The slow escalation of involvement is in part because of the myriad ways in which it is conceptualised and discussed. Thus, we conclude that one of the greatest barriers to truly integrating patient involvement into health services, policy and research is the conceptual muddle with which involvement is articulated, understood and actioned. RELEVANCE TO CLINICAL PRACTICE. Clinicians need to be supported to seek clarity in the use and operationalisation of involvement if the agenda is to be truly adopted and strengthened.