A useful reminder that what comes out of engagement depends on the context created for the communication and the extent to which people are allowed the freedom to express themselves in ways which have meaning to them.
A number of recent policies promote public participation in health service design. Yet, a growing literature has articulated a gap between policy aims and actual practice resulting in public participation becoming tokenistic. Drawing on theory from participatory design, we argue that choosing appropriate artefacts to act as representations can structure discussions between public participants and health professionals in ways that both groups find meaningful and valid. Through a case study of a service improvement project in outpatient services for older people, we describe three representational artefacts: emotion maps, stories, and tracing paper, and explain how they helped to mediate interactions between public participants and health professionals. We suggest that using such representational artefacts can provide an alternative approach to participation that stands in contrast to the current focus on the professionalisation of public participants. We conclude that including participatory designers in projects, to chose or design appropriate representational artefacts, can help to address the policy–practice gap of including public participants in health service design.