This case study explores the organisational response of St. Andrew’s Community Hospital (SACH) to changes implemented by the Ministry of Health in four policy areas, namely: expansion of means testing; clustering and re-clustering health services in search of optimal organisational sizing; changes in funding and awarding of services; and changes in domain responsibilities. In each policy area, the case study looks at how the SACH management led their organisation, as well as the sector. From a similar perspective, the case study analyses the motivations and responses of other actors, and how these affected the choices of the SACH leadership in steering their staff and the organisation as a whole.