Paper F
Leicester City PCT Board Meeting
28 August 2008
LEICESTER CITY PRIMARY CARE TRUST
BOARD MEETING
28 August 2008
GP Practice 084 Phone Numbers
Background
1. In response to feedback from patients at the October 2007 Board meeting, the
PCT committed to undertake a review of GP practices with non-geographic
phone numbers to develop a better understanding of the local issues and to
identify if there are any actions that the PCT can take to address these.
2. In March 2008, the Board received an interim report on the issues emerging from
the Review. This paper builds on the material presented in the interim report. It
does not seek to duplicate the information already provided but sets out a final
analysis of the scale of the issue together with an appraisal of the options
available to the PCT.
What is the issue?
3. Depending on the type of line and phone package that patients call on, the cost
of calling a GP practice on non-geographic number can vary significantly. There
are significant variations in the cost of calling 084 numbers from mobiles lines as
well as some fixed lines call packages with the patient very much in the hands of
his or her service provider.
4. To illustrate the difference, for a patient with a BT residential landline on a
standard contract the cost of a daytime call to a 084 number is 5 pence per
minute (inc. VAT). In comparison, the cost of a call to a 084 number from a
Vodafone pay as you go mobile is 35 pence per minute. This means a ten
minute call to a 084 number from a BT landline would cost 50p whereas the
same ten minute call from the mobile provider described would be £3.50.
5. In addition, significant numbers of patients will be on low cost call packages,
either with BT or other providers, which may include free daytime calls but will
exclude 084 numbers.
How many people may be affected?
6. Quantifying the number of patients across the City who may be paying more than
the cost of a local call to phone their GP practice is not straight forward, not least
because the telecoms market is both extremely competitive and in certain sectors
dynamic. However, it is possible to estimate the broad range by using a series of
assumptions.
Toby Sanders
Director of Primary & Community Care
1
Paper F
Leicester City PCT Board Meeting
28 August 2008
7. First, we know how many GP practices in the City have 084 telephone numbers 25 out of a total of 63. These practices are contracted to three service providers
– NEG Telecom Ltd (Surgery Line), NTL and Ecocall.
8. Second, we know how many patients are registered with these 25 GP practices 178,010 as at 1 July 2008. Set against the PCTs total registered population on
the same date of 350,726, this equates to 51% of the city’s registered patient
population.
9. Using these data we can then apply a series of assumptions to form a view of the
broad order of patients who may be affected:
 We know from recent local analysis of actual GP practice call logging
that around 6% of incoming calls to GP practices are made from mobile
phones. This would equate to around 11,000 of the 178,010 patients
registered with the 25 GP practices that have 084 phone numbers
 Alternatively, we know from a recent Eurobarometer survey undertaken
for the European Commission1 that around 15% of UK households are
‘mobile-only’. That is, they have mobile but no fixed telephone access.
This would equate to around 27,000 of the 178,010 patients registered
with the 25 GP practices that have 084 phone numbers
 However, we also know that this is not just an issue for mobile phone
callers – certain low cost telephone packages exclude calls to nongeographic numbers. The Eurobarometer survey found that 30% of UK
households buy two or more communication services as part of a
bundle from the same provider at a single price. These packages can
include television, fixed telephony, mobile telephony and/or internet
access, with a combination of fixed telephony and internet access being
the most popular package. This would equate to around 53,000 of the
178,010 patients registered with the 25 GP practices that have 084
phone numbers.
10. Although fairly crude, the above analysis suggests that somewhere in the range
of 6-30% (11-53,000) of the 178,010 patients registered with GP practices with
084 phone numbers may potentially pay more than the cost of a local rate call to
phone their GP practice because of the telephone package that they are on.
Options appraisal
11. Acting on the mandate given by the Board at it’s March 2008 meeting, the PCT
has engaged over the intervening period with GP practices with 084 phone
numbers, the Local Medical Committee and the largest single provider of 084
services to city practices (NEG) in order to explore the range of potential options.
Eurobarometer No.293 “E-Communications Household Survey” undertaken by the TNS Opinion &
Social network (June 2008). This survey comprised interviews with 26, 730 EU citizens across 27
Member States between during November and December 2007, of which 1,305 interviews were with
UK citizens
1
Toby Sanders
Director of Primary & Community Care
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Paper F
Leicester City PCT Board Meeting
28 August 2008
The PCT has also retained the services of an independent telecoms consultant in
order to access specialist technical advice and has sought independent legal
opinion to review the contractual arrangements between GP practices and 084
number providers.
12. The PCT met with NEG, the provider of the Surgery Line Service, on 16 May
2008 in order to explain the dilemma facing the PCT and to see if any workable
solutions could be found for all parties. The outcome of this meeting was that
NEG is willing in principle to work with the PCT to look at how its existing Surgery
Line System is managed at a practice level. However, it is equally clear from this
meeting and subsequent correspondence that NEG has little commercial interest
in renegotiating existing contracts, for example to enable their service to be
fronted with a 03 phone number rather than the current 084 number. Whilst this
position is disappointing, from a commercial perspective it is not surprising given
the number of contracts already held across the city, the period left to run on
each of these of between 5-7 years and hence the value of the existing
guaranteed return.
13. Given the commercial stance adopted by the main provider of 084 phone
services to city GP practices, there are effectively three options that remain open
to the PCT.
Option 1
14. The PCT could decide to do nothing. This is the position that has already been
adopted by a number of PCTs across the country, many of whom swiftly reached
this conclusion earlier this year when the issues associated with 084 phone
numbers were attracting a particularly high level of national political and media
attention. This approach would effectively recognise that most GP practices are
independent contractors and as such the decision on the type of telephone
system they use is arguably their own business decision.
15. However, the findings of the Review exercise conducted over recent months
suggest that this may not be the most appropriate course of action for Leicester
City for three reasons. First, the legacy PCTs in the City actively facilitated the
existing 084 phone arrangements at many practices in order to realise the very
real functionality benefits to practices in terms of call handling and management.
This means that the PCT already has a stake in the decisions that some
practices took about choice of system. Second, the current uncertainty across
the local market from both a GP practice and telecoms provider perspective is
stalling investment in improvements to telephone systems at a number of
practices. Third, the review has identified that there are practical measures that
the PCT could take to improve the current position, as set out in options two and
three below, not all of which would involve significant financial investment.
Toby Sanders
Director of Primary & Community Care
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Paper F
Leicester City PCT Board Meeting
28 August 2008
Option 2
16. The PCT could buy out all the existing 084 contracts held by GP practices across
the City and then work with them to implement a new standardised solution. This
would be a complex, multi stranded solution that would require significant
financial and technical support but it would be technically feasible.
17. Strand one would require the PCT to buy out all of the existing 084 contracts held
by GP practices across the city. The existing 084 systems have been paid for via
a leasing arrangement over a seven year period. Legal opinion provided to the
PCT and confirmed by the main 084 provider indicates that the leases would
need to be settled in full in order to terminate the agreement. Based on the
average monthly payment to the lease company, annualised over the remaining
lease period for each of the practices affected would suggest a total write off cost
of around £500,000.
18. Strand two would require the PCT to invest in a new telephone system to at least
replicate the functionality of the existing 084 service. This would need to include:
 Telephone handsets
 Auto attendant feature “hello and welcome to the practice”
 Intelligent queuing - the ability to queue calls in network, play
messages and route calls to out of hours providers
 Basic call recording
 Management information
19. Indicative costings for a telephone system capable of supporting 15-30 users
supporting the features discussed above for the affected practices would be
around £400,000. Project management costs to design, procure, and deploy this
solution would be likely to add somewhere in the region of an extra £150,000,
giving a total cost of re-provision to existing 084 number practices of around
£550,000.
20. This suggests that the overall budget for implementing the buy-out of existing 084
contracts and the re-provision of an alternative standardised solution would be in
the region of £1.05 million. However, this would only address those practices
with existing 084 contracts. If the PCT was to invest this level of funding in the 25
GP practices with 084 contracts this would raise serious equity issues in respect
of other independent contractors. Among the other 38 practices across the City
who do not currently have 084 phone numbers there is a range from those
practices who have previously considered the offer from 084 providers but chose
to invest in alterative telephony solutions through to those practices who are
currently reviewing their arrangements. It would be inequitable for the PCT to
make a substantial investment in the 25 practices with 084 phone numbers
without taking into account the potential requirements of the other 38 practices
across the city, many of whom will have invested their own resources in providing
a local solution or may currently be considering doing so.
21. In the interests of equity and creating a level playing field for all primary medical
care providers, the PCT would need to consider a third strand under this option
Toby Sanders
Director of Primary & Community Care
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Paper F
Leicester City PCT Board Meeting
28 August 2008
which would offer the same opportunity to the 38 City practices who currently do
not have an 084 phone number. Without entering into individual discussions with
these practices it is difficult to determine their specific requirements. However,
applying the same new telephone system costings set out in strand two above to
the other 38 practices would suggest a potential further cost to the PCT of around
£450,000.
Table 1 below summarises the build up of investment required to implement the
three strands of this option.
Table 1 – breakdown of Option 2 costs
Strand
Cost
1 – Buy out 25 existing 084 contracts
£500,000
2 – Replace with 25 new telephone systems
£550,000
3 – Invest equitably in telephone systems of other 38 practices
£450,000
Total investment required
£1,500,000
22. Taken together, the three strands of this option suggest a total cost to the PCT of
around £1.5 million. The key question is whether this level of investment would
represent good vale for money and be appropriate in terms of allocative
efficiency.
23. In terms of value for money it is possible, based on the estimated number of
patients across the city who may potentially pay more than the cost of a local rate
call to phone their GP practice (see analysis above), to undertake a simple
analysis of this potential investment.
At 6% level
Estimated potential number of patients 11,000
affected
At 30% level
53,000
Approximate cost of implementing Option 2
£1,500,000
£1,500,000
Investment per patient
£136
£28
24. The comparison pence per minute cost difference between calling a 084 number
from a standard contract landline and a pay as you go mobile is £0.30. This
means that the ‘break even’ point on investment per patient would only be
reached once all of the potentially affected patients individually spent between
1.5 and 7.5 hours on the phone to their GP practice (i.e. 7.5 hours or 453 minutes
x 30p per minute = £136 per patient).
25. In terms of allocative efficiency the PCT, as commissioner of services on behalf
of the population of Leicester City, has a responsibility to ensure that the
resources available to it are invested in a way that maximises the benefits in
terms of improving health and reducing health inequalities (i.e. the ‘health gain’ or
return on investment). This is about allocative efficiency – ensuring that the
share of the total resources available to the PCT are allocated a way that is
proportionate to need and potential health gain.
Toby Sanders
Director of Primary & Community Care
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Paper F
Leicester City PCT Board Meeting
28 August 2008
26. Option 2 would represent a £1.5m investment in an area of non-clinical care.
This would reduce the cost that some patients are charged by their telephone
supplier for calling their GP practice and hence may impact on overall levels of
patient satisfaction with GP telephone access. However, it would deliver no
direct patient benefit in terms of improving health or reducing health inequalities.
In terms of opportunity cost, the same £1.5m level of investment made in other
services that the PCT has recently commissioned from primary care could have
purchased the equivalent of:

An extra 2,400 appointments for patients to see their GP at an evening or
weekend (based on the activity and cost set out in the new Local Enhanced
Service for extended GP opening hours)

An extra 42,000 lifestyle checks for patients carried out through community
pharmacy to assess their risk factors in relation to key health conditions such
as cardiovascular disease (based on the unit cost of the current Healthy Heart
Initiative).
Option three
27. During the course of the review it has become apparent that the there are a
number of actions that the PCT could take that would help to address the current
position without requiring the level of investment necessary to implement Option
2.
28. The PCT could implement a package of measures to:
i.
Acknowledge that where GP practices have already signed contracts with 084
phone number providers they should continue to operate within the terms of
their contract, unless they decide locally that they wish to buy themselves out
of this arrangement or unless the provider offers to vary the contract in a way
that would be beneficial to patients
ii.
Send a clear message to all GP practices across the city that the PCT will not
support any new contracts being entered into with 084 phone number
providers
iii.
Work with GP practices with 084 phone numbers to make it clearer to patients
that the cost of a call from mobiles and certain fixed line packages may be
more than the cost of a local call. This could include some minor changes to
the front end messages played to customers and practice patient information
material to explain that the cost of calling a 084 is charged at 5p per minute
from a landline and up to 35p per minute from a mobile
iv.
Work with GP practices with 084 phone numbers and their suppliers to redesign the call scripts to allow quicker access and passage through the
system, and to make it clearer to callers where they are in the queue. This
will reduce the length of time that patients are on the phone and hence
minimise call cost
v.
Make provision for GP practices with 0116 phone numbers who are currently
considering changing their systems to be able to re-invest PBC savings
Toby Sanders
Director of Primary & Community Care
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Paper F
Leicester City PCT Board Meeting
28 August 2008
(where available) in upgrading their telephone systems to a non-084 solution
where this would deliver improvements in patient access and satisfaction
vi.
Support practices in monitoring the commercial options available to them,
both as the length of their contract periods reduces and in light of any
potential national negotiations that may impact on the offer available from the
telecoms providers.
29. In addition to the above series of actions, the review considered the feasibility of
GP practices with 084 phone numbers operating a parallel 0116 number for some
patients to call direct in order to avoid paying the cost of a call to a nongeographic number. This measure is not included in the proposed package set
out above for two reasons. First, whilst this measure has obvious initial appeal,
feedback from GP practices suggests that operationally this would have limited
benefit because it would not be possible to manage which patients called this
number as opposed to the main 084 number. Second, it is likely that GP
practices could be considered by their 084 number providers to be in breach of
their contracts by operating a parallel number which diverted call volume away
from the main practice number.
30. In considering the package of measures set out under Option 3, which are
primarily about how practices manage their telephone systems, it is interesting to
consider patient feedback from the recent GP Patient Experience Survey
2007/08. This is the most comprehensive patient survey of satisfaction with GP
services that is undertaken across the city, and this year the survey carried out
between January and March 2008 generated 14,128 completed questionnaire
responses.
31. One of the key questions asked of people who reported seeing a doctor in the
last six months related to patient satisfaction with GP telephone access.
Appendix 1 sets out the feedback from the survey. Each bar in the chart relates
to one of the City’s 63 GP practices. The bars that are shaded black are the 25
GP practices that have 084 phone numbers.
32. Satisfaction with telephone access is clearly a much broader issue than what
telephone number the GP surgery operates. However, what these data
demonstrate is that while the bottom eight GP practices in terms of satisfaction
with telephone access are all practices with a 084 telephone number, there are
other practices with similar telephone numbers where patient satisfaction is as
good and in many cases better than in other GP practices across the city.
Indeed, three of the top five rated GP practices for patient satisfaction with phone
access operate 084 numbers.
33. The findings from the patient survey on this issue are not conclusive. What this
suggests is that it is not necessarily the telephone number that a practice
operates that alone determines the level of patient satisfaction with this aspect of
service but a number of other factors. These factors are likely to include the way
that they practice manages their phone system and call handling – all issues that
would be addressed under the package of measures set out under Option 3.
Toby Sanders
Director of Primary & Community Care
7
Paper F
Leicester City PCT Board Meeting
28 August 2008
Recommendation
34. For the reasons set out above, the advice to Board is that doing nothing (Option
1) is not an appropriate option given the background and current position in
Leicester City. Equally, it is difficult to construct a credible case for the PCT
buying GP practices out of their existing 084 phone number contracts (Option 2)
and investing equitably in new telephone systems from a cost benefit and
allocative efficiency perspective.
35. The Board is therefore asked to:

Note the final findings of the review

Approve the package of measures set out in Option 3.
Toby Sanders
Director of Primary & Community Care
8
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Satisfaction with phone access
Paper F
Leicester City PCT Board Meeting
28 August 2008
Appendix 1
(NB: black bars = GP practices with 084 phone numbers)
GP Patient Access Survey 2007/08 - satisfaction with phone
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: NHS Information Centre (www.ic.nhs.uk)
Toby Sanders
Director of Primary & Community Care
9