The “NHS Long-Term Plan” (2019) is a five-year plan describing how NHS services should be redesigned for the next decade. This plan includes making better use of digital technologies, such as video consultations. While video consultations have potential advantages for patients and hospital systems,[1] they may make patients uncomfortable. If patients do not walk through the ‘digital door’ to attend a video consultation, then potential advantages cannot be realised. Likely the motto of “build it and they will come” is insufficient. Instead, we need to support patients so that they come the first time and return after that.
What support that patients need is, at least in part, an empirical question that we plan to address in a future study. One way to support attendance may be with the behavioural science principle of ‘defaults’ – people tend to ‘go with the flow’ of pre-set options.[2] Defaults have been used to influence organ donations by adding the word ‘don’t’ to an application, i.e. “If you want to be an organ donor, please check here,” vs. “If you don’t want to be an organ donor, please check here”. In a simulated study, 42% of people opted-in to become organ donors given the original phrasing, and 82% did not opt-out given the second.[3] In other words, the realised organ donation rate nearly doubled by changing the default option. Until April 2020 England had an opt-in system with 38% of people having opted-in to become organ donors. When England’s law changed to an opt-out system in May 2020 the assumed donor rate has increased instantly. Time will tell how many people fill out the form to opt-out, but the present authors suspect the resultant donor rate to remain higher than 38%.
Defaults have been used to influence people’s behaviour in many contexts, e.g. how much money people save for retirement,[4] physicians’ medication use,[5] and purchases of healthy foods.[6] At least three psychological mechanisms are at play: endorsement (believing the proposed default is recommended), endowment (believing the default is normal), and ease (taking up the proposed default is simpler than refusing it).[7,8] Re-framing an invitation to attend an outpatient appointment from ‘in-person’ to ‘video’ creates a new default ‘endorsed’ mode of attendance that is ‘easier’ to accept than refuse. However, if a substantial number of patients refuse an invitation to attend a video consultation, this would suggest that more support is needed to garner people’s acceptance.
An ideal experimental test of the default effect on out-patient appointment attendance would occur in the field setting, similar to our work on influenza vaccination letters.[9] But (without tremendous follow-up efforts) this approach provides a limited ability to explore barriers and facilitators patients believe influence their choices. These beliefs undoubtably influence whether patients attend. To explore how default options and beliefs influence whether patients accept an invitation to attend a video consultation, we will conduct a simulated study with patients from the site Prolific Academic. Prolific Academic contains thousands of people prepared to answer researchers’ questions who can be filtered on criteria such as health status, age, and education. Our research will utilise an online experiment with quantitative and qualitative items. We plan to compare our findings to real hospital data on video consultations before and after COVID-19, which may have provided the impetus for more patients to engage in digital healthcare.
Conversations with researchers across ARC WM’s themes and with public contributors suggest several barriers and facilitators to the uptake of video consultations. For instance, while the location of in-person consultations was obvious, video consultations require patients to make an additional choice about where they feel comfortable attending. Whether attending from home or work, new privacy concerns arise regarding what other people can overhear across physical and digital space. Our research will show how much such concerns matter to patients, and suggest what additional support should be offered to increase patients’ attendance within their invitation to attend. If COVID-19 hasn’t provided the push that patients need to walk through the digital door, this research will help us understand why. Equally, if it has, we will be better equipped to sustain and expand the shift, and in so doing help realise the NHS Long-Term Plan.
Kelly Ann Schmidtke (Assistant Professor) and Laura Kudrna (Research Fellow)
References:
- Greenhalgh T, et al. Virtual Online Consultations: Advantages and Limitations (VOCAL) Study. BMJ Open 2016; 6: e009388.
- Dolan P, et al. Influencing Behaviour: The Mindspace Way. J Econ Psychol. 2012; 33(1): 264-77.
- Johnson EJ, Goldstein D. Do Defaults Save Lives? Science. 2003; 302(5649): 1338-9.
- Madrian BC, Shea DF. The Power of Suggestion: Inertia in 401(k) Participation and Savings Behaviour. Q J Econ. 2001; 116(4):1149–87.
- Ansher C, et al. Better Medicine by Default. Med Decis Making. 2014; 34(2):147-58.
- Peters J, et al. Using Healthy Defaults in Walt Disney World Restaurants to Improve Nutritional Choices. J Assoc Consum Res. 2016; 1(1): 92-103.
- Jachimowicz JM, et al. When and Why Defaults Influence Decisions: a Meta-Analysis of Default Effects. Behav Public Policy. 2019; 3(2): 159-86.
- Dinner I, et al. Partitioning Default Effects: Why People Choose Not to Choose. J Exp Psychol Appl. 2011; 17(4): 332-41.
- Schmidtke KA, et al. Randomised controlled trial of a theory-based intervention to prompt front-line staff to take up the seasonal influenza vaccine. BMJ Qual Saf. 2020; 29(3): 189-97.
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