As of November 2023, the NHS faced a significant challenge with approximately 7.61 million patients on waiting lists for various treatments. This figure underscores a critical issue within the healthcare system, highlighting both the clinical risks associated with delayed follow-ups and the operational strains on healthcare resources.
Addressing Waiting List Challenges with PIFU
The concept of Patient Initiated Follow-Up (PIFU) has emerged as a strategic response to these challenges. By allowing patients to determine the necessity and timing of their follow-up appointments, PIFU aims to enhance patient safety, optimise appointment scheduling, and reduce unnecessary follow-up engagements, thereby potentially decreasing waiting list volumes.
Despite the theoretical benefits of PIFU, there remains a lack of empirical evidence supporting its efficacy in practice. This, along with the ever-present challenges of changing existing pathways, means that many Trusts will miss the modest target of moving 5% of outpatient attendances to PIFU pathways, that NHS England set for March 2023 as part of the Elective Recovery Strategy.
The Role of DrDoctor and Key Findings: up to £167 million in System-wide Savings
In this context, DrDoctor, which oversees around 20% of NHS outpatient booking activities, including PIFU services, has played an important role. Through its operations across multiple Trusts, DrDoctor has gathered extensive data that, when analysed alongside Trust-specific data, offers insights into the potential health economic benefits of PIFU to inform increased usage and improvement of the service.
Edge Health was commissioned by DrDoctor to combine learning from this data as well as from interviews with clinical and operational staff involved in implementation at two large NHS Trusts to start evaluating this service delivery model. The report sets out the findings from data analysis, literature review and operational and clinical engagement into the potential real-world benefits, and best practice implementation of PIFU.
Key findings suggest that achieving the national target of a 5% PIFU pathway adoption rate could result in the saving of approximately 1,393,154 outpatient follow-up appointments annually, leading to an estimated system-wide saving of at least £167 million, based on 2020/21 figures.
Implementation Insights and Potential Impacts
Our report also provides details on how to effectively implement digital PIFU within Trusts, based on conversations with implementation teams. This highlights the types of specialties proven to be most successful to date, the conditions for the successful delivery of the roll-out of digital PIFU, key challenges services faced with implementation and what learnings they would give other Trusts at the start of their implementation.
The report also highlights the benefits to patients and the NHS of another form of patient-initiated pathway, Patient Initiated New Appointment (PINA). This is where patients referred to secondary care for an appointment are given control over whether they still require the appointment.
This report provides invaluable, real-world evidence highlighting the extensive value of implementing PINA and PIFU at scale within the NHS. It underscores the transformative role digital tools have in simplifying processes, modernising patient care and driving efficiency of system operations. We’re pleased to have worked with EDGE Health in producing this report and are excited about the wider impact this collaboration will have on the healthcare sector in reducing unnecessary follow-up appointments and tackling the backlog.
Tom Whicher, CEO of DrDoctor
From a waiting list perspective, PINA can help reduce the number of unnecessary first appointments at a Trust, in a similar way to PIFU. It is estimated that between 3-15% of patients on the waiting list do not need an outpatient appointment by the time they get contacted. By removing eligible patients who do not actually need a first outpatient appointment and are appropriate for PINA, our report found that the waiting list significantly decreases. This could mean a reduction in the waitlist by between 228,000 and 1,141,500 patients.
Therefore, the findings from our report can be used by Trusts to understand the potential of patient-initiated appointments (both PINA and PIFU) at their Trust and help them meet NHS England targets, while also driving down waiting list size and improving patient experiences.
AI-Teledermatology: Innovating Skin Cancer Diagnostics
The healthcare system in England and Wales is experiencing unprecedented pressure due to the sharp rise in demand for dermatology services. With one in four individuals seeking consultation for skin, hair, or nail conditions each year, the need for innovative solutions has never been greater. The COVID-19 pandemic exacerbated this strain, causing a 30% drop in dermatology appointments during 2020/21 and a subsequent surge in patient referrals post-pandemic, with suspected cancer referrals rising 13% nationally compared to 2018. Rising volumes of urgent suspected cancer referrals have significant impacts for system sustainability – under a strained system, they correlate with higher volumes of patients breaching care standards, such as the 62-day treatment standard, as explored in a previous piece of work.
The potential of teledermatology, particularly AI-powered teledermatology, has been recognised as a promising solution to expand service capacity and ensure equitable patient access to specialist care. The Skin Analytics AI-Powered teledermatology for Skin Cancer 2-week-wait (2WW) Pathway was pilot tested across University Hospitals of Leicester (UHL) sites starting from March 2022. This collaborative project was designed to respond to the local need for improved patient access to dermatology diagnostics and the achievement of 2WW cancer targets.
Edge Health was commissioned by Health Innovation East Midlands (previously East Midlands Academic Health Science Network) to carry out an independent evaluation of the effectiveness of this pilot initiative. Leveraging our expertise, we gathered both qualitative and quantitative data from staff and patient surveys, as well as existing data from UHL and Skin Analytics.
A Novel Pathway
Our evaluation underscored the potential of AI-powered teledermatology. Despite being in its pilot phase, the AI tool demonstrated its capability to enhance patient access to dermatology services. While the initial benefit-cost ratio stood at 1.05, this figure doesn’t fully encapsulate the unquantified benefits, such as a reduction in biopsies, long-term care costs, and WLI clinics. Workforce costs were also front-loaded prior to capacity being fully utilised, leaving room for a higher benefit-cost ratio.
The current pathway model relies on second-reads to be performed on all AI-screened scans, with a further reduction in the potential benefit-cost ratio as well as increased pressure on clinical teams. In our evaluation, the AI outperformed documented clinical diagnostic standards, but our staff survey highlighted current reservations from consultants in dispensing of the second-reads altogether.
The evaluation also supported the health system through highlighting potential administrative challenges that scaled expansion would need to monitor for. These included timely booking of appointments for patients on the novel pathway, as well as ensuring that commissioning arrangements reflect the true costs of providing an innovative service – and are aware of the prospected savings.
Scenario Modelling for Future Savings
Looking ahead, we conducted scenario modelling to explore the potential for greater savings in the future. These scenarios hinge on reducing or removing the cost associated with the second read of dermoscopy images, leading to a benefit-cost ratio ranging from 1.3 to 1.9.
Our evaluation indicates that this novel pathway could be cost-effective in the long term. It could also offer considerable benefits to the wider Dermatology cohort, healthcare staff, and the health system if implemented at scale, with potential yearly savings across the Midlands ranging between £2.1M and £5.7M, depending on who performs the second read.
Recommendations for Enhancements
As part of our commitment to continuous improvement, we proposed several recommendations. These include streamlining administrative processes, evaluating the best option for lesion second reads and conducting further evaluations as the AI versions improve and more data becomes available.
Our work with Health Innovation East Midlands, UHL and Skin Analytics demonstrates Edge Health’s commitment to pioneering innovative healthcare solutions. Evaluating the effectiveness of new technologies such as AI-powered teledermatology is a fundamental step in improving services so that they are accessible, efficient, and patient-centred.
Our overall experience of working with Edge was very positive, and their analysis and evaluation process was robust and innovative. They handled challenges well and always sought a balanced solution with cross-stakeholder agreement. The Final Report was delivered on track and met the expectations outlined in the original scope and MOU.
Michael Ellis – Senior Innovation Lead, Health Innovation East Midlands
Conducted a comprehensive independent evaluation of the AI-powered teledermatology pilot initiative.
Identified potential for significant future savings through scenario modelling.
Proposed actionable recommendations to enhance the programme’s benefits and ensure long-term cost-effectiveness.
Highlighted the importance of considering administrative implications of implementing novel technologies.
Provided insights to guide future evaluations as AI technology evolves and more data becomes available.
This project was carried out in partnership with Health Innovation East Midlands
 Chuchu N, Dinnes J, Takwoingi Y, Matin RN, Bayliss SE, Davenport C, Moreau JF, Bassett O, Godfrey K, O’Sullivan C, Walter FM, Motley R, Deeks JJ, Williams HC. Teledermatology for diagnosing skin cancer in adults. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD013193.
Revolutionising Lung Cancer Diagnosis: The Economic and Clinical Impact of ctDNA Testing in the NHS
In 2020, 37,211 people were diagnosed with lung cancer in England. 68% of this population is at an advanced stage and has limited life expectancy. People with advanced lung cancer have complex care needs and often experience high levels of GP appointments, hospital admissions and extended lengths of stay while awaiting diagnosis and treatment.
Timely genomic testing of the tumour can help identify individualised treatments, which can potentially markedly improve the quality and length of life. Delays in identifying specific gene mutations can result in missed opportunities for patients to receive targeted and more effective treatments, ultimately leading to worse outcomes and higher costs for health systems.
Liquid biopsy, a cutting-edge diagnostic method validated through numerous clinical trials, involves testing blood samples for biomarkers like circulating tumour DNA (ctDNA), among others, to detect cancer-related genetic mutations. This less invasive approach offers several benefits, particularly in vulnerable patients with advanced non-small cell lung cancer.
The NHS in England is working towards being a global leader in adopting liquid biopsy testing into a national health service. Recognising the importance of economic assessment and evaluation of the costs and benefits of broader ctDNA testing, Edge Health was commissioned by NHS England to undertake this work to support an ongoing national pilot involving non-small cell lung cancer testing.
Using health economics to understand benefits and costs
Our initial findings in the early phase of the health economics analysis of ctDNA testing combined academic methods with commercial insight and experienced understanding of how the NHS operates to assess the economic implications. This involved collaboration with clinical experts and synthesis of information from various other sources. As a new technology, our analysis considered various clinical scenarios and sensitivities for critical assumptions.
“Implementing ctDNA testing into the routine diagnostic work up of patients with lung cancer is a huge step forward to improving equity of access to state of the art genomic testing for our patients. This will allow patients to receive the best treatment possible for their condition. The input from Edge Health has been invaluable in mapping out a complex pathway, identifying options for ctDNA implementation and their associated cost benefits”.
Professor Sanjay Popat, Consultant Thoracic Medical Oncologist, Royal Marsden Hospital
Outputs from the initial analysis were extrapolated more generally with national data, which helped identify the potential future costs and benefits.
In the context of stage III and IV lung cancer, from early analysis, the application of ctDNA was found to deliver significant benefits relative to its costs. This finding was primarily driven by ctDNA testing enabling earlier blood testing and potentially avoiding tumour genomic testing, which supported patients to access targeted treatments earlier and more consistently – lowering broader system costs. In the next phase of work, pilot data will be analysed to validate these preliminary findings to support the commissioning of the ctDNA test on the genomic national test directory.
Moreover, ctDNA testing is expected to improve equity in genomic testing access substantially, expanding coverage over a broader spectrum of gene mutations and ensuring the inclusion of patients for whom adequate tissue biopsies might not be viable.
Ultimately, incorporating the latest genomics advances into routine healthcare will help deliver the UK government’s vision in “Genome UK: the future of healthcare”.
“The current work of the ctDNA pilot aligns perfectly with the Genomic Medicine Service goals of delivering equitable genomic testing for cancer patients through accessing cutting edge technology and science. This technology will hopefully, if commissioned onto the national test directory, ensure that clinical services can make better-informed decisions faster, have access to precision treatments which will improve patient outcomes, ultimately leading to more efficient use of NHS resources. The work from Edge Health is vital in helping to demonstrate that this advance in care is also economically viable”.
Paul Ryves, Programme Director, North Thames Genomic Medicine Service Alliance.
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Case Study: Evaluation of the Mental Health Urgent Assessment Centre at LPFT
Edge health led a health economic evaluation of the Mental Health Urgent Assessment Centre (MHUAC) within Lincolnshire Partnership NHS Foundation Trust (LPFT), working closely with both the project team at LPFT and the East Midlands Academic Health Science Network (EMAHSN).
Working in partnership with Edge Health has really added value to the evaluation process, they have been fantastic with regards to communication. It’s obvious from interaction with them that they have a keen interest in the project and really have been supportive with regards to their view on difference our new service is making.
Simon Ringland, Business Manager – Adult Inpatients & Urgent Care, Lincolnshire Partnership Foundation Trust
Innovative support for patients in a mental health crisis – the Mental Health Urgent Assessment Centre
People in a mental health crisis are at their most vulnerable. It is essential that they receive the care and support they need as quickly as possible, in a place where they can feel safe, and are cared for by people who understand their needs.
Patients requiring emergency mental health services often present to the Emergency Department (ED). With EDs under extreme pressures, waiting times for mental health patients attending ED have increased substantially. The busy, often noisy and sometimes crowded ED is also not considered the best environment for patients in mental health crisis to wait to be seen.
To address the needs of patients in mental health crisis who attend ED, Camden and Islington NHS trust implemented a Mental Health Assessment Centre to offer support in a different way. This involved the mobilisation of a Mental Health Urgent Assessment Centre (MHUAC), to offer those that were medically fit a service that did not require attendance at ED for support. The service offered rapid assessment of mental health need and an additional place of safety in an environment that was appropriate and calming. The benefits of the service were identified as lessened 12-hour breaches in ED, decreased footfall through ED, improved patient and system partner satisfaction.
Similarities between the challenges faced by Camden and Islington NHS trust and Lincolnshire Partnership Foundation Trust with mental health crisis care led to the decision that Lincolnshire would benefit for a service similar to Camden and Islington’s Model.
A rigorous evaluation methodology
We conducted an independent evaluation of the measurable impact of the MHUAC at LPFT on patients, staff, and the health system using data from the trust, a patient and staff survey designed and deployed by our team, and several patient and staff interviews. This data collection allowed us to determine the costs and benefits of the pilot and the potential annual savings if the pilot were to expand across the Midlands.
We took the following approach to achieve this:
mapped out a patient journey, identifying the changes in behaviour brought about by the new service delivery model;
using this journey, summarised an “impact pathway” to set out a long-list of potential benefits across a number of different stakeholder groups;
quantified and valued these benefits, based on available data, literature and stakeholder engagement; and
scaled these results to give an indication at a Midlands-wide scaling of the potential costs and savings from wider roll-out of the pilot.
The work involved a visit to the site at Lincoln County Hospital where we spoke with both patients and staff about their experiences and views on the new service. This work helped guide the analysis, informed our findings and enabled our team to have a deep understanding of the service.
Project outputs included clarity on the big-ticket drivers of benefit and value delivered by the MHUAC and a clear, impactful and robust estimate of the savings delivered to health systems, delivered within the client’s timeframes.
Our analysis demonstrated that the innovative service delivery transformation has been incredibly well-received by patients and all staff involved in the mental health crisis pathway, with approximately 85% of both staff and patients suggesting this is a better alternative to ED for patients in mental health crisis.
Alongside the extremely positive feedback from staff and patients, there is also evidence to suggest that this pilot has been cost effective. So far, this pilot has seen measurable benefits, such as, a reduction in inpatient attendances (£789,239 saved) and relapses (£61,473 saved). When scaled across the Midlands region, these benefits could reach over £14.4 million annually.
Therefore, we reported the MHUAC has a benefit cost ratio of 3.5. This ratio may also still improve with time, with a number of significant benefits, including societal benefits, not possible to quantify at this early stage of the pilot.
Given the significant potential of this initiative, it is important the right processes are in place to maximise the benefits it delivers. To aid with this, the evaluation also generated several considerations to improve the service both at the Lincolnshire site and to aid other Trusts if the MHUAC were to expand to other sites.
The evaluation report is now helping to drive conversations locally to recommend the MHUAC initiative to other local organisations. The report has also helped the AHSN to robustly articulate the success of the project which they are now planning to submit to the national Health Service Journal awards.
Quantifying the private market: an opportunity for NHS trusts
For many NHS Trusts, care for private patients is a critical part of their business model, with the income generated directly funding front-line NHS care. As budgets continue to come under pressure, there is an opportunity to expand the private care offer, delivering greater benefits for both private and NHS patients. However, deciding if as well as where to invest requires a detailed understanding of patient flow and the size of the private market.
Edge Health was commissioned by a leading NHS Trust to identify and size market investment opportunities for growth on one of their sites. Through analysis of trust activity, finance and cost data, 3 themes of the greatest market growth opportunity were identified:
Market growth opportunity top areas:
Supporting patients withprivate medical insurance (PMI) to receive privately-funded care;
Acquiring patients from competitors; and
Relocating patients between sites to provide care closer to home
Options for investment within these 3 core themes were then developed, with a minimum, medium and maximum option investments for each theme. Each of these options was presented with projected demand growth, associated costs and the potential income generated through the investment.
The conclusions of this work led to further analysis to identify where and when investments in additional capacity would be required to meet higher demand. This assessment considered the implication of doing nothing, as well as providing a year-on-year breakdown of how much additional resource (beds, theatres, radiology etc.) would be required to reach demand.
Taken together, these pieces of analysis provide evidence on the scale of the market opportunity for private treatment and provide operational support to aid in strategic decisions ahead of any investment. This analysis can be used to support proposals and business cases for investment.
Supporting Vitacam to develop their health economic proposition
Atrial fibrillation (AF) is the most commonly occurring heart arrhythmia, and a major preventable cause of stroke, heart failure, and other cardiovascular complications. Many patients are only diagnosed with AF when they experience complications, with an estimated half a million undiagnosed AF patients living in the UK. Causing an estimated 20% of strokes in the UK, AF places considerable strain on the NHS, estimated at up to £2.5 billion in 2020. Improved early detection of AF therefore provides a significant opportunity to reduce the impact of AF on NHS and social care resources, as well as on patients and carers.
Mass screening: an opportunity
While not currently recommended in the UK, mass screening programs are being increasingly promoted to improve detection of AF, reducing morbidity and mortality through early intervention and treatment. A number of technologies have recently been developed to enable remote monitoring of heart rhythm: Vitacam is one such technology, offering a potential mass screening tool that is simple, safe, and well accepted by patients and carers. However, evidence of the cost-effectiveness of Vitacam in a screening program is vital in order to promote further research and clinical trials.
Cost-Effectiveness Evaluation made Interactive
Edge Health were commissioned to undertake a health economic evaluation of Vitacam as an AF screening tool, providing insight on the cost-benefit that the technology could deliver under different future scenarios. To do this we modelled the number of additional AF diagnoses that would be made through use of Vitacam in an at-risk elderly population, compared to the current diagnostic approach, and estimated the number of strokes that would be avoided as a result. We quantified cost benefit of avoided strokes and stroke-related disability, and compared this to the costs of delivering screening, additional diagnostics, and treatment. We built an adjustable model in Excel, enabling users to understand the impact of varying different input parameters (e.g. screening population, Vitacam sensitivity and specificity) on the cost-effectiveness of the pathway. Our analysis provided novel insight, enabling future research and clinical trials to be designed and targeted appropriately, and providing target figures for Vitacam to reach in order to deliver cost-benefit.
“Edge Health worked closely with us to develop a deep understanding of the Vitacam technology and its potential impact, which they brought to life in their evaluation.”
Moyeen Ahmad: Co-founder and CEO of Vitacam
Transforming patient experience into valuable insights
What support networks exist for people with long-term conditions requiring specialist treatment?
Long-term conditions affect around 15 million people in England, with many needing specialist care. Learning to live with a specialist long-term condition requires a strong support network of healthcare professionals, family, friends and loved ones.
“The Company” is a charity-run social network that fosters a unique and diverse community of over 40,000 people affected by a long-term specialist condition. It connects people remotely so they can share personal experiences, and hosts platforms and tools to facilitate autonomous peer support.
The social network is a collection of hundreds of thousands of textual data points, for users all around the world. The Company asked Edge Health to help it to understand how its data could be used to provide greater insight and understanding to its clients and the pharmaceutical companies that provide them with life-changing treatments.
Edge Health possesses the skills to extract maximum value from complex and nuanced data
Edge Health was selected to help because of their deep understanding of healthcare data and the importance of privacy and information governance. It was essential to ensure the security and confidentiality of The Company’s personal and identifiable data.
The interactions on the social network create a rich text-based source of information. Edge Health undertook an exploratory investigation on what could be learnt from data relating to two different pharmaceutical treatments that represent over a quarter of the market in England. This analysis was expanded to include data on all treatment courses for the long-term condition, using tools ranging from natural language processing (NLP) and sentiment analysis to multiple correlation analysis.
Edge Health worked with The Company to extract valuable insights, using these analysis methods to understand user preferences and discussions surrounding topics specifically relevant to the long-term condition. This was especially true at product launch where user sentiment activity spiked on the site as users shared and discussed experiences of new treatments – experiences that are often unseen or overlooked.
Marked-up and classified text data is a rich source of information – it provides countless unique perspectives on real-world events
Changes in conversation topics and post activity revealed posts on the social media network closely mirror real-world events. Post activity regarding certain treatments for the condition were linked to market availability of drugs, driven by changes in supply due to manufacturing and the COVID-19 pandemic.
Current and ubiquitous models provide a retrospective view on how the drug market has changed. Novel analysis by Edge Health showed that interpreting the buzz around a new treatment can provide real-time insight and be a leading indicator.
This novel use of real-world data emphasises the need to understand user perspectives. These data can be harnessed to develop a better understanding of who individual users are, an empathetic understanding of what they value, and how conversations on the platform reflect real-world events. It provides an opportunity for pharmaceutical companies to better tailor the development of their products, and to seek to better understand and support new or prospective users.
Extracting maximum value from text data for healthcare partners will lead to improved patient outcomes, as patient needs are better understood
As social media platforms like The Company continue to grow and expand into the health care sector, they offer substantial opportunities to deliver societal value. They possess rich data sources with potential for a variety of applications. However, to fully utilise the qualitative data from such sources to its full potential, high quality data collection and processing is necessary as well as tailored methods of analysis.
Interpreting a dynamic and nuanced data source requires modern analytical solutions. This includes techniques that longitudinally track discussion sentiment, effectively segment users, and use “smart” topic categorisation. These are necessary to filter masses of textual data, and to respond to and interact with key changes happening within the community.
The analysis by Edge Health and The Company demonstrates immense potential to better understand user preferences, to tailor and enhance the user experience, and to identify and strategize around areas of improvement on the platform. This can enable healthcare partners and pharmaceutical providers to optimise their products which in turn would improve quality of life for those affected by long-term conditions.
Changing access to medicines from over-the-counter (OTC) to prescription-only, or vice versa, has varying implications for individuals, healthcare systems, and society as a whole. Understanding the potential impacts of reclassifying a drug enables informed decisions to be made around it’s access.
With a need for robust analysis and modelling, Edge Health were approached to undertake a health economic evaluation of the impact of restricting access to an OTC medicine, in collaboration with a healthcare communications agency.
We built a comprehensive understanding of the effects of reclassifying the medicine as prescription only. Surveys were administered to individuals who reported to use the medicine, to gain insight into their current usage patterns as well as how they would respond if it was only available by prescription.
Data from this survey was then used to inform the modelling. We carried out a scenario analysis, combining survey results with evidence-based assumptions to quantify impacts, amongst the sample, across three areas – wellbeing, economic and social. Baseline OTC usage of the medicine was calculated for the survey sample, and used to scale these impacts to a national level based on national OTC sales data.
We reported that restricting access to the drug would impact the individuals who used it (both their wellbeing and economically), the healthcare system (through increased use of GP and A&E services), and the taxpayer. The figures we provided on national impact will be valuable in building the evidence base on changing access to the medicine, informing decision makers and ensuring both sides of the discussion are fully considered.
In 2019, there were 748,000 people living with dementia in England. This population typically has complex care needs, placing considerable strain on the health and social care systems as well as on individuals themselves and their carers/families – at an estimated total cost to the UK of £37.4 billion a year.
Minder is a remote care platform that aims to improve the quality of life for people with dementia and their carers. It uses home sensors to detect an individual’s activity at home, and builds a model of ‘usual activity’ through use of artificial intelligence, allowing any deviations to be detected and flagged for follow-up, enabling early prevention. Minder has been developed by the research team at the UK DRI Care and Research Centre based at Imperial College London and the University of Surrey, in partnership with Surrey and Borders Partnership NHS Foundation Trust.
Recognising the benefits that Minder could have for people living with dementia, the UK DRI commissioned Edge Health to undertake a health economic evaluation of Minder. Through engagement with stakeholders and experts in the field, as well as review of existing evidence and literature, we built an understanding of the impacts that Minder could have on the health and social care systems, as well as on individuals with dementia and their carers. By modelling the costs associated with each of these impact pathways, we were able to estimate the Benefit Cost Ratio of Minder among the dementia population in England.
As part of their translation exercise, the UK DRI realised the need to have cost benefit figures at local population level. Through development of an adjustable model, enabling selection of specific geographies and dementia populations of interest, we were able to provide the UK DRI with a dynamic output demonstrating the value that Minder could bring for local populations, and the return on investment that could be made. This work will facilitate wider rollout of the technology in England, which if successful would allow a range of benefits to be realised across a large population of individuals, with huge benefits for health and social care systems.