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Please complete the form below to tell us about your innovation and your current needs, so that we can determine how best to help you. A member of our team will review your response and get in touch.
Title *MrMrsMsDrOther Forename * Surname * Telephone Number * Email Address * Website * Name of the product (one product per application) *
Organisation * Organisation Address Line 1 * Organisation City * Organisation County * Organisation Country * Organisation Postcode *
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Please provide a brief description of your product and why it is innovative (2000 characters max) * Please indicate whether your innovation directly impacts onPatient outcomesEfficiency of clinical staffEfficiency of non-clinical staff or processes
e.g prevention, cure, avoiding harm
i) What is the clinicial problem that your product will solve? (2000 characters max) ii) How many patients in England does this problem affect each year? (500 characters max) iii) How will patients benefit as a result of your innovation? (1000 characters max) iv) If your clinical benefits are supported by published third party research please provide the reference (500 characters max)
e.g. faster diagnosis, faster communication
i) What is the efficiency problem? (2000 characters max) ii) How often does this occur in England each year? (500 characters max) iii) How will your innovation improve efficiency? (1000 characters max) iv) If your clinical efficiency improvements are supported by published third party research please provide the reference (500 characters max) PreviousNext
e.g. improved staff morale, better patient experience, fewer missed appointments, reduced use of locum staff
i) What is the efficiency problem? (2000 characters max) ii) How often does this occur in England each year? (500 characters max) iii) How will your innovation improve efficiency? (1000 characters max) iv) If your non-clinical efficiency improvements are supported by published third party research please provide the reference (500 characters max)
i) Which of the clinical areas below does your innovation impact on? If you have selected staff or back-office efficiency gain in 2ai, please pick 'Generic' below BloodCancerCardiovascularCongenitalEarEyeInfectionInflammatoryInjuriesMental HealthMetabolicMusculoskeletalNeurologicalOral & GastroReproductionRespiratorySkinStrokeGenericUrology and IncontinenceOther: ii) In what setting will your innovation be used? (Please tick all that apply HospitalPrimary CareCommunityCare HomePatients' HomesAmbulance or ParamedicHigh StreetWorkforce education and development
Please give us an idea of how your innovation will be financially sustainable
a) Who will pay for your product or innovation? b) If you can tell us what your product will cost, please do. If that's confidential, or not yet decided, please let us know. c) Please estimate the direct clinical cost savings to the NHS that your product could achieve per year if fully implemented in England (800 characters) d) If your answer to (c) is supported by independent economic analysis please let us know who did this (or mark as n/a if none available) (500 characters) e) Please estimate, if possible, social care/other savings from your product per year if implemented in England (400 characters) f) If your answer to 3e is supported by independent economic analysis please let us know who did this (or mark as n/a if none available) (500 characters)
a) Do you have an existing research collaboration?NoYes b) If yes, who with? (500 characters or n/a) c) Have you had previous conversation with any of the Academic Health Science Networks?NoYes d) If yes, which?East MidlandsEasternGreater ManchesterHealth Innovation NetworkImperial College Health PartnersKent, Surrey and SussexNorth East and North CumbriaInnovation Agency: AHSN for the North West CoastOxfordSouth WestUCLPartnersWessexWest MidlandsWest of EnglandYorkshire & HumberNone e) If yes, can you please give us a contact name at this AHSN? (or mark n/a) f) Tell us briefly about any external funding you have received in support of developing your innovation (tick all that apply)Friends and FamilyAngel investor/venture capitalResearch councilsNIHR/SBRI/NHS EnglandCharityOther:
From the first idea to international sales is a long journey; please let us know how far you've got
i) Please tick all that apply :Idea onlyIntellectual Property protectedProof of concept testedWorking prototype/pathway developedSmall scale pilot completedLarger pilot/trial completedSpread beyond initial siteCommercial customersCommercial customers in more than one country
There are processes you need, and processes that are helpful. From the below, let us know how far you've got.
Do you need a CE Mark? (link) :Not neededNeedObtainedNot sure Do you need MHRA marketing license? (link) :Not neededNeedObtainedNot sure IG ToolKit compliance (link) :Not neededNeedObtainedNot sure NHSE Approval (e.g. ITT/ITP) (link) :Not neededNeedObtainedNot sure App Approval Process (Digital Assessment Questionnaire) (link) :Not neededNeedObtainedNot sure CQC registration needed for service providers (link) :Not neededNeedObtainedNot sure NHS procurement framework (e.g. NHS Supply chain) :Not neededNeedObtainedNot sure If your innovation relates to Technology Enhanced Learning, have you read the TEL commissioning guidelines? (link) :YesNoNot neededNot sure
a) What do you consider is your next significant milestone (e.g. secure grant funding, recruit to clinical trial, obtain CE mark)? (400 characters) b) What support are you hoping for?Research collaboration/clinical co-developmentHelp with clinical evaluationHelp with economic evaluation/building a business caseHelp with spread and adoptionSupport to obtain grant fundingOther: c) Who are your competitors and why is your product better than their product/s? (300 characters) Where did you find this form?Health Innovation SurgeryWessex AHSN and CRN Technology Support ProgrammeWessex AHSN 'Work with us' webpageOther
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