Successful health care transformation or innovation requires disruption (Brook, 2009). Disruption occurs when linear change is no longer possible due to vast differences between service providers and clients (Bower and Christensen, 1995; Brook, 2009; Hwang et al, 2015). Transformation in health care requires leadership and a holistic approach (Senzon, 2011). In occupational therapy transformation leaders are pushing for a ‘paradigm shift’ to a focus on occupation (Gustafsson et al, 2014). What this paradigm shift means in real practice and how it fits in with current reforms in health care policy and practice is not well understood. Understanding why and how this disruption has come about, and recognising the limitations of such internally led reform are critical to appreciating the opportunities and challenges of our profession at this moment in time and into the future.