Participants

A total of 108 stakeholders were interviewed (see Additional file 2). The consumer group included 34 women who primarily shopped at discount supermarkets with less healthy in-store environments [5], and mostly had lower levels of educational attainment (Additional file 2: Table S1). The business group consisted of 24 participants including 15 retailers from the supermarket, convenience store, online and non-food retailers and their trade representatives and 9 manufacturers or wholesalers who supplied these retailers, along with their trade representatives (Additional file 2: Table S2). A total of 22 enforcement stakeholders (including some primary authorities who advise large retail businesses on legislation) across a range of northern and southern regions in the UK participated. This sample consisted of 13 trading standards officers and their organisational representatives, 6 environmental officers and their associated professional organisations and 3 public health officers (Additional file 2: Table S3). Enforcement is more likely to be carried out by trading standards officers but as decisions about enforcement are made at a local level some authorities may also involve environmental health officers. Overall, 28 health representatives participated in the study consisting of 9 world-renowned public health/food policy academics and 19 representatives from health charities involved in lobbying about food policy and/or campaigning for action on obesity-related illness (Additional file 2: Table S4).

Aim 1: Rapid analysis of stakeholders’ views on the legislation

The rapid analysis identified two key themes. Theme 1, ‘This legislation is a “good first step” but there is potential for unintended consequences’, incorporates perspectives from the four stakeholder groups. Theme 2, ‘Inconsistent approaches may affect legislation impact’, highlights the concerns and support needs of business, enforcement and, to a lesser extent, health stakeholders. These two themes are detailed below with verbatim quotes from participants to illustrate. The six policy recommendations that were informed by these results and validated with conference delegates are subsequently presented.

Theme 1: This legislation is a ‘good first step’ but there is potential for unintended consequences 1a. Real hope for positive impact on health

Stakeholders from all groups believed that the legislation has great potential to (i) reduce impulse purchases of HFSS products, (ii) increase opportunities to promote healthier foods in prominent locations and (iii) drive cultural change about food shopping environments that could increase consumer demand for healthier foods. There were, however, concerns that the continued availability of HFSS products in retail stores will weaken the impact of this legislation and result in consumers simply changing their journeys through stores without altering purchasing patterns.

I do think it [legislation] would be good for the general health of the public if the temptation wasn’t there as you walked in shops and at the checkouts as well because when you’re queuing the children tend to fiddle. It would help families more if them products were a bit more out of sight. (6054, Consumer).

If it works then the placement of these rich delicious goods won't be in the footfall places where people just throw a cheeky Twix into the trolley to have on the way to the car. I think it will influence behaviour like that by taking away the choice and the opportunity. [ … ] or people will just learn and will just pick up the Twix earlier on in the shopping. (13012, Enforcer, Environmental health).

1b. Impact of exemptions on health and inequalities

Product exemptions (e.g. products not prepacked for direct sale like doughnuts/pick-and-mix sweets and alcohol), promotion exemptions (e.g. meal deals, reduced price promotions) and omissions of prominent promotional spaces (e.g. middle-aisle baskets, gondolas) have resulted in genuine concern from retailers, enforcers and health stakeholders that retailers will exploit these loopholes and subsequently undermine the legislation’s health aims.

Something we’ve called for is no exemption for unpacked foods because it’s the same number of calories regardless of the packaging that they’re in. Alcohol is totally exempt, pies are totally exempt, and these do actually make quite a strong contribution to total calorie intakes. (11012, Business, Retailer).

Will the problem shift so we will potentially see a huge amount of 25% off or 50% off price promotions instead? (13013, Enforcer, Trading standards).

Across stakeholder groups, there was concern that the exemption of businesses with less than 50 employees and stores smaller than 2000 square feet has real potential to increase health inequalities. Enforcer and health stakeholders highlighted that consumers who rely on these smaller stores often have lower incomes, or are younger or older adults. These groups are known to have less healthy diets and poorer access to larger supermarkets. Some study participants expressed the importance of including all business types (both small and large) in the legislation.

The sorts of people that are going to benefit from the impact are the people that shop in larger supermarkets, which are more likely to be our more affluent residents. From a health inequalities angle, that’s why it will be important to start trying to shake the smaller businesses down the line. (13037, Enforcer, Public Health).

There shouldn’t be any exceptions, everyone should have to follow it whatever size of the business so that it becomes a social norm then so that it actually feels quite weird if anyone isn’t following the rules. (12003, Health, Academic).

1c. Healthy products remain less affordable than unhealthy products

There were mixed views about the impact the legislation could have on food shopping affordability. Retailer, enforcer and some consumers (particularly those who described feeling tempted by impulse purchases and were less likely to use a shopping list) expressed concern that the legislation could increase household food shopping costs if multibuy promotions were no longer available. Some also expressed concern about the negative effect on business profits which could further drive up food costs for consumers.

Whenever new regulations come in, then there’s obviously some pass through of that cost to consumers, and we’re seeing the pass through of costs because of cost pressures in the business, which are really significant. (11037, Business, Retailer).

I think prices will go up [if multibuys were banned], if you need 12 chocolate bars ‘cause you’ve got a large family, you’re paying more for it eventually, aren’t you? (13012, Enforcer, Environmental health).

Conversely, health representatives believed removing value-based promotions on HFSS products could improve food costs for consumers. Similarly, some consumers who planned their shopping and felt less tempted by promotions believed there would be little effect on their shopping habits because HFSS was only bought as a treat.

Far from saving people money promotions lead to more purchases and contribute to greater consumption, resulting in overweight and obesity. That’s the bottom line. (12039, Health, Charity).

There are certain things that I do buy as treats for my children but like I said they’re treats so if they’re not on offer then I would still get them but probably not as frequent. (6029, Consumer).

Nonetheless, many consumers, health representatives and some retailers raised concerns about the affordability gap between HFSS and healthier products. They felt it was an essential issue for policymakers to address in future policies because reducing price promotions on HFSS will not automatically make healthier products more affordable.

I would advise the government they need to provide the supermarket with the lower prices for fresh fruit and veg, so we can then afford it as well. No point in them discouraging the non-healthy food when the healthy food prices are going really high. (6301, Consumer).

Sharon Hodgson (Member of Parliament) actually phrased this really well today and to use her words: ‘It’s a stark reality that the cheapest food is often the most calorific. It’s far more expensive to fill up hungry children with healthy food. To give an example for chocolate muffins for a pound in a supermarket, 6 apples are usually £2.00.’ It’s that price discrepancy that we know drives a lot of purchasing and leads to the fact if you’re living in a deprived area, then you’re twice as likely to have obesity. I’d be really worried that the price gap is not levelled and ideally that would be something that is monitored as part of the evaluation. (12055, Health, Charity).

1d. Legislation is only one part of a bigger strategy

Each stakeholder group felt this HFSS regulation formed an important first step of a broader policy agenda to address obesity and poor diet, but alone it would be insufficient to solve these issues. Stakeholders felt a clear, comprehensive, long-term policy strategy is needed.

This [is] a step in the right direction but it is one of many policies. We talk about a comprehensive strategy and sort of coherent policy landscape to make sure that the availability and visibility of HFSS foods is limited (part of) a larger shift towards greater accessibility, affordability and visibility of healthier options so that health is the default, and it isn’t about individuals having to make that choice, it’s about the environment that provides that. (12035, Health, Charity).

Hopefully it achieves its goal, not necessarily on its own, but as one element within a package of public health measures to help customers make the healthier choice whether it’s on its own or as a mix of elements. (11004, Business, Retailer).

Manufacturers expressed that the lack of clear, long-term policy direction on food and health from the government made it difficult for them to set their strategic business priorities. Some have spent time and resources following recommendations to reduce portion size or reformulate products to reduce sugar or salt. These efforts, however, do not align with the requirements of the nutrient profile model which forms a key part of this legislation.

I’d be interested to know what their [the Government’s] long-term plan is. It doesn’t affect all categories now, I don’t know whether they would ever roll it out to more categories in the future. Also we know there’s HFSS2, that was a new nutrient profile that was out for consultation years ago. And as far as I know Government have signed it off internally but they’ve never come out...a new profile would be more restrictive again. I guess it would be disappointing to see that come out when a lot of work has been done to reformulate for this profile. (11079, Business, Manufacturer).

Theme 2: Inconsistent approaches may affect legislation impact 2a. Legislation complexity and ambiguity leave room for interpretation

Stakeholders felt this legislation was complex and ambiguous, making it difficult to implement and open to interpretation. There were concerns that the complexity increased the likelihood of inconsistent implementation and enforcement across store types and geographical regions. As participant 11011 describes below, stakeholders felt this ambiguity in the written regulation could have been avoided if stakeholders’ concerns had been considered more thoroughly. Furthermore, enforcement officers, including 13023, explained that inspection visits to stores may require individual interpretation (i.e. a ‘designated queuing area’, ‘aisle-end’ or ‘meal deal’ may be interpreted differently by retailers and may not match definitions in the regulations).

There is a lack of clarity and forethought on writing the regulations, and a consistent refusal to listen to industry and understand the challenges. (11011, Business, Retailer).

A lot of situations are unclear, and they don’t fall neatly within what is written and then it’s up to enforcers and businesses to look at where their situation falls in and interpret the guidance of the legislation accordingly. (13023, Enforcer, Trading standards).

The nutrient profile model used to define in-scope products is complicated and results in products within included product categories being unexpectedly exempt (e.g. high-protein pizzas, high-fruit buns) which could make enforcement difficult. Retailers were concerned that product definition complexities and their dependence on accurate scores from manufacturers will make them liable for non-compliance.

All the retailers are reliant on colleagues in a store making sure they are fully adhering to the rules which in some areas don’t make a huge amount of sense to the general person scoring goods. For example, a meat lovers’ pizza is non-HFSS on the basis that it has a high quantity of protein. (11004, Business, Retail).

There’s such variety, and [you need to consider, for example] how many nuts are in it and all the rest of it, when we get down to those kind of discussions, that creates huge problems for regulators, because you don’t want to be arguing over whether a product’s in scope or out of scope, you want it to be very clear. (13011, Enforcer, Trading standards).

2b. Differences in prioritisation of the legislation

Inconsistencies in the level of prioritisation retailers and enforcers will give this legislation were clear. Some businesses were already making changes, hoping to gain a competitive edge on promoting healthy choices and accelerating existing health-related business plans. Other businesses, however, were focused on making changes to ensure compliance, whilst exploring ways to ensure profits from HFSS products were not affected.

We feel like this is an opportunity to differentiate ourselves if we can do it well, you know, make it better for people. [ … ] there could be that rush to the top as it were, instead of the bottom where we’re all trying to find new ways to promote healthy stuff. (11011, Business, Retailer).

We will still sell the same range of confectionery it just won’t be on an end facing a till. But I will make sure that it’s as close to a till that is legally compliant. (10000, Business, Retailer).

Regional differences in enforcement approaches are also likely according to local authorities’ prioritisation of healthy eating and obesity as a public health concern. This could result in somewhat patchy enforcement activities.

You could have a situation of Councillor X who becomes leader says, “I really believe in child health, and I want to promote this,” and will drive it. But in other authorities, they might say, “No, we’ve got no time for that, we’ve got all this to deal with.” (13003, Enforcer, Trading standards).

2c. Differences in resource availability and capacity

Understanding the legislation, determining which businesses qualify and making changes to shop infrastructure has been time-intense and costly for retailers. Larger businesses have had better access to legal support (i.e. through primary authority links) and will be less affected by short-term profit loss and implementation costs than smaller stores. The quote below from an independent retailer illustrates this point clearly:

We do promotions because of attracting customers in the shop, to come to buy stuff. If we can’t do it, they have that mentality to go to a supermarket. Obviously we’re losing customers. Prices going up, wages going up, electricity bills going up. Everything’s going up, if we’re not getting customers the way we used to be getting, how are we going to survive? (11086, Business, Retailer).

Generally you can be pretty sure that an independent’s due diligence procedures won’t be anywhere near as robust as a national supermarket, particularly regarding training [ … ] They’re focused very much on the business, [the] sale of products and less so on diligence. And that reflects in the kind of problems that we [environmental health] get. (13015, Enforcer, Environmental Health).

Enforcement stakeholders clearly described how resource issues will mean the majority of local authorities cannot prioritise this legislation. Limited staff and funding cuts result in prioritisation of immediate risks to health (e.g. allergens, crime, safety).

And when you’re making the decision between do we try and deal with this unsafe chainsaw that could kill somebody today, or do we deal with these products that contribute to obesity, that is a long term issue, it’s very difficult to get priority for long term issues over immediate short term issues. You’ve got limited resources, you have to target those at stuff that has probably the most imminent risk. And this (legislation) doesn’t fall into that category. (13011, Enforcer, Trading standards).

Aim 2: Determination and prioritisation of policy recommendations

Figure 1 illustrates how the identified themes and sub-themes informed the development of the six recommendations for policymakers. If acted upon, these recommendations could help to overcome issues of inconsistent legislation implementation and minimise unintended consequences, particularly inequalities in health and commercial competition. The numbering of these recommendations represents the priority order for stakeholders according to the results of the priority setting activity undertaken by conference delegates. Detailed descriptions of these recommendations, alongside stakeholder quotes supporting their development, are shown in Table 1.

Fig. 1

Links between stakeholder sub-themes and the development of six policy recommendations to optimise legislation’s intended impacts

Table 1 Six policy recommendations based on stakeholder views

Three recommendations are for immediate action to enable effective implementation and enforcement of the legislation, namely (i) provision of a free central HFSS calculator to support consistent and accurate identification of in-scope products across store types and regions, (ii) providing additional ring-fenced resources to local authorities to ensure support is offered to all business types and enforcement activities are conducted consistently across geographical regions and (iii) providing greater guidance and support to smaller businesses to enable them to comply.

The remaining three recommendations are medium- to long-term actions that aim to help optimise the intended impact of the legislation, including (i) conducting a robust evaluation to assess implementation and enforcement, as well as outcomes of food purchasing, diet and obesity patterns across consumer groups, business types and regions; (ii) applying evaluation data to refine the legislation to facilitate consistent implementation and enforcement within the spirt of improving public health; and (iii) the creation of a long-term roadmap for food and health that unifies stakeholders on a strategy and timeframe to achieve a food system supportive of a healthy, sustainable population diet for all.