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This is the first of a two-case series. This case series shows how Fiona Jenkins, Head of Physiotherapy for South Devon Health Services, reviewed and redesigned the stroke service care pathway. She had just four months to present a proposal and then implement it in accordance with the National Service Framework (NSF) guidelines. These guidelines specified that a stroke specialist should examine all individuals admitted with a diagnosis of stroke. Her challenge was to co-ordinate the different stakeholders - primary care, secondary care and social services. In addition, she had to do this without any additional funding. The case series describes the different options open to her and how she decides on a plan. Some of the players are suspicious, and even threaten to resign if the plan is implemented. The teaching purpose is to understand the process of leading organisational change, with a focus on the sequencing of actions, leadership skills, engagement and input from various stakeholders and: (1) know key systems and structures associated with service integration (ie, shift from unit to service focus); (2) understand leadership strategies to engage powerful constituents in the change process; and (3) know management practices to promote the implementation of externally mandated regulations/service innovations.