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                                                                                                                Technology in business

The practice telephone system
2. New technologies

John Taylor

New technologies are changing the way telephones are viewed and used.
In the May issue of In Practice (volume 32, pp 210-213), John Taylor discussed
various ways of handling telephone inquiries. Here, he looks at the ‘nuts and
bolts’ of various telephone systems, and what they have to offer.                                                          John Taylor graduated from
                                                                                                                           Cambridge in 2000 and is the
                                                                                                                           owner of a small animal practice
                                                                                                                           near Banbury. As well as a strong
                                                                                                                           desire to offer something special
                                                                                                                           in terms of veterinary care, he
The public switched telephone network (PSTN) has             Voice over internet protocol                                  runs a consultancy providing
been around for a long time, but the past 20 years have                                                                    specialist telephony solutions
seen an exponential growth in its use. From the private      In the UK, normal telephone calls are carried over the        to the veterinary industry.
branch exchange (PBX) to voice over internet protocol        telephone provider’s (usually BT’s) own digital net-
(VoIP), how does it all fit together?                        work. Your voice is broken down into small bite-sized
                                                             ‘packets’ which are transmitted digitally like any other
                                                             piece of data. VoIP is a set of technologies that wrap
Going digital                                                these packets into a form suitable for transmitting
                                                             over the public internet. The most familiar applica-
Until the 1970s, when you made a phone call you were         tion using VoIP is Skype, a proprietary technology
physically connected to the other party by a copper          that transmits voice packets to other Skype users or
wire. The phone was linked to an exchange which              to the PSTN. However, VoIP encompasses much more
was full of mechanical switches that connected you           than Skype, and has been in development since the
to more exchanges or the final destination via that          early 1990s. Well-managed VoIP set-ups are reliable
same copper wire. The number of lines available to           and easy to configure. Calls to other VoIP users are
you or a long distance trunk was limited to the number       free, while calls to the PSTN are usually substantially
of copper wires in that cable. Since the 1970s, more         cheaper (especially international calls) and have very
and more of the telephone network has been replaced,         low or no maintenance costs. Installation and run-
with the old analogue wires having been superseded by        ning costs are typically half those of a traditional
digital networks. In the UK today, the only analogue         PBX. Many small, medium and large companies such
bit of the network that even resembles the old copper        as Mitsubishi, the London Borough of Newham and
wire is the bit that connects the traditional phone to       the USA Social Security Administration are migrating
the local exchange or street box (‘the final mile’ or        exclusively to VoIP. With BT pushing out its next gen-
copper local loop). Even this will disappear as more
and more homes get digital connections from their
telephone company via DSL (digital subscriber line) or
digital cable services.

The traditional private branch

The familiar PBX present in many medium to large com-
panies offers a way of creating a phone network within
the practice. This is usually a physical box in the build-
ing that routes calls to and from the extensions, and to
and from the PSTN. Incoming and outgoing lines are
limited to the number of external telephone lines con-
nected to the PBX. PBXs provide features such as call
queuing, interactive menus, voicemail and forwarding,
and are generally reliable and resilient, but expensive in   VoIP telephones look very similar to traditional
terms of installation, upgrades and maintenance.             telephones                                                    doi:10.1136/inp.c2679

                                                                                                        In Practice June 2010 | Volume 32 | 267–269    267
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Technology in business

                                    Typical lag times                                                    Many businesses are understandably cautious
                                                                                                     about adopting VoIP. This is often due to bad first
                                    Type of line                    lag time
                                                                                                     impressions after using free technology or poor qual-
                                    Traditional landlines           40-50 ms
                                                                                                     ity PC microphones and speakers. It is worth asking a
                                    Mobile phones                   200-250 ms                       VoIP company for a free demonstration of dedicated
                                    Good VoIP                       100-200 ms                       VoIP hardware with an optimised internet connection.
                                    Lag is the time between a word being uttered, and the            Hardware phones (eg, Snom, Cisco, etc) are strongly
                                    recipient hearing the word. Any lag timings of more than         recommended.
                                    300 to 400 ms usually results in unacceptable quality                Disaster planning should be as for traditional phone
                                                                                                     systems. Key extensions should be powered by an unin-
                                  eration network (known as the 21st Century Network,                terruptible power supply (UPS). Alternatively, power for
                                  or 21CN), which relies heavily on internet protocol                every extension can be supplied via ‘power over ether-
                                  (IP), VoIP is only going to get bigger and better.                 net’ (ie, power delivered over your existing computer
                                                                                                     network), which, in turn, is powered by a UPS. Every
                                  How does VoIP work?                                                VoIP supplier will provide a failover solution; this usu-
                                  Just as you need a telephone and a telephone line to               ally means that if power is lost to the building or the
                                  make traditional phone calls, VoIP requires telephone              internet connection is dropped, all incoming calls are
                                  hardware/software and an internet connection. You                  diverted to another existing landline or mobile number.
                                  can either use a VoIP telephone that is very similar to                A VoIP phone call should be at least as reliable as
                                  a normal telephone, or a VoIP adapter for a traditional            a mobile phone call in an area of good reception, and
                                  telephone. Alternatively, software such as Skype, Xlite,           if business quality hardware is used on a good inter-
                                  iChat or Linphone running on a PC or Apple Mac can                 net connection, it should approach landline reliability.
                                  use a microphone and speakers to make VoIP calls; there            VoIP call quality is usually at least as good as land-
                                  are even hardware telephone handsets that plug into a              line calls, while VoIP to VoIP quality is similar to that
                                  PC to control the software in a more traditional manner.           heard on CDs.
                                  Your internet telephone service provider (ITSP) will be                You can test your ability to make VoIP calls either
                                  able to give you an incoming VoIP number (beginning                by signing up to a free service, which most VoIP provid-
                                  with 05), a geographic number with a normal area code              ers offer, and using the free software recommended, or
                                  or any of the 0800 or other premium rate numbers.                  by carrying out a free line test at http://myvoipspeed.
                                  VoIP quality and reliability
                                  Your internet connection is crucial for VoIP. Since the            VoIP private branch exchange
                                  data travels over the public internet, your router and             A large or medium-sized company may house a server
                                  ITSP must be able to offer a quality of service (QoS)              on its premises that performs all the same functions as
                                  mechanism to ensure data reaches the recipient in a                a traditional PBX. Increasingly, small to medium-sized
                                  timely and ordered manner. If there is no QoS, voice               companies are using a virtual internet protocol private
                                  data packets can lag (see table above), be delayed by              branch exchange (IP-PBX), which is housed remotely in
                                  varying amounts (‘jitter’) or be lost entirely, causing            a data centre. A web-based configurator gives the owner
                                  audio dropout. Poor quality hardware and an inferior               of the virtual IP-PBX complete control over opening
                                  ITSP can lead to an unsatisfactory VoIP experience.                hours, call diversions, call groups, call forwarding,
                                  A good wired broadband connection at the very least                menus, call queues, teleconferencing, call recordings,
                                  is recommended to achieve the quality and reliability              call logs, fax to email, assigning caller identification to
                                  levels equivalent to traditional landlines.                        outgoing calls, etc. The number of incoming and outgo-

                                    Comparison of a traditional private branch exchange versus an internet protocol
                                    private branch exchange
                                    Features                                     Traditional PbX                        iP-PbX
                                    Cost of calls                                Moderate                               Cheaper than traditional PBX
                                    Ability to remotely connect                  Difficult                              Very easy
                                    Call quality                                 Very good                              Usually very good, but depends on
                                                                                                                        the internet connection
                                    Reliability                                  Very good                              Good
                                    Scaleability                                 Difficult                              Easy
                                    Ease of use                                  Usually good                           Good
                                    Features                                     Depends on system hardware             Depends on the configuration, but at
                                                                                                                        least the same as a traditional PBX
                                    Vendor lock-in                               Usually locked in to the               None
                                                                                 system provider
                                    Installation cost                            High                                   Low
                                    Ease of installation                         Difficult                              Easy
                                    Maintenance cost                             Moderate                               Low
                                    Ability to integrate with other IT systems   Poor                                   Good
                                    Ability to update to new technology easily   Difficult                              Easy

268   In Practice June 2010 | Volume 32 | 267–269
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                                                                                                                       Technology in business

ing lines available is limited only by the bandwidth of       Number of simultaneous calls that can be made at
your internet connection. The physical telephone exten-       different bandwidth speeds
sions can be located anywhere with an internet connec-                                              number of simultaneous          number of simultaneous
tion, be that over a network connection, wireless, via                                              calls with no compression       calls with compression
3G or over the power lines. You can assign geographic         upstream bandwidth                    (cD quality)                    (mobile phone quality)
incoming numbers to dial whichever extensions are             256 kbps                              3                               8
required, and internal and VoIP to VoIP calls are free.       512 kbps                              6                               16
                                                              1024 kbps                             12                              32
Connecting to a VoIP system                                   (1 Mbps – maximum ADSL upload)
There are three main methods of connecting an exist-
ing incoming number to a VoIP system:
                                                              Cost of installing a traditional PBX versus a virtual IP-PBX
■■ Port the number. This means moving an existing
   number to your ITSP. The existing line carrying the                                                       Traditional PbX                   Virtual iP-PbX
                                                              installation cost
                                                                                                             (eg, Panasonic KX-TeA308e)        (eg, Voipfone)
   number will be disabled so you will need to move
                                                              PBX                                            £210                              £0
   services such as broadband on that line to another
   line. The number of simultaneous incoming calls            Voice message card and 2 caller ID cards       £340                              £0
   that can be handled is limited only by the hardware        VoIP internet router                           £0                                £50
   and bandwidth;                                             8 telephone extensions                         8 x £75 = £600                    8 x £85 = £680
■■ Call forwarding. This requires setting all incoming
                                                              Installation of the system including cabling   £300                              £0-£300*
   calls to forward to an assigned VoIP number. This
                                                              Initial line installation†                     2 x £125 = £250‡                  £0
   is an expensive option because you have to pay for
   the call cost from the original number to the VoIP         Total capital outlay                           £1700                             £730-£1030
   number, but is easily reversible;                          Monthly cost
■■ Use an adapter. This adapter answers incoming              Line rental                                    3 x £15 = £45                     £15
   calls at the BT master socket and sends them to            Broadband service fee                          £25                               £25
   the VoIP system (eg, Linksys 3102). Apart from the
                                                              Call costs§                                    £174.75                           £105
   cost of the adapter (£65 at the time of writing), this
   option is free, but you are limited to one incom-          PBX feature charges                            £20                               £5

   ing call at a time. This limitation can be overcome        Support contract                               £35                               £35
   by enabling ‘call forwarding when engaged’ on the          Total monthly cost                             £299.75                           £185
   line to your VoIP provider.
                                                              Total first year cost                          £5297                             £2950-£3250
How many lines does VoIP offer?
                                                              Annual cost thereafter                         £3597                             £2220
The glib answer is ‘unlimited’. However, the limiting fac-
tor is usually the available upstream internet bandwidth      * Free if an existing computer network is available or if powerline networking is used
                                                              † Assuming one existing line with the internet already connected
(that is, from you to your ITSP), which you can find out      ‡ BT charges £125 to install a line
using any of the various online speed testers available.      § Assuming 1500 minutes to a daytime landline at 5.4p per minute (using BT) or 1p per minute
The table (top right) gives an indication of how many         (using Voipfone), 750 minutes to a mobile at 12.5p per minute (using BT) or 12p per minute
simultaneous calls your bandwidth will allow.                 (using Voipfone)
                                                              Note that this is for a typical medium-sized practice set-up, with three incoming lines and eight
                                                              extensions. All prices exclude VAT
VoIP systems available
VoIP can be as simple as a free account with free PC         ■■ Once outgoing calls have been tested successfully,
software, or a multibranch in-house managed enter-                test incoming calls by giving out the VoIP number,
prise level system tailored to your requirements. There           or by diverting some incoming calls to the phone;
are many providers that allow you to try VoIP for free       ■■   If the VoIP quality is acceptable, install the IP-PBX;
(eg, www.voipfone.co.uk.) Many of these also offer a         ■■    Use the original system until all staff are trained on
virtual IP-PBX service, with one UK provider offer-               the new IP-PBX;
ing an IP-PBX tailored to the veterinary market. For         ■■   Divert all calls to the IP-PBX using a BT call divert
larger in-house PBX solutions, practices should con-              or VoIP incoming call adapter and use the system
sider employing a VoIP consultant to ensure that an               for both outgoing and incoming calls. This divert
appropriate system is installed.                                  can be cancelled at any time;
                                                             ■■   Port the surgery numbers across to the IP-PBX.

Implementing a VoIP system
Anyone with a good understanding of computer net-
working should be able to set up a simple VoIP system.       The explosion in communication technology over the
For more complex requirements, it is best to talk to a       past 15 years means any successful practice needs to
VoIP provider or consultant. A gradual, step by step,        reappraise its communications strategies regularly. From
installation will ensure successful implementation.          e-mails and text messages to VoIP and Twitter, every
The following approach is therefore recommended:             business should consider how it can best make use of
■■ Check and optimise the internet connection. Install       the available technologies to provide a better service to
   software first, after which a VoIP hardware phone         clients. A well-designed phone system should be part of a
   can be plugged into the network and tested for out-       wider communications plan that gives new and existing
   going calls only;                                         clients the best possible impression of a practice.

                                                                                                              In Practice June 2010 | Volume 32 | 267–269    269
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                                  The practice telephone system 2. New
                                  John Taylor

                                  In Practice 2010 32: 267-269
                                  doi: 10.1136/inp.c2679

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