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4. Telephony
This chapter looks at how supporting practices undertake an assessment of their current infrastructure in order to make a decision about enhancing the existing system or consider a new one.
Glossary of telephony terminology
Telephony terminology
ACD – Automated Call Distribution
This system includes a range of sophisticated call management solutions employed in call centres.
ADSL – Asymmetric Digital Subscriber Line
A broadband technology that delivers very high data transfer speeds over existing telephone lines. More bandwidth is delivered downstream than upstream; ie you can download items faster than you can upload them. This is ideal for residential connections or businesses not running a server.
Alternative carriers (also known as CPS)
This feature allows the telephone system to be programmed to select more than one carrier (telephone line provider) for your calls. You program the system to recognise which type of call is to be carried over which network at which time of day. This enables you to always get the lowest available call rates.
Analogue lines
The original telephone lines. They are still the common choice in smaller telephone systems; however, current technology has resulted in a shift towards more cost-effective options such as ISDN and SIP trunking.
Auto attendant (see IVR)
An automated answering system that uses prompts to guide the caller to the correct department or extension by pressing keys on the telephone handset, eg ‘For appointments, press 1’.
Bandwidth
A measurement that gives an indication of the amount of data that can be sent through a connection.
BlackBerry
A handheld device that gives you mobile phone, email and other useful functionality away from the office.
Call forwarding
This feature enables incoming calls to be forwarded automatically to a different number, eg a mobile or home number.
Carrier
The telephone company or the provider of telephone lines into your facility.
Centrex
Centrex is a PBX-like service providing call handling at the main telephone exchange of the telephone company, such as BT, instead of at the customer’s premises. Typically, the telephone company owns and manages all the communications equipment and software that is necessary to implement the Centrex service and then sells various services to the customer.
Channel
This is another word for telephone line, usually in the context of digital lines.
CPS – Carrier Pre-Selection
This feature allows the telephone system to be programmed to select more than one carrier (telephone line provider) for your calls. You program the system to recognise which type of call is to be carried over which network at which time of day. This enables you to always get the lowest available call rates.
CTI – Computer Telephone Integration
Also known as unified messaging, this system provides one centralised mailbox for all email, voice and fax messages, and all messages can be received, replied to, saved or deleted in this one inbox.
CLI (Calling Line Identification) Presentation
Clever technology that displays the telephone number of the caller on the receiver’s telephone display.
DDI – Direct Dial-In
This is the ability to assign individual telephone numbers (DDI numbers) to extensions, faxes, computers and departments, enabling callers to dial them directly and automatically through the switchboard without having to go via a receptionist.
DECT – Digital Enhanced Cordless Telephony
DECT handsets provide wireless communications within an office, building or site, and they can be fully integrated into the company telephone system.
DSL – Digital Subscriber Line
This technology brings high-bandwidth information to homes and small businesses over telephone lines. It can carry both data and voice signals (see ADSL).
Hosted
This phrase is used to describe a service that is provided to the customer using equipment that is located remotely from their facility.
IP – Internet Protocol
This is the generic term to describe the way that voice and data signals can be sent between devices connected to a network, including across the internet and LANs.
IP Centrex
IP Centrex provides similar functionality to Centrex but calls are handled via a broadband connection.
IP PBX
An IP telephone system.
IP telephony
IP telephony is the use of IP signalling methods to send voice traffic across a data network. It can eliminate the need for separate voice and data networks by converging all traffic on one network, and it provides a wide range of other benefits for business telephone users.
IP/VoIP gateway
A gateway for existing telephone systems, converting traditional telephony traffic into IP for transmission over a data network. Using an IP gateway can be considered as a ‘migration path’ towards IP telephony, as you can gradually transfer to IP telephony while adding longevity to your existing telephone system.
ISDN – Integrated Services Digital Network
ISDN is a digital public network for voice and data communications with charges for line rental and calls. ISDN is available as ‘ISDN2e’, where the lines come in pairs, or as ‘ISDN30e’, which comes in groups of up to 30 lines, the minimum order being eight.
IVR – Interactive Voice Recognition (also known as auto attendant)
An automated answering system that uses prompts to guide the caller to the correct department or extension by talking instead of by using telephone keys, eg ‘What do you want to do? Book appointments? Order a repeat prescription?’ The caller then tells the system what they want to do based on the suggested options.
LAN – Local Area Network
A computer network within a limited area, eg within a building or a specific floor of a building.
MAC or Moves/Adds/Changes
These are the processes of moving staff to a different desk location, adding an extension or changing an extension number at a certain location.
Network
A computer network consists of two or more computers that are connected to each other so that they can share and exchange resources.
PBX (or PABX) – Private Branch Exchange
A private business telephone system.
Pots vs. Pans
One of our favourite acronyms: Plain Old Telephone Systems versus Pretty Amazing New Systems!
PSTN – Public Switched Telephone Network
This network was traditionally analogue but now includes digital (ISDN).
QoS – Quality of Service
This is used to provide acceptable voice quality across IP networks.
SIP trunking (Session Initiation Protocol)
In order for your telephone system to be fully IP enabled, you will need a SIP trunk. A SIP trunk is a pure IP connection between your premises and the national telephone network. SIP trunks can work on broadband and other types of data connectivity such as leased lines.
Smartphone
A mobile phone that is like a mini-computer and can browse the internet, receive email and let you work on documents and spreadsheets while on the move.
Softswitch – Softphone
A software application providing server-based telephony, eg a softphone on your laptop allows you to make calls from it.
Telephone extensions
The number of extensions that you will require depends on how many staff you have needing desktop phones.
Telemedicine
The prefix ‘tele’ originated from the Greek meaning ‘far off’ or ‘at a distance’; medicine being defined as ‘the science and art concerned with the treatment, alleviation and prevention of disease and the preservation of health’. Telemedicine is a telecommunications and computer technology that allows medical care to be delivered for remote patient care, continuing education and research using electronic signals to transfer information from one site to another, irrespective of location.
Telecare
The term ‘telecare’ is used to refer to care for the chronically sick, who are usually being managed at home from a health centre or hospital. It is seen to be part of telemedicine as a whole.
Trunk
Not to be confused with the front end of an elephant, in telephony a trunk is another way of saying a ‘line’ or ‘channel’ that you need for making a call.
Unified messaging
Also known as CTI, this system provides one centralised mailbox for all email, voice and fax messages, and all messages can be received, replied to, saved or deleted in this one inbox. When used in conjunction with CLI (Caller Line Identification), information is selected automatically that relates specifically to the incoming caller’s ID and can ‘pop up’ on receptionists’ PCs.
Virtual
This phrase is used to describe a service that is provided to the customer using equipment that is located remotely from their facility.
Voicemail
Allows callers to leave messages in individual mailboxes. These messages can often be retrieved remotely.
VoIP – Voice over Internet Protocol
VoIP = IP telephony. VoIP is the transmission of voice traffic over a WAN, VPN or the internet.
VPN – Virtual Private Network
Linking telephone systems and/or data networks together across the internet. A VPN is a fast and secure way to transfer data between remote sites.
WAN – Wide Area Network
A computer network that covers a large area rather than being limited to one building or site.
WCA – Web Content Accessibility
Web content is accessible when it may be used by someone with a disability.
4.1. Understanding your current telephone infrastructure
Your telephone system is often the first point of contact that a patient has with your practice. This system can enhance the patient journey or disrupt it.
Negative phone experiences include:
- getting an engaged tone frequently;
- a ringing phone that no one answers;
- going through to an answering machine rather than to practice staff; and
- a telephone system that has a complex variety of options (eg press 1 for X and press 2 for Y etc).
Your telephone system should be driven by your patients’ needs. This section will enable you to:
- understand your current telephone system and help you to make a decision to invest in a new system or upgrade your existing one;
- research and identify the options and solutions that are available using your current set-up; and
- use all this knowledge to invest in the most appropriate system for your practice.
The majority of solutions in this section will be dependent upon your financial resources,which may limit your options. The glossary helps to explain any technical terms thare are used in this section.
By understanding how your current telephone infrastructure operates, you will be able to decide whether to upgrade or replace it.
Your current telephone infrastructure will include the following parts:
- the physical telephone system itself;
- equipment such as switchboard, telephone switch, private branch exchange (see glossary);
- the telephone and fax lines (analogue and digital); and
- Advanced telephone infrastructures such as an internet broadband connection.
How to gain an understanding of your current telephone infrastructure
It’s useful to break this task up into three parts as below. On each of these pages, you will find a process map and corresponding checklist to work through. You may find it helpful to talk through some of the checklists with your current telephone supplier.
Process Map and Checklist 1
Checklist 1 - Understanding your telephone system
Process Map and Checklist 2
Checklist 2 - Number of telephone lines
Process Map and Checklist 3
Checklist 3 - Your internet connection for more advanced solutions
4.2. Making a decision
Finances may determine whether you have the resources to invest in a new telephone system or upgrade your existing one.
If you’re unsure, then consider the following:
- How much funding or capital investment do you have?
- Have you consulted your PCT on the financial resources available?
- Do you see yourself changing your telephone system in the next 12 months?
If you are considering replacing your telephone system within 12–24 months, you may want to consider small, cost-effective upgrades to your existing system.
Investing in the right system for your practice, now and in the future
If you decide to invest in a new telephone system, then consider your options before buying.
Your PCT may be able to provide financial help. You will also need to consider staff training and possible disruptions to day-to-day operations during installation. Before making a purchase, you must consider patients’ current and future needs. (Visit our section on‘Patient engagement’.) A change management strategy may need to be developed and various consultations may be required. (Visit our section on ‘Change’.)
Your Options
Choosing a new telephone system is a long term investment. You will need to ensure that the system has spare capability, so it can expand with your practice. Find a supplier who can help you, but be aware of technical language and jargon. Don’t be fooled into buying an overpriced, older system. Make sure that your supplier gives objective advice. Some may only describe a limited range of systems that are offered by their own companies.
Hosted telephone solutions
Hosted solutions work in a similar way to a telephone system that is based at your practice. However, the switch sits at a central location. In most cases, the telephone company owns and manages the equipment and then sell services to customers. A hosted solution comes with extremely flexible features. However, certain features may come with a minimum contract length. Lines will be provided as part of the package and you will be provided with telephones that suit your needs. In some cases, you can hire them as part of the ongoing monthly costs or buy them outright. For more information, look at the IP Centrex telephone solution. (section 4.6)
03 systems
Ofcom, the UK telecommunications regulator, has issued the 030 number ranges, eg 0300 and 0303, for public sector and not-for-profit organisations requiring a presence, but without callers incurring the additional charges associated with calling 08 numbers. Charges for calling 03 numbers are the same as for calling standard 01 and 02 numbers, even from a mobile where they are included in call plans and bundled minutes.
More and more suppliers are developing 03 systems. So do your research – look on the internet or contact your PCT. The Department of Health is currently considering the results of its consultation on the use of 084 numbers in the NHS. For more information visit the DH website.
Tips
- Invest the time and resources to get it right. Do your homework and understand exactly what you need. Understand the features that your telephone system needs to improve the patients’ experience.
- Ask other practices. If you like the way a telephone system works at another practice, ask them what system they use and, if possible, how much it costs. Talk to other practices or contact your PCT to get a feel for pricing, suppliers and options.
- Don’t under invest. You have decided to invest in a telephone system to improve your practice and your patients’ experience. If the new telephone system is unfit for purpose, patients may get an inferior service.
- Beware of over-zealous sales people. Most salespeople will sell you the benefits of the system without fully explaining the cost of add-on modules. Make sure that you know what’s included in the base price and agree terms before signing any agreement. (You may want to consult other practices or your PCT before signing.)
- Take advantage of your existing assets. Consider what assets you already have. For example, telephones can be very expensive. You may want to buy a new system that uses your existing telephones.
- Prioritise features. List what you want and create a checklist. This will help you to make the best decision. For example, do you need an auto attendant feature? Do you want to provide information when patients are on hold? Do you need to monitor telephone usage? What are your voicemail needs?
- Find a good supplier. You will usually need to consult and hire experts to install and program a telephone system, so finding a good telephone dealer is key. Always ask for references and contact the supplier’s other customers.
- Consider VoIP telephone systems. Voice over Internet Protocol (VoIP) technology allows practices to place and receive calls using the internet. You shouldn’t rely solely on VoIP solutions, because internet connections are not as reliable as telephone lines. However, VoIP solutions can be a perfect solution to managing peak demand, when your practice may require an extra line to deal with calls.
- Consider voicemail compatibility. Ensure your telephone system can work with a wide range of third-party voicemail systems. This keeps your options open and minimises the chance of you getting stuck with an inferior or overpriced voicemail system.
- More wires than needed. Telephone experts recommend doubling the number of wires for future proofing. If you need to install wires for the telephone system, consider adding more than you need. This will up the initial cost of installation, but may offer a huge future saving.
- Consider financing options. Ask your supplier whether you can pay for your system over time. This can be a big benefit if cash is limited. But be warned that leasing costs can drastically increase the final price of your telephone system.
4.3. Wireless headsets
Wireless headsets are easy-to-use, hands-free accessories. They allow the user, for example the receptionist, to carry out a range of other duties without missing incoming phone calls.
Benefits
- Allows more calls to be answered over the course of the day.
- Compatible with most desk phones.
- Cost effective – increases productivity and allows receptionists to multitask.
- Reception staff are freed up while answering calls, and can move around the practice if necessary.
- Some models can also act as an intercom between staff at reception and clinicians in the consultation room.
Is this equipment right for my practice?
Consult first
Check with staff to see whether they would be happy to wear headsets. Contact your PCT to see if they are using similar systems or have funded their installation at another practice.
Check your telephone system
Check with your existing supplier whether:
- they offer any products; and
- the product you are considering is compatible with your telephone system.
Ensure value for money
Is this the most cost-effective solution for you? It could be cheaper to employ a member of staff to support the reception desk at peak times.
Monitor and evaluate
What do your staff think about their headsets? Have they been able to take more incoming calls?
Drawbacks
- Can cause discomfort if worn over long periods.
- Possible interference with other wireless systems.
- Staff may need training.
Costs
Costs vary depending on the quality of the unit. Some systems can cost around £200 for a cordless unit, remote handset lifter and compatible telephone.
Tip
A good quality unit incorporating noise cancelling can minimise background interference and is a sound investment.
4.4. Answering machines
Allowing callers to leave a message may relieve some of their frustration if they are unable to get through to the practice. It’s no substitute for answering calls, but may help during peak periods.
Is this right for my practice?
Consult first
Before installing an answering machine, consider the following:
- What do your staff think of the idea?
- Do they understand the risks involved?
- Do they feel that the benefits outweigh the risks or vice versa?
- How would your patients feel about leaving messages? Why not discuss the idea with your Patient Participation Group?
- Are there other practices with answering machines that you could learn from?
Check your telephone system
Check with your existing supplier if you can add a voicemail service easily. If not, stand-alone units work with most telephone systems and may be easier to manage.
Set guidelines
Ensure that staff and patients are aware of the new system and understand the usage guidelines. You might want to encourage patients to leave messages only for things like repeat prescriptions, advance appointments or general enquiries. Messages should be checked frequently and dealt with quickly.
Benefits
- Missed calls are recorded during peak times.
- Patients don’t have to keep redialling the practice.
- It can be a cost-effective, quick-fix solution.
Drawbacks
- Not suitable for all telephone systems or situations.
- Expense of voicemail cards for some telephone systems.
- Additional cabling may be required.
- Significant clinical risks if messages are not picked up and dealt with systematically.
Costs
Answering machines usually cost very little. You can run one through your existing system or buy a stand-alone unit.
4.5. Centrex
Centrex is a ‘virtual’ phone system providing a number of extensions. It is a ‘hosted’ service, which means that the physical equipment and technology is provided, run and maintained by a supplier company. If your practice is looking for a new system but cannot afford an initial outlay on services and hardware, Centrex is often a good solution.
Benefits
- Offers integrated facilities such as voicemail and call forwarding.
- No financial outlay is required for hardware such as telephones.
- As equipment is provided by a supplier, it can be easily updated as technology advances.
- Enhancements may be available to improve access for hard-to-reach groups.
- Enables extra lines to be added easily.
Costs
Line rental fees and one-off charges are applicable. Some start at around £17 a month with a connection charge of £25 (current prices for a five-year contract as at March 2009). Telephone handsets providing full functionality cost around £80 each.
Drawbacks
- Managed by a third-party supplier – you have less control and there may be issues with service level agreements.
- Monthly fees are payable over a contracted period.
- New telephone handsets are required for the best use of the system (a supplier may hire these to you or they can be bought outright).
- There is a limitation on using alternative suppliers for lower call charges.
4.6. IP Centrex
IP Centrex is a hosted ‘virtual’ telephone system service that is similar to a private branch exchange. Unlike traditional Centrex, this system uses a broadband internet connection. Before considering an IP Centrex system, it’s advisable to conduct an audit of current and potential broadband availability together with your existing IT hardware.
Benefits
- Uses sophisticated telephone system facilities controlled locally via a PC interface.
- No financial outlay is required for telephone system hardware.
- As equipment is provided by a supplier, it can be easily updated as technology advances.
- Enhancements may be available to improve access for hard-to-reach groups.
- Potential reduction in call outgoing charges.
- Move/add/change costs for extra extensions may be reduced.
Costs
Some systems start at around £15 a month. There are no long-term contracts to sign and no capital investment in hardware is required. As incoming calls are diverted, extra charges may become expensive. 0800 or 0844 numbers may be required and consideration should be given to the potential extra cost to patients, as covered earlier on in the chapter.
Drawbacks
- Monthly fees payable over a contracted period.
- Managed by a third-party supplier – you have less control and there may be issues with service level agreements.
- New telephone handsets are required for full functionality (a supplier may hire these to you or they can be bought outright).
- Monthly charges for diverted calls may become expensive.
- Relies on a broadband connection and reliable local IT hardware.
- Local area network cabling is required.
4.7. Interactive Voice Response
Interactive Voice Response (IVR) allows callers to interact with the telephone system using the keypad or voice commands. This can help to direct the caller to the most appropriate person or department quickly and easily.
Benefits
- Can streamline receptionist function.
- May reduce staff costs.
- Allows patients to access or request information (such as repeat prescriptions) without speaking to staff.
- No financial outlay is required for telephone system hardware.
- Can provide patients with 24/7 access to information by using recorded messages.
- Can make focused announcements targeting hard-to-reach groups.
Drawbacks
- A change of telephone number will be required for hosted systems.
- Requires significant testing and piloting with patients – older people and people whose first language isn’t English may experience difficulties.
- Some patients may prefer to speak to a receptionist.
- Careful planning of available options and continual monitoring of effectiveness are required.
IVR systems are ideal for busy surgeries, enabling staff to deal with patients while the telephone system takes care of incoming calls, directing them as necessary.
Your current telephone system may be capable of supporting IVR. In addition, some newer telephone systems already have an auto attendant option available where simple keypad presses can access system options, information and particular people or services. Ensure that a full audit of your system is carried out before entering into any agreement.
4.8. Overflow call handling
This service activates when a patient can’t get through to the practice and it is particularly useful during busy periods. It diverts calls to an answering service or call centre where call handlers identify which practice the call is coming from and handle it appropriately.
Benefits
- Incoming calls are always answered.
- Messages can be taken and forwarded to a nominated individual at the practice.
- Messages can be relayed verbally, via email or SMS. This enables the practice to take immediate action.
- Call handlers could be given access to the practice appointment system and book the patient in themselves. However, this would require strict guidelines and may undermine the role of the receptionist.
Drawbacks
- Monthly service charges based on price per call could be expensive.
- Patients who are sensitive about privacy may prefer to speak with someone at the practice.
- It is unknown whether call handling is being used by practices so many risks and issues cannot be identified.
Costs
Monthly service charges can be around £25, with each call handled costing around 85p. There may be additional costs for diverting calls.
4.9. Computer Telephony Integration
Computer Telephony Integration (CTI) allows interactions on a telephone and computer to be integrated or co-ordinated. For example, when a patient calls, the computer system recognises the number and automatically brings up the patient’s details.
Benefits
- Personalisation receptionists can answer the telephone using the patient’s name.
- Can save time accessing records and reduce telephone call time.
Drawbacks
- Telephone and GP systems may not currently be offering such services.
- Requires electronic patient details or records.
Further information
You will need to contact your GP system or telephone provider to see whether this functionality is being considered
Case studies
There are no case studies in this section.
Useful resources
Suppliers
There are no suppliers mentioned in this section.