Service Evaluation of the Elton John AIDS

Foundation’s Zero HIV Social Impact Bond

intervention in South London:

An investigation into the implementation and sustainability

of activities and system changes designed to bring us closer

to an AIDS free future.

Alec Fraser, Clare Coultas & Alexis Karamanos

Final report March 2022

2

Methodological and theoretical approach .............................................. 11

Qualitative approach ............................................................ 12

Quantitative approach........................................................... 12

Ethics ........................................................................ 13

Theoretical approach............................................................ 14

Zero HIV SIB programme background ................................................. 15

Findings .......................................................................... 16

Evaluating the impact of the Zero HIV programme .................................... 16

Evaluating the processes through which the Zero HIV programme functioned ............. 25

Narrative overview .............................................................. 25

Opt-in HIV testing in Primary Care ................................................. 39

LTFU and HIV Support in Primary Care ............................................. 40

Community Care ................................................................... 42

Sustainability...................................................................... 44

Conclusions ....................................................................... 47

References ....................................................................... 50

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This service evaluation is supported by the National Institute for Health Research (NIHR) Applied

Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS

Foundation Trust. The views expressed are those of the authors and not necessarily those of the NIHR or

the Department of Health and Social Care.

past year or so.

Thank you to Professor Peter Littlejohns of King’s College London for help and guidance in the

establishment of this service evaluation. Thanks to Clare FitzGerald of King’s College London and

Richard Boulton of Kingston & St George’s University of London for help and advice as the project

developed.

Many thanks also to Steve Hindle, Social Impact Bond Performance Manager, Elton John AIDS

Foundation and Neil Stanworth, Director, ATQ for support throughout the project and for commenting on

earlier drafts of this report.

The interpretation of all the data remains that of the authors.

Please cite this report as Fraser, A., Coultas, C., & Karamanos, A. (2022) Service Evaluation

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Dr Alec Fraser is a Lecturer in Government & Business at King’s College London (KCL). He is a member

of the Public Services Management and Organisation Group within the King’s Business School. Alec’s

research centres on the use of evidence in policy making and practice across the public sector with a

particular focus on health and social care. He has extensively researched the development of Social

of working as a third-sector research, evaluation, and development practitioner in the UK and East and

of people, organisations, and institutions using ethnographic, qualitative, and participatory methods.

Clare holds a PhD in Social Psychology from the London School of Economics and Political Science, and

an MSc in International Primary Health Care and BSc in Human Sciences, both from University College

London.

Dr Alexis Karamanos is a Population Health Analyst for the London Borough of Hackney and the City

of London, and a visiting Research Associate in Social Epidemiology and Public Health at King’s College

London. He is interested in the social, economic, and political determinants of human development, and

health inequalities over the life course. Alexis holds an undergraduate degree in Political Science and

Public Administration from the National and Kapodistrian University of Athens, Greece. He also holds

an MSc in Health and Society: Social Epidemiology from University College London (UCL), which was

funded by the Onassis Foundation, and a PhD in Population Health from UCL which was funded by the

UK Economic and Social Research Council (ESRC).

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Foreword

The Zero HIV Social Impact Bond was the Elton John AIDS Foundation’s response - despite excellent

clinical care within the health system - to the seemingly intractable problem of continued undiagnosed/

late HIV diagnosis in England. When I first started talking back in 2015 with interested people from

Lambeth council, NHS England, and NHS clinical colleagues about the potential of creating the world’s

first ever HIV SIB to expand testing and linkage to care, I was confident that we could make an impact.

But what an impact! Over 460 people have been either newly diagnosed with HIV or reengaged into care

across South London, providing access to lifesaving treatment, preventing onward transmission of HIV,

and avoiding over £90m of costs to the healthcare system.

Our partnership with Terrence Higgins Trust and National Aids Trust in developing the HIV Commission,

so ably chaired by Dame Inga Beale, gave a great opportunity for us to share the learning from the SIB.

The HIV Commission 2020 report emphasised the importance of HIV testing at every opportunity. In

response the government committed to develop the HIV Action Plan, giving us the chance to lay out our

evidence to DHSC and the Action Plan taskforce. The HIV Action Plan, launched by the Dept of Health

contextualise this data against related health and social care needs, thus informing broader planning

for service delivery by Integrated Care Systems and local authorities. The SIB also highlighted missed

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who are Lost to Follow Up. SIB partners reengaged over 250 people back into treatment, improving their

health and wellbeing, avoiding potentially expensive hospital treatment, and contributing to the HIV

Commission goal of Zero HIV transmissions by 2030.

As you will see, the SIB approach itself brought benefits. Its structure allowed for considerable flexibility

and innovation by implementing partners, matched as it was with the reassurance of upfront payments.

Southwark and Lewisham councils; the team at NHS England and Public Health England (in their

support and Maclaren Consulting for developing our PowerBI management and reporting system.

We are deeply grateful to all those involved in the project and those who have created this evaluation

report. We look forward to a national roll out to continue this vital work.

Anne Aslett

Chief Executive Ocer of the Elton John AIDS Foundation

March 2022

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This service evaluation takes a combined qualitative and quantitative methodological approach to

explore an innovative public health intervention with significant public management implications in

South London. The intervention is known as the ‘Elton John AIDS Foundation Zero HIV programme’ (we

term it the Zero HIV SIB programme in this report). The intervention ran in the boroughs of Lambeth,

A key facet of the SIB approach is to encourage multi-agency collaboration across public, private, and

work, their strengths and weaknesses – is very important for informing wider commissioning decisions

not only in HIV but across other chronic diseases.

We find that the 3-year Zero HIV SIB programme has been eective in both (1) delivering improved

health outcomes for people living with HIV and (2) improving inter-organisational collaboration and

service collaboration across what has historically been a rather fragmented HIV healthcare ecosystem in

South London.

In terms of the health impacts, key actors expressed confidence that this programme had reached (i)

people living with HIV who were previously undiagnosed and brought them into contact with specialist

NHS services and (ii) people living with HIV who were previously diagnosed but had become ‘lost to

follow-up’ (LTFU) treatment services. However, the absence of robust baseline data for key outcomes

or a commitment to a counterfactual evaluation design means it is not possible to attribute outcomes to

specific interventions.

Data from EJAF show that 124 new HIV diagnoses were identified through ED testing, and 53 LTFU

patients were also identified through participating EDs in South London hospitals. These hospitals also

re-engaged a further 153 LTFU patients separate to ED testing. Primary Care providers identified 26 new

HIV diagnoses through GP testing and also re-engaged 45 LTFU patients. Finally, 46 new diagnoses were

made by community providers and 5 LTFU patients were re-engaged by community providers as part of

In terms of the organisational impacts, key actors expressed confidence that this programme

perceived the increased use of data and monitoring and the realignment of incentives as positively

promoting collaboration and better outcomes. In terms of financing (ii) the programme very eectively

8

actors felt had stymied attempts for providers to implement evidence-informed practice (for instance

in relation to ED and Primary Care testing), or to adapt to practical realities (such as identifying LTFU

patients and providing more flexibility for not-for-profit provider organisation outreach work).

The programme adapted and grew over the three years with new provider organisations recruited

over the lifetime of the programme and new emphases on delivery developed – for example through

players in the design, financing, and delivery of the programme acting as co-commissioners, financial

inter-organisational, financial, and institutional barriers that historically inhibited more systematic

implementation of testing, LTFU and better joined-up HIV service provision. EJAF were instrumental

in shaping an ‘outer context’ (Damschroder et al, 2009) conducive to improving HIV services in South

London.

Rather than one ‘intervention’ the qualitative data in this report highlight that the actors involved

in commissioning and delivering HIV services through the Zero HIV SIB programme felt they were

delivering a suite of ‘interventions’. Some of these have a strong existing evidence base and have been

recommended in existing guidelines whilst others are more organisational and pragmatic. Some were

new and developed as part of the Zero HIV SIB programme whilst others were already in existence in

some or other settings. A key finding is increased flexibility and local discretion to use funds to tailor

services more closely to the needs of those using services as we have seen in other health focused SIBs

in the UK (Fraser et al, 2018).

A central aim of the Zero HIV SIB programme was to further the evidence for these interventions and

change practice going forward. A criticism of the programme raised by some informants was that more

work could have been done to ‘baseline’ existing practice and prove the attribution of some of these

interventions in order to provide a more robust body of evidence to sustain these going forward once the

SIB financing ended in December 2021. Though beyond the scope of this current service evaluation, it

appears that learning from the programme (particularly in relation to ED testing) may have been used to

There are mixed views from informants in relation to the sustainability of the improvements to South

9

This service evaluation takes a combined qualitative and quantitative methodological approach to

explore an innovative public health intervention with significant public management implications in

South London. The intervention is known as the ‘Elton John AIDS Foundation Zero HIV programme’. The

goals of the intervention include improving a person living with HIV’s health outcomes by linking them

SIB in the world to focus on HIV treatment and care. A SIB is an outcomes-based contract, in which a

of HIV and re-engaging patients who dropped out of HIV care) have significant beneficial social impacts as

well as hypothetical cost-savings for the NHS. A key facet of the SIB approach is to encourage multi-agency

collaboration across public, private, and philanthropic partners (Carter et al, 2020). A deeper understanding

of these collaborations – how they work, their strengths and weaknesses – is very important for

informing wider commissioning decisions not only in HIV but across other chronic diseases.

This service evaluation is informed by an Implementation Science approach (Damschroder et al,

2009) to explore the impacts and implications of the Zero HIV programme from the perspectives of

service users, clinical sta, health service managers, local authority commissioners, private sector, and

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Evaluating the impact of the Zero HIV programme

We firstly present an overview of the impact of the Zero HIV programme through a series of textboxes

and discuss some of the key quantitative findings before moving on to the qualitative findings of the

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(where 1 is most deprived 10% of LSOAs) (bins) (groups)

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Index of Multiple Deprivation suggests that this work is highly eective in engaging those people who are

already experiencing significant health inequalities (data from EJAF).

Figure 3: Index of Multiple Deprivation (IMD) Decile (where 1 is most deprived 10% of LSOAs) (bins)

(groups)

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Bringing these data together, there are a number of points we can make about the impact of the Zero

HIV programme. Firstly, in terms of the age of people living with HIV identified in the programme we

may say the following. Older participants identified by the programme were more likely to be known

to be HIV positive. Those aged 15-34 years were more than twice as likely to be newly diagnosed as

SIB participants aged 35-49 and 50 years and over. Participants aged 35-49 years were more likely to

be re-engaged to care than participants aged 15-34 years and 50 years and over. There was a higher

participants who could not be contacted).

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Table 2: Unadjusted predicted probabilities of outcomes by age group

In terms of ethnicity, our data suggest the following. White participants in the programme had a

Caribbean participants were two and three times as likely to be re-engaged to HIV care as White

participants. Black African and Black Caribbean participants had a lower probability of not being able to

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Table 3: Unadjusted predicted probabilities of outcomes by UKHSA ethnic categorisation.

22

Table 4: Unadjusted predicted probabilities of outcomes by London borough council.

the data suggest that participants in Lewisham and other London borough councils had a significantly

lower probability of being known to be HIV positive than SIB participants in Lambeth and Southwark.

Participants in Lambeth had a significantly lower probability of being newly diagnosed than other borough

councils, and finally, participants in Lewisham and other London borough councils had a significantly

higher probability of being re-engaged to care than SIB participants in Lambeth and Southwark.

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can state that after mutual adjustment of demographic characteristics, it was observed that the relative

risk of a female is RRR=.68 for being newly diagnosed vs. being a known positive. In other words, the

expected probability of being newly diagnosed was significantly lower for females (32%). The expected

probability of being newly diagnosed was significantly higher for those aged 15-34 compared to those

aged 35-49 years old. Black Africans were twice and Black Caribbeans almost three times as likely as

White British to be newly diagnosed. Participants in the SIB from other/mixed ethnic background were

as likely as White British to be re-engaged. Participants in the Zero HIV programme were more likely to

re-engaged is not statistically dierent for Southwark and Lambeth.

After mutual adjustment of demographic characteristics, it was observed that the expected probability

of not being able to be contacted was 71% higher for females. The expected probability of not being

able to be contacted was 53% lower for those aged 35-49 compared to those aged 15-34 years. Black

Africans and Black Caribbeans had a lower probability of not being able to be contacted compared to

White British. However, these dierences were not statistically significant. This is possible due to the

small number of those who could not be contacted. Compared to Lambeth, participants in other borough

councils were more likely to not being able to be contacted. The probability of not being able to be

contacted was similar for participants in Lambeth, Southwark, and Lewisham.

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expressed as relative risk ratios-an RRR below 1 indicates a lower probability, above 1 indicated a higher

probability).

There are limitations to these data that must be considered. Firstly, the small sample size of those

re-engaged to care and those who decided not-to re-engage does not allow a detailed exploration

of any ethnic, sex and age dierences in the odds of being re-engaged into HIV care by HIV clinics

and GP practices. Secondly, the small number of counts (sample size) does not allow to explore how

the demographics of people disconnected from care & reached through HIV clinic or primary care

audit/recall interventions dier from those found through ED testing or another route. Finally, most

statistical power to explore inequalities in HIV care in SIB at the intersection of socio-economic

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The qualitative findings of the service evaluation are structured as follows.

› Thirdly, we explore the dierent intervention elements across their separate healthcare settings in

three subsections – secondary care (hospitals), primary care (GP practices), and the community.

› Fourthly, we present the views of participants in relation to the sustainability of these HIV service

interventions beyond the period of SIB-financing.

Narrative overview

The headline finding from this service evaluation is that the 3-year Zero HIV SIB programme has been

eective in both (1) delivering improved health outcomes for people living with HIV and (2) improving

inter-organisational collaboration and service collaboration across what has historically been a rather

fragmented HIV healthcare ecosystem in South London.

In terms of the health impacts, key actors expressed confidence that this programme had reached (i)

people living with HIV who were previously undiagnosed and brought them into contact with specialist

NHS services and (ii) people living with HIV who were previously diagnosed but had become ‘lost to

follow-up’ (LTFU) treatment services. However, the absence of robust baseline data for key outcomes

or a commitment to a counterfactual evaluation design means it is not possible to attribute outcomes to

promoting collaboration and better outcomes. In terms of financing (ii) the programme very eectively

negated many aspects of the existing siloed payments systems for various aspects of HIV services which

actors felt had stymied attempts for providers to implement evidence-informed practice (for instance

in relation to ED and Primary Care testing), or to adapt to practical realities (such as identifying LTFU

patients and providing more flexibility for not-for-profit provider organisation outreach work).

32

A strong and consistent finding was the level of personal and professional dedication that the vast

majority of informants had towards people living with HIV and career-long desire to improve HIV services

– however, these commitments from HIV champions were sometimes not taken-up by non-HIV specialist

clinical sta. This is important because the majority of work actually done to deliver opt-out testing was

not carried out by HIV specialist clinicians – but ED nurses. Therefore, a significant implementation

challenge revolved around changing the perceptions, attitudes and working practices of ED nursing sta.

This involved changing the culture and dialogue from asking ‘do you want an HIV test’ to ‘this is an area

of HIV incidence. We test everyone unless you ask us not to’.

Non-specialist HIV nursing sta reported how in the years prior to the Zero HIV programme, opt-out

testing in ED had not been the norm – indeed HIV testing in ED was rare and only tended to occur when

ordered by doctors if clinically relevant. With the introduction of the Zero HIV programme, a programme

of awareness raising had taken place:

The new opt-out testing initiative adds further complexity to the interactions that nurses must have with

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Hospital nurse 3

Hospital nurse 1

The CNS role is significant in terms of boundary spanning from the HIV-specialist setting to the ED.

Numerous informants spoke of the significance of the regular presence of the CNS during shift handover

and also the feedback in relation to patient outcomes that the CNS provided. This is important as a way

of expanding support for the intervention through highlighting the significance of the intervention and

the value it has for patients and improving care:

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HIV specialist colleagues highlights the organisational prioritisation of HIV services linked to the

Zero HIV programme – such prioritisation had previously been lacking. The CNS role was partially

funded by outcomes from the Zero HIV programme. In addition to the clinical champion activities, the

CNS also plays a substantial role in data collection and presentation related to ED diagnoses and has

a clear understanding of the links between new diagnoses and outcomes payments, reiterating the

significance of how the wider financing model/outer context/incentives de-risks the hospital to

of greater examination in further research.

Notwithstanding these implementation issues, the overall picture is one in which ED opt-out HIV testing

is better established than before the Zero HIV programme in the hospitals in which we conducted

our research and has generated new HIV diagnoses which would have been less likely without

the intervention. Key factors in driving this change are a clear and reliable funding stream for the

intervention and dedicated HIV specialist sta support – from the CNS working in a boundary spanning

role, encouraging ED sta to implement the intervention, and feeding back results, generally raising

awareness, and acting as a clinical champion with other HIV specialist colleagues.

These positive changes are attributed by informants to the Zero HIV programme.

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The second significant intervention in the secondary care setting is LTFU work. This work involves

hospital HIV Clinic sta systematically reviewing databases of known HIV patients and reaching out

to those who have stopped attending NHS care, talking to them, and encouraging them to re-engage

with HIV services. The work is dicult as contact details may be out of date and some patients may

intervention, there was (1) some confusion and complexity in relation to which commissioning body

work. Unlike opt-out testing, sta resistance and HIV stigma are themes that do not emerge as barriers

in relation to LTFU as the team consist of HIV specialists. Neither is there an established evidence base

proving the benefit of LTFU work (in contrast to opt-out ED testing) – it is more of a practice-based

intervention, dependent on relationship-building with often vulnerable populations, and time-consuming

data cleaning activities and analyses. Finally, the boundary spanning role of the CNS emerges as

a significant factor, as does the payment mechanism and somewhat unexpectedly, the COVID-19

pandemic is seen by some informants as something of a facilitator in the successful development of

hospital led LTFU strategies.

The quote below from one of the HIV consultants captures key elements of the story around the existing

barriers and eventual facilitators rather neatly:

Hospital Consultant 1

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lack of ‘ownership’. Community nurses received some funding to pursue patients who were LTFU, but

some informants questioned whether these were the best placed actors to do so. At the same time,

clinical sta from the hospital engaged in ad hoc LTFU work but were not able to focus systematically

on this work due to other work commitments. A further key issue expressed by informants related to

problems with the data – i.e., missing data, or poorly categorised data, and that no one ever had the

time to fix such problems. As part of the Zero HIV programme, responsibility for the LTFU work (of

which was highly beneficial for all parties. Once more this highlights the flexibility and adaptability of the

In summary, the LTFU strand of the Zero HIV programme developed over time to become highly

significant and eective in re-engaging HIV patients. The programme increased the organisational

importance of this work through mandating the practice within the work-role of relevant and capable

hospital sta and incentivising HIV teams to do this work through the outcomes-based financial model. It

was particularly useful and durable during periods of COVID-19 ‘lockdown’.

37

38

Primary Care

We collected data from GPs acting as ‘Champions’ for the programme working in three dierent GP

practices in two Southeast London boroughs. Primary Care is dierent from Secondary Care in that

services are less coordinated, meaning that there was quite a bit of variation in the activities that made-

up the intervention. Nevertheless, the intervention at the Primary Care level can be broadly grouped into

three main activities: awareness raising with GPs; opt-in HIV testing; and LTFU work. In this section we

compile the findings from across these dierent settings integrating some discussion on variations and

will explore the dierences between them in more depth through further academic work.

Awareness Raising

Across the interviews the GP Champions discussed how many in Primary Care hold the view that HIV

prevention and care ‘wasn’t something that GPs did’ (GP2), and that HIV is currently not a ‘priority’

mindful of HIV patients… [and more generally be] a bit more aware of HIV’ (GP1). All interviewees

39

GP2.

Examples of innovative thinking towards raising awareness of HIV in Primary Care include the organising

of educational events for GPs, nurses, and GP trainees, that in one borough also included networking

with secondary care HIV specialists, as well as stigma reduction trainings for administrative sta

GP3.

One interviewee identified the cross-borough HIV Champion monthly meetings (facilitated by EJAF) as

an important space for developing ideas and sharing learnings, and suggested, if anything, that more

time for experimentation and evaluation would have been useful. This innovative thinking can also be

seen in the other two intervention activities.

Opt-in HIV testing in Primary Care

Owing to issues of consent, opt-out HIV testing was found to not be possible in Primary Care settings.

Therefore, eorts were put towards increasing opt-in HIV testing. One approach developed by a GP, and

which was shared and taken-up by practices in other boroughs, was to alert GPs through the electronic

records system that they use, when an attending patient has never been tested for HIV or has not been

tested in the last year. The awareness raising activities (described in the previous section) included

promoting information about these alerts along with skills-building exercises with Primary Care sta on

how to initiate conversations about HIV testing. In one borough, three GP practices trialled sending out a

text message to patients asking if they would like an HIV test, however this ultimately was not considered

opportunistic testing with GPs initiating the conversation was concluded to work best in Primary Care.

40

As with Secondary Care, lost-to-follow-up work largely involved the time-consuming work of auditing

records and trying to make contact with patients, often from vulnerable groups, who do not always have

consistent phone numbers and addresses. One identified challenge in relation to the SIB, was that it

was not always clear who the payment for LTFU outcomes should go to (i.e., Secondary Care or Primary

GP2.

Another GP described this work as being about ensuring that HIV is treated as a chronic disease, and

that it is normalised in Primary Care, but that this change in culture will likely be enormously dicult to

achieve.

The Zero HIV programme work in Primary Care has therefore supported the further development of

integrating HIV prevention and care into GP practise. This has included the building and strengthening of

relationships with HIV services in Secondary Care, along with relationship-building across GP practices,

federations, and boroughs aimed at mobilising GP engagement in, and commitment to HIV prevention

and care. As indicated by the HIV GP Champions, this area of work remains a challenge in Primary Care,

and questions around sustainability are particularly pertinent in regard to the potential loss of financing

for the HIV GP Champion role.

41

48

solutions to these – encouraging flexibility and adaptability through the COVID-19 pandemic.

Furthermore, the programme encouraged greater inter-organisational collaboration and increased

sharing of ideas through a more cosmopolitan approach within and across the organisations involved.

In terms of the health impacts, stakeholders were likewise confident that the programme was reaching

new HIV patients and very eectively engaging with them and enrolling them on to HIV treatment. The

ongoing care. The oer of a rapid HIV test, early diagnosis and excellent all-round care from NHS

right medication alongside good overall emotional support from NHS clinicians has transformed the lives

of these individuals.

For the provider organisations including NHS hospitals, GP surgeries and non-NHS organisations

such as local charities providing HIV outreach, testing and support, the Zero HIV programme enabled

them to reach a wider selection of people living with HIV than previously. This is linked to changes in

what Damschroder et al. (2009) term as the ‘outer setting’ – or the inter-organisational space which

influences change at the individual provider level. Key here was increased cosmopolitanism and

cross-organisational exchanges prompted by the programme. EJAF were identified as valued external

change agents who met regularly with all provider organisations and worked with them where needed

to help them achieve their outcomes. This fostered a positive culture in which measurement and

evaluative practice were used productively. The programme encouraged increased and more accurate

measurement and reporting of both new diagnoses and LTFU across all providers.

This measurement regime was stimulated by the need to evidence performance in order to access the

increased and better targeted funding for provider organisations that came with the programme. The

shift to an outcomes-based approach to financing HIV services was reported to have been significant

for some of the provider organisations. The increased emphasis on HIV testing and LTFU work in

provider organisations alongside the increased and more generous funding stream in turn increased the

visibility and salience of HIV within each provider organisation, thereby achieving greater organisational

the passion and dedication of sta to identify and help those living with HIV was allowed to flourish

LTFU. They also welcomed the work done by EJAF as external change agents and that learning from

the programme has value in guiding their decisions in relation to how to manage HIV services in the

49

generally quite removed from issues around implementation of the organisational and clinical changes

prompted by the programme. We expect their roles will be discussed in greater detail by the Ecorys/ATQ

research team in their third and final report.

We now turn to questions of sustainability. The timing of this report is rather unfortunate falling as it does

between the end of the SIB-financed programme (December 2021) and the establishment of the new

to answer at this time. Much will depend on national government and regional NHS decisions. However

Inquiry, the APPG Impact of HIV on BAME Inquiry, and the HIV Action Plan working group, which led

to the HIV Action Plan 2021 introducing £20m funding for ED HIV testing in very high areas of HIV

incidence – so EJAF certainly hope this programme can influence the agenda at a national level – but

once more, time and further research are required to answer the question properly.

In relation to the quantitative questions we explored, we found evidence that the programme managed

to reach marginalised groups of people who perhaps would not normally come into contact with HIV

testing services elsewhere - thus suggesting the programme may have the potential to address health

inequalities in a positive manner.

We conclude this report with a note on the need for further research and the possible avenues this

might take.

In terms of HIV service provision in South London, further mixed methods research into the sustainability

of the testing and LTFU work pioneered as part of this programme would be valuable – both from

an implementation and improvement science sustainability perspective, as well as to inform wider

understandings around the longer-term impacts of policy innovations such as SIBs and outcome-

oriented approaches to the commissioning of public services.

In addition, it would be very helpful to have detailed independent research into the health economic

of the programme facilitating future policy decisions to be better informed by evidence.

50