The distributional and financial impacts of the soft drinks industry levy on childhood dental caries in England

Queen Mary University of London (QMUL) requires access to NHS England data for the purpose of the following research project:

The distributional and financial impacts of the soft drinks industry levy on childhood dental caries in England.

The following is a summary of the aims of the research project provided by QMUL:

The aim of the project set out by QMUL is to evaluate the impact of the Soft Drinks Industry Levy (SDIL) on social inequalities in severe dental caries among children in England. The UK government announced a SDIL in March 2016, which came into effect in April 2018.

The objectives of this project are:

1) To evaluate the impact of the SDIL on absolute and relative inequalities in hospital admissions for caries-related extractions according to area deprivation, ethnicity and urbanicity.

2) To evaluate the distributional consequences of the SDIL in terms of both financial and health outcomes through an extended cost-effectiveness analysis (ECEA).

While objective 1 will focus on dental caries, QMUL's ECEA will incorporate two health outcomes (childhood obesity and dental caries) to provide a comprehensive and realistic health equity assessment. Findings from objective 1 will inform the ECEA. Information on the impact of the SDIL on rates and social inequalities in childhood obesity will be extracted from available resources to inform the ECEA.

Hospital Episode Statics (HES) Admitted Patient Care (APC) data for caries-related extractions are a robust population-level marker that captures the most severe end of the caries distribution among children. A previous analysis of (HES) found a relative reduction of around 12% in hospital admissions for caries-related in 0-18-year-olds, 22 months after the SDIL was implemented. Reductions were seen in 0-4- and 5-9-year-olds but not in older children. Reductions were also seen in all five deprivation quintiles but the middle one.

This project will expand the time series to the post-pandemic period and focus on measuring trends in absolute and relative inequalities in hospital admissions according to age groups, area deprivation, ethnicity and urbanicity.

The interrupted time series analysis will directly inform the second objective of the project which is to evaluate the distributional consequences of the SDIL in terms of both financial and health outcomes through an (ECEA). The project’s ECEA will take a societal perspective relating the cost associated with the implementation of the SDIL to the cumulative impacts on three major outcomes: health gains, financial benefits and the distributional impact across social groups.

Inequalities in admission rates for the primary and control outcomes will be measured according to area deprivation, ethnicity and urbanicity. Area deprivation will be measured using the English Index of Multiple Deprivation quintiles at Lower Super Output Area (LSOA) level. The largest minority ethnic groups in England (Indian, Pakistani, Bangladeshi, Black African, Black Caribbean, Mixed and Other white) will be compared separately against the white British group. Some groups may need to be combined into broader categories (Asians, Blacks, Mixed and other ethnicities) depending on size. As for urbanicity, LSOAs will be grouped using the ONS Rural-Urban classification.

The HES APC data will also be used for (i) bilateral tonsillectomies, (ii) ventilation support for asthma, (iii) appendicectomy and (iv) removal of a foreign body from the nose or ear as negative control outcomes.

These control outcomes are common reasons for hospitalization among children that were affected by COVID lockdowns but are unlikely to be affected by the SDIL. By comparing trends in the primary and control outcomes, QMUL can disentangle the effect of the SDIL from the effect of contextual factors (i.e. COVID).

The following NHS England Data will be accessed:

Hospital Episode Statistics

• Admitted Patient Care – necessary to provide information on hospital admissions for caries-related extractions and for (i) bilateral tonsillectomies, (ii) ventilation support for asthma, (iii) appendicectomy and (iv) removal of a foreign body from the nose or ear as negative control outcomes

The level of the Data will be:

• Pseudonymised

QMUL will receive unfiltered data via the SDE and QMUL will minimise the Data as follows:

• Limited to data between January 2008-June 2024 for 0–17-year-olds. For eligible patients, data will only be provided from 26 months between announcement and enforcement (implementation period) and 75 months after enforcement of the SDIL. Data prior to March 2016 SDIL announcement is required to provide an accurate prediction of the counterfactual trend (what would have happened if the SDIL was not implemented), which serves as control for the observed post-SDIL trend.

• Limited to entries that contains a primary procedure code that relates to dental, tonsilitis, ventilation support, appendicitis, or removal of a foreign body from the nose, ear or respiratory tract.

The lawful basis for processing personal data under the UK GDPR is:

Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller;

The lawful basis for processing special category data under the UK GDPR is:

Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

This processing is in the public interest because it adheres to the UK Policy Framework for Health and Social Care Research, which protects and promotes the interests of patients, service users and the public, and aims to produce generalisable and publicly available information to inform future decisions over patients’ treatments or care.

The funding is provided by National Institute for Health and Care Research (NIHR). The funding is specifically for the project described. Funding is in place until January 2026.

The funder will have no ability to suppress or otherwise limit the publication of findings.

Outputs such as written reports, lay summaries, press notes and website content, which will be developed with the help of the Lay Advisory Group (LAG). These outputs will be used to maximise impact on stakeholders (Consultants in Public Health and Dental Public Health, NHS leadership and Local Authorities). LAG will be formed at the start of the study. It will include the Principal Investigator , who will act as the Patient and Public Involvement lead, and 3-4 parents. Monthly meetings will be arranged with the LAG to discuss progress, organize next activities and provide training.

No data will flow to NHS England for the purposes of this Data Sharing Agreement (DSA).

NHS England will provide the relevant records from the HES datasets to QMUL.

The Data will contain no direct identifying data items. The Data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient.

SDE users can request exportation of aggregated analysis results (suppressed and summarised according to the NHSE SDE Disclosure Control rules) subject to review and approval by the NHS England SDE Output Checking team. The SDE Output Checking team will ensure that no output contains information which could be used either on its own or in conjunction with other data to breach an individual's privacy.

Users must identify themselves via a multi-factor authentication mechanism and are only able to access the datasets detailed within this DSA. The access and use of the system is fully auditable, and all users must comply with the use of the Data as specified in this DSA.

Users are only authorised to access the Data specified in this DSA and can utilise a variety of analytical tools available within the SDE platform. Users are not permitted to export record-level data from the SDE.

The Data will be accessed by authorised personnel via remote access.

The Controller(s) must confirm and provide evidence upon audit by NHS England that access via any remote device complies with the data security obligations within this DSA and the Data Sharing Framework Contract.

For remote access:

- Remote access will only be from secure locations situated within the territory of use (as further restricted elsewhere within the DSA if so done) stated within this DSA;

- Access controls granting users the minimum level of access required are in place;

- Remote access is only via secure connections (e.g., VPNs or secure protocols) to protect data;

- Multifactor authentication (MFA) is required for remote access;

- Device security, including up-to-date software and operating systems, antivirus software, and enabled firewalls are utilised for the remote access;

- All remote access is undertaken within the scope of the organisation’s DSPT (or other security arrangements as per this DSA) and complies with the organisation’s remote access policy.

The above applies in addition to any condition set out elsewhere within the DSA (e.g. who may carry out processing, and for what purpose).

Remote processing will be from secure locations within England

Access is restricted to employees of Queen Mary University of London.

The aggregated information derived from the Data will be combined with aggregated data from other sources. Aggregated information derived from HES data (numerator) with mid-year ONS population estimates for 0-17-year-olds, derived from census data (denominator) to create population-based rates of hospital admissions. Only aggregated HES data (monthly population-based rates of hospital admissions by age groups, deprivation, ethnicity and urbanicity) will be used for analysis.

There will be no requirement and no attempt to reidentify individuals when using the Data.

Analysts from the Faculty of Medicine and Dentistry at QMUL will process the Data for the purposes described above.

All personnel accessing the Data have been appropriately trained in data protection and confidentiality. The Data will not be linked with any other data.

There will be no requirement and no attempt to reidentify individuals when using the Data.

The expected outputs of the processing will be:

• A dissemination plan report which includes three complementary strategies to maximise impact at national and international level will be presented.

Firstly, the project will proactively contribute commentaries and viewpoints in media outlets and post summaries on Queen Mary’s website, raising the profile of the study from the outset.

Secondly, the project will disseminate the findings to relevant national stakeholder groups through our strong professional networks. Outputs will be aggregated data with small numbers suppressed disseminated using mailing distribution lists. The British Association for the study of Community Dentistry (BASCD) and Office for Health and Disparities (OHID) and follow-up meetings.

Thirdly, QMUL will engage with the World Health Organisation (WHO) Collaborating Centre for Evidence-based Dentistry at New York University.

• Submissions to peer reviewed journals: Journal of Dental Research (expected submission date: July 2025)

• Presentations at the International Association for Dental Research (IADR) annual meeting in Barcelona (June 2025).

The outputs will not contain NHS England Data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived.

The outputs will be communicated to relevant recipients through the following dissemination channels:

• Journals

• Social media

• Public promotion of the research via Queen Mary of London's website

• Outputs will be disseminated using mailing distribution lists (BASCD and OHID) and follow-up meetings.

• QMUL will engage with the WHO Collaborating Centre for Evidence-based Dentistry at New York University.

Target dates for the outputs July 2025.

The findings of this research study are expected to contribute to evidence-based decision-making for policy-makers, local decision-makers such as doctors, and patients to inform best practice to improve the care, treatment and experience of health care users relevant to the subject matter of the study.

It is hoped that the interrupted time series analysis will directly inform the second objective of the project which is to evaluate the distributional consequences of the SDIL in terms of both financial and health outcomes through an extended cost-effectiveness analysis (ECEA). The ECEA will take a societal perspective relating the cost associated with the implementation of the SDIL to the cumulative impacts on three major outcomes: health gains, financial benefits and the distributional impact across social groups.

The impacts of the proposal can be measured in multiple ways. Nationally, a clear statement from the government committing to the continuation of the SDIL would be an important impact measure. Another impact measure is that our findings inform updates of the government’s obesity strategy focused on sugar reduction and reformulation. Internationally, disseminating our findings through WHO channels will support more countries to consider taxes on sugar-sweetened beverages (SSBs), which is one of the indicators for global target 2.1 (policies to reduce free sugars intake) in the WHO Global Oral Health Action Plan. The research findings could support the target of 50% of countries implementing such policies by 2030.

Yielded Benefits is not a requirement for new applications.