Application Form: Primary Care Triumvirate Leadership and Change Agent Programme 2017-18

Please register your practice interest by completing this form and emailing it to:XXX by XXXwith the following information. Please provide as much detail as possible to enable the panel to make a decision on your readiness to engage in the programme. Following a panel review, we will then be in touch to confirm if your application has been successful and next steps.

Important:Please ensurethat all nominated participants are able to make all the learning dates for your chosen cohort dates.

Our details:

Practice name and address / Midlands Sub-Region / 
West Midlands
East Midlands
Who is the main contact for your application?
(This should be one of your identified triumvirate team members as our main point of contact around your application)
Name / Phone / Email
Names of the triumvirate practice team you are putting forward:
Team Role / Job role / Name / Email
Medic: / Please change
i.e. GP/Medic/Dental etc.
Clinician: / Please change
i.e. Practice/Dental Nurse / Pharmacist etc.
Manager: / Please change
i.e. Practice Manager

Why we are applying:

Why apply? Please state the reasons that your practice is applying for this course – what does your organisation want to gain as a result?(200 words max)
Readiness: Why is your practice organisation ready for this programme now? (200 words max)
Your participants: Why have you put these people forward? (100 words max)
Participant name / Why are they ready to attend the programme? More about them…
1.
2.
3.
Change project: What is the change project / initiative that you plan to use the programme to progress for your practice? (100 words max)
Any other supportive comments?Why should we pick youover others to attend the programme? This is your last chance to shine…!(100 words max)

More about our practice:

Vision: Please state the vision for your practice in the medium term i.e. 2 years (100 words max)
What are the strengths and current challenges for your practice? (100 words max)
Strengths / Challenges

Learning agreement

We acknowledge and commit as a practice:

We will attend all of the learning dates and will ensure that the three participants we put forward are all able to freely engage on those dates.

We will fully commit to the programme and will engage in supporting all aspects to make it a success for our practice and wider participants on the programme.

We feel that as a practice we are ready to embrace the programme and commit to progressing our identified organisational change project identified above.

We understand that the funding to run this programme has been provided by the NHS Leadership Academy and understand that failing to complete the programme may incur a fee of £100 per participant.

Signed on behalf of the practice (electronic signature):

Name / Role / Signature

This programme is delivered in partnership with West Midlands and East Midlands Leadership Academy