2.2.1 Privatisation and Accountability

Private sector actors are playing a prominent role in designing, constructing, and operating algorithmic and data-driven technologies in the mental health context. Traditional accountability mechanisms are not always equipped to ensure these interests align with the public good, particularly where the divide between public and private entities becomes blurred.²⁶⁷ Philip Alston, former UN ‘Special Rapporteur on extreme poverty and human rights’, has written that ‘[a]ccountability is the linchpin of human rights, but privatization has rendered existing mechanisms increasingly marginal’.²⁶⁸ The information economy has arguably accelerated this process.

Accountability requires a clear definition of who is accountable and who can hold actors accountable, including effective oversight systems that can trace the conduct of actors and to assess whether standards and requirements are met. Privatisation of services, such as mental health and social services, can undermine this clarity and oversight. The rise of private sector actors in ‘social protection services’, according to Alston, has been accompanied by a ‘deeply problematic lack of information about the precise role and responsibility of private actors in proposing, developing and operating digital technologies in welfare states around the world’.²⁶⁹ Further:²⁷⁰

This lack of transparency has a range of causes, from gaps in freedom of information laws, confidentiality clauses, and intellectual property protections, through a failure on the part of legislatures and executives to require transparency, to a general lack of investigation of these practices by oversight bodies and the media. The absence of information seriously impedes efforts to hold governments and private actors accountable

The case study of ‘Serenity Integrated Monitoring’ (or ‘SIM’) in England (see Section 2.3.2), in which mental health legislation data was used to flag individuals for police intervention and exclusion from emergency psychiatric services in the UK, offers one such example. The SIM program was rolled out to 23 National Health Service mental health trusts in England despite a lack of evidence of its impact on patient safety or outcomes. Instead, the little research supporting its implementation simply demonstrated reduced costs to services. SIM was owned and run by the High Intensity Network, a private limited company that was financially supported by the ‘NHS Innovation Accelerator’ and ‘Academic Health Science Network’.²⁷¹ This latter network comprises of the ‘NHS and academic organisations, local authorities, the third sector and industry’ and seeks to ‘spread innovation at pace and scale – improving health and generating economic growth’.²⁷² After a coalition of activists called for an immediate halt to the program, the High Intensity Network appears to have closed permanently; its website was removed and its social media presence wiped.²⁷³ Activists raised concerns that the outsourcing of service provision to a private company meant the program fell between gaps of traditional accountability mechanisms. The ‘StopSIM Coalition’ wrote:²⁷⁴

Following this statement, the Royal College of Psychiatrists (UK) called for an ‘urgent and transparent investigation’ not only into the SIM program and the High Intensity Network, but also into the ‘NHS Innovation Accelerator’ program that supported it.²⁷⁵ The ‘Innovation Accelerator’ program supports several digital mental health initiatives, including remote biometric monitoring of patients in acute psychiatric wards, which are being expanded through the NHS—arguably with a similar lack of robust supporting evidence.²⁷⁶

At a policy level, governance and regulatory discussions also risk being driven by private interests. In 2019, a ‘White Paper’ titled, Empowering 8 Billion Minds Enabling Better Mental Health for All via the Ethical Adoption of Technologies, was published by the World Economic Forum and authored by the multinational corporation, Accenture, which specialises in IT services and consulting.²⁷⁷ The authors urged:

Framing ethical consideration and sufficient evidence as barriers to digitally-enabled treatment reverses the typical academic method, in which ethical review and evidence are needed before determining whether a particular treatment is beneficial and effective. Reading generously, it is possible the authors were instead suggesting more research and ethical discussion are needed to expand on promising preliminary research. Yet clearly, vigilance is needed. There must be transparency about the business models of private firms, and the motives of brokerage organisations like the World Economic Forum. Many tech vendors and other private sector actors will be seeking lucrative government contracts or angling for a predetermined path to bringing certain technologies to market. The role of such actors in developing governance systems in the digital mental health context, and the growing economy and vested interests that surround them, must be made transparent, with consideration as to the appropriateness of that involvement.

The World Economic Forum has now published two prominent reports on digital technologies in mental health services. The other prominent report, a ‘Global Governance Toolkit’, was led by the multinational accountancy/professional services company, Deloitte.²⁷⁹ As an international body, the World Economic Forum is one of the primary agenda-setting organisations today. Yet, the Forum has been criticised for operating in ways that do not align with democratic values. Christina Garsten and Adrienne Sörbom conducted a detailed ethnographic study of the World Economci Forum and concluded that it operates using ‘discretionary governance’ at the transnational level, which entails ‘the exercise of a discreet form of power and control according to the judgment of the Forum and its members’ that operates in ‘ways that escape established democratic controls’.²⁸⁰

This is not to criticise the aspirations of everyone involved in these reports, whether as contributors or advisors, many who will hold their views on digital mental health care in good faith (even as others will have solely been interested in increasing company margins). Instead, it is to highlight the increasing role of private sector actors in pushing digital technologies, including growing efforts to shape governance frameworks and institutions, and steering regulatory attention in preferred directions to reproduce and protect their business model.