‘User involvement’ is a contemporary policy initiative in the UK National Health Service which requires the managers of the service to pay greater attention to the wishes of individual patients/clients and their carers, but also to the representatives of users and the general public. This paper focuses on the responses of health and social care managers to user groups: on the the employment of groups outside the policy/managerial hierarchy as contributors to and legitimators of decisions. Such an approach to legitimation poses the risk that such outside groups will express views or engage in activities which are unacceptable to the hierarchy. This paper provides illustrative evidence about how such tensions may be dealt with in order to maintain tactical policy/managerial independence and to buttress representative democracy against the spread of participatory democracy.