Company engagement form

Our company engagement form allows you to register to attend a NHS Insights Briefing or access other support and signposting from UCLPartners.

Please use this form to help us to understand your innovation, and your progress to date. Please note it is a generic form for innovations of all types and all stages of development. Please feel free to leave blank any questions that are not applicable to you at this stage
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
Your information may be shared across the Health Innovation 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 just share a copy with enterprise@uclpartners.com
If you have any queries please contact: enterprise@uclpartners.com

Company engagement form

"*" indicates required fields

Relationship 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? * Required

For more information please see https://www.gov.uk/government/collections/uk-sanctions-regimes-under-the-sanctions-act

Yes

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. * Required

Yes

If you answer Yes to either question or are unsure, please provide further details below, or email separately to: enterprise@uclpartners.com

Title * Required

First name * Required

Surname * Required

Email address * Required

Your telephone number * Required

Street Address

Address Line 2

Town/City

Post Code

Organisation name * Required

Company registration number * Required

Website * Required

Parent company if relevant

Plan to form or spin out company in the future?

Organisation size * Required

Micro (1-9 employees)

Small (10-49 employees)

Medium (50-249 employees)

Large (250+ employees)

Organisation type * Required

SME

Public sector / Government

Test Sector

Mixed – NHS / Private Patients

Private Large Company

University / Education / School

Charity / Not for Profit

NHS

Summary of the Innovation

Name of the innovation. * Required

Please complete one innovation per application.

Is the innovation a product or service? * Required

Product

Service

Innovation type? * Required

Medicine

Device

Digital

Service

Complex intervention

Brief description of the innovation * Required

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) in 500 characters.

What are the care settings for your innovation?*

Academia

Acute Trusts – inpatients

Outpatients

Ambulance

Commissioning (ICS)

Domicilliary

Industry

Mental Health

Pharmacy

Primary Care

Social Care

What is the primary theme of the innovation? * Required

Please select one option.

Communication/consultation

Operations/logistics

Diagnostics

Education and Training

Environmental Sustainability

Management

Monitoring

Prediction

Prevention

Treatment

Which of the areas below does your innovation impact most on? (please select no more than four options)

Ageing

Anaesthesia, Perioperative Medicine and Pain Management

Cancer

Cardiovascular Disease

Children

Critical Care

Data Analytics

Decision Support

Dementias and Neurodegeneration

Dermatology

Diabetes

Ear, Nose and Throat

Education & Learning

Efficiency

Gastroenterology

Genetics

Haematology

Hepatology

Infection

Injuries and Emergencies

Mental Health

Metabolic and Endocrine Disorders

Musculoskeletal Disorders

Neurological Disorders

Ophthalmology

Oral and Dental Health

Pain Management

Primary Care

Public Health

Renal Disorders

Reproductive Health

Respiratory Disorders

Social Innovation

Stroke

Surgery

Urology

Workforce (e.g. recruitment, training and development)

Environmental Sustainability

Other

Other (please specify below)

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?

Market research undertaken: * Required

Describe any engagement you have had with key stakeholders (e.g. clinicians, patients, commissioners)

Competitor analysis * Required

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?

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?

Stage of innovation * Required

Initial development

Intellectual property protected

Working prototype/ Pathway developed

Clinical trial/ pilot

On market (presale)

Single purchase by NHS/ other

Purchased by several (3+)

>30% Market share

Progress to date

Tell us briefly about any external funding / support you have received in support of developing your innovation .

NHS Innovation Accelerator

MedTech Funding Mandate

Rapid Uptake Products

NHS England

NHS Clinical Entrepreneur Programme

National Institute for Health Research (NIHR)

UK Research and Innovation (UKRI)

Innovate UK

Small Business Research Initiative (SBRI)

Digital Health London

Charity / patient organisation

Angel investor / venture capitalist

Friends and Family

The current maturity of the innovation (please provide any relevant associated links or attachments) for following:

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
Adoption & spread
Other (NICE guidance, case studies, inclusion on any accelerator programmes etc.)

Health Innovation Network Engagement

Have you already discussed this innovation with any health innovation network? * Required

East Midlands

Eastern

Health Innovation Manchester

Health Innovation Network (South London)

Imperial College Health Partners (North West London)

Kent Surrey Sussex

North East and North Cumbria

Innovation Agency: North West Coast

Oxford

South West

Wessex

West Midlands

West of England

UCLPartners

Yorkshire & Humber

None of the above

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.)?

What support are you seeking from the health innovation network? * Required

I agree for the above information to be stored securely by UCLPartners * Required

Yes

Consent * Required

For more information about our privacy practices please visit our privacy policy.

I agree to the privacy policy.

Verification

Please tick the “I’m not a robot” box below. This helps us to prevent automated submissions.

This field is for validation purposes and should be left unchanged.

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Company engagement form

Company engagement form

Relationship with sanctioned states

Summary of the Innovation

Progress to date

Health Innovation Network Engagement