Submit an innovation We want you to get the most from working with us. Before we meet, it helps if you give us some brief details about your business and the products or services that you want to discuss. That means we can get an idea for where we can add most value, and if we need to bring in any specialist expertise. If you’ve previously completed the Health Innovation Network company engagement form, either here or for another health innovation network, there’s no need to do it again. Simply email us and we’ll get back to you. About this form Please use this form to help us to understand your innovation, and your progress to date. Please do not disclose any unprotected intellectual property via this form. Data from this form will be used to assess whether, and how, we are able to support you. By completing this form, you are agreeing that your information may be shared across the Network. We will not share your information with other innovators or companies. You do not need to complete this form twice. If you’ve already completed it for any other health innovation network, please tell us which one. By completing this form, you agree to completing the Network Economic Growth Annual survey. Please complete this form in as much detail as possible as this will help us better understand what support may be required. Health Innovation Network Innovator Engagement Form Please use the form below to submit your innovation. We recommend downloading this draft form to plan your answers first before completing the online version. 1Relationship with sanctioned states2Organisation Details3Summary of the innovation4Progress to date5Health innovation network engagement1/5Relationship with sanctioned statesRelationship with sanctioned states As a publicly-funded NHS organisation we are required to comply with national policy on sanctioned states. Please respond to these questions: *Is your organisation constituted or organised under the law of any UK Sanctioned State or Regime? Please see https://www.gov.uk/government/collections/uk-sanctions-regimes-under-the-sanctions-act* YesNo *Is your organisation owned or controlled by an entity based in a UK Sanctioned State or Regime? This may be a Parent Company or Person with significant control. YesNo If you answer Yes to either question or are unsure, please provide further details below Next0%Organisation Details Applicant Details (please enter all those that apply) *Title *Forename *Surname *Organisation Company Registration No. (if relevant) *Registered Address Line 1 *Registered Address City *Registered Address County *Registered Address Postcode *Registered Address Country *Telephone Number *Email Address *Website Parent company (if relevant) *Plan to form or spin out company in the future? YesNo *Organisation size Micro (0-9 employees)Small (10-49 employees)Medium (50-249 employees)Large (250+ employees) *Organisation type AcademicClinical entrepreneurHealth and social careHealth innovation networkIndustryOther Public SectorPatientVCSE/Not for profit BackNext25%Summary of the innovation *Name of the innovation (one innovation per application) *Is the innovation a product or a service? ProductServiceProduct with service *Innovation type? Medical deviceIn vitro diagnosticPharmaceuticalDigital (including apps, platforms, software)Artificial intelligence (AI)Education or training of workforcePersonal protective equipment (PPE)Models of care and clinical pathwaysEstates and facilitiesTravel and transportFood and nutritionOther *Please provide a brief description of the innovation, including its intended purpose, functionality (how it works), clinical setting/pathway, and the opportunity (size of intended patient group) *What is the primary theme of the innovation? (please select one option) Communication/consultationOperations/logisticsDiagnosticsPredictionManagementPreventionMonitoringTreatmentEnvironmental SustainabilityEducation and Training *What are the care settings for your innovation? AcademiaAcute Trusts – InpatientAcute Trusts - OutpatientsAmbulanceCommunityDomiciliary CareIndustryMental HealthPharmacyPrimary CareSocial CareICS / ICBUrgent & EmergencyOther If you selected other above please specify *Which of the areas below does your innovation impact most on? (please select no more than four options) AgeingAnaesthesia, Perioperative Medicine and Pain ManagementCancerCardiovascular DiseaseChildrenCritical CareData AnalyticsDecision SupportDementias and NeurodegenerationDermatologyDiabetesEar, Nose and ThroatEducation & LearningEfficiencyGastroenterologyGeneticsHaematologyHepatologyInfectionInjuries and EmergenciesMental HealthMetabolic and Endocrine DisordersMusculoskeletal DisordersNeurological DisordersOphthalmologyOral and Dental HealthPain ManagementPrimary CarePublic HealthRenal DisordersReproductive HealthRespiratory DisordersSocial InnovationStrokeSurgeryUrologyWorkforce (e.g. recruitment, training and development)Environmental SustainabilityOther If you selected other above please specify *What problem are you addressing and how does your innovation solve this? *Have you undertaken any customer discovery or stakeholder mapping work to see if this aligns with NHS priorities? *Please provide the following details about any market research you have undertaken Describe any engagement you have had with key stakeholders (e.g. clinicians, patients, commissioners). Highlight existing, similar or equivalent technologies, products or services. Outline how your innovation is different to existing technologies, products or services. *Briefly describe how you have engaged and involved patients and the public in the design, development and evaluation of your innovation (It is important that innovations are acceptable (informed by what patients want) and accessible (usable) to the people who will use or be affected by them. Assurance that innovations are informed by patient views, improves safety, health outcome and saves money. In this section, briefly describe if and how patients, carers, and the public have been involved in your innovation, including any feedback patients have about your innovation). *Briefly explain how your innovation could address the needs of certain patients who may be at greater risk of health inequalities and poorer health outcomes? (Health inequalities happen when health innovations have a negative impact on some patients, which may result in them not being able to access or use an innovation. We are keen to support innovations that are available and can be used by as many people as possible - particularly patients who face worse health outcomes. For example, certain groups may be at greater risk of health concerns such as diabetes, mental health conditions, neonatal maternity and cancer. Where people live, economic status, age, ethnicity, literacy levels, access to data and technology all affect how people may access your innovation. Tell us for example, if your innovation addresses digital access, data poverty, barriers for people with physical, learning or sensory disabilities, or the needs of different ethnic minority communities. Read more about what Health Inequalities is here. Find the current NHS England priority areas to tackle health inequalities for adults and children here). *Briefly explain how your innovation currently or plans to have an impact on NHS Net Zero / environmental sustainability Does your innovation have a direct or indirect impact on NHS Net Zero / environmental sustainability? (Direct refers to when an innovation is created solely to reduce carbon emissions / provide environmental benefits - e.g. reusable product / better use of materials and natural resources in creation of product / reduce fossil fuel usage. Indirect refers to when an innovation is created for healthcare use but net zero / environmental benefits are a secondary benefit – e.g. Digital platform to manage patient care - that can help reduce travel / make care more efficient and effective). *Does your innovation contribute to other environmental benefits e.g. air / water quality, climate adaptation, biodiversity, food security, better use of natural resources etc. If so, please provide details *Do you have a carbon reduction plan / Net Zero commitment? *Have you quantified the carbon impact of your innovation? If so, please provide details. *Have you quantified the carbon impact of your innovation on the NHS pathway? If so, please provide details. BackNext50%Progress to date *Tell us briefly about any external funding / support you have received in support of developing your innovation (tick all that apply) NHS Clinical Entrepreneur ProgrammeNHS EnglandRapid Uptake ProductsUK Research and Innovation (UKRI)Small Business Research Initiative (SBRI)Charity / patient organisationFriends and familyNHS Innovation AcceleratorMedTech Funding MandateNational Institute for Health Research (NIHR)Innovate UKDigital Health LondonAngel investor / venture capitalistOther If you selected other above please specify The current maturity of the innovation (please provide any relevant associated links or attachments) *Initial idea *Intellectual property protected *User testing *Proof of concept tested *Early prototype *Working prototype / pathway developed *Clinical evidence (or equivalent) *Pilot / real-world evaluation *Regulatory status / standards (including CE marking and classification, Digital Technology Assessment Criteria, ISO certification etc.) *Adoption and spread (where is this currently deployed or planned to be deployed) Other (NICE guidance, case studies, inclusion on any accelerator programmes etc.) BackNext75%Health innovation network engagement Have you already discussed this innovation with any health innovation network? Please select all that apply Health Innovation North East and North CumbriaHealth Innovation East MidlandsHealth Innovation EastHealth Innovation ManchesterHealth Innovation Network South LondonImperial College Health PartnersHealth Innovation North West CoastHealth Innovation Kent Surrey SussexHealth Innovation Oxford and Thames ValleyHealth Innovation South-WestUCL PartnersHealth Innovation WessexHealth Innovation West MidlandsHealth Innovation West of EnglandHealth Innovation Yorkshire and Humber If you have worked with any of the health innovation networks how did you hear about them? If you have worked with any of the health innovation networks, please provide details of what support you have received and which organisation provided this Please provide names of any contacts you have worked with at these health innovation networks *Have you already held advanced discussions with any other NHS organisations in England (e.g. Integrated Care Boards / Systems (ICB / ICS), NHS Supply Chain, NHS England Specialised Commissioning etc.)? *Future plans *What support are you seeking from the health innovation network? Back100%