Philip Sands, director of corporate strategy, Calderdale and Kirklees health authority

'Going back to the old hierarchies would be a retrograde step as it would involve the centralisation of power and the assumption that people in the centre and at the top of the organisation know best. The reason for hierarchies in the past was that information was hard to come by and tended to be held by those at the top, and therefore they were in the best position to take action. This is now an outdated concept. Also the whole thrust of healthcare today is to generate more involvement by patients and communities and to break down the boundaries with outside organisations. You don't do that by creating a centralised inflexible hierarchy.

'The central challenge for management today is to put in place structures that support staff and enable them to work in today's dynamic climate. Of course those organisational structures need to be clear but that can be the case with matrix management, project management or whatever system of flatter hierarchies you choose.

'Some people seem to think if only we brought back matron then everything would be straightforward again. But hierarchies and all the old certainties don't fit in with today's reality.'

Pat Bignell, business manager, City Hospitals Sunderland trust

'I suspect that the difficulty these days is with the word hierarchy and its association with bureaucracy. You don't need a hierarchical framework, but you do need clearly defined roles and responsibilities. To allow people to develop you want to get away from a dictatorial system but you don't want an 'anything goes' philosophy either.'

'Staff need to know what and why and when they are doing something. Though some people thrive on chaos, the majority don't. Order can be prohibitive but it doesn't have to be. Under the old system, matron managed all the nurses and that stopped people from growing. Now we have a director of nursing who, though she doesn't manage all the nurses, does have a strategy for them, and the system established across the organisation has her fingerprints all over it.

'We've stripped away the old-type 'Greek temple' hierarchies where everything was centrally controlled and now the decisions have been devolved to the clinical directorates. One effect of the changes is that G-grade ward managers now have real clout and they can make decisions.

'People flourish in small teams, but you need to ensure they are working towards a common strategy. New theories come along every now and again in the health service - they say if you stay in the job long enough all you have to look forward to is what happened in the past. We are in danger of moving back to the old hierarchies, perhaps calling it something else.

'Maybe we have reached a point where we focus too much on the people and have forgotten the task. But the old way was to focus on the task and never mind the people. We need to get the balance right.'

Maggie Downton, head of physiotherapy services for Tower Hamlets Healthcare trust

'People do need to know who their boss is otherwise they get hung up on quite simple things like who should they ask about their annual leave. It's also important because, although we are all qualified autonomous professionals, our work still has to be monitored and when that doesn't happen you get disasters. But you don't have to have just one boss - there can be different bosses for different aspects of your work.

'There needs to be consensus, but when things get really crunchy there has to be someone with the authority to make a decision.

Across the NHS, tiers of management have been stripped out when money needed to be saved and people tend to dress that up in this idea of flatter hierarchies. Nobody seems to have a deputy any more which means you have no one to act up for you when you are off. You can delegate more but you end up delegating to clinicians, and that means patients get treated less, so you try to avoid that.

Rosemary Stewart, director of Oxford University's Health Care Management Institute and emeritus fellow of Templeton College, Oxford

'It's fashionable these days to talk about the end of hierarchy and sometimes people argue the opposite case just to be controversial. It's nonsense to say there's no need for hierarchies in a large bureaucracy like the NHS. You can run small bits of the NHS with other models but as a whole there needs to be a hierarchy, not just because of the size of the whole thing but because of the political accountability.

'The nub of the issue is how you play the hierarchy, not whether it exists.

'Relationships within the NHS structure have changed, and should change, but that doesn't mean you don't need somebody who is accountable.

'In a public organisation you have to have a chain of accountability. But that sort of hierarchy is not inimical to working towards a more open and consultative organisation.'

Shirley Procter, quality and risk manager, Dudley Group of Hospitals trust

'I think that the fewer the layers of management, the fewer obstacles there are to getting something done. But to make that work, the people at the bottom need to have the ability that the people in the middle used to have and that means they have to be developed.

'I've been with the NHS for 23 years and things have been moved around a lot in that time but there is no more or less of a hierarchy then when I started. As a nurse I've come up through the ranks, and what used to happen was the channels of communication went upwards and downwards and it seemed to work. Now with the directorate structure people have developed their own communication channels within the directorate. But there is less communication with the rest of the trust and you get more empire building. Things may be done better in one directorate than another as so much depends on the calibre of the senior people at the top of each directorate. But at the end of the day it's not the structure that matters, it's the people within it.'