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Background: It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability. Methods: In NSW—the largest populational jurisdiction in Australia, and over three times the size of the UK—the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people. Conclusions: In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets—emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general. Plain English summary: This review outlines a $30 million health system reform to eating disorder treatment implemented by the NSW State Government six years ago which has seen large-scale service and workforce development across 15 geographical districts. This spans almost one million square kilometres and services 7.75 million people in Australia. The reform is very large in scale and is now in its second phase of implementation. Here outlined is the strategic process of policy and practice change of the entire reform and initial findings from an external review of phase one, which demonstrates positive effects on all three service targets—emergency departments presentations, hospital admissions and community occasions of service—including increased rates of treatment provision, improved perception of eating disorders amongst health professionals, improved pathway options and better communication within multidisciplinary teams. This type of whole-of-health system government led reform has relevance and learnings for health systems internationally. [ABSTRACT FROM AUTHOR]