Health Care Systems' relationships with the public are an essential factor if they are to survive financial pressures on the NHS in England

A redesign across the National Health Service (NHS) in England aims to transform services and make them sustainable, in response to significant financial pressure. We argue that the scale of economies and changes required will inevitably have impacts on patient care and on staff, and that ways of managing these impacts may not be transparent or may involve unwanted consequences. Important ways of mitigating these risks are to involve people and communities, and to adopt a style of leadership that makes openness more possible. We describe frameworks and approaches that can be used for these. They are not simple propositions, in the NHS's context of some continuing centralised command and control, pressure for very rapid change and likely gaps in capability. A review of using other policy levers to improve services suggests that they would not be sufficient on their own to achieve the change sought without priority to both engaging people and communities and developing leadership approaches.