This paper describes the development and implementation of care pathways in two orthopaedic units in Scotland. Although originally developed as a tool of project management, care pathways have been promoted internationally as a response to concerns for patient safety, variability in care and increasing costs. Generally, care pathways can be seen as an example of clinician led rather than management led reform. However, it does reflect a wider shift towards process and away from hierarchical approaches to management. Within the UK care pathways have been promoted as a response to the modernization initiative of the Labour Government. While the initiative was a success in both units it was more difficult to implement care pathways in a trauma rather than an elective unit. In conclusion, it is questionable whether care pathways are a universal response to the requirement for modernization and service redesign in the NHS.