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Background: Health policy in the UK increasingly demands that shared decision-making and participative models of practice are at the heart of all health care. In this paper we discuss aspects of involvement that, we suggest, are largely absent from policy discourses and also relatively neglected in dominant currents of research on shared decision-making. Study and findings: We draw upon qualitative data from fifteen interviews with nurses, doctors, and pharmacists in various area of clinical care to illustrate how engagement with and understanding of ‘patient agendas’, a commitment to overcome common obstacles to participation, and the existence of flexibility within services were central to the involvement practices of a group of health professionals who practise participative models of care. Discussion and conclusion: We suggest that discourses of patient involvement and shared decision-making should – in policy but also in academic research – give more emphasis to the three dimensions summarised here. More broadly, we call for a conceptual and discursive re-framing of involvement; one grounded more in the language of support and interdependence and less in consumerist conceptions of choice.