Peter Johns is convincing when he describes how community health councils can support the work of primary care group lay members (feature, page 30, 8 July). But without clarifying the objectives of lay involvement in primary care, discussion about the means of achieving it lacks an important dimension.

At the Office for Public Management, our work has highlighted three main issues to be tackled. The first is quality and governance. Activities need to include obtaining and clarifying patients' views of services and developing and disseminating good-quality information. More innovative approaches involve using patients as 'educators' of health professionals about aspects of effective care and events that bring professionals and patients together to build dialogue.

The second area is decision- making. With PCGs responsible for an increasing part of spending, accountability is key. Learning from local government initiatives on best value and involving patients, carers and members of the public in planning, monitoring and evaluating the performance of PCGs is vital. For this, patient and public representatives must be supported to get to grips with variations in practice and promote equity and fair access to services. Deliberative workshops, where people have time to reflect on information to make informed judgments about complex technical topics, can lead to better quality decision- making in some of these areas.

Public debate on priority- setting and rationing of drugs is long overdue. The National Institute for Clinical Excellence will give guidance on the use of some treatments, but local arrangements for involving the public in priority-setting will still be needed. Citizens' panels, health panels and citizens' juries are useful to help promote informed debate.

The third area is PCGs' need to link with public interest groups, community development projects and marginalised groups as a first step to providing locally responsive services. But a community development approach challenges traditional thinking. People might be more concerned with 'non-health' issues, such as access, community safety and transport than with a narrow definition of quality. PCGs will need to be open to alternative methods of evaluation and bring different agencies (and their budgets) together.

Stakeholder involvement in the past has been criticised as tokenism. Views are listened to and not acted upon, or consultation legitimises decisions already taken. Going beyond this means building the capacity of communities to take an active role in planning.

This bottom-up approach to service delivery may be too challenging for some. But there is no turning back from involving patients and the public in primary care. Making it real means appreciating the value it can add to effective working.

David Gilbert

Fellow, stakeholder engagement

Office for Public Management