This paper examines the role of middle managers in creating change in the Irish health service from interviews with conducted with middle and senior level managers. The research examines the interface between top down and bottom up approaches to change and contributes to showing how ambivalence towards change by middle managers can at the same time contribute to the dismantling of structures and systems that are a necessary precondition for successful change to take place. However, the additional workload and tensions created by dealing with the interface between top-down and bottom-up changes may result in considerable additional workload and stress for the managers themselves.