During September-December 2018 we conducted a randomised controlled trial (RCT) with 705 Worcestershire County Council (WCC) domiciliary care users to reduce the number of unpaid service invoices and increase the number of people who sign-up to direct debit. We tested two behaviourally optimised conditions against the control across the Invoice, Reminder 1 and Reminder 2 phases. Relative to the control, our test letters significantly increased: direct debit sign ups by 61% (P<.10), people paying their invoice via the WCC website and automated telephone line by 33% (P<.10), and people calling the helpline by 36% (P<.20).
Many people receiving social care services at home are required to contribute financially to their service, but many invoices for these contributions often go unpaid. When invoices are not paid an investigation needs to be undertaken to determine the reasons behind non-payment. This is time consuming and involves looking at social care notes and possible discussions with social workers before making a decision on how best to contact the service user.
Focusing on the Invoice, Reminder 1 and Reminder 2 letters, we defined three key behaviours for successful payment:
- Open: helping clients to notice their letter from WCC
- Accept: helping clients to understand the purpose of the letter and the information included
- Act: making it as easy as possible to pay the bill or get in contact with WCC
To gain an understanding of our audience, and their perceptions of payment and the service we interviewed social workers and frontline staff, as well as analysing current payment data. Using the COM-B model of behaviour change, we then analysed the three sub-behaviours, and identified the barriers to completing each task:
Barriers to Open
- Some clients may not open their letters due to the high volume of received letters, or because they believed it could be bills or spam;
- There was no indication of who the letter was from.
Barriers to Accept
- The invoice didn’t outline the previous agreement to undergo care, therefore some clients may not be expecting an invoice;
- Some service users may not agree that they have to pay for their care;
- Service users may be confused about the state of their current care plan.
Barriers to Act
- It wasn’t clear on the steps necessary to make a payment
- The helpline number included on the invoice was no longer in use
- There was no perceived consequence for non-payment, as well as a lack of positive reinforcement for paying
- There was no ‘preferred’ way to pay, to help guide the payer.
To overcome these barriers, we optimised the Invoice, Reminder 1 and Reminder 2 letters with 58 behaviourally informed ideas. We then clustered these ideas into three themes: increase the ease to process information, increase the perceived value of the service and increase the consequences of non-payment.
The below details a selection of the behavioural principles executed within each theme:
1) Increase the ease to process information:
- Chunking: Parts are easier to process than “wholes”. Breaking information into chunks and highlighting important areas (eg ‘Your invoice at a glance’), helps the reader process the information more easily.
- Ambiguity aversion: We have an instinctive avoidance of the unknown. By describing each payment option in terms of the behaviour required for each (e.g. ‘I want to pay manually online every month’) with a time estimation and difficulty rating, we can increase service users’ understanding of what is required to perform each task.
- Default: We are more likely to go with the flow of pre-set options. By subtly highlighting the direct debit option with colour cues and framing it as the easiest, safest and quickest way to pay, we are suggesting that this is the ‘standard’ method of payment.
- Social norms: Our behaviour is heavily influenced by that of others. For the Reminder 1 and 2 letters, we also included extra information that helped those who felt they were unable to pay their invoice. Through stating that ‘we answer hundreds of calls from Worcestershire residents every month’ we highlighted how there are others who may also have money issues too. We also indicated when lines are “least busy”, to reinforce the norm of calling the helpline.
We applied these ideas to optimise each Invoice, Reminder 1 and Reminder 2 letter.
Using these redesigned letters as a base, we then included information that laddered up into two separate conditions for testing:
2) Increase the perceived value of the service
- Concreteness: We process concrete words easier than abstract words. Stating that ‘every penny you pay goes back into providing your care’ with an image of a penny increases the ease for users to understand how their care is funded.
- Endowment Effect: The prospect of owning something increases its value to us. Highlighting that the council is ‘providing your care’ increases the client’s feeling of ownership and control over their care.
- Labour Illusion: We value things more when we believe extra effort has been exerted on our behalf. Highlighting the effort that the care workers go to, to deliver ‘thousands of hours’ of care increases the perception of the service’s value.
- Goal Gradient: The closer we think we are to completing a goal, the more we try to achieve it. Showing the behaviours that the client has already achieved along the care journey, and indicating the fewer remaining steps to complete payment, helps to motivate users to complete the task.
3) Increase the perceived consequences of non payment.
- Commitments: We need to be seen to be consistent in our actions. Referring to the previous agreement signed by WCC and the service user increases their feeling of commitment and the obligation to pay.
- Reciprocity: We feel compelled to return favours done on our behalf. Communicating the actions of the council that go towards continuing the client’s care for them, ‘we have paid your care providers’ increases the incentive to act.
- Goal Gradient: The closer we think we are to completing a goal, the more we try to achieve it. Using a ‘negative’ goal gradient to show the user where they are currently in the journey and indicating the consequences of non-payment (e.g. ‘investigation commences in 14 days’).
We conducted a three-month RCT where we randomly assigned 705 domiciliary care receivers across 3 conditions, testing our two experimental conditions against the control in the Invoice, Reminder 1 and Reminder 2 phases. In each case, those who failed to pay their invoice then received a Reminder 1 and/or Reminder 2 letter.
The increased consequence condition significantly increased people paying their invoice via the WCC website and automated telephone line by 33% (P<.10), compared to the control.
The increased consequence condition significantly increased people calling the helpline by 36% (P<.20), compared to the control.