Application 1

PRODUCT/SERVICE DETAILS

NAME OF PRODUCT/SERVICE:

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BRIEF DESCRIPTION (250 words max)

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TYPE OF PRODUCT/SERVICE

MEDICAL DEVICE
IN VITRO DIAGNOSTIC	X
CAPITAL MEDICAL EQUIPMENT
HEALTHCARE SERVICE
IT (CLINICAL)
IT (NON-CLINICAL)
BUSINESS SUPPORT PRODUCT OR SERVICE
PHARMACUETICAL

Other (please specify)

DO YOU HAVE REGULATORY APPROVAL? YES

IF CE MARKED GIVE CE NUMBER:

WHAT NEED OR PROBLEM DOES IT ADDRESS? (250 words)

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SUPPORTING INFORMATION

WHICH NHS OUTCOME Framework DOMAIN(S) DOES IT FIT WITH AND IN WHICH ONE WILL IT HAVE MOST IMPACT?

NHS OUTCOME Framework DOMAIN	FIT	IMPACT (one only)
Domain 1 - Preventing premature death
Domain 2 - Enhancing the quality of life for people with LTCs	X	X
Domain 3 - Helping people recover from episodes of ill health and following injury
Domain 4 - Ensuring people have a positive experience of care	X
Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm
None of above

WILL IT

Reduce outpatient appointments	X
Reduce DNAs
Improve or offer the ability for self-care
Improve patient/carer experience
Improve diagnosis of disease in primary care	X
Improve the efficiency/productivity and/or cost of current primary care services?
None of above [tell us below what it will achieve]

HOW WILL IT CHANGE SETTING OF CARE?

Will your product/service enable care to move from

	Y/N/Possibly	Comments
Community to Primary Care
Primary to self-care	Possibly
Acute to Community care
Acute to primary Care	Y
Acute to self-care	Possibly
Maintain current setting of care
Addresses unmet need
None of above (please describe)

TELL US HOW IT WILL ACHIEVE THIS (250 words)

[Tell us how it will change current practice/care]

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HOW WILL YOUR PRODUCT/SERVICE IMPROVE PATIENT OUTCOME AND EXPERIENCE OF THEIR CARE (250 words)

[Provide quantitative data on number of patients in a population of 250,000 affected and by how much their care is improved. Refer to any relevant NHS and/or CCG outcome indicators. State assumptions used]

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WHO WILL USE THIS PRODUCT/SERVICE?

[Tell us if it is a healthcare professional e.g. GP, Nurse, physiotherapist etc. and/or the patient or carer and in what setting i.e. primary/community care, acute care, at home, ]

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WHAT EVIDENCE DO YOU HAVE THAT YOUR PRODUCT/SERVICE IS BETTER THAN CURRENT PRACTICE?

Evidence	Is it Published (yes/no/in process)	Reference/link
Published papers	Yes	See below
Audits	No
Company sponsored case studies	Yes?
Independently conducted Case studies	No
Comprehensive service evaluation (RCT)
Health economic models	Yes
NICE Appraisal or recommendation	In progress
Other (please tell us what you have)
None

SUMMARY OF EVIDENCE

References cited:

ARE YOU CURRENTLY SELLING TO ANY NHS ORGANISATIONS/LOCAL AUTHORITIES/OTHER ORGANISATIONS PROVIDING OR COMMISSIONING HEALTHCARE SERVICES? YES

ARE YOU ON NHS SUPPLY CHAIN OR ANY NATIONAL PROCUREMENT FRAMEWORK AGREEMENT? YES/NO

IS YOUR PRODUCT/SERVICE CURRENTLY BEING EVALUATED IN A PILOT OR RESEARCH PROJECT? YES/NO

If so please tell us by whom

FINANCIALS & HEALTH ECONOMICS

DO YOU HAVE A FINANCIAL MODEL FOR THE COST OF PURCHASING YOUR PRODUCT/SERVICE? YES/NO

IF YES PLEASE UPLOAD IT AND COMPLETE THE SUMMARY BELOW

	Value (£'s)	Notes
COST TO IMPLEMENT per 250,000 population*
Cost to purchase product/service	£123456
Revenue costs
Recurrent (per annum)	£1234 £12345
Non-recurrent	£0
Capital costs
Recurrent (per annum)	£0
Non-recurrent	£0

*note this is not for 250,000 patients but must take into account prevalence and incidence

FINANCIAL SAVINGS per 250,000 population
Who will see these savings?
Commissioner	YES
Provider	NO
Where will savings be made (insert amount in value column)
Primary care appointments
Diagnostic tests ordered by GP
Non-attendances to primary care appointments
Planned referrals to hospital (outpatients)	-£12345 £123456 -£1234
Planned admissions to hospital ( inpatients)
Unplanned admissions to hospital
Prescription costs
Home visits by community healthcare professionals
Other (please describe)

HEALTH ECONOMICS for 250,000 population
What is the overall cost of care compared to current practice?
Greater (insert amount in value column)
Same (insert amount in value column)
Less (insert amount in value column)	£123456