Adam D. M. Briggs

Background: Many challenges facing the public health system have causes and solutions that are complex and contradictory. Overcoming these requires leadership across systems, yet little is known about what factors influence successful public health systems leadership. This study aims to identify key enablers and barriers to public health systems leadership in England. Methods: Semi-structured interviews were conducted with leaders working in the English public health system to identify enablers and barriers to success. Interview data were analysed using an inductive approach based in grounded theory to identify key themes and dimensions. Results: Enablers and barriers to successful systems leadership were constructed under four dimensions: the importance of the individual, the importance of the systems leadership team, overcoming organizational obstructions, and managing system tension and enabling success. Three paradoxes were identified where leaders need to adapt their approach based on the specific context and where success will require the use of enablers from each of the four dimensions. Findings are brought together into a novel conceptual framework to support public health systems leadership. Conclusions: The framework provides a tool to support public health professionals and leadership teams identify their systems leadership strengths and weaknesses, and balance areas of paradox and uncertainty.

Background: In March 2016, a tiered tax was announced on industries manufacturing or importing sugar-sweetened beverages in the United Kingdom. The Soft Drinks Industry Levy was implemented in April 2018 with two tiers: £0.18/l on drinks containing ≥ 5 g/100 ml and < 8 g/100 ml of added sugar, £0.24/l on drinks containing ≥ 8 g/100 ml of added sugar, with no levy on drinks containing < 5 g/100 ml of added sugar. The Soft Drinks Industry Levy is a complex intervention that acts as a disruptor in the commercial food system. As such, it demanded an evaluation that went beyond a narrow focus on a single outcome to incorporate assessment of a range of theorised intervention effects and their dynamic inter-relationships, taking a ‘systems’ perspective. Objectives: We undertook formative work over 6 months to underpin the evaluation, leading to five work packages, which aimed to evaluate: Work package 1: impacts on formulation, marketing, prices, purchases and consumption of sugar-sweetened beverages, and early health impacts. Work package 2: estimated impacts on medium- to long-term health outcomes. Work package 3: estimated economic impacts on food and other industries, His Majesty’s Treasury, health and social care systems. Work package 4: impacts on key stakeholders: the public, policy-makers and industry. Work package 5: the wider implications of the Soft Drinks Industry Levy in a synthesis of all findings and other evaluations. Methods: Work package 1 adopted a natural experimental evaluation design and used quantitative methods, including interrupted time series analysis. Work package 2 employed epidemiological modelling to simulate longer-term health outcomes. Work package 3 used micro- and macroeconomic modelling to estimate the net costs and benefits of the Soft Drinks Industry Levy and to simulate longer-term economic outcomes. Work package 4 used qualitative methods to explore acceptability and impacts of the Soft Drinks Industry Levy for diverse stakeholders. Work package 5 synthesised findings from this and other evaluations of the Soft Drinks Industry Levy and identified implications for policy and further research. Results: Our evaluation shows that the Soft Drinks Industry Levy: incentivised reduction in sugar purchased in soft drinks and in food and drinks overall; was associated with reduced inequalities in sugar purchased from soft drinks, with a 1.6% point reduction in prevalence of obesity in Year 6 girls, and with a 12% reduction in hospital admissions for carious tooth extractions in children and adolescents up to 18 years; was viewed favourably by policy-makers and the public; and did not have lasting negative impacts on the economic performance of soft drinks companies. Based on changes in sugar consumption observed, epidemiological modelling suggested that the Soft Drinks Industry Levy will lead to health gains and to net monetary benefit to the health sector, as well as to reductions in health inequalities. The Soft Drinks Industry Levy was forecast to produce a 0.004% cumulative gross domestic product loss to the United Kingdom economy over a 22-year period. Nevertheless, the Soft Drinks Industry Levy represents good value for money when balancing the overall health benefits against the economic impacts. The results of this evaluation are consistent with the results of studies undertaken by others. Limitations: There were limitations of all the studies we undertook, which are detailed in each of the 18 publications referenced in this report. Since we commenced this research, newer methods have become available for evaluations of interventions in complex adaptive systems. We have taken a narrative approach to triangulating and synthesising findings from our diverse range of studies. The use of more formal methods, such as contribution analysis or process tracing, may have strengthened causal inference. Future work: Government is strengthening the Soft Drinks Industry Levy, by reducing the lower levy threshold to 4.5 mg of sugar per 100 ml of soft drink, increasing the levy rates over time in line with inflation, and including milk-based drinks, and the benefits of such changes should, when implemented, be evaluated. The principles underlying the Soft Drinks Industry Levy could be applied to similar levies on other unhealthy foods, and the benefits of these also need to be modelled. Meanwhile, the longer-term impacts of the Soft Drinks Industry Levy, including industry adaptations, should be monitored, including its impacts on the sugar and soft drinks markets in the United Kingdom and globally. Further research is also needed on the implications of rising levels on non-sugar sweeteners in soft drinks and on ways to reduce the sweetness of all foods. Conclusions: The Soft Drinks Industry Levy was a novel, tiered sugar-sweetened beverage tax that incentivised industry reformulation to remove sugar from soft drinks. It was effective in incentivising reformulation and was associated with observed and projected future health benefits. Although it is estimated that the Soft Drinks Industry Levy had costs for the United Kingdom economy, these were mitigated by benefits for the public, the National Health Service and other sectors. The Soft Drinks Industry Levy has been positively received by the public, policy-makers and, to an extent, industry, and offers a model for future fiscal food policy in the United Kingdom and internationally. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/130/01.

Background: The public health grant is used by upper-tier and unitary local authorities in England to fund public health services. Public health grant allocations have declined by 26% per person since 2015/16, with cuts being made without any adjustment based on population needs, resulting in absolute cuts often being greater for more deprived local authorities. This study seeks to investigate how these cuts have affected spending decisions across different areas of public health and how changes in spend relate to population health needs. Methods: In this longitudinal ecological study, data on local government revenue expenditure and financing to 146 upper-tier local authorities in England were extracted from the Ministry of Housing, Communities, and Local Government for the years 2017/18, 2018/19 2019/20 and 2022/23. Demand for each function of the public health grant was proxied using a publicly available indicator of need. Descriptive analyses explored changes to grant expenditure over time by function and IMD quintile. A compositional regression model was developed to account for the relatedness of spend data. The significance of associations between indicators of need and spend on functions of the grant was tested using MANOVA, producing Pillai’s Trace statistics as an indication of the effect size of each explanatory variable relative to others. Findings: Public health grant spending reductions were widespread. More deprived local authorities often experienced deeper absolute cuts against a backdrop of greater need, with spend being protected across all IMD quintiles in only three areas: children’s 0 to 5 non-prescribed functions, health protection, and public mental health. In the multivariate regression, there was limited relationship between indicators of health need and patterns of grant spend between public health categories. Interpretation: There is no clear relationship between potential indicators of need and expenditure of the public health grant in different reporting categories. Instead, spending decisions are being driven by other factors that may include historic spend, wider local priorities and financial pressures. These findings suggest a review of the public health grant formula to support local authority public health teams to more strategically apportion spend based on population health need. What is already known on this topic Local authority public health teams in England receive a ring-fenced grant from central government which was originally based on an allocation formula that has not been updated since 2012/13. The grant has been cut substantially over the past decade, often with larger absolute cuts for more deprived local authorities. No previous study has investigated how public health teams allocate a diminishing grant across competing areas of public health need and how this may vary by deprivation. What this study adds This study found limited evidence that indicators of health need have driven public health grant allocation in related spend categories, nor any differences by deprivation. Our analysis is the first to explore multiple indicators of need and to employ compositional regression to account for corelations between categories of grant spend. How this study might affect research, practice and policy This study supports a review of the public health grant funding formula to better distribute the public health grant according to local population health need.

Background: The United Kingdom Soft Drinks Industry Levy was introduced in April 2018, resulting both in changes in sugar levels in drinks and purchases of drinks. Both mechanisms could impact on the incidence and prevalence of raised body weight, diabetes and diet-related diseases, and therefore, have implications for economic costs to the health sector. Objectives: To model future impacts of the Soft Drinks Industry Levy on population health and health sector costs and to estimate net monetary benefit to the health system. Design and methods: Proportional multistate lifetable modelling study – open and closed cohort analyses. Setting and population: All children and adults in the United Kingdom. Intervention: The Soft Drinks Industry Levy is a two-tier levy of £0.18/l on drinks with between 5 and 8 g of total sugars/100 ml and of £0.24/l on drinks with ≥ 8 g of total sugars/100 ml. Main outcome measures: We evaluated impact of the sugar reduction on: (1) prevalence of overweight and obesity, obesity-related diseases and dental health out to 2050 and (2) lifetime population health (measured in quality-adjusted life-years), change in costs to the health sector and the resulting net monetary benefit. Data sources: We estimated a per person reduction in sugar from a previously published interrupted time series analysis, which found an 8.0 g/household/week (95% confidence interval 2.4 to 13.6) reduction in sugar at 1 year after implementation. Our multistate lifetable model is parameterised using data from population health monitoring surveys, the Global Burden of Disease project, the Human Mortality Database and the Office for National Statistics. Health sector costs were obtained from Department of Health and Social Care budget allocations. Results: The model predicts that the Soft Drinks Industry Levy will reduce the prevalence of overweight and obesity in the United Kingdom by 0.18% points (95% uncertainty interval: 0.059 to 0.31) for males and by 0.20% points (0.064 to 0.34) for females. In the first 10 years of implementation, the reductions in sugar and overweight/obesity are predicted to prevent 270,000 (35,000–600,000) dental caries, 12,000 (3700–20,000) cases of type 2 diabetes, 3800 (1200–6700) cases of cardiovascular diseases and 350 (110–590) cases of obesity-related cancer. For the current United Kingdom population, it is estimated that the Soft Drinks Industry Levy will add 200,000 quality-adjusted life-years (63,500–342,000) over their lifetime and avert £174 million (£53.6–319) in their costs of health care (discounted at United Kingdom Treasury rates). At a United Kingdom Treasury value of £60,000 per quality-adjusted life-year, it is estimated that the Soft Drinks Industry Levy will produce a net monetary benefit of £12.2 billion (£3.88–20.8) for the health system. Limitations: Modelled results assume that the effect of the Soft Drinks Industry Levy remains constant into the future. The longevity of the effect of the Soft Drinks Industry Levy has not been tested. Conclusion: This study of the United Kingdom Soft Drinks Industry Levy tiered tax on sugar content provides further evidence that sugar-sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/130/01.

SUMMARY: Background: Consumption of sugar-sweetened beverages (SSBs) is associated with weight, weight gain and incidence of a number of chronic diseases. The World Health Organization recommends taxation on SSBs to reduce consumption. In 2018 the United Kingdom introduced the Soft Drinks Industry Levy (SDIL), a tiered tax on manufacturers and importers of SSBs. We aimed to review the consequences of the SDIL across all potential outcomes, informed by a systems thinking approach, to understand the range and importance of its effects. Methods: We undertook a systematic scoping review of empirical studies of the SDIL. We used a conceptual systems map of the hypothesised pathways of effect to inform data extraction and narrative synthesis. Findings are presented in an evidence map and their consistency assessed. Results: 38 studies met our inclusion criteria. The SDIL was consistently associated with reformulation of soft drinks to reduce sugar content. It was also consistently associated with: reduced purchasing of sugar from eligible drinks without increasing purchasing of substitute products such as alcohol and confectionary; longer-term improvements in acute and chronic health outcomes; and reduced health and social care costs, with few negative economic impacts for industry. Conclusions: By systematically mapping all outcomes evaluated, we have demonstrated the systemic and interconnected impacts of the SDIL. Further research should seek deeper understanding of how to evaluate such interventions as events in complex adaptive systems.

The King's speech confirmed Labour's manifesto commitments to "restrict the advertising of junk food to children along with the sale of high caffeine energy drinks to children." 1 2 It's a welcome signal that Labour is taking childhood obesity seriously. Although it will be rightly applauded, more still needs to be done to reverse persistently high obesity rates

Objectives: Despite significant investment in social prescribing in England over the last decade, we still do not know if it works, or how models of social prescribing fit within wider health and care policy and practice. This study explores current service delivery structures and assesses the feasibility of a national evaluation of the link worker model. Methods: Semi-structured interviews were conducted between May and September 2020, with 25 key informants from across social prescribing services in England. Participants included link workers, voluntary, community and social enterprise staff, and those involved in policy and decision-making for social prescribing services. Interview and workshop transcripts were analysed thematically, adopting a framework approach. Results: We found differences in how services are provided, including by individual link workers, and between organisations and regions. Standards, referral pathways, reporting, and monitoring structures differ or are lacking in voluntary services as compared to clinical services. People can self-refer to a link worker or be referred by a third party, but the lack of standardised processes generated confusion in both public and professional perceptions of the link worker model. We identified challenges in determining the appropriate outcomes and outcome measures needed to assess the impact of the link worker model. Conclusions: The current varied service delivery structures in England poses major challenges for a national impact evaluation. Any future rigorous evaluation needs to be underpinned with national standardised outcomes and process measures which promote uniform data collection.

Objective: To model future impacts of the UK Soft Drinks Industry Levy (SDIL) on population health and health sector costs, and to estimate net monetary benefit to the health system. Design: Proportional multi-state lifetable modelling study Setting: United Kingdom Population: All children and adults Intervention: The SDIL is a two-tier levy of £0.18 per litre on drinks with between 5g and 8g of total sugars per 100mL, and £0.24 per litre on drinks with 8g or more of total sugars per 100mL. We estimated a per person reduction in sugar from previous interrupted time series analysis, which found an 8.0 g/household/week (95% confidence interval: 2.4 to 13.6) reduction in sugar in purchased drinks at one year after implementation. Main outcome measures: W e evaluated impact of the sugar reduction on: (a) prevalence of overweight and obesity, obesity-related diseases and dental health out to 2050; and (b) lifetime population health (measured in quality-adjusted life years [QALYs]), change in costs to the health sector and the resulting net monetary benefit. Results: The model predicts that the SDIL will reduce prevalence of overweight and obesity in the UK by 0.18 percentage points (95% uncertainty interval: 0.059 to 0.31) for males and 0.20 percentage points (0.064 to 0.34) for females, for as long as the sugar-reduction effects of the SDIL are sustained. In the first ten years of implementation, the reductions in sugar and overweight/obesity are predicted to prevent 270,000 (35,000 to 600,000) dental caries, 12,000 (3,700 to 20,000) cases of type 2diabetes, 3,800 (1,200 to 6,700) cases of cardiovascular diseases, and 350 (110 to 590) cases of obesity-related cancer. For the current UK population, it is estimated the SDIL will add 200,000 QALYs (63,500 to 342,000) over their lifetime and avert £174 million (£53.6 to £319) in their costs of health care (discounted at UK Treasury rates). At a UK Treasury value of £60,000 per QALY, it is estimated the SDIL will produce a net monetary benefit of £12.2 billion (£3.88 to £20.8) for the health system. Conclusion: This study of the UK SDIL tiered tax on sugar content provides further evidence that sugar- sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending. What is already known on this topic: Numerous modelling studies have shown that sugar-sweetened beverage taxes are likely to be cost-effective and improve population health, whether the tax is applied on the volume of product or to the sugar content (absolute or tiered), but there have been few modelling studies that have been informed by evaluation of real-world taxes. A volumetric sugar-sweetened beverage tax of 1 peso per litre, implemented in Mexico in 2014, reduced purchases of sugar-sweetened beverages by 7.6% in the first two years, and health economic modelling estimated that it would be cost-effective from a health sector perspective. In the UK, the Soft Drinks Industry Levy (SDIL), announced in March 2016 and implemented in April 2018, was designed as a tiered levy to encourage soft drink manufacturers to reduce sugar content. Follow-up at one year indicates that it has reduced purchases of sugar from drinks by 8.0 g/household/week (95% confidence interval: 2.4 to 13.6). What this study adds: Population health modelling suggests that changes in sugar consumption due to the SDIL will reduce prevalence of overweight/obesity and related diseases and improve dental health in the UK, including 12,000 (95% uncertainty interval: 3,700 to 20,000) fewer cases of type 2 diabetes, 3,800 (1,200 to 6,700) fewer cases of cardiovascular diseases, 350 (110 to 590) fewer cases of obesity-related cancer, and 270,000 (35,000 to 600,000) fewer dental caries, in the first ten years after implementation. Health economic modelling indicates that over the lifetime of the current UK population the SDIL could add 200,000 quality-adjusted life years (63,500 to 342,000) and avert £174 million (£53.6 to £319) in health care costs, leading to a net monetary benefit of £12.2 billion (£3.88 to £20.8) for the health sector. This study of the UK SDIL tiered tax on sugar content provides further evidence that sugar- sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending.

Background Social prescribing encourages health-care and other professionals to refer patients to a link worker, who will develop a personalised plan to improve the patient’s health and well-being. We explore the feasibility of evaluating the service. Objective The objective was to answer the following research questions. (1) What are the most important evaluation questions that an impact study could investigate? (2) What data are already available at a local or national level and what else would be needed? (3) Are there sites delivering at a large enough scale and in a position to take part in an impact study? (4) How could the known challenges to evaluation (e.g. information governance and identifying a control group) be addressed? Data sources Data sources included MEDLINE ALL (via Ovid), searched from inception to 14 February 2019, and the first 100 hits of a Google (Google Inc., Mountain View, CA, USA) search. Review methods Rapid systematic review – electronic searches up to February 2019. Studies included any study design or outcomes. Screening was conducted by one reviewer; eligibility assessment and data extraction were undertaken by two reviewers. Data were synthesised narratively. Qualitative interviews – data from 25 participants in different regions of England were analysed using a pragmatic framework approach across 12 areas including prior data collection, delivery sites, scale and processes of current service delivery, and known challenges to evaluation. Views of key stakeholders (i.e. patients and academics) were captured. Results Rapid systematic review – 27 out of 124 studies were included. We identified outcomes and highlighted research challenges. Important evaluation questions included identification of the most appropriate (1) outcomes and (2) methods for dealing with heterogeneity. Qualitative interviews – social prescribing programmes are holistic in nature, covering domains such as social isolation and finance. Service provision is heterogeneous. The follow-on services that patients access are often underfunded or short term. Available data – there was significant heterogeneity in data availability, format and follow-up. Data were collected using a range of tools in ad hoc databases across sites. Non-attendance data were frequently not captured. Service users are more deprived and vulnerable than the overall practice population. Feasibility and potential limitations of an evaluation – current data collection is limited in determining the effectiveness of the link worker social prescribing model; therefore, uniform data collection across sites is needed. Standardised outcomes and process measures are required. Cost–utility analysis could provide comparative values for assessment alongside other NHS interventions. Limitations This was a rapid systematic review that did not include a systematic quality assessment of studies. COVID-19 had an impact on the shape of the service. We were not able to examine the potential causal mechanisms in any detail. Conclusions We describe possible future research approaches to determine effectiveness and cost-effectiveness evaluations; all are limited in their application. (1) Evaluation using currently available, routinely collected health-care, costing and outcomes data. (2) Evaluative mixed-methods research to capture the complexity of social prescribing through understanding heterogeneous service delivery across comparative settings. Cost-effectiveness evaluation using routinely available costing and outcomes data to supplement qualitative data. (3) Interventional evaluative research, such as a cluster randomised controlled trial focused on the link worker model. Cost-effectiveness data collected as part of the trial. Future work Mature data are currently not available. There needs to be an agreement across schemes on the key outcomes that need to be measured, harmonisation of data collection, and follow-up referrals (how and when). Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 29. See the NIHR Journals Library website for further project information.