The NHS GP - 084 "co-payment" club

Another pair of NHS GP surgeries join the 084 "co-payment" club by adopting revenue sharing telephone numbers

The proposed "NHS reforms" do not explicitly allow patients to pay towards the cost of the NHS treatment, however many GPs have long been benefitting from co-payment;  another practice joined the “084 co-payment club” only last week.

The River Lodge and Ringmere surgeries in Lewes have just adopted a 0844 telephone number. This number enables the practice to have the cost of a new telephone system subsidised (to the tune of around 4p per minute on every incoming call) at the expense of patients and other callers.

There is nothing unusual about the particular surgeries in Lewes. Like all other NHS surgeries in England and Wales using 084 numbers, the practice is in breach of its NHS contract. Co-payment cannot be a feature of the NHS. I do however have a database of 1372 cases from NHS Choices (for England) and other official sources (for Scotland and Wales). These are all represented on a map – this view shows the 38 cases in Sussex.

In common with the overwhelming majority of cases in my database, these surgeries have a Talk Talk telephone line from which the revenue subsidises the cost of a system known as “Surgery Line” provided by Daisy Communications (the identity of the relevant Chief Executive Officer is deemed confidential).

If the government will not intervene to ensure that the terms of contracts are enforced and whilst the BMA continues to support the principle of co-payment, one assumes that we must look forward to this principle being continued and extended – the end of the NHS as a service that is universal and “free at the point of need”.

Denial

Some surgeries seek to hide their breach by claiming that the revenue share benefit, which is accrued on all 084 numbers, is a free gift to them from the telephone companies and that the cost should not be passed on to callers. Most of us recognise that the cost is (obviously and properly) passed on to the caller. Because these calls are excluded from packages and telephone companies also add their own additional charges, as a rate per minute or a call setup fee, the caller commonly ends up paying a lot more than just the amount passed on to the surgery.

Contract mobile callers pay up to 41p per minute, when a call to a "geographic rate" 01/02/03 number would incur no call charge. BT is prohibited by regulation from adding to the pence per minute rate that is passed on, although it does add a 12.5p call setup fee. BT subscribers are required to stick to the terms of their selected Call Plan when making (inclusive) calls to geographic rate numbers; severe penalty charges are incurred on calls made outside the terms of the plan. It is however commonly claimed that these penalty charges are “the standard BT rate” – a gross misrepresentation being used to exploit an admittedly complex situation.

There are others, notably the BMA GPC, who argue positively in favour of "co-payment", suggesting that patients should pay according to the quality of NHS service they receive. This argument is used to justify use of an expensive telephone number to meet the cost of a telephone system that the practice does not wish to pay for itself. After this proposal was not accepted by government however, the BMA GPC urged its members to state that co-payment was not happening, with support from a friendly source. (see this guidance note.)

Prohibition

Since April 2010, NHS GPs have been prohibited from adopting a telephone number which costs patients more than the cost of an equivalent call to a geographic number. Those with one of these numbers already in use had to change to a geographic rate number before a deadline of 31 March 2011. It is important to note that there is no prohibition on use of advanced telephone systems requiring "non-geographic" numbers. These can be used on 03 numbers, which are invariably charged at “geographic rate”. On 03 numbers the practice benefits from all of the same technical features, but must meets the cost of their system out of the funding provided for this purpose, without subsidy from patients – that is how the NHS works. Migration from a 084 number to the equivalent 034 number can be made, without penalty, at any point during the term of contract for telephone service.

I cannot understand how any Primary Care Trust that has taken the trouble to check on the cost of calling these numbers, from a reliable source such as the telephone companies used by patients, can allow this to continue. Subjective opinions about what telephone companies should charge and which tariffs patients should be using are of no value in determining compliance with the terms of the revised contract, especially when they originate from highly interested parties.

Co-payment for Health Services replacing the NHS

Many of us fear that "co-payment" will eventually become a feature of a new health service in England that is partially funded by public money - the term "NHS" refers to a service that is universal and “free at the point of need”, albeit subject to charges set by parliament. If pressure for more choice and better outcomes (like advanced telephone systems) cannot be met out of the money paid to NHS providers from our taxation, then elective patient contributions would seem to be a likely route to be followed. Surgery telephone systems are only a very modest part of the cost of providing NHS services, however they have been used to blaze a trail.

If no action is taken to deal with the "co-payment pathfinders" - GPs with 084 telephone numbers - we will be able to recognise that the coalition government is leading us towards co-payment - the end of the NHS in England. This must be either stopped or formally acknowledged as an acceptable feature of the “English Health Service”.

The most sickening part of this is that the necessary regulations are in place to prohibit it (except for NHS Direct, which has been explicitly exempted so that it may continue to benefit from co-payment). They are being deliberately flouted, no enforcement action is being taken by PCTs and the government is standing back.

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Links

The following recent blog items may be of interest:

>>>	Links to telephone company tariffs with a summary of the relevant call costs
>>>	Copy of a message to PCT Cluster Chief Executives (the enduring guardians of the principles of the NHS) about their position on "co-payment"
>>>	Detailed notes on how the regulations are being evaded
>>>	A news release covering another recent adopter of a 084 number and the approach of the government

Primary Care Trusts accused of sanctioning "co-payment" in the NHS

Many Primary Care Trusts have failed to enforce GP contract revisions that should have eliminated use of 084 telephone numbers by 1 April 2011 - see my database of those in breach. If this is anything more than falling for the misrepresentations made by those who believe that patients should pay to fund GP telephone systems, then it is a positive sanction for co-payment.

Many of us fear that co-payment will have to become a general feature of the NHS, as the proposed "reforms" are unlikely to achieve the cost savings on which they depend. More choice and improved outcomes may be desirable goals, but they cannot be expected to deliver cost savings. Replacing one centralised bureaucracy with lots of separate versions of the same thing is not guaranteed to save money either.

Sanctioned co-payment (which is presently prohibited) is undoubtedly coming on a grand scale. Do we see a model in the way that revenue sharing telephone numbers are used by 12.25% of English NHS GP surgeries? The Department of Health declares no interest in this matter - see this written answer.

I have written to the Chief Executives of the PCT's who are clearly having the greatest difficulty in protecting the patients they serve from being forced into co-payment. See my letter - see my "Top 20" lists.

I have asked them to confirm whether or not their failure to ensure compliance with contract revisions within the specific time limits indicates incompetence, or a policy of sanctioning co-payment by the NHS patients that they serve.

Amidst all of the politicking around the "NHS Reforms", the fact that co-payment is already here and likely to increase significantly has perhaps been missed. The relatively modest issue of use of revenue sharing telephone numbers has however perhaps been pointing the way forward.

The BMA GPC has expressed the principle of co-payment very clearly by its policy on use of expensive telephone numbers. The following quote is from its guidance to members on how to get around the contract revisions - by offering a meaningless, and essentially false, assurance about telephone call charges from an interested party with no competence in the matter being addressed.

"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."

Balancing cost to patients with the quality of service delivered by the NHS is exactly what co-payment is all about. A patient's right to choose cannot be divorced from their "right" to pay for a quality of service that the NHS "cannot afford". That however is the end of a universal comprehensive National Health Service "free at the point of need".

IF "OUR NHS" IS TO SURVIVE, THE GP RIP-OFF TELEPHONE NUMBER SCAM MUST END

•	If the UK Government believes in the principles of the NHS it must prove this by acting to protect them NOW. Otherwise we cannot believe its alleged intentions for the future when it proposes changes that can only undermine their application.
•	My revised, extended and enhanced database lists 1,366 NHS GP surgeries in England, Scotland and Wales which benefit from subsidy at the expense of patients through use of 084 telephone numbers – a clear breach of the principle of “free at the point of need”. All data is from NHS sources.
	Visit http://tiny.cc/GP084 for links to detailed lists, summaries, league tables and MAPs.
•	084 numbers are invariably more expensive than “geographic rate” (01/02/03) numbers for most, if not all, NHS patients to call.
•	GPs can vary their arrangements to switch from 084 to 034 numbers at any point during their contract FOR TELEPHONE SERVICE.
•	Contracts for advanced surgery telephone systems including leases on equipment must be paid for in full by GPs. Our taxes provide them with NHS funding to meet their expenses in providing NHS services. That is how “our NHS” works - not through private arrangements made between patients and GPs.
•	English PCTs and Welsh Health Boards must enforce the contractual conditions already imposed on GPs. NHS Scotland must act.
•	The UK and National governments must drive and support this effort. If not, they will be seen to permit an abuse of the NHS to persist.

IF THE SCAM IS ALLOWED TO CONTINUE THIS WOULD PROVE THAT “OUR NHS” IS DEAD

At the same time, the respective managements of NHS England, Scotland and Wales must ensure that they (and their subsidiary bodies) also cease relying on the subsidy earned from use of 084 telephone numbers.

Where a non-geographic number has a benefit, e.g. for a national or regional service, the 034 equivalent must be immediately brought into use and offered, at least as an alternative - e.g.

NHS Direct England - 0345 4647

NHS Direct Wales - 0345 4647

NHS 24 Scotland - 0345 4 24 24 24

(As the cost of publicising a complete number change is perhaps prohibitive - these alternatives must simply be switched on immediately. This will take only a few days to arrange.)

Notes

1.	This message is distributed to the media, MPs, MSP and AMs, NHS Management in government, local NHS management.
2.	Detailed notes on avoidance of the provisions of the revised GMS contract are published in this blogging - Resistance to the ban on use of 084 numbers by NHS GPs.
3.	Recent comments on NHS Direct (and NHS 24) are found in - NHS Direct has caught up with mobile apps - but not mobile voice calls!
4.	Features of the database of GPs using 084 numbers include:
	•	Links to the website holding the data published by (or, in the case of Scotland, linked to) the commissioning NHS Organisation - on NHS Choices for England. Each item may thereby be verified at any point in time.
	•	A map - seen here for all of Great Britain. This may be zoomed and panned. Use View>Search from the map menu to select only particular NHS Organisations etc.
	•	A sortable (sic) and filterable (sic) version of the data list.
	•	A "Top 20" list of the NHS organisations with most work to do.
5.	I will be very happy to extract / prepare listings to cover a particular area. The data can be copied directly from a browser into a spreadsheet for local treatment, if desired.