telephone system, the cost of which is subsidised by the proceeds from the revenue share.

Unless the Minister still believes, like his predecessor in 2005, that 084 numbers offer callers a "guaranteed low rate", then it must be for GPs to offer the "precise concrete evidence" of compliance that he demands. The duty to determine relative call costs under the terms of the contract rests on the GP, not on its patients.

The Department will soon clarify the existing guidance, which I hope will help GP practices and PCTs to understand this issue more fully and to dispel some of the myths and misunderstandings about the use of 084 numbers.

I sincerely hope that the Department will also be able to dispel some of the myths and misunderstandings promoted and demonstrated by the Minister. This clarification has however been expected "shortly" (the word actually used by the Minister) since April 2011. This evidence-based interpretation of the word "shortly" may provide some understanding of when the clarification will actually be issued.

This Government are committed to creating a patient-focused NHS ... It is right that GPs remain responsible for their own access arrangements, including their telephone number

The reluctance of the government to ensure enforcement of nationally-set regulations that reflect the principles of a National Health Service is very clear from this statement.

GP practices are adhering to the regulations and not costing patients more than they should. The PCTs vigorously enforce the regulations.

Clearly this is what the Minister wishes to believe. It is simply untrue.

I hope that this debate has not only clarified the situation but has set a challenge to the right hon. Gentleman and others to provide evidence if they have it or come across it, so that if there are any abuses we can put an end to them.

I would have been delighted to hear some meaningful comment on the evidence that I have provided. It is however not clear as to whether this has not been read (as is strongly implied by the suggestion that it does not include a listing of cases) or whether the government regards co-payment for access to NHS services as being acceptable.

In fact, I believe that the government wishes to replace a National Health Service, funded by taxation, with a patient-focussed health service, funded mostly by patients, with some central financial support to maintain the "NHS brand".

Tuesday, 24 January 2012

Government blind to NHS GP contract breaches

Responding to a Westminster Hall debate today, Health Minister Simon Burns pleaded blindness as his defence against a failure to ensure enforcement of a requirement for GPs to give up the subsidy they receive, at the expense of patients, by using expensive 084 telephone numbers.

I have published a database of NHS GPs with 084 telephone numbers. For England, this is based entirely upon, and in each case referencing, NHS Choices.

This currently lists 1,292 surgeries (not practices, some of which operate from more than one surgery).

In my published and circulated briefing for the debate (including a link to the list) I referred to this figure as being "nearly 1300".

Mr Burns said (watch him here) "... We can find no evidence of this ... what they don't say is which they are ... please send us the evidence"

HERE IS THE LIST (verification with NHS Choices will enable any recent changes of number to be identified and cases removed.)

Local cases can be found from this map, or by links from this summary by NHS organisation.

HERE is a summary of the call costs incurred under the terms of commonly used tariffs for the "call type" listed against each number. I provide links to the actual tariffs as published by the telephone companies.

The regulations placed an obligation on GPs 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”. I agree with Mr Burns; practices should be able to provide “robust evidence" to support any claim that none of their patients call under the terms of the tariffs that cause them to pay more.

Assurances of compliance submitted by GPs have been based on the false assumption that callers from mobile telephones, payphones, Virgin Media Lines and BT’s most widely used tariff need not be considered. These assurances have been provided by "a friend of a friend", their telephone system company, as suggested by the BMA. Perhaps Mr Burns thinks that commercial providers to the NHS do not need to present "robust" evidence, that responsibility only applies to patients – if so, then I disagree.

If each individual patient has to fight their own legal consumer battle with their local "medical services retailer", then we no longer have a NATIONAL health service. Many believe that this is exactly what this government wants and suggest that this is why it is blind to evidence presented nationally.

I will comment at greater length when the full Hansard is available.

Sunday, 22 January 2012

084 telephone numbers in the NHS - proposal for resolution

I have prepared and published an outline proposal for how the government, through the Department for Health, may now deal with the situation of the NHS GPs who continue to use 084 telephone numbers in breach of contractual requirements introduced in April 2010.

This has been done ahead of the Westminster Hall adjournment debate at 12:30 on Tuesday 24 January, which is covered by this general briefing.

The full draft of my proposal is published here.

It is summarised below:

The following steps are necessary:

Clarify the position
The following objective truths must be made clear to all:
084 numbers are "banned"
The ban is not stated explicitly, however this can be the only effect, under current conditions.
The terms of existing arrangements may be varied to enable compliance
Migration to the 034 equivalent of each 084 number is a "reasonable" option available to those who wish to, or are obliged to, retain use of a non-geographic number.
Remind (clustered) PCT Chief Executives of their statutory duty
Each PCT has a primary duty to all citizens whom it serves, elements of which are declared in statute; other relationships are important, but secondary:
GPs and the BMA
Guidance from the BMA to its members does not guide the formation of PCT policy.
The Department of Health
Assistance may be provided to PCTs by the Department of Health, however the absence of such assistance does not excuse any failure to perform statutory duties.
Ensure that the will of parliament and government policy is carried out
Enforcement of provisions approved by parliament is important for there to be faith in our democracy, and the government commitment for the principles of our NHS to be protected must be seen to be effective, if it is to withstand challenge and attack of its proposals for yet further liberalisation.
Engage opponents who are able to assist
Those who have continued to oppose the intentions of the provisions, and are seen to be impeding their implementation, must now be brought "on board".
GP representative groups
The BMA and LMCs must represent the interests of the members in preventing them from being made subject to enforcement action - by urging proper compliance, rather than encouraging evasion.
Telephone network and system providers
Companies such as Talk Talk and the Daisy Group, who may wish to continue to serve the public sector, should be persuaded to do all they can to enable their GP clients to comply, by offering the best possible terms for migration to 03 numbers.
Ensure a mechanism is in place to protect the principles of the NHS
Proposed changes to the management structure of the NHS should make this task easier than it is under the present arrangements, however an effective mechanism is required immediately to deliver the required effect on this particular issue.
My role
I stand available and ready to assist in any way I can, being totally independent and having considerable knowledge and understanding of this particular issue.

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