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NHS Public and Patient Involvement (PPI) is often just aimed at getting a tick in the box. Service User representatives who like to come in for a coffee and then roll over and have their tummies tickled are especially welcome.

More serious is that some NHS organisations encourage patients to become involved when they have barely finished treatment for serious illness, and sometimes when they are still undergoing treatment. If they have the physical and emotional stamina to become involved at that stage, they should not be prevented from doing so. However many will be still vulnerable and it's not surprising if people recruited too early to PPI bring their frustrations with them. There's a responsibility here for clinicians to help their patients ensure that they are not exploited merely to get a tick in the box for PPI. Independent Cancer Patients' Voice, a UK advocacy organisation, advises prospective members to consider waiting for two years following initial diagnosis before joining because it recognises the stresses of effective involvement.

Many service user representatives bring valuable external experience with them to the many hours of pro bono work they do with the NHS - experience of other public sector organisations, community and charity work, project management, service management, change management, financial management. Sadly they sometimes find their skills and experience are not matched by the NHS.

We badly need grown-up behaviour from some NHS staff towards service users. Those service users who constructively question and challenge, using facts and evidence, are regarded as a threat because some NHS staff are ill-prepared and lack the skills to debate the issues raised - and that generates conflict.

Effective PPI is not for the faint hearted.

The view of some service users is that some NHS managers try to behave towards them as they do to their own clinical staff who express different opinions - try to shut them up. I know that passion and will to challenge exists in NHS staff. But I have seen it squashed so many times.

If, as Richard Russell says, it is often left to the Project Lead to make decisions, that points to lack of effective stakeholder engagement by the Project Lead. The goal should be to obtain support from all stakeholders for the final decision. It's unrealistic to expect it to be everyone's preferred decision. However if they are given the opportunity to express their concerns, fully explore proposals for change and allowed to help shape proposals so that they can own and commit to them, unanimous consensus can be reached and people will feel able to support a decision even if it not the one they would have preferred.

John McGowan, if you have never met service users with the skills and experience described above, it sounds very much like you work for an organisation that is not very good at stakeholder engagement and that is why you question the value of service user involvement.

Daphne Havercroft.