Digital transformation and the uptake of welfare technology in care services is expected to improve the quality and cost-effectiveness of care provision. The implementation of these technologies in municipal care is still hindered by many factors, ranging from lack of infrastructure and insufficient resources to juridical and ethical issues [10, 17, 20, 37]. Welfare technologies, providing assistance in practical tasks, health monitoring, remote treatment and rehabilitation for older adults or persons in a risk of disability, are launched as a solution to optimise the provision of care work, such as support care delivery and performance of care related tasks [17, 18, 21]. These health systems, embodied in variety forms of technologies ranging from safety alarms, night monitoring, digital surveillance and sensor and movement detectors to assistive robots and exercise apps, aim increase the safety, autonomy and independence for older adults, resulting to patient empowerment and improved professional practices in health and social care [28].
Research has acknowledged several reasons for the low uptake of welfare technology in municipal care. Welfare technology gathers a heterogeneous group of technologies that introduce technologies in new areas, such as home care services in private homes. These technologies adopted and used by a diverse group of end-users, from older adults to informal and formal care providers [27] and patients with dementia or intellectual disabilities or cognitive impairments [37]. The implementation of these technologies raises ethical debates on surveillance, quality of life and assessment of the benefits of welfare technology to different stakeholders [9, 10, 27]. The implementation entails adjustments at the individual and organisational level, often resulting to several forms of resistance [32, 37, 41]. Adopting and using welfare technologies in care practices contests new ways of working, changes in professional roles and identities, requiring new types of skills and competences among the health care professionals [24]. Participatory design methods have been applied to augment the implementation of welfare technology in care settings [25, 43].
Municipalities are responsible for purchasing welfare technology to care services that often follows a standardised structure of public procurement in Sweden [6, 20]. The procurement, defined as a process in which authorities and other public actors purchase goods, services and public works, can significantly delay or complicate the implementation of welfare technology. Procurement of welfare technology gathers different actors, procurement administrators, health care professional and suppliers in the complex task of requirement specification, where technological identities of medical devices are socially constructed and negotiated between different actors [2]. Diffusion and innovation of new medical devices is governed by socio-technical processes, and negotiated logics between health care professionals and administrators in their conversations of diffusion of innovations [47, 48, 49]. Purchasing welfare technology also requires a set of managerial and technical skills, ranging from communication, problem-solving, teamwork, cost analysis and persuation [30].
Against this background, this paper investigates the complexities of decision-making among municipal actors in the task of purchasing welfare technology for digital transformation in care services. Based on qualitative interviews for municipal actors in Sweden, the study analyses how municipal actors negotiate and interpret barriers and enablers of procurement practices in relation to their skills and competences of purchasing welfare technology. Building on these findings, the study conceptualises the procurement competence to address the different layers of knowledge and expertise required during implementation of welfare technology. As a conclusion, the study discusses how purchasing welfare technology entails socio-technical understandings of the need assessment, cost-benefit analysis and juridical and legislation issues that often are interpreted and negotiated in a specific cultural context.
The paper begins with introducing welfare technology and procurement practices in municipal care. This is followed by a presentation of qualitative approach to procurement practices, based on semi-structured interviews for procurement managers in municipal care. The result section presents the complexities in the decision-making in each stage of the procurement model, resulting to definition of procurement competence as economic, technical, juridical and ethical skills to assess, evaluate and conduct procurement of welfare technology.
Background
Welfare technology in municipal care
Welfare technology has been launched as a concept to describe the digital transformation and health system changes in the Nordic countries [5, 6, 9, 10, 17-20]. Welfare technologies are assistive technologies providing physical, social and cognitive assistance for older adults and persons in a risk of disability, with a purpose of increasing safety, participation and independence, together with improving care delivery and working environment of health care professionals [20, 39]. These technologies include various forms of digital devices from care robots [4, 35], telecare and alarms [29, 49], monitoring systems [3, 26], digital reminders [8] and mobile health applications [12, 34]. Welfare technologies embody devices such surveillance cameras, key-free locks, GPS alarms, virtual doctors, security bracelets and mobile access to patient documentation and digital signing of medication [20], aiming to offer care at a distance, and new divisions of labour and responsibility [28].
The implementation of new technical solutions to care practices is not linear process, and many factors hinder the adoption, use and implementation of welfare technology in municipal care [51]. The implementation of new technological innovations entails changes in health care professionals’ work, tasks, roles identities and relationships, which requires management and technological leadership in organisations. Adopting and using care robots, for instance, influences work atmosphere, meaningfulness of work and professional development of care professionals, such as need for orientation, problems with time usage and overall attitudes towards renewing of care service [35]. Confrontations that older adults and their care providers need to phase may include technical incompatibilities, professional identities and roles, lack of orientation and fears [40]. For this reason, technology implementation is increasingly becoming co-produced, and the testing and deployment is often conducted in collaboration between technology developers and customers. Implementing new technologies encounters different types of organisational, cultural, technological and ethical resistance. This may include, for instance, resistance to chance established routines, resistance due to language differences, clash of professional cultures, resistance due to patient safety, concerns on quality of care, patient privacy, dignity and justice [37].
In the Nordic countries, municipalities carry the responsibility to organise, manage, procure and implement welfare technologies [6, 18]. The implementation of welfare technology in municipal care is influenced by a variety of structural factors such as procurement legislation, political directives, available resources and competence [17]. According to Socialstyrelsen [44], in 2018 the majority (78 %) of the Swedish municipalities had implemented safety alarms for older people living at home; in 2019 the number had risen to 86 %. Other welfare technologies, such as medication reminders, were implemented by one third (35 %) of the municipalities in 2019, also showing a rising trend from previous years. Especially GPS-alarms and night monitoring systems are still less implemented. In practice, municipalities show a great variance in the implementation and procurement of welfare technology: some municipalities are innovative, testing state-of-the-art innovations, and other municipalities have implemented only the most common welfare technology such as safety alarms [44]. Even though the utilisation of welfare technology is increasing, most of welfare technologies have still remained as test and pilot services [11].
Procurement of welfare technology
Public procurement has been recognised as an important instrument of innovation policy [23, 33, 48]. Procurement is a process where authorities and other public actors purchase goods, services, and public works for the purpose of innovation and diffusion of new technologies. This has the potential to push innovation based on both supply and demand of new technologies [13]. The procurement process is defined in Swedish Public Procurement Act to ensure that public procurement is based on equality, non-discrimination, openness, mutual recognition and proportionality [31]. Additionally, a number of policy documents and recommendations guide the procurement process at the European level [15].
Procurement is a stage that often delays and hinders the implementation of welfare technology [5, 6, 17]. Nordic countries have developed guidelines and recommendations for the procurement of welfare technology [6, 38]. One of these guidelines is the procurement model created by the National Agency for Public Procurement. The model consists of three chronological steps. The preparation phase (1) includes planning, mapping and analysing the need and the market for the technology to be procured. The municipal actors need to identify and recognise the need for the welfare technology, and map out relevant suppliers in the field. This is followed by the procurement phase (2). Municipalities choose either direct procurement or the public procurement, based on the value of the procured welfare technology, resulting to an agreement between supplier and the municipality. The realisation phase (3) includes implementing and managing the procurement of welfare technology by reviewing the delivery.
Procurement process involves many actors from different organisational levels, which make it a resource-demanding practice that complicates the implementation of welfare technology [20]. Barriers and challenges that prevent a well-functioning procurement process are derived from the organisational structures, mechanisms and processes [2, 45]. An important factor is the interaction between procurers and suppliers. Suppliers often lack feedback from procurement managers on previous bids, and therefore they have limited possibilities for improving their capability. Procurement managers show a low interest in suppliers’ experience as a private sector deliverer, and suppliers often have difficulties in initiating a dialogue with the procurer in the procedures and conditions [48].
Purchasing welfare technology requires a set of managerial and technical skills, ranging from communication, cost analysis, teamwork, problem-solving, negotiation and persuasion [30]. Research has acknowledged that procurement managers often have low competence and limited expertise in conducting complex purchases [22]. This lack of competence hinders the innovation diffusion [14, 22, 23, 36, 48]. The lack of skills and expertise can result to insufficient communication between potential suppliers and procurement actors. Procurement process compiles a variety of actors who are influenced by social processes, such as negotiations, values and ideals of welfare technology [2, 18, 47]. To date, research has shown a connection between the procurement results and the competence within those performing the procurement, but no studies have defined or covered the characteristics of procurement competence of welfare technology in detail. Based on this research gap, the study investigates different dimensions of procurement competence and aims to evaluate its impact and connection on the implementation of welfare technology in municipalities.