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FrancoAngeli Journals

Regular Articles

No. 2 (2025)

Appropriateness and Accountability in Clinical Psychology within the NHS: Towards a Conceptual Framework: Towards a Conceptual Framework

DOI
https://doi.org/10.3280/rpc2-2025oa20575
Submitted
luglio 5, 2025
Published
2026-02-26

Abstract

Clinical psychology within the Italian National Health Service (NHS) is undergoing a structural transition, increasingly required to align with governance principles such as appropriateness and accountability. Yet, these constructs ‒ central to international health policy ‒ have not been systematically articulated within psychological practice. This paper develops a conceptual framework that redefines appropriateness and accountability as intrinsic disciplinary dimensions rather than external administrative requirements. Appropriateness is framed as the alignment of psychological intervention with clinical need, psychosocial context, care pathway positioning, and proportional use of public resources. Accountability is defined as the ability of psychologists to justify decisions, demonstrate outcomes, and contribute to the governance and sustainability of public health services across individual, organisational, and participatory levels.

The framework is situated within current developments in the Italian NHS, including the experimental introduction of the primary care psychologist (psicologo di base), the formal integration of psychologists within multidisciplinary care pathways (PDTA), and the increasing relevance of digital data systems and outcome monitoring. A conceptual matrix of appropriateness and a three-phase model of strategic integration are proposed to guide policy, training, and professional practice.

By positioning clinical psychology as a system-based public health discipline, the paper offers a theoretical foundation for enhancing its institutional role, improving coordination across care levels, and supporting value-based and equitable healthcare delivery.

References

  1. Allen, D., Gillen, E., & Rixson, L. (2009). The effectiveness of inte-grated care pathways for adults and children in health care settings: A systematic review. International Journal of Evidence-Based Healthcare, 7(2), 61-162. Doi: 10.1111/j.1744-1609.2009.00127.x.
  2. Arah, O. A., Westert, G. P., Hurst, J., & Klazinga, N. S. (2006). A conceptual framework for the OECD health care quality indicators project. International Journal for Quality in Health Care, 18(suppl_1), 5-13. Doi: 10.1093/intqhc/mzl024.
  3. Brinkerhoff, D. W. (2004). Accountability and health systems: Toward conceptual clarity and policy relevance. Health Policy and Planning, 19(6), 371-379. Doi: 10.1093/heapol/czh052.
  4. Burchard, J. D., & Schaefer, M. (1992). Improving accountability in a service delivery system in children’s mental health. Clinical Psychology Review, 12(8), 867-882. Doi: 10.1016/0272-7358(92)90007-U.
  5. Castelnuovo, G., Pietrabissa, G., Cattivelli, R., Manzoni, G.M., & Molinari, E. (2016). Not only clinical efficacy in psychological treatments: Clinical psychology must promote cost-benefit, cost-effectiveness, and cost-utility analysis. Frontiers in Psychology, 7, 563. Doi: 10.3389/fpsyg.2016.00563.
  6. Castelnuovo, G. (2021). Luci e ombre nel futuro della psicologia clinica italiana. Rivista di Psicologia Clinica, 16(2), 16-23.
  7. Castelnuovo, G., Di Nuovo, S., Lingiardi, V., Madeddu, F., & Salvato-re, S. (2023). Psychology profession, clinical psychology, psychotherapy: Specificities and boundaries. Rivista di Psicologia Clinica, 1, 7-25. Doi: 10.3280/rpc1-2023oa16357.
  8. Denis, J. L. (2014). Accountability in healthcare organizations and systems. Healthcare Policy, 10(Spec issue), 8-9. Doi: 10.12927/hcpol.2014.23933.
  9. Donia, J. (2025). Algorithmic accountabilities and health systems: A review and sociomaterial approach. Big Data & Society, 12(2), 1-14. Doi: 10.1177/20539517251334099.
  10. Emanuel, E. J., & Emanuel, L. L. (1996). What is accountability in health care? Annals of Internal Medicine, 124(2), 229-239. Doi: 10.7326/0003-4819-124-2-199601150-00007.
  11. Fan, Y. (2025). Accountability in Public Organization: A Systematic Literature Review and Future Research Agenda. Public Organization Review, 25, 295-310. Doi: 10.1007/s11115-024-00792-y.
  12. Frank, R. G., & Shim, R. S. (2023). Toward Greater Accountability in Mental Health Care. Psychiatric Services, 74(2), 182-187. Doi: 10.1176/appi.ps.20220097.
  13. Ganju, V. (2006). Mental health quality and accountability: The role of evidence-based practices and performance measurement. Administration and Policy in Mental Health and Mental Health Services Research, 33, 659-665. Doi: 10.1007/s10488-006-0071-1.
  14. Graffigna, G., Barello, S., & Triberti, S. (eds.) (2015). Patient engagement: A consumer-centered model to innovate healthcare. Berlin/Boston: De Gruyter Open Poland.
  15. Graffigna, G., Barello, S., Riva, G., Castelnuovo, G., Corbo, M., Coppola, L., Daverio, G., …, Bosio, A. C. (2017). Promozione del patient engagement in ambito clinico-assistenziale per le malattie croniche. Recenti Progressi in Medicina, 108(11), 455-475. Doi: 10.1701/2812.28441.
  16. Gray, M. J. A. (2017). Value-based healthcare. British Medical Journal, 356, j437. Doi: 10.1136/bmj.j437.
  17. Keepnews, D., & Mitchell, P. H. (2003). Health systems’ accountability for patient safety. Online Journal of Issues in Nursing, 8(3), 2. Doi: 10.3912/OJIN.Vol8No03Man02.
  18. Leichsenring, F., Steinert, C., Rabung, S., & Ioannidis, J. P. A. (2022). The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults. World Psychiatry, 21(1), 133-145. Doi: 10.1002/wps.20941.
  19. Levi, J., Fukuzawa, D. D., Sim, S., Simpson, P., Standish, M., Kong, C. W. & Weiss A. F., (2018). Developing a common framework for assessing accountable communities for health. Health Affairs Forefront. Doi: 10.1377/hblog20181023.892541.
  20. Lombardo, C. (2021). Psicologia clinica della salute e bisogni emergenti. Rivista di Psicologia Clinica, 16(2), 40-46.
  21. Margison, F. R., Barkham, M., Evans, C., McGrath, G., Clark, J. M, Audin, K., & Connell, J. (2000). Measurement and psychotherapy: Evidence-based practice and practice-based evidence. The British Journal of Psychiatry, 177(2), 123-130. Doi: 10.1192/bjp.177.2.123.
  22. Merlo, E. M. (2024). Considerations on the Fundamental Relationship between Clinical Psychology and Epistemology. Mediterranean Journal of Clinical Psychology, 12(1). Doi: 10.13129/2282-1619/mjcp-3965.
  23. Ministero della Salute. (2023). Annuario statistico del Servizio Sanitario Nazionale: Anno 2022. Roma: Ministero della Salute.
  24. Ministero della Salute. (2024). Rapporto salute mentale. Analisi dei dati del Sistema Informativo per la Salute Mentale (SISM). Roma: Ministero della Salute.
  25. Mulgan, R. (2000). ‘Accountability’: An ever-expanding concept? Public Administration, 78(3), 555-573. Doi: 10.1111/1467-9299.00218.
  26. Nejatian, A., Arab, M., Takian, A., & Ashtarian, K. (2024). Social Accountability in Health System Governance: A Scoping Review. Iranian Journal of Public Health, 53(1), 35-47. Doi: 10.18502/ijph. v53i1.14681.
  27. NHS Digital (2023). Psychological Therapies: Annual Report on the Use of IAPT Services, England 2022-23. London: NHS Digital.
  28. NHS Executive (1999). Clinical Governance: Quality in the new NHS. London: Department of Health.
  29. OECD (2023). Health at a Glance: Europe 2023. OECD Publishing.
  30. O’Hagan, J., & Persaud, D. (2009). Creating a culture of accountability in health care. The Health Care Manager, 28(2), 124-133. Doi: 10.1097/HCM.0b013e3181a2eb2b.
  31. Peteet, J. R., Witvliet, C. V., & Evans, C. S. (2022). Accountability as a key virtue in mental health and human flourishing. Philosophy, Psychiatry & Psychology, 29(1), 49-60. Doi: 10.1353/ppp.2022.0008.
  32. Pfadenhauer, L. M., Gerhardus, A., Mozygemba, K., Lysdahl, K. B., Booth, A., Hofmann, B., & Brereton, L. (2017). Making sense of complexity in context and implementation: The Context and Implementation of Complex Interventions (CICI) framework. Implementation Science, 12, 21. Doi: 10.1186/s13012-017-0631-2.
  33. Porter, M. E. (2010). What is value in health care? New England Journal of Medicine, 363, 2477-2481. Doi: 10.1056/NEJMp1011024.
  34. Rahman, S., Kiran, T., & O’Cathain, A. (2022). Nothing about us, without us: Is for us. Research Involvement and Engagement, 8(1), 21. Doi: 10.1186/s40900-022-00372-8.
  35. Rebecchi, D. (Ed.). (2018). I percorsi clinici in psicologia. Milano: FrancoAngeli.
  36. Ricciardi, W., & Tarricone, R. (2021). The evolution of the Italian National Health Service. The Lancet, 398, 2193-2206. Doi: 10.1016/ S0140-6736(21)01733-5.
  37. Ridolfi, A. (2024a). Psychological interventions in the Italian national health system: appropriateness and accountability. Research in Psychotherapy: Psychopathology, Process, and Outcome, 27(2), 820. Doi: 10.4081/ripppo.2024.820.
  38. Ridolfi, A. (2024b). Psicologia clinica e psicoterapia nel servizio pubblico. Appropriatezza dei percorsi assistenziali, responsabilità dei processi clinici e valutazione degli esiti. Roma: Alpes.
  39. Rosenberg, S., & Salvador-Carulla, L. (2017). Accountability for Mental Health: The Australian Experience. Journal of Mental Health Policy and Economics, 20(1), 37-54.
  40. Scally, G., & Donaldson, L. J. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal, 317(7150), 61-65. Doi: 10.1136/.317.7150.61.
  41. Sturmberg, J. P., & Taher, M. (2025). Maximising value in healthcare systems by putting the patient at the centre. Journal of Evaluation in Clinical Practice, 31(6), e70270. Doi: 10.1136/bmj.317.7150.61.
  42. Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and implementing value-based health care: A strategic framework. Academic Medicine, 95(5), 682-685. Doi: 10.1097/ACM.0000000000003122.
  43. Wiktorowicz, M. E., Di Pierdomenico, K., Buckley, N. J., Lurie, S., & Czukar, G. (2020). Governance of mental healthcare: Fragmented accountability. Social Science & Medicine, 256, 113007. Doi: 10.1016/j.socscimed.2020.113007.
  44. World Health Organization (2000). Appropriateness in health care services: Report on a WHO workshop. Copenhagen: WHO Regional Office for Europe.
  45. World Health Organization (2021). Ethics and governance of artificial intelligence for health. Geneva: WHO.