As described in Chapter Two, participation and accountability are intrinsic to governance. This chapter is concerned with aspects of public accountability, in particular, ways of engaging and representing the public in commissioning decisions, and the role of local authority overview and scrutiny committees (OSCs), which had been set up to strengthen public accountability. Public involvement in commissioning is intended to promote transparency in decision making and is also seen as a route for ensuring that services are relevant to people's needs. It is argued that involving local communities in commissioning can also help ensure effective implementation of health promotion strategies and is more likely to result in the effective mobilising of community assets and the engagement of local community organisations. However, as originally reflected in Arnstein's eight-step ladder of engagement (Arnstein,1969) there is a spectrum of involvement, culminating with citizen control – a concept which applies to individual consumers as well as to the public as collective decision makers (Harrison et al., 2002).

Involvement in decisions about individual treatment and care, or about the quality of services, forms only part of the picture and is not to be equated with broader public involvement in decisions over the nature, accessibility and prioritisation of services related to health and the prevention of ill health. The two areas are not mutually exclusive: as one example, involvement of patients and expert patient groups in redesigning pathways of care for specific conditions is a wellestablished route for informing commissioning decisions. However, public involvement in commissioning raises broader governance issues related to accountability and representation. Although it has its own history and dynamic, patient and public involvement in health (PPI) does not occur in isolation from wider political and policy commitments to promote public participation, scrutiny and community engagement in decision making. The importance of communitybased and participative approaches in developing social capital and addressing health inequalities is increasingly recognised in national and international policy initiatives and reiterated in Health 2020 (WHO, 2012a).