I have been on some crowded trains lately. The sort which have their own micro-climate bubbling inside.

On more than one occasion passengers have chosen to pile high their belongings on the empty seat beside them. Perhaps they think if they put enough stuff on a seat it will look like another person?

Anyway, so begins the charade. You ask in that very English way: is this seat taken? And they huff and they puff in an equally English but very passive aggressive way while removing bags that have suddenly been loaded with rocks.

That’s what it’s like for patients in the NHS at the moment. Having to seek permission for their rightful place at the top table. Meanwhile professions and managers jockey for the best seat in the house. It’s the proverbial game of musical chairs.

I sometimes feel that when it comes to the NHS patients are further away from being involved in the decision-making than ever before. For when the music stops – as it clearly has for our health service at the moment – the seats are less and the other players already know which ones will be taken away.

That’s also how I read the reactions of patient activists to Francis, Keogh and now Berwick. All of these reports have their merits and deserve our respect. But none disrupt the norm from a patient and public perspective.

I sometimes like to remind audiences when I speak that it was less than two decades ago that patients and the public had to picket the MRC and others to get them to wake up to the patient agenda in research.

It is perhaps time to turn things on their head.

Not to generate conflict. But to help colleagues truly understand what it feels like to be excluded, to not to be listened too, to be told that you don’t understand about your own health and and what you need to feel human and respected and cared for.

I was interested to watch the tweets emerging from NHS England’s AGM yesterday. It’s all about ‘we’ not ‘them and us’ etc etc they said. I know how it feels to emerge from such events as if you have fallen in love all over again. If it makes things happen great. On the other hand the NHS’ track record on building a relationships with patients has sometimes rivalled Rod Stewart. Some of us will therefore be wary of another ‘marriage made in Richmond House.’

Maybe what we should be doing is taking all the seats in the room before the meeting has even started. We also get to choose the music. Then, as our colleagues arrive, they get to ask the question for once: ‘is this seat taken?’

The answer is up to you.