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Clear and accountable leadership is essential for any organisation that wants to be successful.

That is particularly true for something as large as the NHS in England, which has more than 1.3m staff and deals with 1m people every 36 hours.

But the latest report by the Health Select Committee raises an extremely worrying question: who is taking responsibility for what?

The MPs were left surprised by the lack of accountability.

Committee member and Labour MP Barbara Keeley said some of the sessions "verged on the comical" as officials and ministers tried to explain how the system worked.

At different points the committee was given the impression the urgent care boards - set up to develop local action plans to tackle A&E problems - were temporary and permanent, voluntary and compulsory.

Confusion was also expressed as to how many there were.

One thing, though, that was certain was that they were meant to provide some oversight and coordination locally.

But then so too are health and well-being boards, set up by local authorities.

So the MPs asked why they weren't taking the lead. Again no clear answer was forthcoming.

This would be bad enough if it was an isolated example. But it isn't.

Since the reforms came into force in April there have been a number of tensions simmering under the surface.

That is true as much at the national level as it is the local one.

Under the shake-up, NHS England was created - led by Sir David Nicholson - to take charge of day-to-day running of the health service.

Officials at the new organisation have privately expressed concern that the structure has enabled the Department of Health to avoid difficult questions from journalists.

"When things go wrong we are wheeled out, but when its something positive they are all over it," one official told me.

It has also led to the bizarre situation whereby there are two major reviews being carried out covering very similar ground.

There is the Department of Health's review into how vulnerable elderly people are being treated across the service and another by NHS England into the urgent and emergency care system (the primary users of which are the elderly).

The reviews are looking at the same data and talking to the same people.

Unsurprisingly, some have asked why the two are not merged.

Signs of a developing problem were also seen when senior managers gathered at the NHS Confederation's annual conference in Liverpool at the start of June.

During the event Sir David, who is retiring next year, gave a speech, trailed in advance, in which he said he wanted to end the "tyranny of the electoral cycle".

The message was clear. He wanted his legacy to the NHS to be one where the whims of politicians could be resisted.

Health Secretary Jeremy Hunt was there as well. He was frank when quizzed by journalists covering the conference, saying the "buck stops with me".

The contrast is clear.