David Hickson's NHS Patient Blog

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

2012-01-25T23:21:00.002Z

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.

PLEASE RESPOND TO THIS URGENT REQUEST FROM MR BURNS

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

2012-01-25T12:28:00.000Z

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".

Government blind to NHS GP contract breaches

2012-01-24T23:34:00.002Z

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.

084 telephone numbers in the NHS - proposal for resolution

2012-01-22T22:00:00.001Z

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.

Local campaigners publish geographic numbers for 0844 surgery

2011-12-04T10:05:00.001Z

After failing to get the local PCT - West Berkshire (clustered with East Berkshire under Chief Executive Charles Waddicor) to do its job by enforcing the terms of the NHS GP contract, the Neighbourhood Action Group for the district of Earley, near Reading, has adopted a tactic that could be used by similar groups elsewhere.

After securing coverage of the issue in local newspapers, members of the group are now distributing the poster shown below around local shops, community centres and other places where patients of the particular large practice that serves this whole area may see it.

Action like this is not "the solution" to the problem of GPs using expensive telephone numbers, however it is a worthwhile exercise. Those patients who get to hear of the alternative numbers, and recognise that they are cheaper for them to call, may be saved considerable sums of improper expenditure. The consequent loss of subsidy to the practice, because the number of calls to the 0844 number is reduced, may perhaps cause it to wonder whether it makes sense to continue in breach of its contract with the risk of suffering action, for the sake of a relatively small financial benefit.

For myself, I would rather that the practice and the PCT respected the principles of the NHS, on all matters, and behaved accordingly.

Your NHS GP practices using 084 telephone numbers (message to PCTs and MPs)

2011-11-29T15:18:00.006Z

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.

Contribution to a Which? conversation

2011-11-18T10:51:00.000Z

In a Which? "conversation" "GPs – stop using expensive phone numbers", I have been asked to provide statements confirming that

"0344 provides the same functionality for the surgery as 0844"

I regret that I cannot provide a link to the specific comment to which I reply, nor has it been possible to add the comments that follow to the "conversation".

I can offer the following (hyperlinks are supported by page references where necessary):

1. From Daisy Group / NEG

This may be the most suitable, although I cannot confirm this. It is from a company called NEG, now part of The Daisy Group. It claims to be "the market leader in the provision of enhanced telephony services to NHS Primary Care".

Identical functionality can be provided to organisations
through 084 and 03 numbers

This is found on page 10/75, labelled "Page 4" of this pdf document, authored by NEG and published by Ofcom.

There is much else in this document, on which I comment in this blog posting.

It is likely, but not confirmed, that the Daisy Surgery Line system is used by the only GP in Hadleigh shown on this map.

2. Ofcom

Some basic information about 03 is published by Ofcom in this press release.

3. The Department of Health

The Department of Health Consultation document - The use of 084 telephone numbers in the NHS included (on page 5/16) the following statement:

03 numbers offer the same extra functions as 084 numbers
but are charged at the same rate as a call to a local number

General Comment

It is taken as given that all non-geographic numbers provide the same potential for use of "Enhanced Telephony" features because, unlike geographic numbers, they terminate at the same type of equipment - an "intelligent switch" - from where calls are distributed as appropriate.

Similar facilities may be provided on some (or perhaps all) geographic numbers, however this is said to be less convenient and may cause greater costs to be incurred.

References to comments made in the conversation

There can be no instruction more specific than the terms of the contract between the practice and the PCT. This was approved by parliament, and the Department of Health cannot vary these terms by issuing its own instructions.

Ministers of the Department have commented that the requirement to consider call costs applies to all types of telephone service and tariff. This only draws attention back to the terms themselves, and away from misleading guidance issued by certain parties.

If the practice believes that "having regard to the arrangement as a whole", persons do not pay more to call its 0844 number than for an equivalent call to a geographic number then it is shutting its eyes to obvious facts.

It is perhaps relying on guidance based on the situation as it relates to a selected group of potential callers, who incur penalty charges for calling geographic numbers outside the terms of their chosen call plan. Unlike all others, this select group may not pay more.

No matter how convincing and reassuring that guidance may be, it is partial in two senses. Firstly, it comes from a pair of organisations working together and known to be opposed to the objective of prohibiting use of numbers that cost more than the cost of a geographic call. Secondly it admittedly addresses only some callers, rather than "the arrangement as a whole".

The NHS is universal, the rights and principles outlined in its Constitution apply to everybody, arrangements relating to the provision of NHS services cannot be made with regard only to a group which conveniently allows the objective of GPs continuing to benefit from revenue sharing at the expense of patients to be achieved.

References to published comments from the practice

The benefit from revenue sharing is used to subsidise the cost of the GP's chosen telephone system. The full cost should be carried by the practice. "The practice profits" by using a revenue sharing telephone number, not by "providing an advanced telephone system".

The term "local rate", when applied to a 0844 telephone number, represents a "serious factual inaccuracy".

Daisy Surgery Line and "Enhanced Telephony"

2011-11-08T15:30:00.000Z

There is keen public debate over the still unresolved issue of NHS GPs using 084 telephone numbers to gain subsidy of their costs at the expense of patients. As a contribution to this debate, Daisy Group, the provider of the Surgery Line system used by many NHS GPs, has issued a helpful leaflet -

• Enhanced Telephony - THE FACTS

Noting this useful contribution to the debate, I have published two documents:

• Daisy Surgery Line - The Facts

This addresses some omissions from the Daisy Group document in an attempt to further public understanding of the issues.

In particular, it highlights the fact that no NHS GP using a 084 number can be assured of compliance with the principles of the NHS and the specific terms of their NHS contract. In truth, it is only under inconceivable circumstances that a 084 number could be used.

• How to use Enhanced Telephony as a NHS GP

This refers to the specific options available to NHS GPs who wish to use Enhanced Telephony whilst remaining in compliance with their NHS contract.

In particular, it refers to the option for existing and committed users of non-geographic numbers to migrate to 03 numbers so as to be assured of compliance with the principles of the NHS and the specific terms of their NHS contract. It highlights the need for identification of the telephone service providers who are alleged to be deviating from the standard industry practice by preventing such migration.

Whilst there are many opinions about the way in which the NHS should develop, it is vital that public discussion is conducted on the basis of truth. I will be pleased to engage in debate on the former, but must urge any alleged inaccuracies in any of my comments to be brought to my attention immediately.

References

For the sake of simplicity, neither of my documents contains detailed references to relevant materials. I list the specific materials referred to, and from which quotations are taken, along with other relevant items.

Key documents

→ Calling costs
A summary from the most commonly used tariffs giving the costs of calling 084 and geographic numbers. This document provides links to the relevant published tariffs, which can be the only relevant source of information for those wishing to be assured about the costs that will actually be incurred by callers.

→ Statements from Ofcom
This series of formal statements issued by Ofcom covering relevant issues should be of interest to those who wish to review an objective presentation of the relevant facts. This key document is also presented embedded below.

→ The 03 alternative
A media release from Ofcom confirming the benefits of use of 03 numbers as an alternative to "the service provider generating revenue from those making the calls to offset the cost of equipment to the organisation".

Department of Health material

→ Revisions to the NHS GP contracts
the Statutory Instrument passed by parliament to provide the revised terms of the GP contracts.

→ The use of 084 Numbers
a letter from Nick Hall of the Department of Health confirming the basis for possible continuing use of 084 numbers - "… providing that patients are not charged more than the equivalent cost of calling a geographical number to do so".

→ Hutton rings the changes
an announcement by the Department of Health in February 2005 including the false advice that 084 numbers "offer patients a guaranteed low rate call". There never was any such "guarantee", Mr Hutton was mistaken or misinformed.

→ Clarification of the terms of the requirements placed on GPs
an exchange in parliament on 12 July 2011 providing clarification of the meaning of the terms of the contractual terms, including "It is absolutely clear that there is no distinction between landlines, mobiles or payphones".

Other material

→ Surgery Line is "co-funded"
Confirmation that a key feature of Daisy Surgery Line is the fact that users benefit from revenue sharing - "The revolutionary co-funded enhanced telephony service, designed specifically for GP surgeries. "

→ BMA Guidance vn 1
Indicating a clear position of continuing opposition to the objectives of the contract revisions - "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". It is use of numbers on which a premium charge is applied to achieve the "balance" which is now explicitly prohibited for the NHS.

→ BMA Guidance vn 2
This alleges that some telephone services providers are not allowing GPs to vary their arrangements by migrating to 03 numbers, so as to retain the benefits of Enhanced Telephony whilst complying with the principles of the NHS and the terms of their NHS contracts - "many GP practices have signed multi-year contracts with telephone services providers which cannot be varied, renegotiated or terminated without substantial financial penalty". Any company which is preventing migration to 03 by imposing unreasonable penalties, contrary to Standard Industry Practice, needs to explain the reasons for this unusual conduct.

→ Example of call cost statement
This is a typical example of a practice indicating that the "5p per minute" revenue share charge (as levied by BT) is used to pay for the enhanced telephony it uses, not to provide income to the practice. Despite being proud to "offer NHS Services", the practice appears to forget that the payments it receives for providing these services are intended to be used to cover the costs of telephony. "lo-call" means that the premium rates charged for calling revenue sharing 084 numbers are generally lower than those for calling numbers used for "Premium Rate Services", which can attract much higher premiums.

→ Example of surgery letter to patients
This example shows how a practice and its patients are benefitting from the use of "Enhanced Telephony". Unfortunately this practice has failed to "have regard to the arrangement as a whole" by only considering a claim about rates charged by their "own phone supplier". I have no evidence, but I suspect that the company in question does not provide telephone service to even one of the practice's patients, and so the "written guarantee" about the charges it makes is worthless. (The reference to "guidance of The Department of Health" is utterly spurious. There is no "OFCOM regulated rate for, or related to that for, "local geographic calls", other than the regulation covering 03 numbers, which applies to all providers. I have no idea of what could possibly be meant by "a standard BT tariff", it is certainly not that most commonly used by BT residential customers.)

Under the terms of the most commonly used BT residential tariff (the "Unlimited Anytime" Call Plan), a geographic call costs zero whereas a call to a 0844 "g11" or "g6" number, as used by Surgery Line users, costs 4p or 5p per minute to the benefit of the practice, plus a call setup fee to the benefit of BT.

NHS Bodies in Breach of Directions to uphold the principles of the NHS

2011-08-21T10:57:00.000+01:00

On 21 December 2009, the Department of Health imposed "Directions to NHS Bodies concerning the cost of telephone calls".

The Directions

The Directions covered the costs incurred by callers contacting the NHS, which are set by their respective telephone company. All telephone companies have to pay on a "revenue share" when connecting calls to all 084, 087 and 09 numbers. They pass this cost on to callers.

The Directions required that:
"having regard to the arrangement as a whole,
persons will not pay more to make relevant calls to the NHS body
than they would to make equivalent calls to a geographic number".

The terms are defined to apply to all NHS patients, with no exclusion from NHS entitlements for those who do not have a landline telephone or are on the social tariff "BT Basic". It is well known and understood that landline providers charge more for calls to 084 numbers than to geographic numbers, for the reason given above.

Because NHS bodies do not themselves provide telephone service to those who call them, the only way that they can comply is by ensuring that the number they choose is never subject to additional charges from telephone service providers.

The Implications in practice

There are some perverse situations where the penalty charge for calling a geographic number outside the terms of a Call Plan exceeds the premium paid to fund the revenue share to the benefit of the receiving party on 084 calls. Exceptional marketing practices, enabled by special regulations which apply only to BT, create further perverse effects with 0845 numbers. These distort the natural situation for some BT customers, but not those on its social tariff "BT Basic".

There is however no doubt whatsoever that all calls from Virgin Media landlines, mobile phones and public payphones to 084 numbers are more expensive than those to geographic numbers. The situation with other providers may be mixed.

The statement "having regard to the arrangement as a whole" can only refer to the fact that NHS services are provided on a UNIVERSAL basis. Entitlement to access NHS services under the terms of the NHS Constitution (i.e. without charge from the service provider) and as specified in these Directions cannot be sacrificed as a result of not calling under certain specific and unusual terms from a particular type of telephone service provider.

Unless the assertions made above can be shown to be false,
THE DIRECTIONS AMOUNT TO A PROHIBITION OF THE USE OF ALL 084 NUMBERS.

The above comments relate to the situation as it is today, has been since 19 December 2009 and is likely to continue (with some of the perverse exceptions likely to be removed) in future. Potential regulatory changes anticipated by the comment "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" HAVE NOT OCCURRED, indeed Ofcom has taken a totally different direction from that which some anticipated. As things have remained, and are likely to continue, there are no 084 ranges or numbers that meet the stated conditions.

For those reluctant to verify the truth of the matter for themselves, I can offer a quotation from a formal Ofcom statement on this matter:

"Only 03 is charged precisely the same as 01 and 02 numbers by all telephone companies.

"084 numbers are frequently charged at a higher rate than a 01, 02 or 03 number. Where they are not charged at a rate above a 01/02/03 number they are, however, frequently not included in a calling plan, thus callers will pay an additional charge for the call."

If anyone wishes to challenge these assertions, I would be most grateful if they would contact me, so that I may consider revising these comments, and attempt to persuade Ofcom to change its position also.

Implementation

The Directions imposed a deadline of 21 December 2010, by which those already using numbers which cause a greater expense to be incurred must, notwithstanding other possibilities, "vary the terms of the contract or other arrangement". As all telephone companies allow migration from a 084 number to the equivalent 034 number at any point during a contract, there can be no case where the NHS body was unable to comply with this requirement. (Calls to all 03 numbers are charged on the same basis as calls to geographic numbers.)

If anyone wishes to challenge my assertion, with evidence of a case where a request to migrate from 084 to 034 was refused, I would be most grateful if they would contact me, so that I may consider revising these comments.

Many of those listed from research undertaken some years ago have now moved into compliance with Directions. (My publication - NHS bodies using revenue sharing telephone numbers - is now OUT OF DATE.)

There are however many other NHS bodies which are both

• defying these explicit Directions, and

• continuing to breach their duty under the Health Act 2009 to "have regard to the NHS Constitution".

By benefitting from the subsidy provided by use of revenue sharing telephone numbers, at the expense of patients, they are effectively imposing a charge for accessing NHS services which is not "sanctioned by parliament".

NHS Bodies in breach

I list those seen to be in breach below, along with the name and position of the senior officer responsible, to whom I have written.

Cases where an alternative geographic number is advised alongside the 084 number are annotated "*". Unless it could be shown that sufficient advice is provided to ensure that nobody would ever call the 084 number in error, then the breach remains uncorrected by advice of an alternative number. (I have excluded cases where two numbers are published simply to cover a period of transition.)

Barking, Havering and Redbridge Hospitals NHS Trust	0845 130 4204 *	Averil Dongworth - Chief Executive
Barnet and Chase Farm Hospitals NHS Trust	0845 111 4000 *	Mark Easton - Chief Executive
Basildon & Thurrock University Hospitals NHS Foundation Trust	0845 155 3111 *	Alan Whittle - Chief Executive
Calderdale and Huddersfield NHS Foundation Trust	0844 8110101 *	Diane Whittingham - Chief Executive
Gloucestershire Hospitals NHS Foundation Trust	08454 222 222	Frank Harsent - Chief Executive
Luton and Dunstable Hospital NHS Foundation Trust	0845 127 0 127	Pauline Philip - Chief Executive
Maidstone and Tunbridge Wells NHS Trust	0845 155 1000	Glenn Douglas - Chief Executive
Mid Yorkshire Hospitals NHS Trust	0844 811 8110	Julia Squire - Chief Executive
Northumbria Healthcare NHS Trust	0844 811 8111	Jim Mackey - Chief Executive
Plymouth Hospitals NHS Trust	0845 155 8155 *	Helen O'Shea - Acting Chief Executive
University College London Hospitals NHS Foundation Trust	0845 155 5000 *	Robert Naylor - Chief Executive
East Kent Hospitals University NHS Foundation Trust (Patient Service Centre)	0845 084 0500	Stuart Bain - Chief Executive
Blackpool Teaching Hospitals NHS Foundation Trust (National Artificial Eye Service)	0845 60 50 561	Aidan Kehoe - Chief Executive
North East London NHS Foundation Trust	0844 600 1200 *	John Brouder - Chief Executive
Northumberland, Tyne and Wear NHS Trust	0844 811 5522	Gillian Fairfield - Chief Executive
Marie Stopes International (many centres - providing NHS services)	0845 300 3740	Di Hendry - Head of Marketing
Spire Parkway Hospital, Solihull (providing NHS services)	0845 850 1451	Will Knights - Hospital Director
Bradford and Airedale Teaching Primary Care Trust	0845 111 5000 *	Matt Neligan - Acting Chief Executive
Gloucestershire Primary Care Trust	08454 221500	Jan Stubbings - Chief Executive
North Staffordshire Primary Care Trust	0845 602 6772	Graham Urwin - Chief Executive
NHS Direct NHS Trust; Health Advice and Information Line	0845 4647	Nick Chapman - Chief Executive

Note on NHS Direct

The NHS Direct Health Advice and Information service is to be withdrawn in the near future, once the mandate for the Urgent-Only NHS access 111 service has been enforced in all localities. It is therefore reasonable not to incur the expense and confusion of a complete number change for the Advice and Information service, which now has less than two years of operation left. The alternative number - 0345 4647 - (charged at the same rate as a call to a geographic number for all callers) has however been configured ready for use in parallel.

There is no justification for the decision to continue to totally withhold availability of this alternative number for the remaining life of the service. The total exemption from the terms of the Directions, which applies to all telephone services provided by the NHS Direct NHS Trust, was totally unnecessary. It being ruthlessly exploited by the NHS Direct NHS Trust and the many NHS bodies which use it as an agency to deliver their services, covering many other numbers not listed above, in disregard of the clear duty under the Health Act 2009.

Comment on Sheffield Star article - GP phone numbers switch

2011-08-06T09:09:00.001+01:00

I added the following comments to an article published by the Sheffield Star - GP phone numbers switch.

As the comment item was published as an unbroken string of characters, it may be more easily read below:

The work being undertaken by NHS Sheffield is to be commended.

Both it and the practices should however be aware that switching to a geographic or 03 number is the ONLY way of achieving the compliance with the terms of the contract, which was demanded by 1 April 2011.

GP contracts covering leasing of equipment and use of a particular system cannot preclude use of a legitimate telephone number. Migration to a 03 number is an option available to every practice.

The revisions to the contractual terms were applied in April 2010. Practices have had plenty of time to make the necessary arrangements.

NHS Rotheram has no need to continue to "review its policy"; its duty to enforce the terms of the contract has been unchanged since these revisions were applied 16 MONTHS AGO.

Along with the other PCTs, NHS Rotheram is set to be abolished in 20 months time.This behaviour does not help those of us who are campaigning to defend the NHS and the public servants who are charged with uploading its values.

NHS Doncaster and its practices should take a little trouble to check what patients are actually paying to call their GPs. When one looks at the facts it may be seen that the providers to the practices were mistaken in their assurances!

The implication that those calling from a BT line do not pay more to call 084 numbers than for an equivalent call to a geographic number is incorrect.

Whilst BT itself includes calls to 0845 numbers in the consequently inflated cost of its Call Plans, other call providers who may be used by those with BT lines do not.BT does not include calls to 0845 number in its "social tariff" - BT Basic. Nobody includes calls to 0844 numbers in their standard packages, so these invariably cause callers to incur a premium charge.

The expense of a "call back" system that prevents those wishing to speak with their surgery from incurring illegal surcharges is a ridiculous waste of money. Every practice is readily able to move swiftly into compliance - the call back idea is pure nonsense.

Example of how PCTs are failing

2011-07-28T09:41:00.003+01:00

UPDATE - This matter was discussed on the Ronnie Barbour Show on BBC Three Counties Radio - Listen here.

A good example of how the ban on use of expensive telephone numbers is failing to be enforced is highlighted by an article published by Bedfordshire PCT - 22 July 2011 : Dr Cakebread and Partners to get ‘local code’ phone number.

I quote below the text of an email message I have sent, circulated to various interested parties, but aimed directly at the key players:

• Paul Cooper – Press Officer – NHS Bedfordshire

• Tony Medwell - Head of Primary Care Commissioning - NHS Bedfordshire

• Vivien Kinch-Jameson - Managing Partner - Dr Cakebread and Partners

• Lynnette Brennan - Practice Manager - Dr Cakebread and Partners

The text of my email message follows:

[The article] includes some errors and a notable omission. As a national campaigner for the NHS, with extensive engagement in this issue, I point these out and comment.

Any belief that a 0844 number may be called “for the cost of a local call” has always been, and remains, false. Under the terms of contractual requirements introduced in April 2010, NHS GPs have a duty to determine whether the cost of calling a non-geographic number may, having regard to the arrangement as a whole, is greater than that of an equivalent call to a geographic number.

By its failure to make a proper determination, the practice was directly in breach of its contract by adopting this number.

As for the allegation that no money was made from this choice of number – this is at best misleading (one hopes that it is false). All 084 numbers are subject to revenue sharing – the call originating telephone company has to pass on part of its call charge to the call terminating company, the provider to the practice. That is why these numbers are more expensive to call.

This financial benefit is normally passed on, by being reflected as a reduction in the cost to the practice of the services provided. If not, then the practice was being “ripped-off”. If the practice did not make any money, as alleged, then it was doubly at fault (or perhaps commercially naive) by allowing its telephone service provider to profit at the expense of its patients.

It should be noted that all of the technical features available on a 0844 number are available on every other non-geographic number. It is only the 03 range which enables these to be utilised “for the cost of a call to a local or other geographic number”. It is the commercial benefit of revenue sharing which is available on 0844, but not 03, numbers. On discovering its error, the practice could have retained all of the same features by migrating to a 03, even the equivalent 0344, number. One suspects that is was on seeing the true cost of these features (which was being borne by patients) that the practice decided to abandon them in favour of a new system.

Ms Brennan may care to note that in the NHS the interests of patients are protected by principles, such as the right to access NHS services without charge to the benefit of the provider. This is not a “view” which they have to articulate. Had some patients expressed a view that they would like to pay the practice for improved services, this request would have had to be denied. It is the PCT, not the body of patients, which is responsible for ensuring that a contracted practice follows the principles of the NHS and respects the rights declared in the NHS Constitution. (The practice itself also carries this statutory duty.)

When Mr Medwell expresses his “strong feelings” he is doing nothing more than reflecting the terms of the contractual obligations which he is required to enforce, although he is clearly failing to do so. According to NHS Choices, NHS Bedfordshire has 8 GP surgeries (6 practices) using 0844 numbers in breach of the terms of their contracts, which demanded compliance (for those with such numbers in place in April 2010) by 31 March 2011.

A list of these surgeries is published at this link.

It is fair to note that Mr Medwell’s failure is echoed in neighbouring PCTs and across England and Wales. More information is available via this link.

I am naturally delighted that this practice has discovered its error and taken the necessary action. I am however disturbed that this was done for the wrong reasons and that the full nature of the mistake has not been acknowledged. Yet more disturbing is the fact that the PCT appears to be totally unaware of its proper responsibilities. If the PCT had discharged those responsibilities properly in respect of the other practices, then it is likely that this mistake would never have been made.

As all parties look to take this matter forward, I would be delighted to assist in any way.

PCTs failing to understand DH Guidance

2011-07-10T19:29:00.008+01:00

... on use of expensive telephone numbers to contact NHS providers

Introduction

Contrary to the understanding of many PCTs, the Department of Health position on the topic of use of expensive telephone numbers to contact NHS providers is very clear, simple and unqualified.

It is specified in the wording of Directions to NHS bodies [Directions] and revisions to the GMS contract [GMS] - NOTHING MORE.

Additional clarification of the Directions was provided in a "Dear Colleague" [letter]. No further guidance has been issued by the Department. This position has been confirmed in many written answers (see below).

The requirement is very simple, it amounts to -

prohibition of the use of telephone numbers which can cost
NHS Patients more than equivalent calls to a geographic number

Despite the clarity of the statement, there is a widespread mistaken assumption that the requirement is much more complex. In particular, there is a failure to recognise that the NHS is a universal service, with rights that extend to all patients, not just to a select group, even if that represents a majority.

For the record, and with apologies for the necessary repetition, I will quote all of the relevant references from the publications referred to above. Some quotations cover what is permitted, others what is prohibited (please use the respective links given above to confirm the context):

"... having regard to the arrangement as a whole, persons will not pay more to make relevant calls to the practice than they would to make equivalent calls to a geographical number." - GMS 29B

"... 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 ... " - GMS 29B.2.1

"... 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 ..." - GMS 29B2.2

"... having regard to the arrangement as a whole, persons will not pay more to make relevant calls to the NHS body than they would to make equivalent calls to a geographical number." - Directions 2(1)

"... 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 ... " - Directions 2(3)(a)

"... 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 ..." - Directions 2(3)(b)

"... prohibiting the use of telephone numbers which charged the patient more than the equivalent cost of calling a geographical number to contact the NHS." - Letter para 1.

"... contact telephone numbers which have the effect of the patient paying a premium above the cost of a call to a geographical number." - Letter para 2.

"These Directions do not prohibit an organisation from using specific number ranges for the purpose of contacting NHS services. 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." - Letter para 3.

Could it be any clearer?

Possible Omission

The only clarification that may have been omitted is the possible need for PCTs to understand that in the UK we purchase telephone call services from telephone call service providers, not from the person we are calling.

The person called may receive a financial benefit, but they do not determine the charge we pay, relative to the cost of an equivalent call to a geographic number. Obviously callers can expect to incur the cost of this benefit, however neither the person called, nor any agent of theirs, can control any further additional cost we may incur, simply due to the existence of "revenue sharing" on the call. (In some cases a benefit of 2p per minute, causes callers to incur an additional cost of 41p per minute).

We pay the charges set by our chosen provider under the terms of our chosen tariff. These are subject only to the charge regulations that are currently in force - not the regulations which some may wish to see, or mistakenly believe to be in effect. We pay the charges which are set, not those which some may argue "should be charged".

All telephone call service providers set rates for the UK as whole. Certain services are only provided to residents of the Kingston-upon-Hull area and other services are not available in all areas - there are however no local price differences.

Telephone call service providers publish their various tariffs, so these are available for inspection by GPs, telephone system providers to GPs, PCTs and all other persons. All parties may wish to determine the cost of calling particular numbers as against the cost of an equivalent call to a geographic number. NHS providers have a duty to make themselves aware of whether or not any caller pays more than the cost of an equivalent call to a geographic number to call their number.

I have prepared a summary of relevant charges from widely used providers, with links to their published tariffs for verification - a regularly updated version may be viewed here.

It would have been helpful for the Department of Health to have done something similar to save the cost of the same exercise being repeated by each practice and PCT, not to mention the danger of it being done ineffectively or not at all, however it chose not to do so.

A further Omission

It would perhaps have been helpful of the Department of Health to advise that those who are committed to a long term contract for systems which require the features of a non-geographic telephone number are able to migrate to a 03 number at any point during their telephone service contract without penalty.

Migration to 03 guarantees compliance with the terms of the Directions and Contract Revisions because all telephone service providers (under regulation) charge no more for calls to 03 numbers than for equivalent calls to geographic numbers.

The contract renewal, contract termination and "call back" provisions in the Directions and Contract Revisions are totally unnecessary, because this change to the arrangements for telephone service can be made in every case and at any time. Lease contracts on surgery telephone equipment and service contracts for telephone system software may be maintained notwithstanding revisions to a contract for provision of network telephone service. The possibility of premature termination of such contracts is of no direct relevance to the issue of use of expensive telephone numbers.

It is deeply regrettable that many practices and PCTs are unaware of this fact. Much energy is being wasted on the issues of contract termination, non-renewal and arranging to call back to patients.

The current position

The deadline for compliance with the requirements was 31 March 2011. This listing shows the PCTs with GPs in breach - cases are listed and shown on a map.

The Department of Health was, and remains, correct to say that "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 Department clearly wished to cover the possibility of forthcoming changes to telephone charges, as Ofcom had indicated the imminent possibility of regulatory changes affecting 084 numbers (0845 in particular). The regulations cover the reality of what callers actually pay, which is potentially subject to change. I address the current position in the following statement.

For a large number of commonly used tariffs 1, i.e.

BT Anytime 2, BT Basic, ALL Virgin Media landline tariffs 3,

ALL commonly used Mobile contract and Mobile PAYG tariffs

and the tariff for public payphones,

weekday daytime calls to 084 numbers cost more

than an equivalent call to a geographic number.

Notes: 1 Adherence to the terms of the tariff is assumed. 2 BT Anytime exceptionally includes calls to 0845 numbers. 3 Some Virgin Media tariffs offer cheaper calls to some 0844/3 numbers under some circumstances.

Unless it can be shown that no "person" would ever call under the terms of the tariffs listed then no 084 number can be used.

There are tariffs and circumstances under which unregulated penalty charges imposed for calling geographic numbers outside the terms of the Call Plan in effect exceed the regulated charge for calling 084 numbers. These perverse and anomalous cases are likely to disappear if the current Ofcom proposals for revised regulation are taken forward to meet the declared objective of simplification.

(These new Ofcom proposals will enable BT to join its competitors by being able to raise an "access charge" on calls to all 084 numbers and require the "service charge" element of currently bundled rates to be declared by users. The expectation, by the Department of Health and others, that revenue sharing would be removed from 0845 was not met. Further announcements from Ofcom are expected in the Autumn of 2011.)

To maintain that use of any particular 084 number is compliant one must disregard the possibility of any call being made under the terms of one of the tariffs listed above.

By permitting use of a 084 number, a PCT excludes those subject to any of these tariffs from the meaning of a "person" in the terms of the Directions and Contract Revisions.

Misrepresentation

The Guidance issued by the Department of Health is the Guidance issued by the Department of Health. Certain parties may have their own ideas about the Guidance which they would have wished the Department to have issued. They are entitled to their opinions, but they cannot claim that the DH Guidance is anything other than what is actually published by the DH. Any definitive statement about the Guidance issued by the Department, or its policy position, must include the appropriate references if it is to carry any authority.

Sadly, there are materials in circulation which make allegations about Guidance from the Department of Health, and its position on relevant issues, which cannot be sustained in the way that they have been understood. From the quotations in the following section of this briefing it would appear that some have been misled into believing that what is stated below represents the position of the Department of Health.

I offer quotes, highlighting key phrases and adding brief comments:

From - "GPC GUIDANCE: USE OF 084 NUMBERS IN THE NHS" January 2010, issued by the BMA and published here.

"GP practices (and all others bodies within the NHS using 084 numbers) should obtain written confirmation from their phone service supplier that the charge for a call to their number is no more expensive than making an equivalent local call. The DH has been assured by the main phone service supplier, NEG (Network Europe Group, a national provider of telephony services such as Surgery Line), that this is the case."

The competence of a particular "phone service supplier" to consult the tariff tables published by the various suppliers to callers is no greater than that of any other party. The idea that NEG is in any better position to provide the necessary assurance about the charges levied on callers than any other person is mistaken. NEG cannot be accountable for anything other than the accuracy of its reading of information published by others, and ensuring that the extent of its research is sufficiently comprehensive to cover all those who may call the practice.

There is no basis for an apparent claim that the Department of Health believes NEG to have privileged access to the tariffs of telephone companies, knowledge of which tariffs apply to callers, or particular skill in reading and interpreting publicly available documents.

Whilst NEG may have sent a document offering an "assurance" to the DH, there is no evidence that the DH has accepted it as such. It is likely that the DH will recognise that because NEG has an interest in the matter, as the reseller of Talk Talk numbers, it may have difficulty in approaching the task of investigating competitors' call charges with the necessary objectivity.

"As long as the tariff is equivalent to local rates, and the practice obtains a written guarantee from their phone supplier (usually NEG) that they are charging rates in line with local geographic calls, then they will be deemed to have fulfilled their medical services contract."

Rates charged by NEG (or any other supplier of surgery switchboard systems) to unspecified persons are of no relevance whatsoever to compliance with the relevant Directions and Contract Revisions. It is the charges imposed on callers by their telephone call service provider which are relevant. (See also the comment below the next quotation.)

There is no indication that "will be deemed" represents anything more than an opinion held by the BMA. There is no evidence whatsoever to show that the DH or anyone else would share the rather odd view that some unspecified charge levied by NEG had anything to do with compliance with the relevant contractual requirements.

"Practices can also ask their supplier to provide the information necessary to demonstrate that their call charges are in line with geographic call charges, as required by the new legislation."

This comment touches on the Omission from the guidance highlighted above. It falsely implies that it is charges imposed by the practice's telephone system provider ("their call charges") rather than those incurred by callers which are covered by the Directions and Contract Revisions.

In drafting the Directions and Contract Revisions, the Department refers only to the cost incurred by callers, whether they take service from NEG or any other provider. In fact, NEG does not provide network telephone service to private individuals, so no NHS patient pays charges set by this company.

From - Circular letter "Dear Surgery Line User" issued by NEG - 19 January 2010, copied and distributed by many Surgery Line Users - copy published here.

"The Government recognised that some telecoms providers (e.g. NEG) 'have chosen to charge no more for an 084 call than a call to a geographic number when dialing from a fixed line'"

Although it has failed to address this point in its Guidance, one must assume that the Department of Health is aware that NEG does not set the costs which callers incur (relative to that of an equivalent call to a geographic number) when calling NHS providers. The original reference was to the telephone company (BT) that chooses to impose unregulated "penalty charges" for 'out of contract' calls to geographic numbers, which exceed the regulated charge for calling 084 numbers, and those others who mirror its charges.

The Directions and Contract Revisions make no reference to "dialing from a fixed line". If this qualification applies to subsequent comments from NEG, then it is not stated.

"The Directions from the Secretary of State make clear that any NHS organisation is free to choose to continue with an 084 number. All that is required is for the NHS organisation to satisfy itself that the cost of calls to the NHS body is no higher than equivalent calls to geographical number.

"Having held many meetings with the Department of Health over the past year, we understand that the Department of Health would be happy for an NHS body such as yours to get this reassurance in the form of this letter from NEG to you confirming that the cost of calls via the Surgery Line solution is no higher."

There is no evidence to show that the Department of Heath regards all Surgery Line users, including GMS contractors, as "NHS organisations" or "NHS bodies".

There is no reason why NEG could not consult the relevant telephone tariffs so as to establish the relative cost incurred in calling any particular number to which the Surgery Line system is connected, as against that of an equivalent call to a geographic number. If somehow reaching the false conclusion that the cost was no greater, then there is no reason why NEG could not provide the reassurance which it wishes to offer with reference to the actual requirement stated by the Department of Health.

There is however no evidence to show that the Department of Health would be happy with such a reassurance if it were ill founded. As NEG offers no indication of the extent of its research into telephone tariffs, nor the period for which this is thought to be valid, one must have cause to question the reliability of its reassurance.

"During the consultation period, we provided evidence to the Department showing the comparative cost of calls to NEG Surgery Line under your existing contract compared with the OFCOM regulated tariff cost of calling a geographic number. The Department accepted our evidence, ..."

Ofcom does not regulate the cost of calling geographic numbers. BT is the only telephone service provider subject to absolute regulation of some of its charges - this does not include any of its charges for calling geographic numbers. There is no evidence that the Department of Health accepted this simple falsehood. This apparent misunderstanding (or deliberate misrepresentation) of the nature of telephone charge regulation should give any reader cause for concern.

The actual evidence submitted by NEG was flawed in a number of respects, not least because it only covered only one provider and only one of its tariffs, whilst claiming to make a universal point. The actual figures given were even incorrect with reference to that tariff, to the point where they inverted the proper conclusion. I covered this at length at the time - see this commentary.

There is no evidence to show that the Department of Health did anything more than acknowledge receipt of this submission. It may have accepted the document, this does not mean that it accepted the arguments advanced on this point! (At a different point in its submission NEG argues that patients are prepared to pay more if this means that they can thereby enjoy a better telephone service from their GP!)

"your decision to continue to deliver excellent services for your patients using NEG Surgery Line has the full support of the Department of Health"

The Department of Health may well support use of the Surgery Line system - that is not the point at issue. Given that the letter addresses only the regulations covering use of expensive telephone numbers as a means of funding the system, it would not be unreasonable for the reader to wrongly infer that this represents an allegation of Department of Health support for the funding arrangements.

Misunderstandings

I quote below extracts from recent communications from Primary Care Trusts, indicating how they are interpreting their duty to enforce the terms of the Directions and GMS Contract Revisions. In many cases they seem to believe that the additional qualifications which they have applied to the strictly drafted terms reflect DH Guidance and policy.

Every one of these statements indicates some degree of failure to understand the simply drafted terms of the Directions and Contract Revisions and a failure to recognise the option for re-arrangement which is available to every user of 084 numbers.

I quote extracts from various statements below. These were generally provided in response to being challenged over a failure to enforce the terms of the Directions and Contract Variations. In each case, I will be happy to provide full references and copies of the entire item from which I quote.

I have underlined key phrases. Please read these comments recalling that the significant, unqualified guidance from the Department of Health is expressed in the phrase "persons will not pay more".

From Berkshire West PCT (updated 19 Jul)

"The advice given by the Department of Health was that the cost of calling the 0844 numbers should be in comparison to the cost of using a fixed line to call a geographical number at the local BT rate."

From Surrey PCT

"... some telephone packages mean that patients don’t have to pay for daytime phone calls, but the 0844 might not be included in this and therefore they will be charged for these numbers. If this is at a local call rate – patients should still be expected to pay. ... if practices are meeting the terms of the Department of Health directive we are unable to influence this."

From West Kent PCT

"Generally calls made to NHS contractors using 0844 number should be charged at a local rate if calls are made from callers with a BT Standard Rate Tariff only. However if a customer is not on a Standard Rate Tariff their Service Provider can charge more for the call, if that is the case the customer should follow this up with their Service Provider as customers are informed of the T & C their Service Provider offer and this is so as there is freedom of choice as to which Service Provider a person signs up to for their phone service"

From East Berkshire PCT

"GP practices across east Berkshire are committed to ensuring patients pay no more than they need to when contacting their local surgery. The PCT is encouraging practices to fully explore all options when current contracts are up for renewal."

From Dorset PCT

"We can confirm that we have three practices in Dorset which use 084 numbers. These practices comply with the regulations, which means a call to them would cost no more than a call to a geographically equivalent number."

From Norfolk PCT

"We are working with practices to make sure they put in place arrangements which are convenient to patients and consistent with contractual requirements."

From Bournemouth and Poole PCT

"Within the NHS Bournemouth and Poole area there are nine practices using an 084 number, all of which report to be charging local rates. We have requested that a contract variation is signed which commits practices to reviewing call costs to ensure they are in line with guidance so that calls to their 084 number are charged at a local rate for fixed lines."

From Warwickshire PCT

"Primary Care Trust NHS Warwickshire said it was happy that no surgeries broke rules"

From Rotherham PCT

"The majority of our practices use the 0844 numbers or a local number. Calls to 0844 numbers are charged at the same rate as a local call when dialed from a landline."

From Barnsley PCT

"While for some it is still possible to be charged more than the cost of a landline call when phoning from a mobile, we are committed to supporting those GPs that operate 084 numbers to make changes"

From Leicester City and Leicester County and Rutland PCTs

"We do recognise the use of this number is a problem for patients"

"if practices were unable to renegotiate or terminate contracts they should consider a system where a patient can ask for a call back from the surgery"

From Suffolk PCT (Added 30 July 2011)

"We are in discussion with the practices and the provider to try and find a way of exiting earlier from the contracts."

From Bedfordshire PCT (Added 31 July 2011)

"We have been assured by the GP practices using 0844 numbers that their phone providers do not charge patients more than the cost of calling a local geographical number. However, neither NHS Bedfordshire nor the practices have access to details regarding the cost levied by patients’ own telephone providers for calling these numbers."

The accountable officers of these PCTs (and others) must be made to recognise that they are deciding to limit the scope of the simply drafted requirements for themselves. They are not guided, directed or bound by the Department of Health to apply any qualification to the simple phrase "persons will not pay more".

ALL patients must be able to access NHS services without charge from the provider, as the first of their rights under the terms of the NHS Constitution. The Health Act 2009 places PCTs under a statutory obligation to have regard to these rights.

Confirmation of the duty of PCTs

Many written ministerial answers from the Department of Health have confirmed the position. The most recent was on 14 June 2011, as follows:

"The Department issued guidance and directions to national health service bodies in December 2009 on the cost of telephone calls, which prohibit the use of telephone numbers which charge the patient more than the equivalent cost of calling a geographical number to contact the NHS. It is currently the responsibility of primary care trusts to ensure that local practices are compliant with the directions and guidance."

One may also read the same essential point being made as follows:

At the time of publishing this blog entry I am hoping that further clarification will emerge when this matter is raised in Questions to the Secretary of State for Health on Tuesday 12 July 2011.

PCT Cluster Chief Executives asked to remove "co-payment" from the NHS

2011-06-24T18:07:00.002+01:00

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.

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

2011-06-15T15:43:00.006+01:00

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

Background

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.

Links

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.

Distribution

•	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

How will NHS reforms meet the funding gap?

2011-06-13T13:59:00.000+01:00

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?

NHS GPs using expensive telephone numbers - new database

2011-06-08T23:00:00.007+01:00

(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

Comments on my campaigning efforts

2011-05-16T16:58:00.019+01:00

The thread of comments published below were originally added to "Resistance to the ban on use of 084 numbers by NHS GPs". As a discussion on much wider issues has developed they have been moved here - exactly as originally published.

Forward links to this item are being created.

Further contributions to the discussion or any comments relevant to this broadly focussed item, are warmly welcomed. All submitted comments are subject to moderation prior to publication.

This is a private blog, not a public forum, however I welcome public discussion of the issues. There is no easy way for me to prove this, as unsupportive comment that I choose not to publish here will not be published here! Furthermore, anyone who seeks to draw attention to any improper "censorship" should not expect such comments to be published here!

David Hickson

29 June 2011 (the date of the item to which the comments were originally added is preserved.)

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

2011-05-16T16:58:00.005+01:00

The revision to the GMS contract (adding clause 29B) has not effected a ban on the use of 084 telephone numbers by GPs.

This posting addresses the relevant provisions in detail and covers some of the (spurious) reasons that may be offered to suggest that they do not apply to cases where clearly they do.I am advised that even after PCTs have gained some understanding of the issues, they are unable to ensure compliance with the stated contractual terms.

Further to these remarks, I would be delighted to address any specific obstacles to achieving compliance. If, after noting the remarks below, there are seen to be reasons why PCTs permit practices to continue using these numbers after all necessary processes, prior to and including formal action in respect of a breach, have been concluded, then I am most anxious to know what they may be.

Please contact me with any such cases, either directly or by adding a comment to this posting, and I will respond.

Introduction

It is important to understand that the Department of Health has issued no formal explanation or advice about how the terms should be interpreted or applied. Others, notably the BMA, have expressed their views and opinions, however none of these have been endorsed by the Department.

It is for each PCT to decide how it should interpret the terms, as drafted (and nothing more), when making a determination about whether any particular GP is complying with its contractual duties.

I am totally convinced that proper application of these terms would have ensured that no 084 telephone number was being used by the deadline for compliance of 1 April 2011. Every such number fails the test of acceptability, and every GP is able to vary the terms of its arrangement for the provision of network telephone service so as to migrate to an acceptable number.

Readers may find it convenient to refer to a copy of the terms of the GMS contract, clause 29B, (available in various forms from the Department of Health) as I address the essential elements of the clause as it is worded. I quote extracts that should stand by themselves, but it is vital to ensure that they stand in context.

Structure of my comments

>>>>	The key element of the requirement relates to the cost incurred in telephoning the practice
	>>>	How to determine which numbers are covered
	>>>	Statement from Ofcom confirming that only 03 numbers meet the requirements
	>>>	The stated policy of the BMA GPC and how this is applied to undermine the requirements
	>>>	Confirmation of why calls to 084 numbers are more expensive
	>>>	Attempts to suggest that the requirements do not apply to all callers
>>>>	Applicability of the requirements to newly adopted non-geographic numbers
>>>>	The need for those with existing non-geographic numbers to review their position
	>>>	The action that those with existing numbers are required to take
	>>>	The competence of GPs, as recognised and to be applied under the proposed "NHS reforms"
	>>>	The worthless "Call Back" provision, which would never apply
>>>>	Various possible terminations

... WILL NOT PAY MORE ...

having regard to the arrangement as a whole, persons will not pay more to make relevant calls to the practice than they would to make equivalent calls to a geographical number

The first point to note is that the actual cost of a telephone call (what "persons" pay) is set by the telephone company through whom the call is made - not by Ofcom, the practice, its telephone system provider (commonly NEG) nor its network telephone service provider (commonly Talk Talk). There is some regulation of some absolute call charges set by BT, but this does not apply to calls to a geographical number, nor the relationship between the two.

Secondly, the practice is required to have regard to "the arrangement as a whole". Not the circumstances of some of its patients, nor even that of a majority, but the arrangement as a whole. Any significant number of cases where "persons" will pay more would cause a number to fail this test, regardless of any cases where they would not.

Thirdly, the phrase "will not pay more" is used. This implies that the practice must have some reasonable degree of confidence that the telephone number they are using, or are to use, actually is charged at no more than the rate applicable to an equivalent geographic call. There can be no consideration of what some may wish or think proper. This requirement is not limited to those cases where the practice, or its agents, may perhaps be able to exercise control over what is charged.

Determining which numbers meet the requirement

There is no assistance provided by the Department of Health as to which ranges of non-geographic numbers are likely or guaranteed to meet this requirement.

With reference to the Directions to NHS Bodies, which are quite separate but impose very similar requirements, the Department of Health has perhaps gone a little too far in stressing that it is the actual cost found to be incurred by the caller, rather than the type of number per se, which is important.

In this different, but related, context the Department has stated:

"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".

084 was a poor example to choose as an illustration of the type of range where only numbers that are "not charged more than the equivalent cost of calling a geographical number" may be used. Whilst the statement is true in principle, in fact there are no cases of 084 numbers which can be found to meet this requirement.

At the time when this comment was drafted, Ofcom was (informally) considering the possibility of introducing regulations to fix the rate charged for calls to 0845 numbers to be no greater than that for geographic numbers. Such regulation could not however have been introduced before the Autumn of 2011, after Ofcom acquired the necessary new powers, so it was always irrelevant. As it happens, Ofcom has now abandoned this idea, as it has chosen to proceed in another way.

What Ofcom has chosen to do will remove the present perverse and exceptional cases where calls to 084 numbers are not more expensive than calls to geographic numbers; it will also cause the "Service Charge" which exists on all such calls to be more transparent, including being declared by all those who use such numbers. An announcement of the plans for implementation of these measures will be made in the coming months.

When all publication of 084 numbers has to be accompanied by the declaration of the level of Service Charge, it will be much easier to determine which numbers are more expensive.

In the meantime, Ofcom has been helpful in providing me with formal quotable statements in response to specific questions about its understanding of the present situation.

I asked;

Can telephone companies set charges for 0845/44/43 above geographic number (01/02/03) rates? If so, is it common for them to do so?

Ofcom replied;

Aside from BT, fixed and mobile telephone companies are able to set their own charges for 0845/44/43 numbers and have no requirement to align these charges to the rates used for 01/02/03 numbers.

Only 03 is charged precisely the same as 01 and 02 numbers by all telephone companies.

084 numbers are frequently charged at a higher rate than a 01, 02 or 03 number. Where they are not charged at a rate above a 01/02/03 number they are, however, frequently not included in a calling plan, thus callers will pay an additional charge for the call. Charges for these numbers are highest on mobiles, particularly on pay as you go contracts, and not generally included in their calling plans.

It is a simple task to verify the facts behind this general statement, by reference to the commonly used tariffs. I have published illustrative examples and links to published tariffs.

It should be noted that 03 numbers are guaranteed to meet the requirements absolutely. This is due to Ofcom regulations to this effect, which have 100% compliance.

There is no other range of non-geographic numbers (not even 080) that can be shown to meet the requirements.

The BMA, assurances, interpretations etc.

The BMA has offered guidance to its members (published here). It is free to do so, however this advice carries no authority whatsoever. It may also be relevant to understand that the advice is provided from a position of opposition to the intention of the measures.

The BMA GPC repeated states its policy that NHS patients should be required to pay to subsidise the cost of some GP telephone systems. This was proposed in the BMA submission to the Department of Health consultation on this subject and is repeated in the guidance issued after this proposal was rejected:

"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 comment is made with reference to the quality of communications service provided by the GP and can therefore only relate to charges made by the GP, as indirectly applied through use of revenue sharing telephone numbers.

This proposal, which would have required an alteration to the terms of the NHS Constitution or for specific parliamentary sanction to be granted, was roundly rejected.

As the BMA restates this policy position at the head of the guidance, it may be assumed that what follows is intended to assist members in evading the contractual provisions. By choosing to re-state its opposition to the measures at the head of the guidance, there can be little doubt as to the intention.

The BMA interpretation of the position of the Department of Health has not been endorsed by the Department of Health. The Department repeatedly confirms that there is nothing to add to what is contained in the published terms. The PCT must draw its interpretation from these alone.

The key element of the BMA guidance is the idea that an "assurance" about the relative cost of calling, offered by the provider of a telephone system to the practice, can show that the requirements are met. To those who understand that this company can have no influence over what the various telephone companies charge, this "assurance" is clearly seen as being totally worthless. One who has no competence to deliver on an "assurance" cannot be held to it.

If a practice can perhaps naively claim not to understand how telephone charges are set and thereby to have been adequately "satisfied" by a worthless "assurance", then it may claim to have fulfilled its duty under the terms of the GMS contract. I may be going too far if I were to accuse the BMA of seeking to deliberately mislead its members so that they can meet the requirement of being subjectively and falsely "satisfied" by a worthless assurance. This condition of "satisfaction" may however need to be corrected, if proven ignorance and stupidity on the part of the practice were to be considered valid ways of achieving compliance.

I have not yet seen any actual "assurance" about the relative cost of calling any specific telephone number. The text of this publication from NEG is often quoted, but it only contains a general offer to provide such an "assurance". (It also pre-dates publication of the actual terms of the revisions to the GMS contract!) The author seems to be very careful to refer only to what has been said to and by various parties, holding back from making any explicit statement that amounts to an assurance that could be used in a particular case.

If anyone has an evidence of such an assurance being provided in respect of a 084 number (without qualification that causes it to fail to meet the need for consideration of "the arrangement as a whole"), then I would be very interested to see it.

Just for the record, it may be noted that NEG uses Talk Talk as the provider of telephone service to its clients. Talk Talk charges its residential customers more than the cost of an equivalent call to a geographic number for calls to the 0844 numbers it provides to GPs, through NEG. Whilst NEG cannot control the cost of calling the numbers used by its clients and may not be fully appraised of what this is, one might expect its relationship with Talk Talk to be sufficiently close for it to be aware that the assurance it offers would not even cover patients who share the same telephone service provider as their GP.

Why 084 numbers are used, and why they are more expensive

Ofcom provides the essential facts:-

I asked;

Do companies using 0845/44/43 numbers rather than geographic rate numbers (01/02/03) gain a financial benefit from doing so?

Ofcom replied;

0845/44/43 numbers include a revenue sharing component in their charges which allows part of the revenue from the calls to be passed to the organisation using one of those numbers. Geographic rate numbers (01/02/03) do not include a revenue share.

The revenue available in those ranges is relatively low and to our knowledge is not normally passed as cash to those companies but is used to offset the cost of operating the communications systems used (eg automated call handling, answering machines, call centres etc).

This subsidy enables the cost of the surgery telephone system to appear to be much less than it truly is. The payments being extracted from patients and used to meet expenses that properly belong with the practice are unseen, because they are obtained indirectly through the revenue sharing mechanism involving the two respective telephone companies. All that is visible to the practice is smaller charges for its telephone system than those to which it has committed itself, because it has been using payments by patients to make up the difference.

It is of course natural that the provider of a system will do all it can to prevent the true costs from being exposed. It is also natural that the practice would wish to take advantage of an opportunity to benefit from subsidy. NHS providers are not able to take advantage of financial contributions from NHS patients as a charge for accessing NHS services - even if paid willingly! If England remains within the NHS, this will continue to apply.

Confusion about responsibility for charges

Some suggest that the terms of the contract only cover those charges which the provider of the number is able to predict or control. This is a total invention; there is no reference to any such limitation.

It is perfectly correct for NEG to say that it can do nothing about the cost of calls from mobiles. The GMS contract does not attempt to tell NEG, or anyone else, what to charge for telephone calls.

It simply tells GPs that they cannot use numbers that are expensive for callers. Because this means that they can no longer benefit from subsidy derived from high rates paid by patients so as make the NEG system seem cheaper than it is, then NEG must look to providing a more cost effective system.

The only range of non-geographic numbers which a practice may predict to be no more expensive to call than a geographic number is 03.

Under present regulations, which are intended to be withdrawn shortly, the pence per minute rates charged by BT for calls to 084/087/09 numbers are fixed. There is however no longer any enforced relationship with the cost of calling geographic numbers, as this is no longer regulated.

Although BT includes calls to 0845 numbers in some of its packages (e.g. Call Plans) they are excluded from others (e.g. BT Basic). Calls to 0844 numbers are invariably excluded from packages that cover calls to geographic numbers, by all providers.

The terms of the GMS contract clearly refer to the actual cost of telephone calls, without any qualification in respect of regulation or control of prices. Had it been intended that the requirements were to be limited in this way, then the whole exercise would be a waste of time, as there is so little regulation or control.

One must remember that it is perfectly natural for a telephone company to recover the cost of paying on a revenue share from callers. Furthermore, this is a fairer approach than that of recovering this cost from callers in general.

Anyone who seriously believed that GPs could benefit from a subsidy of their costs, amounting to up to 5p per minute on incoming telephone calls, without this cost having to be met by callers, must be guilty of a most unworthy degree of naivety or carelessness towards patients. (It is not for me to judge whether it is this foolishness, or a knavish disregard for the principles of the NHS that lies behind the decisions to get involved in this affair.)

... ENTER INTO, RENEW OR EXTEND ...

The Contractor shall not enter into, renew or extend a contract or other arrangement for telephone services unless it is satisfied that ...

This is the provision (sub-clause 29B.1) which applies to those who did not have a non-geographic number in use when the variation notice was served by the PCT and acknowledged (the draft was published by the Department of Health in April 2010), or who may have renewed or extended use of such a number after that date. It stands for the future.

From that date (depending on how quickly PCTs served the notices) there should have been no more 084 numbers coming into use by GPs. Sadly that has not been the case.

This implementation date occurs before the deadline of 1 April 2011, by which those with such numbers already in use had to modify their arrangements.

... review the arrangements ...

Where the Contractor is party to an existing contract or other arrangement for telephone services under which persons making relevant calls to the practice call a number which is not a geographical number, the Contractor must ... before 1st April 2011, review the arrangement ... and ... take all reasonable steps ...

This provision (sub-clause 29B.2) is intended to bring all those currently failing to comply with the requirements that apply henceforward into line. A specific deadline is set, there is no provision for serving out the term of any existing arrangement, unless it cannot be varied.

Having been alerted by the BMA in January 2010, practices had up to 15 months in which to do the necessary work and take the necessary corrective action. With no advance notice prior to publication of the terms of the revisions in the necessary Statutory Instrument, PCTs were only engaged in this process for around 12 months. This nonetheless should have provided sufficient time to prevent what has occurred - the 1 April 2011 deadline has passed with most of the 084 numbers still in place.

Given that the review element was however largely seen to be flawed and inadequately reviewed, there is no reason why the necessary steps may not now be taken, even though the deadline of 1 April 2011 has passed.

Of the various "steps" suggested in sub-clause 29B.3, there is one which is relevant to most cases.

... varying the terms of the contract or arrangement

Many practices would defend their use of 084 numbers on the basis that they need to use the "network waiting" feature readily available with all non-geographic numbers. This feature provides an unlimited capacity for queuing up callers waiting to get through to speak to someone. Waiting callers are effectively held at the telephone exchange rather than at the surgery, whereby the number of callers kept waiting is limited by the capacity of the incoming lines.

Practices may be keen to retain this feature, or may indeed be contractually committed to continuing use of a system which depends on it. This would preclude migration to a geographic number, however migration to a 03 number, charged at the "Geographic Rate", is an option open in all cases.

All providers of network telephone service are known to permit customers to vary any existing contract, at any time, so as to migrate from any one type of geographic number to another. As calls to 03 numbers are charged at the same rate as calls to geographic numbers, 03 numbers fully meet the requirements. They obviously provide all of the same technical facilities as other non-geographic numbers.

If migrating from 084 to 03, a further facility is available to perhaps ease the process of changing number. The equivalent 034 number is reserved and available for use in every case. A number change could therefore take place by changing only the second digit of the number, e.g. 0844 477 1799 to 0344 477 1799.

I am not aware of any case where a network telephone service provider has refused a request for such a variation.

Migration from 084 to 03 involves giving up the financial benefit of the revenue share so that the practice would need to meet all of the costs of its chosen telephone system from the funding provided for the purpose. The subsidy at the expense of patients is lost.

One understands that a practice may be reluctant to give up this subsidy, and its system provider may be reluctant to see the true full cost of its system laid bare.

The vast majority of NHS GPs are able to fund their telephone service and other surgery expenses from the funding provided for the purpose. I see no reason why a practice that has chosen a very expensive telephone system and perhaps already benefitted from improper subsidy of its costs for some time should not now be ready to pay its own bills without financial assistance from patients.

The competence of GPs in managing and delivering NHS services

The independence of GPs as businesses, with the consequent capacity to handle commercial and contractual issues, is celebrated. The skills of medical practitioners in general practice in England in dealing with contractual and financial issues in the best interests of their patients are to be exploited by the currently proposed reforms to the NHS.

The BMA's opposition to the principles of the NHS is noted, however I cannot see any reason for there being any problem in complying with the contractual provisions. Every practice must surely be competent to effect the necessary change to the arrangements for provision of telephone service, so that the interests of patients and the principles of the NHS may be upheld. If this relatively modest task cannot be accomplished, then GPs could never have been expected to take on the much wider responsibilities to which many have now signed up.

One must assume that these highly competent commercial operators were fully aware of the implications of the arrangements for telephone service to which they committed themselves. They are surely ready to apply the retained principles of the NHS to their dealings, as they are now required to do (albeit reluctantly). Indeed they should be able to do so without any intervention from "unnecessary layers of management".

Call backs

If, despite taking all reasonable steps ..., it has not been possible to ensure that, having regard to the arrangement as a whole, persons will not pay any more to make relevant calls to the practice than they would to make equivalent calls to a geographical number, the Contractor must consider introducing a system under which if a caller asks to be called back, the Contractor will do so at the Contractor’s expense.

It is important to note that if compelled by this provision (in sub-clause 29B.4) to "consider introducing" such a "system", the GP has already acknowledged that its existing number fails the test set out earlier and has been unable (not unwilling, but unable) to vary the terms of the arrangement (i.e. to migrate to a 03 number).

After having considered introducing an automated system of collecting requests for call backs, most practices would be likely to decide not to proceed with introducing such a system, due to the considerable expense that would be involved. It would also seem to be quite improper to offer such a second class option for contact whilst direct contact was still available to those prepared to pay.

A system that was nothing more than a procedure whereby those answering calls would accept requests for a call back would also be highly inconvenient and expensive for both the practice and the caller. The caller would already have incurred most of the expense involved in any call by the time they got to speak to someone and in many cases making the arrangement for the call back would be likely to take as long as perhaps arranging the appointment, the only purpose for the call.

Given that there would appear to be no valid reason why a request to migrate to 03 should be refused, this provision is utterly worthless. Calling back is certainly NOT available as an alternative option for those who wish to retain an expensive number and comply with the terms of the contract.

... terminating the contract or arrangement

One option suggested for those unable to comply with the revised terms is to terminate their existing arrangement for telephone service.

There may be some who are able to show that they entered into an arrangement on the basis that it enabled full compliance with the principles of the NHS - i.e. causing no charge to be levied on patient. If so, then they may be able to escape the imposition of penal early termination fees if seeking to terminate an arrangement for the provision of telephone service prematurely. That can only be a matter between them and their telephone service provider.

It is important to note that the only issue addressed by the provision is the telephone number used. Other aspects of an arrangement, e.g. a lease on locally installed telephone equipment, use of a particular software system on a local branch exchange are not covered. Costs incurred as a result of a decision to terminate such an arrangement cannot be linked to the need to comply with the requirements covering the telephone numbers used.

The fact that the practice may have chosen to fund these items through use of a revenue sharing telephone number, was a decision that it made freely. Income from the revenue share could have been used for any other purpose. If the practice was unaware of what it was doing then it may have an issue to raise with anyone responsible for having provided false information; that cannot however provide a basis for failure to now comply with its contractual duty to adhere to the principles of the NHS.

There are however two other possible terminations, not stated directly in the contract. The first is for the practice to terminate its contract with the NHS, on the basis that it needs payments from patients in order to provide its services. The other is for the publicly funded health service in England to opt-out from the NHS, on the same basis!

The Minister of State, Simon Burns, has clearly stated that it is PCTs who have the responsibility of ensuring that GPs comply with their contractual obligations; he has also stated that PCTs are to be abolished, because they are "unnecessary" (see this item). This is one of a number of indications that the publicly-funded health service in England is to terminate its association with the NHS. We await developments on this point.

GIG Bwrddau Lechyd (NHS Health Boards in Wales) to enforce principle of "free at the point of need" before the NHS can move forward

2011-04-29T08:13:00.001+01:00

This posting is to complement that covering England - "PCT Clusters to enforce principle of "free at the point of need" before the NHS can move forward". (If someone can offer me a suitable Welsh translation for the full title of this posting I would be delighted to use it - please contact me.)

To support efforts by NHS Officials to enforce the principle of "free at the point of need" and to assist those to whom they are accountable to hold them to this important task, I provide a list of surgeries as shown in the Health in Wales Directory as having failed to adhere to the conditions of the GMS Contract. Direct links to each Directory entry are provided for verification.

I have been assured by the (latest) Minister for Health and Social Services for the Welsh Assembly Government that Local Health Boards in Wales have exactly the same responsibility as that held by PCT Clusters in England. Furthermore, the contractual requirements they are enforcing are drafted IDENTICALLY (see paragraph 1B of Schedule 6 of the GMS Contract Regulations) to those in force in England.

With the single qualification of the section number, every point made under the heading - "What GPs using non-geographic numbers needed to do before 1 April 2011" holds true for Wales.

All of the detail under the heading - "The cost of calling telephone numbers" is equally true for Wales, as is the table of illustrative costs.

The league table of Health Boards (and index to the list)

The following table shows the Health Boards ranked by the number of surgeries shown to be in breach of their GMS contract by my extracts from the GIG Cymru Health in Wales directory. This provides an indication of the caseload faced and could be used as an indicator of the way in which each Health Board serves its patients.

Clicking on the name of the Health Board provides access to the relevant section of the list.

Rank	Surgeries	Health Board
1	14	Abertawe Bro Morgannwg University Health Board
2	12	Cardiff & Vale University Health Board
3	10	Cwm Taf Health Board
4	9	Betsi Cadwaladr University Health Board
5	9	Hywel Dda Health Board
6	7	Aneurin Bevan Health Board
7	0	Powys Teaching Health Board

The list of practices shown to be in breach

This list is grouped by Health Board and area, as in the directory.

Columns in the table

(Press [alt+5] to return to this information.)

The "Practice" links to the directory entry for the Surgery - the sole basis for inclusion of the item in the list.

The "Surgery" is the location where NHS services are delivered. Practices may have one or more surgeries and telephone numbers.

The "Charge type" is a reference to my table of call costs, supported by links to published telephone tariffs.

In every case the "Provider" of the network telephone service is Talk Talk, to whom all of listed numbers are allocated, although this may be arranged through an agent. It is Talk Talk with whom the possible migration to a 03 number would need to be arranged, if the contract for telephone service is to be continued. Talk Talk is known to offer this facility as standard, at any point during the term of a contract.

(The England list has a separate column for the many "Providers". I have not added a column for AM, as there are none as I publish this list.)

Area	Practice	Surgery	Postcode	Tele No	Charge type
Abertawe Bro Morgannwg University Health Board
Bridgend	Dr M Obaidullah	New Street Surgery, 3 New Street, Aberkenfig, Bridgend	CF32 9BL	0844 477 8637	0844 (g6)
Bridgend	Madelin SK	Oak Tree Surgery, Whitethorn Drive, Brackla, Bridgend	CF31 2PQ	0844 477 1795	0844 (g6)
Glynneath	Daniels MK	Vale of Neath Practice, 102 High Street, Glynneath, Neath Port Talbot	SA11 5AL	0844 4773524	0844 (g6)
Maesteg	Rogers MA	Llynfi Surgery, Llynfi Road, Maesteg, Bridgend	CF34 9DT	0844 477 8793	0844 (g6)
Nantymoel	Nantymoel Surgery	Nantymoel, Bridgend	CF32 7NA	08444 770923	0844 (g6)
Neath	Sheehan BD	Castle Surgery, 1 Prince of Wales Drive, Neath, Neath Port Talbot	SA11 3EW	0844 4778970	0844 (g6)
Pencoed	The Medical Centre	Heol Yr Onnen, Pencoed, Bridgend	CF35 5PF	0844 4778890	0844 (g6)
Pencoed	The Medical Centre (Branch surgery)	The Medical Centre, Tredegar Avenue, Llanharan, Pontyclun, Rhondda Cynon Taff	CF72 9QU	0844 4778792	0844 (g6)
Pontycymmer	Meredith-Smith A	Cwm Garw Practice, Victoria Street, Pontycymmer, Bridgend	CF32 8NN	0845 293 7399	0845
Pontycymmer	Meredith-Smith A (Branch surgery)	The Surgery, Heol Arfryn, Bettws, Bridgend	CF32 8TP	0845 293 7399	0845
Pontycymmer	Meredith-Smith A (Branch surgery)	The Surgery, Heol Gellilodrau, Llangeinor, Bridgend	CF32 8PS	0845 293 7399	0845
Port Talbot	Fairfield Surgery	Port Talbot Resource Centre, Moor Road, Port Talbot, Neath Port Talbot	SA12 7BJ	0844 8151980	0844 (g6)
Port Talbot	Morrison Road Surgery	Port Talbot Resource Centre, Moor Road, Port Talbot, Neath Port Talbot	SA12 7BJ	0844 576 9960	0844 (g6)
Port Talbot	Llewellyn MH	Mount Surgery, Margam Road, Port Talbot, Neath Port Talbot	SA13 2BN	0844 477 8975	0844 (g6)
Aneurin Bevan Health Board
Abertillery	Akhtar, Dr B R	Six Bells Medical Centre, Eastville Road, Six Bells, Abertillery	NP13 2PB	08444 778564	0844 (g6)
Caerphilly	Kaushal SC	Meddygfa Tridwr, 30 Thomas Street, Abertridwr, Caerphilly	CF83 4AZ	0844 4778635	0844 (g6)
Crumlin	Ojha S	The Surgery, Crown Street, Crumlin	NP11 4PQ	0844 4778614	0844 (g6)
Cwmbran	Hughes A	Llanyravon Surgery, Llanyravon Way, Cwmbran	NP44 8HW	08444 778630	0844 (g6)
Rhymney	Hughes A (Branch surgery)	Abertysswg Community Centre, Community Centre, The Green, Rhymney	NP22 5AH	08444 998414	0844 (g6)
Ystrad Mynach	Greville WD	Oakfield Surgery, Oakfield Street, Ystrad Mynach	CF82 7WX	0844 4773115	0844 (g6)
Ystrad Mynach	Greville WD (Branch surgery)	Ystrad Mynach Health & Education Centre, 16 Bedwlwyn Road, Ystrad Mynach	CF82 7AD	0844 4773115	0844 (g6)
Betsi Cadwaladr University Health Board
Colwyn Bay	Wynne-Jones G	Rhoslan, 4 Pwllycrochan Avenue, Colwyn Bay, Conwy	LL29 7DA	0844 477 2588	0844 (g6)
Colwyn Bay	Sissons HM	Rysseldene Surgery, 98 Conway Road, Colwyn Bay, Conwy	LL29 7LE	0844 4778574	0844 (g6)
Criccieth	Webb JG	The Health Centre, Criccieth, Gwynedd	LL52 0RR	0844 576 9087	0844 (g6)
Nefyn	Harris K	Ty Doctor, Ffordd Dewi Sant, Nefyn, Gwynedd	LL53 6EA	0844 815 1166	0844 (g6)
Penrhyn Bay	Gilmore R	The Medical Centre, Plas Penrhyn, Penrhyn Bay, Llandudno	LL30 3EU	08444 773342	0844 (g6)
Penrhyn Bay	Gilmore R (Branch surgery)	Medical Centre, York Road, Deganwy, Conwy	LL32 8AT	0844 477 3343	0844 (g6)
Penrhyndeudraeth	Evans DW	Bron Meirion, Castle Street, Penrhyndeudraeth, Gwynedd	LL48 6AL	0844 477 2493	0844 (g6)
Wrexham	Roberts TG	Beechley Medical Centre, 73 Ruabon Road, Wrexham	LL13 7PU	0844 477 0941	0844 (g6)
Wrexham	Wood Helen M	Borras Park Surgery, Borras Park Road, Wrexham	LL12 7TH	0844 477 8601	0844 (g6)
Cardiff & Vale University Health Board
Cardiff	Tiwari RK	Butetown Health Centre, Loudoun Square, Cardiff	CF10 5UZ	0844 4999923	0844 (g6)
Cardiff	Tiwari RK (Branch surgery)	Grangetown Health Centre, Cambridge Street, Grangetown, Cardiff	CF11 7DJ	0844 4999924	0844 (g6)
Cardiff	Brown NK	Cathays Surgery, 137 Cathays Terrace, Cardiff, South Glamorgan	CF24 4HU	08444 778608	0844 (g6)
Cardiff	Naseem M A	Grange Surgery, 150 Clare Road, Grangetown, Cardiff	CF11 6RW	0844 4771890	0844 (g6)
Cardiff	Naseem M A (Branch surgery)	Butetown Health Centre, Loudoun Square, Butetown, Cardiff	CF10 5UZ	0844 4771891	0844 (g6)
Cardiff	Naseem M A (Branch surgery)	The Health Centre, Cambridge Street, Grangetown, Cardiff	CF11 7DJ	0844 4771892	0844 (g6)
Cardiff	Bentley RP	Riverside Health Centre, Canton Court, Wellington St Cardiff, South Glamorgan	CF11 9SH	0844 477 8710	0844 (g6)
Cardiff	Bentley RP (Branch surgery)	31 Penhill Road, Cardiff	CF11 9PR	0844 477 8709	0844 (g6)
Cardiff	Sabir AW	The Surgery St Davids Crt, 68A Cowbridge Road East, Cardiff, South Glamorgan	CF11 9DT	0844 477 8713	0844 (g6)
Cardiff	Sabir AW (Branch surgery)	92 Salisbury Road, Cathays	CF24 4AE	08444 778714	0844 (g6)
Penarth - Vale of Glamorgan	Thomas Sara	Albert Road Surgery, Albert Road, Penarth - Vale of Glamorgan, Vale of Glamorgan	CF64 1BX	0844 477 5191	0844 (g6)
Penarth - Vale of Glamorgan	Lewis Peter R W	Redlands Surgery, Redlands Road, Penarth - Vale of Glamorgan, Vale of Glamorgan	CF64 3WX	0844 477 3591	0844 (g6)
Cwm Taf Health Board
Aberdare	Thomas; Dr DD	Maendy Place Surgery, 1 Maendy Place, Weatherall Street, Aberdare, Mid Glamorgan	CF44 7AY	0844 4778633	0844 (g6)
Llantrisant	Jones; Dr J.W	Newpark Surgery, Heol Y Gyffraith, Talbot Green, Llantrisant, Rhondda Cynon Taff	CF72 8AJ	0844 4778719	0844 (g6)
Llantrisant	Jones; Dr J.W (Branch surgery)	Gwaunmiskin Road Surgery, Gwaunmiskin Road, Beddau, Pontypridd	CF38 2AU	0844 4770933	0844 (g6)
Merthyr Tydfil	Richards; Professor Jonathan P	Morlais Medical Practice, Ty Morlais, Berry Square,, Dowlais, Merthyr Tydfil	CF48 3AL	0844 477 2483	0844 (g6)
Pontypridd	Jones; Dr Christopher D.V	Taff Vale Practice, Duffryn Road, Rhydyfelin, Pontypridd, Mid Glamorgan	CF37 5RW	0844 4773487	0844 (g6)
Pontypridd	Jones; Dr Christopher D.V (Branch surgery)	Station Yard, Windsor Place, Ynysybwl, Mid Glamorgan	CF37 3DW	08444 773487	0844 (g6)
Pontypridd	Jones; Dr Christopher D.V (Branch surgery)	The Health Centre, Bridge Street, Pontypridd, Mid Glamorgan	CF37 4SE	08444 773487	0844 (g6)
Pontypridd	Jones; Dr Christopher D.V (Branch surgery)	The Surgery, Porcher Avenue, Glyncoch, Pontypridd, Mid Glamorgan	CF37 3DB	08444 773487	0844 (g6)
Pontypridd	Jones; Dr Christopher D.V (Branch surgery)	Richards Street, Cilfynydd, Pontypridd, Rhondda Cynon Taff	CF37 4NL	08444 773487	0844 (g6)
Rhondda	Baron; Dr RT	St. Andrews Surgery, 1 De Winton Street, Tonypandy, Rhondda, Mid Glamorgan	CF40 2QZ	08444 996930	0844 (g6)
Hywel Dda Health Board
Fishguard	Mann MS	The Health Centre, Ropewalk, Fishguard, Pembrokeshire	SA65 9BT	0844 5769098	0844 (g6)
Llandysul	Roberts DAT	Meddygfa Teifi Surgery, New Road, Llandysul, Ceredigion	SA44 4QJ	08448 151117	0844 (g6)
Llanelli	Harries AI	Adfer Medical Group, Thomas Street, Llanelli, Carmarthenshire	SA15 3JH	0844 815 1888	0844 (g6)
Llanelli	Harries AI (Branch surgery)	Health Centre, Llwynhendy Road, Llwynhendy, Llanelli, Carmarthenshire	SA14 9BN	0844 815 1888	0844 (g6)
Pembroke Dock	Thomas MD	Argyle Medical Group, Argyle Street, Pembroke Dock, Pembrokeshire	SA72 6HL	08444 996946	0844 (g6)
Pembroke Dock	Thomas MD (Branch surgery)	St Clement's Surgery, St Clement's Road, Neyland, Pembrokeshire	SA73 1SH	08444 996946	0844 (g6)
Pembroke Dock	Thomas MD (Branch surgery)	St Oswald's Surgery, The Parade, Pembroke, Pembrokeshire	SA71 4LD	08444 996946	0844 (g6)
Saundersfoot	Davies HE	Saundersfoot Medical Centre, Westfield Road, Saundersfoot, Pembrokeshire	SA69 9JQ	0844 477 2447	0844 (g6)
Tenby	Griffiths IJ	The Surgery, The Norton, Tenby, Pembrokeshire	SA70 8AB	08444 773 187	0844 (g6)