Written evidence submitted by Centre for Care – University of Sheffield (DTS0002)

Summary

This submission draws on emerging findings from research underway at the ESRC-funded Centre for Care at The University of Sheffield, as well as evidence from the broader literature.

Our expertise is related to issues of procuring digital technologies for use in social care contexts such as by local authorities as part of technology-enabled care services (TECS, or telecare), by providers of residential care, domiciliary care, and supported living services at the level of both commissioning and oversight, as well as service delivery.

●       Suppliers of ‘traditional’ social care technologies such as telecare / TECS have extensive relationships with local government and care providers yet the fragmentation of the care sector, complexity of supply chains (combining devices, logistics, and platforms) and supplier-led nature of the market present challenges to digital transformation[1][2].

●       The emerging digital switchover requires changes in telecare / TECS provision, which presents challenges related to the additional costs of replacing analogue with digital equipment, and the ability of the latter to adhere to existing safety frameworks[3].

●       In this context, there is also an increased interest in ‘mainstream’ smart technologies and their application in care services and settings[4], which raise issues related to regulation and applicable safety standards[5].

●       There is also an increasing onus on care providers to integrate digital technologies into their services, which is complicated with regards to procurement in a fragmented sector.

●       There are also ethical issues which should be addressed, in particular as focus shifts towards the application of smart devices and artificial intelligence[6] [7] [8].

●       Highlighting these challenges, we note that many of the concerns raised by the Public Accounts Committee (PAC) about how digital procurement approaches put patient safety at risk in healthcare are also relevant to social care, which is all too often an overlooked and poorly understood sector.

This submission covers:

1. Complexities in procurement of digital services for social care

○        1.1 Types of technology and the fragmentation of the adult social care sector

○        1.2 Approaches to procurement

○        1.3 Factoring in additional services in judging value for money

○        1.4 Recommendations

2. Impact on the safety, quality and cost of care

○        2.1 Does technology live up to claims by suppliers that it is cost-saving?

○        2.2 Finding a use for technology vs finding technology which meets people's needs

○        2.3 A weak evidence base and ‘pilotitis’

○        2.4 Recommendations

3. Risks and public trust

○        3.1 Public trust

○        3.2 Culture change and monitoring

○        3.3 Infrastructural failure

○        3.4 Recommendations

4. Production issues requiring regulation and guidance

○        4.1 Working conditions in digital supply chains

○        4.2 Environmental impacts

○        4.3 The risks of a supplier-led market

○        4.4 Recommendations

1) Complexities in procurement of digital services for social care

1.1 Types of technology and the fragmentation of the adult social care sector

Technologies have been part of adult social care systems since the 1960s, with an initial focus on ‘telecare’, or systems that enable people to summon help in an emergency. Over time, these technologies have developed to include remote monitoring devices and systems, such as those with the ability to ‘learn’ patterns of behaviour and indicate that changes are occuring. Whilst telecare systems were initially delivered via analogue devices, from the 2010s onwards, there has been an increased focus on digitising ‘Technology Enabled Care Services’ (TECS)[9]. A wider range of digital devices and systems are now part of adult social care provision, in part driven by technological developments but also instigated by the analogue to digital switchover which is taking place across the UK and the increased reliance on online services during the COVID-19 pandemic[10]. Technologies currently used in social care can be described according to their function with crossover between categories[11]. 

These functions are:

●       assisting with care - cognitively or physically;

●       monitoring care - with a shift from traditional telecare devices (where a device such as a pendant alarm will be triggered and send an alert to an ‘alarm receiving centre’), towards digital monitoring via smart sensors (which produce data which is sometimes algorithmically analysed);

●       organising and recording care - including DHSC plans to digitise social care records, with guidance and funding provided by the NHS England and DHSC ‘Digitising Social Care’ programme[12];

●       collecting and analysing care data - e.g., analysing data generated from digital social care records and monitoring systems; and

●       connecting and communicating - care staff and people using care services communicating via the care records systems, mainstream messaging services, and video calls.

These technologies are described in policy documents as playing a key role in promoting wellbeing and independence, with the potential to support prevention[13] [14] [15] in terms of the escalation of care needs, hospitalisation and entry into residential care settings.

With regard to TECS, there is a great deal of complexity in this part of the adult social care system, and variation, in part reflecting differing local populations and priorities and uneven access to funding, with a focus on short-term investment leading to ‘pilotitis’ [16] [17]. Provision varies between local authorities, but TECS are increasingly ‘contracted out’ services, including assessment, installation, monitoring and response elements, in addition to the devices themselves. There is variation in commissioning cycles across local authorities, with some tied into long-term contracts with external organisations. There is a move in some locations to move towards ‘tech agnostic’ ‘brokerage’ services which are not tied to particular contractual relationships with technology providers[18]. Charging and assessment policies are also diverse across local authorities, but again increasingly they no longer provide free technology services. Response arrangements for services also differ, with some local authorities offering a dedicated service while others require users to designate geographically close friends, neighbours or relatives to this role, or automatically contact the emergency services.[19]

At the level of care providers, there too is a great deal of complexity which affects procurement. Focusing on home care, the vast majority is ‘contracted out’ by local authorities to the independent sector, including not-for-profit and for-profit companies (98% of all state-funded homecare in England, 88% in Wales, 87% in Scotland and 73% in Northern Ireland[20]), making procurement at scale challenging. Our research highlighted that the ability of home care providers to procure and utilise digital technologies was mediated by capacity, size and resources, with smaller providers finding it challenging to navigate a complex marketplace of digital devices, as one stakeholder explained, “85% of providers have fewer than 50 employees, so the larger providers tend to have their own IT specialists in house”[21].

Within residential care settings, again, there is fragmentation and barriers to modernising the types of technology in use, as well as ensuring that basic technology is consistent and effective, include infrastructural issues, a dominance of legacy IT systems, and interoperability between systems and devices[22] - barriers reflected in the PAC report on ‘Challenges in implementing digital change’[23]. Concerns have also been raised about the workforce skills required to implement and utilise digital technology. The Digital Skills Framework provided by Skills for Care[24] has been developed to address training needs, alongside the DHSC and industry collaboration guidance ‘Digital working in adult social care: What Good Looks Like’[25]. 

1.2 Approaches to procurement

The way that digital technologies are procured for use in care provision varies. Local authorities are not required to provide telecare / TECS services with resources drawn from adult social care budgets and occasional national funding schemes (e.g. the Preventative Technologies Grant) with some operating a mixed funding model. As such, they vary in scope, scale and composition, and in how they procure devices and the associated services (assessment, installation, maintenance, alarm receiving centres and response services- some of which may be ‘in-house’)[26]. Charging policy varies locally and people using care services might purchase TECS privately, or might be eligible for local authority funded technologies: in our research, a representative from a telecare / TECS supplier provided an example where a local authority said:

“Financial eligibility starts at £21,000 … and if you are eligible, then you can have the service if you’ve gone to assessment and so on. If you aren’t eligible, then you can still have the service if you pay for it yourself”.

Some people might be eligible for funding via the Disabled Facilities Grant, which could enable them to purchase a wider range of assistive technologies beyond TECS. However,  a representative from another technology supplier in our research highlighted that takeup of that grant for technologies is low as people are often unaware that it is an option. Our research also included people who access Direct Payments, ostensibly to offer more choice and control over their care, but they indicated that for some, technologies were seen as “luxuries” rather than necessities by local authorities, particularly if they were deemed to be outside of what was considered to be ‘care’ technologies, even when used for this purpose[27].

With regard to procurement of digital technologies at care provider level, there are examples of national funding to support this.[28] The funding for digitising social care records is an example of this, a three year programme with an aim to digitise 80% of social care records systems within that period, with funding for providers allocated via Integrated Care Boards (ICBs). The initial targets for this were extended[29], as highlighted in our research where an NHS staff member involved in that programme described some of the issues that led to slow take-up:

“If they’re currently using paper based systems, we go in there and try and encourage them and financially incentivise them to move towards a digital care record system. So it’s a quite generous scheme and it comes with plenty of support as an assured set of suppliers that they can pick from. But it is only an implementation scheme and a one-year funding scheme. So a lot of them do balk at the fact, well that’s fine, but what do I do in year two, I can’t afford it … [and] the wider problem which they do say, is how do we manage the continual churn of staff? How do we keep staff up to appraise and up to speed with it, and keep it properly implemented, because we’ve got such a high turnover? So there are quite a lot of issues even when you’re effectively offering them a free good, to try to get them to accept that?”

A technology supplier we interviewed as part of our research said that there are funding pots available for other technologies, but finding which funding is the right ‘fit’ is a challenge:

“I cannot find any pots of money for falls prevention anywhere … there’s some tenuous links to the Technology Reform Fund and also to the Transforming Social Care Fund, but they’re tenuous”.

The ‘complex picture’ of digital technologies in the care sector ‘requires boundaries to be agreed and rules to be articulated and clearly understood’[30]. In our research, an employee of an organisation providing TECs as well as supporting local authorities with their digital strategies, funding comes down through ICBs but it is difficult to engage local authorities in accessing it.

“The ICBs were holding it, and then we were there, trying to work with our local authority customers, saying, “Look. Do you know that there’s loads of money over here? If you go and get some of that and actually come and spend it with us, we’ve got some ideas about how you could do it.” But they say, “Oh, no. We haven’t got time for that. We’ve got too many fires to put out over here.” So probably, opportunities were missed.”

An employee at a technology supplier also highlighted the need for transparency in how national level funding is allocated. Referring to the amount of money allocated via the digital social care records funding in an interview as part of our research, the technology supplier said:

“It was £150 million over three years, so £50 million a year. And in year one £25 million was, sort of, earmarked … And we asked some questions. “Where’s the other £25 million?” Nobody seemed to really know. We asked some questions to people in the Treasury, and they didn’t really know either”.

1.3 Factoring in additional services in judging value for money

There is also a complexity in the procurement relationships which local authorities need to establish when implementing digital services - combining devices, logistics, and platforms requires overcoming any interoperability issues. This is illustrated by a technology supplier, who reported in our research:

“We don’t make devices; we have no interest in making devices. We will take devices from wherever we can get them. We don’t install devices, not interested in it. We don’t do logistics, no interest in that. What we do is… and we don’t want to sell to the public. What we are very clear on is we’ve built a platform that’s very good at taking data and turning it into intelligence.”

The ‘ask’ that local authorities make of technology suppliers can be extensive, in ways which do not always recognise the complexity of coordinating services. A representative from an organisation which provides services including delivering TECs to the community and supporting local authorities in their digital strategies, said:

“[Local authorities] want to buy a comprehensive end-to-end technology-enabled care service with all these things … “Do referrals, Do the special assessments. Do the installations. Do the monitoring. Do the responder services. Do all the service transformation and culture change and training and return on investment. Layer that on top. And now, we want you to do the proactive and preventative stuff. So do the environment monitoring and the data insights. And can you help us manage our data and this mass of stuff which we get from Internet of Things devices now?”

Our research also underscored the importance of ‘wraparound services’ which essentially enable TECS and other digital devices to ‘care’, such as assessment, installation, maintenance and responses services. In some instances, enthusiasm for the technology had led to an underdevelopment of these elements of the services, which in turn resulted in abandoned digital devices, including an example of a trial of 300 smart watches where support to enable a manual update was not available[31]. Procurement practice should therefore focus on ensuring these services are included or the resource is available to ensure they are in place to mitigate abandonment of devices.

1.4 Recommendations:

●       Support beyond short-term funding - using funding is impeded by lack of knowledge of what is available, short-termism in programmes, workforce turnover, and local authorities being under too much financial pressure to take on the upfront additional work that implementing technologies entails. Guidance and transparency in funding routes is also necessary.

●       Account for complexity of chains - expectations and claims around the transformative potential in digital technologies[32], and the claimed efficiencies and improvements in quality of care discussed in section 2, need to take into account the chains of coordination and additional services involved in making technologies functional. The complexity of these chains is exacerbated by the outsourcing of previously in-house telecare services. In supporting local authorities to navigate supply chains, issues of production ethics and sustainability described in section 4 need to feature in regulation and guidance.

●       Additional resources around expertise, interoperability and wraparound services are needed by local authorities to implement technology and overcome interoperability barriers - central government should consider its role in this. There also needs to be an equal emphasis on the procurement of services related to digital technologies, in addition to the specific devices and systems.

2) Impact on the safety, quality and cost of care

2.1 Does technology live up to claims by suppliers that it is cost-saving?

As noted in section 1.1, digital technologies in the care sector are associated with efficiency and prevention in policy and by the technology industry. Local authorities have a similar emphasis. The interviewee from the organisation referred to above providing both strategy support to local authorities and providing TECS said:

“Local authorities also want to know what’s the return on investment … [and] how do you start to understand what’s out there in terms of new technologies which might enable people to be supported to live at home or support the council or the wider care system to become more effective or more efficient, so those sorts of system outputs.”

The Rethink and Local Government Association (LGA) Digital Care Technology: Procurement Planning Guide states that ‘care technology should be value creating and generate savings’, but cautions ‘consider if you have a strong enough focus on quality and its individual elements, and that your framework won’t force you to choose the cheapest, but not necessarily the best value / best quality provider’. Further, issues of coordinating technology services in section 1.3 are barriers to making efficiency gains. This includes an array of wraparound services such as installation, maintenance, and WiFi access which can render seemingly inexpensive technologies costly[33]. Monitoring data within organisations also adds a further cost. A manager of a domiciliary care company interviewed for our research explained,

“I save a few people’s wages here by using the digital technology, but I create three jobs here managing the resource of the digital technology.”

Similarly, a commissioner interviewed noted that technology should augment rather than replace members of the workforce to deliver efficiencies:

“we free people up to do the stuff they need to do…if you do something that, with a piece of equipment rather than a human being it’s cheaper, immediately, however what you then have is the impact around social isolation and everything else that kind of bites you later on”[34].

2.2 Finding a use for technology vs finding technology which meets people's needs

Our research finds that reliance on pilots and trials (described below) can mean that technologies are not always appropriate or personalised for people using care.[35] Telecare suppliers will approach local authorities, who will often carry out a trial. However, ‘through the mechanism of a trial, devices are often bought in bulk and only subsequently are users’ specific needs assessed for a fit with the products on offer’.

Similarly research by Litchfield et al[36] discusses how AI-based technology in social care provision in England can end up purchased in a way that fits the people to the technology. They cite a senior member of staff at a local authority saying,

“we had actually bought a sizeable amount of tech and were then trying to find people to fit the tech … and very quickly the cohorts and the amounts that we could potentially deploy to, the numbers started reducing and reducing”.

The generic aspects of many technologies can reduce their effectiveness. Improving prevention, for example, is often more appropriate for large scale initiatives. A manager at a residential home we interviewed as part of our research about a monitoring technology that they had trialled said:

“It was completely mis-bought. They bought something and tried to do the wrong thing with it … [It] was a number of sensors that monitored people’s activity and, effectively, was designed to give you an idea about what sorts of characteristics people who came into ill health or needed care in the future might have … But it was designed for being used across whole populations, millions of people … it would potentially work well in more of an American insurance style market.”

2.3 A weak evidence base and ‘pilotitis’

There is currently an absence of evidence regarding efficiency claims - as Woolham et al argue, ‘[t]he effectiveness of telecare is still unproven, and there is limited research about cost savings’ but ‘local authority financial commitments to it are considerable’[37]. In part this relates to ‘pilotitis’ in the funding of projects, which makes it difficult to build a knowledge base about what works well and what does not[38], and questions as to appropriate methodological approaches to ‘complex interventions’ such as digital technologies in care provision[39]. Difficulties in finding suitable participants for trials has been a common theme in our research. A sensor trial, for example, struggled to recruit participants as for the technology to be effective people needed to fit certain criteria, as well as feeling comfortable having the devices installed. Technologies also end up funded or purchased based on potential impacts, without always even being adopted. In our research, a manager at a residential care home reported:

“Somebody has developed a sock, or some socks, for people living with dementia, to alert staff to any potential distress reactions. So these socks have sensors in them that will detect temperature, sweat or moisture, and I can’t remember the other things. Basically, it will send information to an online system that will alert us or a carer to the person potentially becoming distressed, so we can intervene … So that was supposed to be introduced in May. We identified a resident, everything was set up, and okay … But because it’s a pilot, everything… people are always working on it, so it didn’t happen, basically.”

An example of abandoned technology is the robot Pepper, which was built to engage people using care services in exercises and games. Research questioned the effectiveness of Pepper[40] as did staff of a local authority who had purchased it[41] and production was ‘paused’.

2.4 Recommendations:

●       Realism around cost-savings - claims made by technology suppliers that their product will generate cost savings need to be interrogated - the cost of wraparound services, monitoring, and overcoming interoperability challenges need to be factored in.

●       Involve people who draw on care and support - in the procurement strategy document ‘National Social Care Category Strategy for local government’, the LGA emphasises ‘involving service users throughout the procurement process and exploring procurement routes that give more choice to service users’. Their involvement needs to also happen in procurement of technology, so that what is being procured fits their needs, not the other way around.

●       Improve the evidence base - technology suppliers themselves are often involved in the evaluation of their own products - which can equate to ‘marking their own homework’ - and pilots are often small. Central government could play a role in driving larger-scale evaluation and improving our knowledge of what works, for whom, and in which contexts.

3) Risks and public trust

3.1 Public trust

A further consideration in procurement decisions is that the conditions and lack of transparency in partnerships and procurement deals with technology suppliers can contribute to public distrust of engaging with digital services and the public sector.[42] Tax avoidance by some companies has been critiqued, particularly given the chronic underfunding of social care: Wright raises questions about “both the ethics and the long-term financial sustainability of paying tax-avoiding international technology suppliers such as Amazon to deliver public services”[43]. Sometimes technology is developed for a care purpose, but then used in different contexts in ways which could increase public distrust. For example, Oxehealth received public funding for development of monitoring technologies for people with dementia[44]. Their technology has since been used in prisons in ways which raise privacy concerns. A HMP inspection report refers to privacy concerns in its use: “during the inspection we identified blanket use of the trust’s Oxehealth video monitoring which operated in all cells within the CAU [Clinical Assessment Unit]. The guidelines assumed consent for all patients with a cell in the CAU regardless of their individual healthcare needs”[45].

The use of data is another issue which has a significant impact on public trust. For example, partnerships between the NHS and Palantir[46] have been widely criticised given the company’s human rights abuses[47]. There was also a ‘watering down’ of the DHSC’s approaches to data under the previous government. The ‘DHSC Privacy Notice’[48] was updated in 2023 which meant the removal of key provisions, e.g., changing “the data we are collecting is your personal information and you have considerable say over what happens to it” to “the data we are collecting is your personal data”[49].

3.2 Culture change and monitoring

A report by Rethink and the LGA refers to ‘culture change work, alongside tactical adjustments to your operational and strategic governance’ as important aspects of strategy in procuring digital care technologies[50]. Culture change is important across stakeholders: a local authority staff member told us that “the most important thing [in creating digital solutions] is your workforce. You have to get that cultural change in place [including] health, housing, and social care practitioners.” Cyber security is, he emphasised, an important aspect of reducing risk and building trust.

One aspect of culture change is gaining trust across the workforce. However, the use of monitoring devices has been found to increase workplace control and indicate a lack of trust in care workers themselves. At a residential home, a staff member discussed the detailed monitoring which care records systems enable in our research:

“We monitor them, we also have a live view that we monitor in the office, as you progress from Client A to Client B, from Client C. We monitor their progress, so if there is any delay we will be able to track that immediately, and we will be able to action what needs to be actioned, so that our clients don’t have delayed care at all.”

A manager at a domiciliary provider was of the view that the increased monitoring indicates a lack of trust in social care staff:

“As a nation we do not trust social care staff, we want to check up on every minute of every single thing that they’ve done”.

While ‘checking up’ via digital records systems had improved safety at his organisation, it had not improved efficiency and also had implications for staff wellbeing and morale.

3.3 Infrastructural failure

There is a risk when technologies are integral to care provision that the sudden failure of systems or devices could have highly detrimental effects on care quality. Sometimes this is because of data inaccuracy. For example, when domiciliary staff fill in care records they need to have enough data on their smartphones (which are likely to be their personal devices), and have signal in areas where they are working. In our research, a manager at a domiciliary care provider described this happening often:

“we know that there are some customers in some areas where there is going to be no signal and some staff who won’t be able to log the information until they get home and have got Wi-Fi”

Alerts would therefore not be received in ‘real-time’.

There are also more infrastructural risks that local authorities need to factor in when procuring technologies - and there is a clear role for central government. Coordinating the ‘digital switchover’ is an example of this, with those using telecare devices impacted by the transferral from analogue to digital phone systems. Local authorities[51], the LGA[52] and the Technology Enabled Care Services Association (TSA – a sector body representing local authorities and TEC providers)[53] have all highlighted risks that digitisation might bring. These include call distortion and call failure[54]. In 2024, risks materialised with reports of the deaths of two people ‘following the failure of their telecare devices after the upgrade process’[55].

Responsibility for overseeing the switchover and accounting for risks has been divided between industry, local government, technology suppliers, telecommunication suppliers, and national government. The latter has taken a backseat: the 2023 ‘Telecare stakeholder action plan’ published by the DHSC under the previous government placed emphasis on local government, and called for ‘the development of realistic and proportionate procurement plans to manage the switchover of telecare equipment locally’[56]. Yet local plans require expertise, bringing additional costs. The TSA has produced ‘Commissioner/Buyer Guidance: Transitioning your Social Alarms Systems from Analogue to Digital’[57] which outlines procurement routes and emphasises the need for expertise to understand interoperability issues across these routes.

3.4 Recommendations:

●       Promote ethical partnerships - to maintain public trust, central and local government need to ensure that ethical considerations underpin purchases, partnerships, and data sharing, so that these are consistent with ‘social values’.

●       Involve the workforce - cultural change must foreground the workforce, e.g. consulting with unions in the sector to understand concerns around technology and monitoring.

●       Clarify accountability in government and industry approaches - the example of the digital switchover raises questions over who has responsibility for risk at the level of infrastructure.

4) Production issues requiring regulation and guidance

4.1 Working conditions in digital supply chains

Currently consideration of ethics in supply chains has mainly applied to NHS services. The ‘Tackling modern slavery in NHS procurement: proposed regulations and guidance’, refers to ‘the government’s view that the NHS has a significant role to play in combating modern slavery through taking steps to ensure that NHS supply chains and business activities are free from ethical and labour standards abuses’. The guidance does include local authorities but only in their capacity providing health services: this could be extended to include social care and to acknowledge issues in digital supply chains. As noted by the LGA, it is also the case that ‘councils are uniquely placed with the wide range of goods and services that we procure placing us at the forefront of the fight against modern slavery’.

It is positive that existing regulation in the Public Contracts Regulations 2015 will be strengthened through the incoming Procurement Act 2023, yet the approach to production issues within supply chains remains overlooked. Ethical concerns have been raised in relation to AI, for instance, which relies on ‘ghost work’ of coding, cleaning, and classifying data. Muldoon et al highlight how these jobs are low-paid and often outsourced to the Global South, and challenge  ‘techno-optimistic accounts of AI’ instead demonstrating ‘the important role played by human labour in AI production networks’[58].

A further consideration is poor working conditions in factories where devices are produced, and whether there is a tension between these contexts and modern slavery regulations. As an example of this, some local authorities have procured consumer Amazon Echo devices, or are creating ‘skills for use via devices people already own[59]. Amazon has been criticised for neglecting exploitative labour practices in factories owned by their supplier Foxconn which produces these devices[60].

4.2 Environmental impacts

Digital technologies also require extractive and energy intensive processes, both in the making of devices and the storing and analysing of data[61]. If local authorities are ‘buying into’ digital solutions for care contexts on a large scale, the environmental implications further down supply chains need to be considered too. These implications can be understood as part of the government’s commercial objectives in the Social Value Model, with the third theme of the model focussed on ‘fighting climate change’ to ensure ‘effective stewardship of the environment’[62].

While technology solutions can act as a way of reducing ‘care miles’ through virtual care[63], the environmental impact of the devices themselves has increasingly been emphasised. So far, this has mainly been considered in relation to health care technologies: Samuel and Lucassen[64] refer to the importance of discussing digital waste and manufacturing processes in data-driven gene technologies. Such concerns also apply to social care technologies, for example, the waste generated by replacing analogue devices with digital devices, or when local authorities abandon technologies which they have procured.

4.3 The risks of a supplier-led market

There are other market-level risks impacting procurement. Technology suppliers aim to ‘capture’ the market leading to a situation Woolham et al describe as ‘supplier induced demand’[65]. The suppliers are often backed both by public funding and by private equity. Mergers of firms providing platforms have increased market dominance of particular suppliers - concerns over competition have been raised in similar mergers in the field of healthcare technologies (with health technology firms Imprivata and Isosec prevented from merging by the Competition and Markets Authority in 2021[66]). The dominance of technology suppliers and the market power that entails is highlighted by the Digital Telecare for Scottish Local Government, which notes that ‘nudging’ is not enough to ensure that telecare providers improve security:

“Governments hope that education and legislation will gently nudge suppliers towards adequately securing their services for fear of losing market share should a competitor offer a provably more secure product … Where there exist niche services, this nudging market force is effectively non-existent and other options to bring suppliers along with on the security journey have to be investigated. One such niche market is telecare[67].”

The issues above around working conditions and ethics are similarly difficult to achieve via ‘nudging’ when suppliers have market dominance. As well as concerns over competition when small numbers of ‘big tech’ providers are relied upon, there are concerns related to supplier failure. Wright, for example, notes ‘the risk of increasing public sector reliance on precarious corporate infrastructures for the wellbeing of older adults under the care of local authorities, and the misalignment between local government adult social care and global technology corporations’[68]. Wright also writes that promises of what technology can achieve are tempting to cash-strapped local authorities. The ‘situation of precarity and desperation’ that many local authorities are in can thus heighten the risk associated with procurement approaches, leading to ‘crisis decision-making’.

4.4 Recommendations:

●       Clear regulation across supply chains - public sector procurement should consider the ethical issues in its digital supply chains, which includes modern slavery, labour exploitation and very poor working conditions (particularly in the Global South), and the environmental impact and carbon emissions.

●       Recognition of  potential environmental impacts - for example, concerns have been raised that ambitions around AI use could ‘derail’ this government’s promises on sustainability[69]. These concerns are relevant to a sector increasingly using digital technology and AI. As Naylor et al contend, ‘health and social care will need to be delivered in ways that are not only financially sustainable, but environmentally sustainable too’[70].

●       Regulation to address the ‘supplier-led’ market - there is a risk that technology suppliers sell products and services to overwhelmed local authorities - who might then identify issues only after purchasing the product. There is a reticence to over-regulate as doing so could stifle innovation, but as O’Donovan notes, ‘innovation on its own cannot be expected to resolve problems with accountability and neglect in social care’[71]. Regulation of AI in particular has been ‘pro-innovation’[72] yet in health and social care contexts AI needs to be used in ‘responsible’ ways to ensure that it does not lead to or exacerbate inequalities[73].

About the Centre for Care

This response is provided by members of the ESRC-funded Centre for Care. The Centre for Care is a research-focused collaboration between the Universities of Sheffield, Birmingham, Kent and Oxford, the London School of Hygiene & Tropical Medicine, the Office for National Statistics, Carers UK, the National Children's Bureau, and the Social Care Institute for Excellence. Funded by the Economic and Social Research Council, with contribution from the National Institute for Health Research (NIHR) and Department of Health and Social Care, as one of its flagship research centres, it works with care sector partners and leading international teams to provide accessible and up-to-date evidence on care – the support needed by people of all ages who need assistance to manage everyday life.

Led at the University of Sheffield by Centre Director Professor Kate Hamblin and Deputy Director Professor Nathan Hughes, our work aims to make a positive difference in how care is experienced and provided in the UK and internationally by producing new evidence and thinking for policymakers, care sector organisations and people who need or provide care. In studying care, we focus on ways of improving wellbeing outcomes and on the networks, communities and systems that support and affect people’s daily lives, working closely with external partners.

The Centre for Care is funded by the Economic and Social Research Council (ESRC, award ES/W002302/1), with contributions from the Department of Health and Social Care’s National Institute for Health and Care Research (NIHR) and partner universities. The views expressed are those of the author(s) and are not necessarily those of the ESRC, UKRI, NHS or NIHR.

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