Health Innovation North West Coast - Business enquiry form

Organisation details

Applicant details

Title

Forname

Surname

Organisation

Company registration No.

Registered address line 1

Registered address city

Registered address county

Registered address postcode

Registered address country

Telephone number

Email address

Website

Twitter handle

Parent company (if relevant)

Company size

Micro (0-9 employees)

Small (10-49 employees)

Medium (50-249 employees)

Large (250+ employees)

Company category

Digital

Diagnostics

Med-tech

Pharmaceutical

Other (please specify below):

Summary of the innovation

Name of the innovation (one innovation per application)

Please answer the following questions about your innovation

Please can you tell us what problem you are addressing and how your innovation solves this

Have you undertaken any market research to see if this fits with any NHS priorities? If so, please provide details:

Brief description of the innovation, including intended purpose, functionality (how it works), clinical setting, and the opportunity (size of intended patient group)

Is the innovation a product or a service?

Product

Service

Describe any existing similar or equivalent technologies / products / services

How is your innovation different to existing technologies / products / services?

Expected benefits

Patients (e.g. clinical outcomes, quality of care, healthcare experience)

Healthcare systems (e.g. cost- effectiveness, sustainability, staff)

Economic growth (e.g. jobs, industry)

Over existing products / technologies

Costs:

Costs of the product / service itself

Costs of deploying the innovation

Any other lifetime costs

Progress to date

Actions taken and progress to date with the innovation

Tell us briefly about any external funding / support you have received in support of developing your innovation (tick all that apply)

Other (please specify below):

Current status of the innovation

Initial idea

Intellectual property protected

Proof of concept tested

Early prototype

Working prototype / pathway developed

Evaluation / clinical trial / pilot

Implemented in a single site

Spread beyond initial site

Other (please specify below):

Which of the areas below does your innovation impact on? (Please select no more than 4)

Clinical specialty areas:

In what setting will your innovation be used? (Please tick all that apply)

Hospital

Patient's Home

Primary Care

Ambulance or Paramedic

Community

High Street

Care Home

Other (please specify below):

If this innovation has already been implemented in a healthcare setting, please provide details of sites and activities

Current evidence (e.g. clinical impact, patient feedback, cost effectiveness - include savings for the Health and Social Care system and period of return on investment). Please provide links to sources, case studies, published papers, expert opinion, independent evaluation (e.g. NICE, etc.)

AHSN engagement

Have you already discussed this innovation with any AHSN? Please select all that apply

Please provide names of any contacts you have worked with at these AHSNs

Have you already held advanced discussions with any other NHS organisations in England (other than an AHSN)?

Which AHSN areas would you like to engage further with?

Next steps

Plans for the future / spread of adoption / scalability

What support are you now seeking?

Clinical input to protect development

Help with regulatory approval

Intellectual property

Clinical evaluation (including access to clinical trials)

Information on funding sources

Brokering of discussions with NHS organisations to support adoption

Other (please specify below):

Is there any other information you can provide about your innovation (e.g. web links, videos, brochures, presentations, case studies, published papers)?

The AHSN Network and 15 AHSNs would like to use this information to send you related news and events by email. Please confirm that you are happy to hear from us. You will be able to opt out of any of these communications at any point.

Yes, I am happy to be contacted

No, I am not happy to be contacted

Before you go, let us know what you are interested in hearing from us about?

Clinical Areas. Please tick all that apply.

Alcohol

Cancer

Cardiovascular / Stroke

Child and Maternal Health

Diabetes

Gastro / Digestion

Genomic Medicine

Hepatic / Renal

Infection Control / Tropical

Long Term Conditions / Ageing

Medicines Optimisation

Mental Health / Dementia

Musculoskeletal

Neurological Conditions

Ophthalmology

Patient Safety

Personalised Medicine

Point of Care Testing

Precision Medicine

Respiratory Disease

Telehealth

Innovation Space. Please tick all that apply.

App

Diagnostic

Digital

Medical Device

Organisational Development

Pathway

Pharmaceutical

Process

Technology

Training / Lecturing

Care setting. Please tick all that apply.

A&E

Assisted Living

Care Home

Community

Home / Domiciliary

Housing Association

Mental Health

Primary Care (GP Surgery)

Secondary Care (Inpatients)

Secondary Care (Outpatients)

Social Care

Tertiary Care (Specialist)

Urgent Care

Business enquiry form

Organisation details

Applicant details

Company size

Company category

Summary of the innovation

Name of the innovation (one innovation per application)

Please answer the following questions about your innovation

Brief description of the innovation, including intended purpose, functionality (how it works), clinical setting, and the opportunity (size of intended patient group)

Is the innovation a product or a service?

Describe any existing similar or equivalent technologies / products / services

How is your innovation different to existing technologies / products / services?

Expected benefits

Costs:

Progress to date

Actions taken and progress to date with the innovation

Tell us briefly about any external funding / support you have received in support of developing your innovation (tick all that apply)

Current status of the innovation

Which of the areas below does your innovation impact on? (Please select no more than 4)

In what setting will your innovation be used? (Please tick all that apply)

If this innovation has already been implemented in a healthcare setting, please provide details of sites and activities

Current evidence (e.g. clinical impact, patient feedback, cost effectiveness - include savings for the Health and Social Care system and period of return on investment). Please provide links to sources, case studies, published papers, expert opinion, independent evaluation (e.g. NICE, etc.)

AHSN engagement

Have you already discussed this innovation with any AHSN? Please select all that apply

Please provide names of any contacts you have worked with at these AHSNs

Have you already held advanced discussions with any other NHS organisations in England (other than an AHSN)?

Which AHSN areas would you like to engage further with?

Next steps

Plans for the future / spread of adoption / scalability

What support are you now seeking?

Is there any other information you can provide about your innovation (e.g. web links, videos, brochures, presentations, case studies, published papers)?

The AHSN Network and 15 AHSNs would like to use this information to send you related news and events by email. Please confirm that you are happy to hear from us. You will be able to opt out of any of these communications at any point.

Before you go, let us know what you are interested in hearing from us about?

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