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Monday, 2 July 2012

The "two tier NHS" has arrived

It has come to my attention that some NHS Primary Care Trusts are permitting their GPs to offer TWO-TIER ACCESS TO NHS SERVICES by telephone. (See details of a new case below.)

These GPs offer a "basic" normal local telephone number, with "enhanced facilities" available on an expensive 084 number as an alternative option. The cost of calling all 084 numbers includes a “Service Charge”, to the benefit of the person called, in addition to the “Access Charge” to the benefit of the caller’s telephone company.

The choice of a 084, rather than 03, number ensures that the generally greater cost of providing enhanced facilities through non-geographic numbers is met by callers, rather than the GP. A 084 number also provides funding for the basic elements of a telephone system, such as switchboards and handsets.

The so-called "enhanced" facilities are those provided by many GPs on normal (geographic) numbers, where they are paid for by the GP out of the NHS funding provided for the purpose; e.g. call queuing, recorded messages, voicemail, re-direction of calls to out-of-hours services.

Regardless of the benefits (or value for money) offered, it has never been permissible to offer two types of access to NHS services, differentiated by a charge …

…, or perhaps now it is, given that this approach is sanctioned by the local bodies responsible for adherence to the principles of the NHS!

This causes me to pose the question: Is a two-tier "NHS" the way of the future?

“Basic” services, at no charge from the NHS provider, for the poor and needy (who meet only their incidental expenses in accessing NHS services),
∗ ∗ ∗“Enhanced” services, charged for (directly or indirectly) by the NHS provider, for those who can afford to chose a better service

That is not the universal "NHS", funded from general taxation, which will celebrate its 64th birthday on Thursday, July 5th.

A line from a Beatles song comes to mind – “will you still need me, will you still feed me …?” – there are many parallels, even “Dave” is named as one of the grandchildren.


The following Primary Care Trust Chief Executives explicitly permit their GPs to offer this two-tier telephone access service:

Christopher LongNHS York and North Yorkshire
Mike PottsNHS Calderdale, Halifax and Kirklees
Caroline TaylorNHS North Central London
Debbie FlemingNHS Southampton, Hampshire, Isle of Wight and Portsmouth

It is strongly suggested that many other PCTs apply the same unusual interpretation of the NHS Constitution in forming their policy on this issue.

Government ministers claim that PCTs have been issued with clear guidance to not only prohibit this appalling breach of the principles of the NHS, but also to enforce the ban which applies to use of expensive telephone numbers under any circumstances. I understand however that the Department of Health is unable to enforce compliance with the statutory duty to have regard to the NHS Constitution held by all NHS bodies and their contractors, nor may it compel PCTs to enforce the terms of GP contracts as approved by parliament.

With the NHS in England now increasingly being "liberated" from central control, unaccountable local bodies have extensive discretion in how they apply the principles of this "National" service. The authority to make these decisions is now even passing from public servants to GPs.

Please refer to the additional information given below. This covers a recent new case which clearly demonstrates my point, and explains the position with older cases.

I must encourage, and am happy to assist with, attempts to obtain a formal statement of the position taken by the Department of Health with regard to enforcement.

Please obtain direct confirmation of the policy being followed by any (every) local PCT. I have named only those cases where I am sure that the policy is stated openly. There is extensive evidence to show that it is in effect.

A clear example to demonstrate this point

Skelmanthorpe Family Doctors, a NHS practice in Huddersfield, has just adopted a new additional telephone number (08443 878186) offering "advanced functions". It retains a "Basic Line" on 01484 766918.

The advanced functions are funded by a subsidy of around 4p per call minute which is paid through the surgery's network telephone service provider, Talk Talk, by whichever telephone company is used to make the call. This cost is invariably met by callers as a "Service Charge", with an additional "Access Charge". (See below examples of relative call costs.)

I have been assured by the local Primary Care Trust, NHS Kirklees (part of the Calderdale, Halifax and Kirklees Cluster, led by Mike Potts), that it has fully investigated this arrangement and it is deemed to be compliant with the PCT's interpretation of the relevant contractual requirements

I personally find Mr Potts (in common with many of his colleagues) to have made a rather perverse decision, given that every NHS GPs is under a contractual obligation not to “enter into, renew or extend a contract or other arrangement for telephone services unless it is satisfied that, 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 option to call an alternative “basic line”, offering inferior services, does not ensure that “persons will not pay more”. This arrangement explicitly presents the opportunity to “pay more” in order to gain “enhanced” access to NHS services.

An indication of how much more is paid to call the 084 number in question is given below. Unless it can be shown that "the arrangement as a whole" does not include any users of the commonly used tariffs listed, then the practice and the PCT may be seen to have been "satisfied" without reference to relevant information about the cost of telephone calls.

Alternatively, they may have deliberately set aside this requirement, which is intended to reinforce the current longstanding principles of the NHS. They may have chosen to adopt the wholly different principle that it is acceptable for patients to have a "Choice" of NHS service, differentiated by price.

It is also possible that, rather than checking actual call costs, they may have only consulted some highly opinionated marketing material, which is referenced on this page of the practice website. I have commented on two of the published items - “Supporting Surgery Line” and “… Enhanced Telephony”. If the "poster" which is illustrated is displayed in the surgery, then a number of items warrant investigation by the ASA.

Relative cost of calling the two numbers

The type ‘g11’ call incurs both a “Service Charge”, which is around 4p per minute in all cases, and an “Access Charge”, which is currently seen to be widely variable. These two elements are currently “bundled” together into a single rate. The cost of calling geographic numbers is also, although far less, variable. Because the relevant regulations refer only to the difference between the cost of calling the practice and the cost of an equivalent call to a geographic number (prohibiting cases where this is positive), only the differences need be shown.

The additional cost of calling 08443 878186 (call type ‘g11”), over that of calling 01484 766918 (for a call of the stated average duration of 3 minutes) is as follows:

£BT (most popular call plan) 8.6p per minute
£Talk Talk (most popular call plan)10.6p per minute
£Virgin Media (most popular Talk Plan)13.3p per minute
£Vodafone (pay monthly)35.0p per minute

(There are many further and more extensive illustrations of the difference between the cost of a call to a geographic number as against various types of 084 number in the table - “NHS 084 numbers - Evidence of call charges”. This includes references to published tariffs in all cases, to support the information given above.)

NHS GPs which have long been using expensive numbers

The case highlighted above is notable because it has only recently arisen, with a new 084 number. This two-tier approach is also followed by many GPs who have been using expensive numbers for many years. In some cases they are explicitly directed to use the two-tier approach by the PCT.

Those who were using expensive numbers when the current contractual revisions were introduced in 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”

The option to call an alternative “basic line”, offering inferior services, does not ensure that “persons will not pay more”. This arrangement explicitly presents the opportunity to “pay more” in order to gain “enhanced” access to NHS services.

All users of 084 telephone numbers are able to take the “step“ of migrating to the equivalent 034 number, so as to retain all of the “enhanced” features of their telephone service. All calls to all 03 numbers are charged at the same rate as calls to geographic number – thereby no caller would ever “pay more”. Because calls to 03 numbers do not incur a "Service Charge", migration would cause the subsidy of the costs of the practice telephone system to be lost.

I have not seen any evidence to show that any PCT thinks that it may not be “reasonable” for a NHS GP to meet the costs of its chosen telephone system in full. I have not seen any evidence to show that any provider of telephone service to GPs imposes penalty charges on those who choose to migrate during the term of an arrangement, so as to cause this step not to be “ reasonable”.

The telecoms industry in general thinks it “reasonable” to offer migration at any point during the term of an arrangement without penalty. I am aware that some have made unsubstantiated claims that one particular provider of GP telephone systems fails to adhere to this general industry policy. Until there is clear evidence of this unreasonable behaviour, one must assume that migration to the equivalent 034 number is a “reasonable step” open to NHS GP users of 084 numbers.

fair telecoms

The fair telecoms campaign fully supports the Ofcom proposals for the “Service Charge” and “Access Charge” elements, which comprise the cost of calling a 084 number to be “unbundled” so that they can each be seen separately.

Under these proposals, Skelmanthorpe Family Doctors would have to declare alongside 08443 878186 -
“A call to use the enhanced facilities will cost you 4p per minute, plus your phone company’s access charge”.

We believe that opening up the situation in this way will be welcomed by those who have difficulty in making their Service Charge clear, whilst the wide variety of Access Charges are hidden within bundled rates, as they are at present. We believe however that there is no essential reason to wait until this becomes a regulatory requirement. Because BT is presently prohibited from adding an Access Charge, the current level of the Service Charge is seen in the current BT tariff.

We encourage all those who benefit from Service Charges to start the process of declaring and justifying this charge now – noting that the same enhanced facilities can be provided using 03 numbers with no Service Charge. The action required of those who cannot justify a Service Charge is obvious and straightforward – if they require a non-geographic number, they must migrate to 03 without delay.

Any comments here that relate specifically to the political issue of retention of the NHS, with its very specific principles, are personal to David Hickson. If the NHS is to be replaced by an alternative service for England which permits charges to be imposed on those accessing health services, as they do so, then the fair telecoms campaign is only concerned that these charges be clearly declared.

It may be that the love affair between the people of England and the NHS has been shown not to have lasted up to its 64th birthday, because COLLECTIVELY they think they do not need it and they are not prepared to feed it. If so, the fair telecoms campaign can only campaign for its new replacement to behave properly, by being totally open in the way that it takes money from them for its services.

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