Patient Activation
At the heart of self-care support
Application form
25 April 2016
Person-centred Care Team
Patients and Public Participation and Insight Division
NHS England
Email:
Website:

Submission deadline:Tuesday 17 May 2016 (12pm)

Applicant information:

Lead Organisation
Proposal Title
Lead Contact

Guidance for completing the application form

Please ensure that you have read our Patient Activation narrative and our frequently askedquestions(FAQs) on our websitebefore completing this form.

We are inviting applications from local NHS organisations and their partners,and organisationsinvolved in the NHS wider change programmes such as Integrated Personal Commissioning demonstrator sites and Vanguard sites for the New Models of Care programme.

When completing your application form, you should use lay language and answer each question in a concise manner. Please use Arial font size 11 and keep to any word limits given. You should not attach any additional information to your application. References, diagrams or charts can be included and are excluded from word limits. Do not attach any appendices or additional information, as they will not be considered.

NHS England may share the applications received with some external colleagues during the selection process.

Guidance on completing the application form is incorporated into the form and greyed out.This guidance page and all the grey boxes should be deleted before submitting your application.

The application should be saved as a Word document using the following format: ‘Lead organisation name - Lead contact name - Application form.doc’and should be submitted via email using this title.

Please email your completed outline application y12 noon on Tuesday 17th May.

We are unable to consider late applications.Please note that we will not accept duplicate or revised application forms, so ensure that you have the final, correct version before sending.Hard copies or incomplete applications will not be accepted.

If you need to supply your signatures securely using PDF format, please make sure that you submit this page at the same time as your main application using the same naming protocol.

We will inform the organisations whether their applications have been successful by 3rd June 2016. We will be happy to provide somefeedback to unsuccessful applicants after this time. These sites may have an opportunity to apply for licences again at a later date.

A schedule of key dates for applicants, including details of mandatory training for successful organisations, is available in Appendix 1.

Please direct any questions you have about this process to .

SECTION 1: About the applicant organisation

1.1Proposal title

The title should be short and descriptive; and should not exceed15 words.

1.2Lead Organisation

Organisation name:
Type of organisation:
Registered address:
Link with NHS England programmes(Tickall that apply)
Integrated Personal Commissioning Demonstrator
New Model of Care Vanguard
Integration Pioneer
Other (please specify):
You should tell uswhat type of organisation will leadyour projects. The organisation named here should be one of the organisations within which PAM licences will be used or they provide/help to deliver health services free at the point of care, or across boundaries such as health and social care.
The organisation named here will be responsible for planning and delivery. It will be accountable toNHS England for reporting on progress. This organisation will receive the PAM licences from NHS England and can share/distribute them to partner organisation(s), including local authorities and the third sector, through local agreements as required.

1.3Primary contact

Name
Job title
Contact address
Email
Telephone
You should name a person from thelead organisation named in 1.2 who will be the primary contact. This should be the person who NHS England can contact if we require further information or clarification through the application process and preferably for the duration of the period in which you intend to use PAM. This individual should have an in-depth knowledge of your proposal.

1.4Key stakeholder organisations with whom licences will be shared

Name of stakeholderorganisation / Organisation type / Links to other NHS England programmes / Role within your proposed use of PAM
Add more rows as necessary
Lead organisationsmay work in partnership with other NHS organisations and non NHS provider organisations, such as secondary care providers, social care organisations, local authorities, voluntary and patient-led groups and CCGs. Ideally; the partnership should involve organisation(s) who represents the interests of patients, service users or carers.
It is important that there isa statement of support from a senior member of all the key stakeholder organisations.
Where a private company or a profit making organisation is involved as a partner, we would not expect more than 15% ofthe licences go to this organisation, directly or indirectly.

SECTION 2: About your proposal

The NHS Five Year Forward View set out a central ambition for the NHS to become better at helping people to manage their own health. To meet this commitment, NHS England has established a ‘Self-Care programme’ to scale-up support for people living with long-term conditions to manage their own health and wellbeing, empower them to make decisions about their health and care whilst delivering financial benefit to the wider healthcare system as part of the £22bn efficiency challenge. Measuring patient activation is a core enabler for the Self-Care programme.

Nationally, the objective of measuring patient activation is to enable a wider system shift towards self-care and person-centred care, particularly for patients with long term conditions. Evidence suggests that measuring individuals’ level of knowledge, skills and confidence, and then tailoring support through interventions that improve their activation,helps to empowerpatients and enables them to be in control of their own health and care.

Locally, this maylead to the following outcomes and benefits:

  1. Changes in patient behaviour, with patients managing and making informed decisions about their own health and care,that is,engaging in healthier behaviours such as those correlated to smoking, obesity and adherence to medication;
  2. Improved health and wellbeing, with better health outcomes and increased patient safety;
  3. Improved patient and clinician experience;
  4. Reduceddemand on services including unplanned care admissions and A&E visits.

2.1 Please describe how your plans will help to realise these benefits/outcomes locally and achieve the national objective of supporting the wider system shift towards self-care and person-centred care? How will you measure and share progress?(750 words)

Actual word count:
You may refer to health issues prevalent in your area and its impacts on individuals, the community and the health service. How will measuring patient activation tailor support to these individuals?You may also include the cohort of people to whom you intend to administer PAM.
Patient activation is a key enabler to scale up interventions that address individuals’ levels of knowledge, skills and confidence to support them with self-management. Describe how any interventions in your area can help to achieve this.Do you intend to commission any new interventions that will help you achieve these benefits locally?How do they align with your organisational approaches for promoting self-care?

2.2Do you foresee any issues or barriers in your plans to use PAM? If so, how do you plan to address these? (400 words)

Actual word count:
These issues or barriers could be related to patients, interventions/services,workforce, engagement, systems, resources, etc. Please outline the mitigating actions you will take to overcome these.
If there are any issues you may need support with, please include them here.

2.3Provide a high-level overview outlining the key milestones and timescales for your plans to implement the Patient Activation Measure. (200 words)

Actual word count:

Information about your local area

2.4 What interventions that support self-care are commissioned in your area?

Intervention / In place / Planned
Please list here

2.5 What system do you/your partner organisations currently use?(Please highlight)

EMIS / SystmOne / Other (please specify):

2.6How many PAM licences do you require each year?

We will monitor the progress in use of licences and delivery against outcomes.Subject to satisfactory progress, sites will automatically qualify for the additional requested licences in subsequent years.Access to licences will cover a five year period (April 2016 - March 2021).

Total duration / Number of licences requested
Year 1 (2016-17)
Year 2 (2017-18)
Year 3 (2018-19)
Year 4 (2019-20)
Year 5 (2020-21)
Total number of licences over 5 years:

SECTION 3: Declarations

To comply with the Data Protection Act, we require your consent to NHS England using personal data supplied by you in the processing and review of this application and in any other legitimate activity as we deem appropriate. We require your further assurance that personal data about any other individual is supplied to NHS England with their consent. The signatory below also confirms that the information provided in the application form is accurate.

Electronic signatures are required as the application form needs to be returned by email to .

3.1 Primary contact from the lead organisation (named in section 1.3):

Name
Job title
Organisation
Signature
Date

3.2 A senior representative (Chief Executive, Chair or executive lead or equivalent role) from the lead organisation must fully support this application by signing the declaration below:

‘I confirm that I have read and fully support this application.’

Name
Job title
Organisation
Signature
Date

3.3 Senior representatives of key stakeholder organisations must fully support this application by signing the declaration below:

‘I confirm that I have read and fully support this application. Our organisation is prepared to support this work should the application be successful.’

Name
Job title
Organisation
Signature
Date
Name
Job title
Organisation
Signature
Date

How did you hear about this opportunity to apply for licences?

Through an email
Please specify source:
Through CCG Bulletin
Through a website
Please specify:
Through the public announcement
Through an article in a publication
Please specify publication:
Through an article in a newsletter
Please specify newsletter:
Through social media (e.g. Twitter/Facebook)
Through word of mouth (e.g. colleague)
Other:
Please specify:

Appendix 1 – Patient Activation Key Dates for Applicants

Licence Application Process

Application Stage / Date
Application process opens / Monday 25 April 2016
Application process closes / Noon - Tuesday 17 May 2016
Successful sites informed / Friday 3 June 2016

The final shortlisted applicants will be informed of their successful licence application by close of play on Friday 3 June 2016, via standard email. A follow-up call will be offered to sites to outline next steps as well as an email with copies of the Affiliate Agreement, MOU and Insignia Health training schedule.

Unsuccessful applicants will be encouraged to remain in contact with the Patient Activation team as there will be future opportunities to apply for licences.

Patient ActivationTraining Workshops

It is mandatory that successful applicants attend one ‘Patient Activation Training Workshop’ provided by NHS England, in collaboration with Insignia Health. These will be full day sessions supporting sites to understand how patient activation can influence the way in which people are supported to manage their long-term conditions and will provide in-depth training on how to use the PAM tool.

Date / Location / Attendees
Tuesday 14June 2016 / London /
  • CCG Administrators
  • Providers/nurses
  • PAM administrators
  • CCG staff trainers

Thursday 16 June 2016 / Leeds

Patient Activation Webinars

In addition to the training workshops, a number of (free) webinars will be led by Insignia Health to support participants in using the PAM tool. It is expected that Patient Activation sites will contribute to the design of these webinars to ensure content is tailored to meet their needs. Webinar attendance by participants is encouraged, but not mandatory. The first dates for these quarterly webinars are:

  • Tuesday 2 August 2016 (60 to 90 minutes)
  • Tuesday 1 November 2016 (60 to 90 minutes)

Page 1 of 10