This chapter discusses the key challenges in commissioning and implementing health improvement programmes that engage volunteers and members of the public in lay health worker roles. It builds on the previous chapters, in particular, the case studies and what can be learned from them about how to develop best practice. The effective engagement of lay people in improving the health of their communities needs a whole-system approach that is holistic in nature (Hunter et al, 2010). A whole-system approach makes it possible to see the interactions between different elements of the system and avoids reducing complex issues to component parts and thereby missing vital interconnections.

Since the People in Public Health study was undertaken, the public sector has experienced unprecedented cuts in funding, which have impacted on Primary Care Trusts, local authorities and the voluntary and community sector in major ways. In this policy context, there is an increasing emphasis on services being provided by the third and private sectors (Cabinet Office, 2011), and an acceleration of a trend to a mixed economy of welfare provision previously encouraged by the New Labour government (Ware and Todd, 2002; HM Treasury and Cabinet Office, 2007). The voluntary and community sector is seen to offer the independence, flexibility and specialist expertise that is often absent in the public sector and, more critically, to provide a bridge to some underrepresented groups (Bolton, no date; Billis and Glennerster, 1998). The recent NHS Future Forum report Choice and competition. Delivering real choice, which was concerned with strengthening marketisation levers, argued that ‘there is a wealth of talent and untapped resource in our country's third sector which can benefit the NHS, so there is a good argument for greater commissioning from alternative providers of care where appropriate’ (NHS Future Forum, 2011a, p 9). The size and diversity of the sector is considerable, for example, in 2002, it was estimated that there were more than half a million voluntary and community sector organisations in the UK (HM Treasury, 2002). Notwithstanding the significance of the third sector, it should be remembered that public services also support volunteering and involve large numbers of volunteers in public service provision.