The implementation of medical innovations has often been something of an Achilles' heel (Berwick, 2003, McGlynn et al, 2003). It is common for such implementation projects to end prematurely and unsuccessfully, and to deliver behind schedule and below expectation (Kotter, 1995; Soumerai and Avery, 2010). Problems are frequently attributed to external barriers, outside the control of the project team, including a lack of time, money and human resources. Internal factors, for example department leadership or the performance of the project group and individuals within the department often receive less critical attention. This might be because these issues may be more challenging to confront. However by failing to do so, there is a real chance that those responsible for strategy, leadership and implementation may miss out on opportunities to improve their performance, leverage existing resources and increase the odds of future success. This article is not about whether it is better to be an early adopter or not, nor is it a systematic review of the evidence base for current technologies. Rather, it has a practical focus on the clinical implementation of advanced radiotherapy technologies for the purpose of trying to improve patient treatment, one of the major challenges in this field. Although much of the content of this article is generic, its emphasis is on the public sector. Inevitably selection has been necessary, and so some topics are not covered and in places the discussion is limited. It does not go into detail about the behaviour of organizations, or the theory of innovation diffusion (Greenhalgh et al, 2004; Rogers 2004), concentrating instead on the current operating environment, implementation barriers, large-scale initiatives to aid technology diffusion, and some suggestions about what can be done in our own departments, to try and increase the chance of successful implementation.