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Internationally, debates are taking place about sustainable healthcare. In England, guidance on patient and public involvement (PPI) advocates ‘engagement’ and references Arnstein’s ladder of participation, but recent proposals provoked controversy around service closures and the perceived exclusion of patients and the public. This article reports an ethnography of engagement, prior to formal public consultation on plans for major service change. Our analysis uses Cultural Political Economy, linking micro interactions between staff and ‘involvees’ to processes of political economy. We found that co-optation and contestation both occurred. Involvees queried whether the forthcoming consultation was genuine or whether decisions had already been made but the issue of whether NHS services should be delivered by public or private bodies was kept off the agenda. We conclude that engagement in system transformation programmes implicates PPI in a neoliberal agenda that rations state support for healthcare and introduces service models from the USA and elsewhere.This research was funded by the National Institute for Health Research\ud(NIHR) Collaboration for Leadership in Applied Health Research and\udCare East Midlands (CLAHRC EM). The views expressed are those of the\udauthors and not necessarily those of the NHS, the NIHR or the Department\udof Health.Peer-reviewedPost-prin

Engagement of patients and the public in NHS sustainability and transformation: An ethnographic study