Nobody is against it. That is the problem.

Why a technology everyone agrees with is still taking so long to arrive in care.

I have been in a lot of rooms about care technology over the last six years and I cannot remember a single person arguing against it. Directors of adult social care want it, housing associations want it, the NHS wants it, and families, once they understand what it does, want it very much. Ministers announce it with enthusiasm every eighteen months or so. The technology works, the evidence exists, and the pressure on services could hardly be greater.

And yet, if you walk into a typical council or care provider today, the proportion of people being supported by anything more sophisticated than a pendant alarm is small, the pilots outnumber the programmes, and the question I get asked most often is still some version of where do we start. Something that everyone agrees with has spent a decade failing to happen at scale. That is worth understanding properly, because the reasons are not the ones usually given.

It is nobody's job

The first reason is the simplest and the most awkward. When everyone agrees something is a good idea, nobody has to own it. Care technology sits between adult social care, health, housing, digital and finance, and in most organisations it reports to none of them. It gets a lead officer rather than a director, a project budget rather than a line in the base, and a steering group rather than a decision. Enthusiasm is spread evenly across six departments and accountability is spread across none.

In a business you would recognise this instantly. A product that every division likes and no division owns is a product that never ships. The fix is not more agreement but one person with the authority to spend, to stop other things, and to be blamed if it goes wrong.

The budget that pays is not the budget that benefits

The second reason is the one I would fix first if someone handed me the pen. Care technology is usually paid for by one budget and the savings land in another. A housing association installs sensors and the hospital avoids an admission. A council funds a response service and the ambulance trust sees fewer call-outs. A provider invests in overnight monitoring and the family carer sleeps, which is priceless and appears on no balance sheet anywhere.

Every finance director in the chain is behaving rationally. They are being asked to spend money so that someone else can save it, with no mechanism to get any of it back. Until the money follows the benefit, or until commissioning is pooled properly rather than politely, adoption will stay at the level that goodwill alone can fund, which is pilots.

If I could get the UK Government to change one thing for the benefit of everyone in this system, it would be this. Link the spend to the benefit financially, so that the budget which pays sees some of what it saves. Nothing else on this list would matter half as much if that one were fixed. It is a big enough subject that I will come back to it properly in the next piece.

Shopping before strategy

The third reason is the one I wrote a whole series about, so I will keep it short. Most care technology programmes start with a device. Someone sees a demonstration, a supplier is persuasive, a grant appears with a deadline, and a few hundred units are bought before anyone has written down what the service is trying to achieve, for whom, and how they will know if it worked.

What follows is predictable. The kit is installed, the alerts flow, nobody has decided who responds to them or how, the care staff treat it as another task rather than a different way of working, and after twelve months the evaluation finds that outcomes are hard to attribute. The conclusion drawn is that the technology did not work, when in truth the technology was fine and there was simply no strategy for it to serve.

Procurement was built to buy things, not to change services

The fourth reason is structural. Public procurement is designed to buy a defined thing at a defined price with minimum risk to the buyer. Care technology at its best is not a thing. It is a change in how a service operates, with the technology as one input. Forcing that through a framework built for buying laptops produces contracts that specify devices in great detail and outcomes not at all, locks providers into one supplier for years, and makes it almost impossible to adjust once you learn what actually works.

The better buyers I have seen treat procurement as the last step rather than the first, buy outcomes and response capability rather than boxes, and leave room to change their minds. That takes nerve, and nerve is in short supply when a procurement challenge is the most career-threatening thing that can happen to a commissioning manager.

The ambulance reflex

The fifth reason is human and it lives on the front line. When an alert comes in, the safe answer for the person receiving it is to escalate. Nobody has ever been disciplined for calling an ambulance. Plenty of people worry about what would happen if they did not. So a technology designed to allow lighter, earlier, more proportionate responses ends up generating more emergency call-outs, the system notices the cost, and the programme is quietly scaled back.

This is not a training problem, although training helps. It is a permission problem. Staff will respond proportionately when the organisation has written down what proportionate means, agreed it with its own legal and governance people, and made clear that following the agreed response is the safe choice. Very few organisations have done that work before switching the technology on.

Evidence in the wrong currency

The last reason is that the evidence, while real, is usually presented in the wrong currency for the person who has to sign. Care technology people talk about reassurance, independence, dignity and earlier intervention. All true, all important, none of them appear in a council's medium term financial plan. The person signing the budget needs avoided care home weeks, avoided bed days and avoided double-up visits, with the assumptions shown and the budgets named.

That translation is entirely possible, and the organisations that do it get funded. Most do not do it, because the people who understand the technology and the people who understand the money rarely sit in the same room long enough.

It is also getting easier to do well. Some of the best evaluation work I have seen in this space comes from my friends at Colligo Labs, who map outcomes geographically so that a commissioner can see, street by street, where the demand is coming from and where the technology is making a difference, and who put a social return on investment figure against it so the dignity and reassurance I mentioned earlier can be expressed in pounds without losing their meaning. When a director of finance can see on a map which wards are generating the hospital admissions, and alongside it what every pound spent on prevention returned, the conversation changes from a plea to a decision. That kind of evidence exists and it is not expensive. What is rare is anyone asking for it at the start rather than scrambling for it at the end.

What would change it

None of these six reasons is about the technology, and that is the point. Faster adoption will not come from a better sensor. It will come from one accountable owner, money that follows the benefit, a strategy written before the shopping list, procurement that buys outcomes, a response model agreed before the first alert, and a business case written in the finance director's language.

Every one of those is a leadership decision rather than a technical one, and that is why, after six years in this sector, I have ended up believing that care technology is mostly a strategy problem wearing a technology costume. It is also why Creating Better now has a strategy arm and a care technology arm, and treats them as the same conversation.

If you recognise your own organisation somewhere in that list, hit reply and tell me which of the six is the one holding you back. If it is the money, you are in luck, because that is next week.

Harry MacLean is the Founder and Managing Director of Creating Better. He has spent his career making complicated things simpler and broken things better, and he has not finished yet. He has run businesses in Scotland and the Netherlands, led a football club through its hardest days, chaired a family manufacturer through succession and spent years helping health, social care and housing organisations get technology in care right, collecting some firm opinions and a lot of useful contacts along the way. Creating Better is where all of that comes together, and it is still being built.