There is no Brain Health without accountability: integrating services means making decisions

The authors’ reflections were prompted by their participation in the SDA Bocconi Brain Health Academy reunion on October 1.

It is relatively easy to reach agreement on the integration of healthcare services. Consensus becomes more difficult when it comes to deciding who should take responsibility for a person’s care, allocate professional time, adjust a schedule, or assume responsibility for a transition between services. It is in these decisions that integration takes concrete form—and encounters resistance.

Brain Health provides a particularly meaningful context in which to observe this gap. Neurological and psychiatric needs can overlap, accompany people for many years, and require responses that span specialties, stages of life, and care settings. Organizations must reconcile this continuity of need with a distribution of expertise, resources, and responsibilities structured around different services.

On the occasion of World Mental Health Day on October 10, the issue also deserves attention for its implications for equity. Every gap in coordination that the system leaves unresolved can translate into additional work for individuals and families. The ability to obtain a response then also depends on their capacity to navigate the system, mobilize relationships, and bear the costs of seeking care.

Research and discussion with professionals

Three research contributions examine different aspects of how services operate and provide a basis for discussion among professionals and management.

The analysis of collaboration between neurology and psychiatry, developed from the case of Prato Hospital, focuses on forms of integration and the professional and organizational conditions that can support them. The Smart Capacity project examines, across seven neurology centers providing headache care, the relationship between available resources, work organization, and access to innovative therapies. A chapter to be included in the OASI Report 2026 introduces the issue of access criteria and selection mechanisms in capacity-constrained services, with reference to mental health, child and adolescent neuropsychiatry, and rehabilitation.

Although they start from different research questions and designs, these contributions make it possible to address a common issue: through what choices do organizations turn expertise and resources into responses that are genuinely accessible?

Consensus on integration and the decisions that remain unresolved

When asked what should be shared across neurology, psychiatry, and child and adolescent neuropsychiatry, practitioners rank a common understanding of needs and shared care pathway objectives first. Roles and responsibilities, indicators and outcomes, access criteria, and priorities rank further down.

When asked instead which decision is least clearly governed in pathways spanning multiple services, about one-third of respondents indicate “who takes responsibility for what,” while just over one-fifth point to “who is responsible for the overall outcome.” Taken together, more than half of the responses focus on the allocation of responsibilities.

The comparison reveals a tension: the importance assigned to sharing is accompanied by uncertainty over who should do what.

This raises a first managerial question:

• How far are we willing to go in specifying what integration actually entails?

A shared objective must translate into decisions about the activities of individual services, the timing of interventions, and the conditions under which they take place. It must also clarify how disagreements should be resolved and who can intervene when the pathway stalls. Otherwise, collaboration remains dependent on people’s willingness to cooperate and on the quality of their relationships.

Specialist expertise and responsibility for the care pathway

Integration requires recognizing the specific contribution of each discipline and making it usable within a shared care pathway. The model required may vary depending on the need: a consultation, a joint assessment, or coordinated care each entails different commitments.

The choice must therefore be justified. What problem is the collaboration intended to solve? Which professionals need to participate, how often, and with what decision-making authority? What results do we expect compared with the previous way of working?

Governing the care pathway requires explicit accountability for individual contributions and a coordination function equipped with appropriate tools and authority. It is necessary to clarify which decisions this function can make directly and which problems it must escalate to the management teams involved. Outcome assessment should accompany this allocation of responsibilities, taking into account interdependencies and the factors that each actor can actually influence.

Indirect work must also be made visible. Discussing a case, talking with a family, and coordinating a transition all absorb professional capacity. If organizations require collaboration, they must incorporate this use of time into activity planning and performance assessment.

Capacity is allocated through care pathways

The relationship between integration and the capacity to respond becomes apparent when decisions about taking responsibility for care are considered.

Consider a hypothetical scenario: demand increases by one-fifth, with no increase in budget or staffing in the following year. When ranking the measures to be adopted, practitioners place managing the duration, intensity, and completion of care pathways first.

This finding draws attention to an issue that is often difficult to discuss. The capacity to accommodate new needs also depends on care commitments already made and on how they evolve over time. The frequency of follow-up visits, the contribution of different professions, the conditions for changing the care setting, and reassessment procedures all have consequences for access.

This makes clinically grounded and transparent choices essential. Reducing the intensity of a care pathway is appropriate when it reflects the evolution of the person’s needs and adequate conditions for continuity are in place. If it simply shifts work and risk onto families or services that are unable to take responsibility for them, freeing up capacity within an individual organization may coincide with a deterioration in the overall response.

The same attention is required when a reorganization is proposed to free up resources. Reallocating professional time entails an opportunity cost: it is necessary to understand which activities will be reduced, who will be affected, and what benefits are expected from the different allocation. To assess the result, the scope of observation must encompass the entire care pathway.

In the consultation, redesigning the care delivery process emerged as the measure considered most difficult to gain acceptance for within organizations. Changing how work is performed affects established practices, roles, and professional identities. It therefore requires leadership capable of discussing the rationale behind these choices and supporting their implementation.

The gap between the problem and the power to address it

Another finding concerns the boundaries where action is needed. Coordination across hospitals, community services, residential care, and home care ranks first both in terms of perceived loss of value and in terms of the practical ability to take action.

Relationships among healthcare, social services, schools, the nonprofit sector, families, and private providers, by contrast, rank second for perceived loss of value and last for the ability to intervene.

This gap points to a limitation of relying solely on professional initiative. Clinicians can be asked to develop proposals, share information, and review practices. Governing relationships among organizations, however, requires decisions involving organizational leadership and institutions. Without this support, there is a risk of assigning professionals objectives over which they have limited control.

For management, the task is to make interdependencies explicit and negotiate sustainable commitments. A network agreement creates value when it makes clear what response each party can guarantee and how to manage situations in which that response is no longer available.

Brain Health can provide a useful framework for addressing these choices, provided that it is translated into the tools used to govern services. The real test is to identify a critical care pathway, determine where it breaks down, assign responsibilities that can actually be exercised, and assess what changes for people.

The reunion was held with an unrestricted contribution from Lundbeck.