Research and analysis

Gambling treatment: assessing the current system in England

Published 7 March 2024

Applies to England

Summary

Gambling is associated with a range of harms for people who gamble and those close to them, including:

• mental health problems and risk of suicide
• breakdown of families or relationships
• financial problems
• health inequalities

Around 0.5% of the adult English population experience problem gambling, 3.8% are at elevated risk of gambling harms, and an estimated 7% of the British population are negatively affected by someone else’s gambling. Members of all these groups may benefit from accessing some form of treatment or support.

In the government’s response to a coroner’s inquest on gambling harms in 2022, the Department of Health and Social Care (DHSC) committed to undertake an initial review of the existing adult gambling treatment system in England, led by DHSC’s Office for Health Improvement and Disparities (OHID). This was to improve understanding of the system’s strengths, weaknesses and identify areas for improvement, because this has not been systematically done before.

In the 2023 white paper High stakes: gambling reform for the digital age, OHID committed to publishing the findings of its assessment, so that the findings can be used for system improvement.

OHID has undertaken an assessment of the adult gambling treatment system in England by:

• reviewing routinely collected gambling treatment and National Gambling Helpline data
• analysing responses to a questionnaire of treatment providers
• interviewing gambling treatment stakeholders
• conducting ‘deep dives’ with a small number of local authorities

Characteristics of the gambling treatment system in England

Location of treatment services

Gambling treatment is provided in clinical settings by the NHS and in community and residential settings by the third sector (charities and community organisations). At the time of our data collection, 35 of 153 upper tier local authorities in England had a treatment provider physically in the area. At the time this report was written, there were treatment providers in all regions, except for the East of England, but these are not evenly distributed across the country.

Routes into treatment

The National Gambling Helpline is the most common route into treatment and mostly sends referrals to third sector providers. Self-referral is the second most-reported route. Most providers recorded a period of less than 3 weeks between contact or triage and accessing treatment, with substantial variation between providers.

Treatment interventions

Most treatment and support takes place online or over the phone, but face-to-face options are available from most providers. The use of some forms of treatment interventions are mostly reported by NHS services, such as cognitive behavioural therapy (CBT) and pharmacological interventions. Other interventions like structured psychosocial, which vary in their techniques and approach, are offered by third sector providers.

Other treatment interventions varied by provider, as did support for specific cultural or social groups, and other services such as debt management. Service users with complex needs or co-morbidities tend to be seen by NHS providers. All providers describe some form of aftercare and involvement or collaboration with peer support. Minimum qualifications of staff differ across providers, particularly in the third sector.

Treatment episodes

In 2021 to 2022, there were 7,072 treatment episodes for residents of Great Britain across NHS and third sector providers, of which 6,467 were for English residents. The majority (86%) of episodes across Great Britain were for people experiencing issues due to their own gambling or risk of gambling harm for themselves and 14% were for people affected by someone else’s gambling.

Most treatment episodes across Great Britain were associated with men (69%) and people who identify as white (88%). The number of episodes peaked in 2019 to 2020, followed by a decline which coincided with the COVID-19 pandemic.

In 2021 to 2022, the median time people in a treatment episode reported gambling before presenting to treatment was 10 years. Around a quarter (24%) of people in a treatment episode that year had previously engaged with gambling services.

Treatment outcomes

In 2021 to 2022, for treatment episodes that had a recorded exit reason, 92% of treatment episodes that completed scheduled treatment recorded an improvement in their Problem Gambling Severity Index (PGSI) score compared to only 62% showing improvement among those who had an unscheduled or unplanned exit. PGSI is a screening tool used to measure at-risk behaviour among people who gamble.

System strengths

Looking across the questionnaire responses, interviews and deep dives, we found the gambling treatment system had:

• a talented and passionate workforce that provides services which some people felt were helpful when they accessed them
• a wide range of treatment options for people who gamble and affected others, including some culturally or socially specific services, connections to other parts of the treatment pathway like aftercare and recovery, and to services such as debt management
• good examples of strong working relationships between some providers as well as the wider health, social care and justice services
• increasingly made gambling a health priority in terms of resources and amount of funding

Challenges and areas for improvement

There were a number of areas that stakeholders thought needed improvement, including the following.

Data collection and reporting

There is no standardised or co-ordinated approach across NHS and third sector providers to collect uniform metrics on service provision and service user treatment journeys. GambleAware’s data reporting framework is used to provide the annual statistics for the National Gambling Support Network (NGSN) (formerly known as the National Gambling Treatment Service). You can find the most recent statistics, and reports going back to March 2019, at the National Gambling Support Network page of the GambleAware website.

Although the GambleAware data reporting framework is an important resource, it could be improved to clarify certain metrics.

Structure of the gambling treatment model and referral pathways

There is a lack of clarity about referral pathways to gambling treatment and inadequate links with wider services, which is a problem particularly for service users with complex needs. Service providers recognise CBT as the ‘gold standard’ treatment, but it was only used in a minority of treatment episodes. The treatment system appeared to be underserving certain minority groups (including ethnic minority groups and LGBTQ+ people) and some stakeholders felt that more could be done to support aftercare.

Co-ordination in the gambling treatment system

Relationships between NHS and third sector providers were poor, partly due to different beliefs about the current funding model for treatment, beliefs about conflicts of interest, and associated tensions. There was a lack of communication between NHS and third sector services which prevented strategic co-ordination.

Governance

Some stakeholders had concerns about service governance structures and their transparency. They felt governance was inadequate or inconsistent, in particular:

• accountability
• quality assurance
• monitoring and evaluation
• standards of care
• occupational standards

Some stakeholders also thought that some treatment providers had stronger governance processes in place than others.

Awareness of gambling harm, supports and prioritisation

There was a lack of knowledge about gambling harms and available treatment options among professionals in wider health care, social care and justice services. Some felt low awareness may mean that gambling is not prioritised as much as other health problems, which has implications for resource allocation and accessibility of support. Stigma, which keeps gambling a hidden issue, was also a factor preventing people from accessing treatment in the first place. But it was also an issue sometimes when they engaged with health or social care professionals.

Wider considerations

Some stakeholders felt that more could be done to reduce the numbers of people requiring gambling treatment.

Suggestions for improving the treatment system

The stakeholders we interviewed for this research had suggestions for how to improve the gambling treatment system. These suggestions follow the same themes we identified, as follows.

Data collection and reporting

There needs to be standards developed for all treatment providers on data collection and reporting and improved longer term monitoring of service user journeys. Lessons about applying these standards to a gambling treatment database could be learned from the National Drug Treatment Monitoring System in England.

Structure of the gambling treatment model and referral pathways

It would be beneficial to develop a standardised triage system with clear referral criteria, while still allowing flexibility for service users. It would also be helpful to consider shifting to a regional model for commissioning.

The system could build from existing structures in place for other health care provision, such as extending the Care Quality Commission (CQC) standards to cover gambling. The Gambling Commission and GambleAware have commissioned CQC to explore the development of an inspection regime for their services. Gambling treatment needs to be further integrated into broader systems like health and social care, capitalising on work already underway to ensure ‘no wrong door’ approach to accessing appropriate support. This means that people are never turned away, or passed from service to service, or told that their treatment is conditional on another treatment. Developing or advertising more tailored support to specific groups (such as women and ethnic minorities) could increase their access to treatment.

Co-ordination in the gambling treatment system

Changing the funding model to remove reliance on gambling industry donations could help improve relationships and system co-ordination between NHS and third sector providers. This is because the current model has caused tension due to different views between providers about what is a conflict of interest.

Changing the funding model could also establish principles of engagement and dedicate efforts, such as mediation, to building professional relationships.

Governance

Governance could be improved by:

• aligning treatment commissioning processes across all treatment providers, with joint working agreements and data sharing protocols
• implementing independent quality assurance processes
• creating occupational standards for gambling treatment

The National Institute for Health and Care Excellence (NICE) guideline on harmful gambling is due to be published in May 2024 and should help clarify standards of care. You can see information and documents for the project at Harmful gambling: identification, assessment and management.

Some stakeholders felt that improved co-ordination between government departments involved in gambling policy was needed.

Awareness of gambling harm, supports and prioritisation

Training and awareness about gambling harm and available support could be introduced or increased for non-gambling frontline professionals.

Wider awareness-raising interventions such as campaigns aimed at the public could increase knowledge, reduce stigma and better support those experiencing harm.

Wider considerations

To reduce gambling harm and the numbers of people requiring treatment, actions to improve prevention, harm reduction, regulation and research needs to be taken by a range of groups at national and local level (including government, academia and local authorities) to build a whole system approach to treat harmful gambling.

Next steps

This assessment highlights priority areas where action could be taken to improve the treatment system for gambling harms in England. We will share these with the relevant public bodies and treatment providers for their consideration and so they can use them to support changes to the treatment system.

1. Context

1.1 Gambling, harms and people in treatment

Gambling is associated with a range of harms, including:

• financial harms
• relationship harms
• health harms
• health inequalities

Public Health England (PHE) report Gambling-related harms: evidence review found that these harms negatively affect people who gamble, as well as people close to them like their families and communities. These harms are not equally distributed across society and people living in the most deprived communities experience the highest levels of gambling harm.

According to the Health Survey for England 2018, which provides the most current reliable data, around 168,000 of English adults reach the threshold for problem gambling.

OHID’s Gambling treatment need and support: prevalence estimates found that around 445,000 adults could benefit from different types of treatment, including:

• 163,000 who may benefit from psychosocial interventions
• 243,000 who may benefit from psychologist-led CBT
• 39,000 who may benefit from intensive residential treatment

A 2020 study by NatCen Social Research for GambleAware Treatment needs and gap analysis in Great Britain (pdf, 768kb) estimated that around 7% of people in the UK experience harms from someone else’s gambling, and could also benefit from some form of treatment or support.

The NGSN statistics for 2021 to 2022 showed that gambling treatment services provided 6,467 treatment episodes to people living in England. This excludes the Primary Care Gambling Service (PCGS) which does not report into the same system (IFF Research, 2022). While treatment episodes are different from the number of people in treatment, these figures still represent a fraction of the 445,000 people who could benefit from these type of treatments.

1.2 Commissioning structure of the current gambling treatment system

Gambling treatment in England is primarily commissioned by 2 bodies, NHS England (NHSE) and GambleAware. GambleAware is a charity operating across Great Britain that commissions research, gambling harm education and treatment services.

The Gambling Commission is an independent public body that grants gambling licenses and regulates the gambling industry in Great Britain. As part of its gambling operators’ licence conditions and codes of practice, the Gambling Commission required gambling operators to make yearly voluntary contributions to one or more organisations from a list of organisations for operator contributions. These financial contributions went towards research, education or treatment of gambling-related harms. The majority of contributions are received by GambleAware, which distributed most of its funding for gambling treatment services. NHS services were co-funded by GambleAware using these voluntary financial contributions. However, in March 2022, as outlined in this letter from National Mental Health Director Claire Murdoch to GambleAware, the NHS chose to stop receiving this funding.

GambleAware commissions the charity Gordon Moody to deliver residential services and GamCare to deliver the National Gambling Helpline. GamCare also provides support and treatment for people experiencing gambling harm, as well as family and friends affected by gambling. The PCGS is also currently funded by GambleAware.

At the time of the assessment, GambleAware supported GamCare to distribute funds to other third sector providers. These providers were charities, social enterprises and voluntary groups delivering gambling treatment services, and make up GamCare’s partner network. However, these arrangements changed in 2023 and GambleAware became the direct commissioner for these services.

The NHS National Problem Gambling Service (NPGS) and the NHS Northern Gambling Service (NGS), along with new NHS clinics that have opened, receive NHSE funding only. NHSE continues to expand the provision of NHS gambling treatment clinics as part of a commitment made in the NHS Long Term Plan.

Some third sector organisations receive direct funding from gambling operators or funds allocated by the Gambling Commission as part of regulatory settlements. This funding is the outcome of regulatory action taken by the Gambling Commission against a gambling operator instead of a fine, where the payment is to be used for socially responsible purposes, as set out in its Statement of principles for licensing and regulation.

In the government’s response to a coroner’s inquest on gambling harms (pdf, 382KB), DHSC committed to undertake an initial review of the existing adult gambling treatment system in England, led by OHID. This was to improve understanding of the system’s strengths, weaknesses and identify areas for improvement, because this has not been systematically done before.

In 2023, the government published the High stakes: gambling reform for the digital age white paper. In it, OHID committed to publishing the findings of this report so they could be used for system improvement.

1.3 Aim of this report

To identify the system’s strengths, weaknesses and suggestions for improvement, OHID undertook an assessment of the gambling treatment system for adults in England. Our objectives were to:

• describe the level and coverage of gambling treatment
• understand what support was available
• explore gambling stakeholder views on treatment provision
• understand how non-gambling services approach gambling harm
• understand links between gambling treatment providers with wider services

We focused on gambling treatment providers funded by NHSE or GambleAware for adults in England, excluding:

• services for people under 18 years old
• private treatment providers
• other UK nations (apart from for gambling treatment episode statistics)

In this assessment, we define ‘treatment’ as any structured intervention delivered by healthcare professionals where the primary aim is to affect gambling behaviour. We define ‘service users’ as people who use gambling treatment or support services related to their own gambling or as an affected other.

2. Approach

Our assessment was informed by a health needs assessment approach (Cavanagh and Chadwick, 2005) to:

• explore the health problems of English adults who gamble and could benefit from treatment
• explore the structures of the existing treatment system including resource allocation to identify where improvements could be made to this population’s health and reduce inequality

We developed a plan to carry out the assessment in consultation with relevant stakeholders, which included:

• a treatment provider questionnaire
• data from the National Gambling Helpline and the National Gambling Support Network
• interviews with gambling treatment stakeholders
• ‘deep dives’ into 5 local areas that included gambling and non-gambling frontline professionals (such as staff in drug and alcohol services, mental health services and other health and wellbeing services)

Stakeholders who contributed to the assessment proposal included:

• NHS England
• GambleAware
• GamCare
• Advisory Board for Safer Gambling
• Gordon Moody
• Primary Care Gambling Service
• Association of Directors of Public Health
• Sheffield City Council
• Greater Manchester Combined Authority
• Gambling with Lives
• Northern Gambling Service

2.1 Questionnaire and mapping of provision

To describe the existing treatment system and understand its geographic coverage, in June 2022 we sent a questionnaire to all treatment providers in scope at the time. It included questions about:

• the services they provided
• the treatment they offered
• their staff
• treatment data they collected

Treatment providers may have a head office as well as additional locations in which they can see service users in person. These are known as satellite locations. All 16 providers completed the questionnaire by October 2022.

To map the provision of gambling services in England, we extracted the postcodes for all treatment providers and their satellite locations, as well as postcodes of 2 NHS clinics that opened after the questionnaire closed. We combined these postcodes with postcodes of the peer support services Gamblers Anonymous and GamAnon. We did this because places with peer support services may indicate a need for support in an area. We found addresses for the peer support services from their websites.

2.2 Reviewing National Gambling Helpline and National Gambling Support Network data

We reviewed data from the National Gambling Helpline for 2021 to 2022, which GamCare provided. We summarised top level treatment episodes statistics for Great Britain from the report Annual statistics from the National Gambling Support Network: 2021 to 2022. This was because the report does not include England-specific data and we did not have the capacity to analyse the raw data. The NGSN provides anonymous service user information to the GambleAware data reporting framework system.

2.3 Stakeholder interviews

Between June and November 2022, we interviewed:

• NHS and third sector treatment providers
• commissioners
• people with lived experience of gambling harm
• local public health staff

We analysed the interviews using framework and thematic analysis methods. This involved applying descriptive codes to the interview notes, capturing relevant ideas and perspectives, and summarising codes by stakeholder type. We then used this data to identify patterns and differences in developing final themes that summarised stakeholder perspectives.

2.3 Local authority deep dives

We carried out deep dives in 5 local authority areas, which were:

• Derbyshire
• Gloucestershire
• Newham
• Sunderland
• Wakefield

Stakeholders for the deep dives included local gambling treatment providers and non-gambling frontline services. The gambling-related harms evidence review found that these services were likely to see gambling service users or people experiencing gambling harm as a co-occurring issue, such as:

• drug and alcohol related problems
• mental health problems
• financial difficulties requiring debt advice
• other health and wellbeing problems

Data collection included:

• treatment provider visits
• discussions from online events
• calls and email correspondence, which we summarised as case studies

3. Findings

3.1 Geography of services

Gambling treatment providers and their satellite locations operate in 52 locations in England. This includes the 16 providers responding to the questionnaire and 2 providers that opened after the questionnaire closed (18 treatment providers in total).

Peer support services operate in 173 locations. These are made up of 164 Gamblers Anonymous and 9 GamAnon services. Gamblers Anonymous is peer support for people with gambling problems and GamAnon is peer support for their families.

It’s worth noting that since we mapped the geography of the services, a further 5 NHS adult gambling treatment clinics have opened. Another 3 are expected to open by March 2024.

Most treatment for gambling harm is online or over the phone but most treatment providers offer the option of face-to-face support, except for GamCare South and GamCare South West who do not have space to do so.

There are treatment providers and satellite locations in all English regions except for the East of England, which only has peer support services. Residential services are in the North West (Manchester) and West Midlands (Wolverhampton and Dudley). The West Midlands has a high concentration of treatment providers, with many in or near Birmingham. Treatment services are often located in or near highly densely populated areas (for example Manchester, Liverpool, Newcastle, Sunderland, Leeds and London). But there are areas in most regions that are moderately or highly dense but do not have a treatment provider.

Gambling peer support services, particularly Gamblers Anonymous, are available in more locations than treatment providers. They are also distributed more evenly across England, though many are in London and surrounding boroughs. Across the 153 total upper tier local authorities in England, 35 have at least one treatment provider located in the area and 111 have at least one treatment provider or peer support service.

3.2 Questionnaire responses

Summary of responses

We received completed questionnaires from every treatment provider operational at the time of data collection, totalling 16 responses from:

• 12 third sector gambling community treatment providers: Aquarius, Ara, Beacon Counselling Trust, Breakeven, Derman, GamCare providers, North East Council on Addictions (NECA), Leeds Community Gambling Service (which is a partnership between GamCare and NECA), Krysallis
• 2 NHS specialist gambling treatment providers: NPGS and NGS
• 1 NHS primary care treatment provider: PCGS
• 1 third sector residential gambling treatment provider: Gordon Moody

All answers we received were self-reported. Treatment providers did not provide uniform responses, so it was not possible to compare certain metrics.

Gambling treatment and support offered

All treatment providers said they offer support for people who experience harm from gambling and affected others.

All services open on weekdays between 9am and 5pm with some flexibility for service users such as weekday evening appointments. Breakeven offers weekend support and Gordon Moody operates residential care, which includes 24-hour support for some of its residents. Most services can offer in-person support and some treatment providers said that demand for face-to-face support is increasing and is likely to increase further as we come out of the COVID-19 pandemic.

NPGS has an adult focused service and a young person’s service for those aged 13 to 18. Most other providers offer support to people aged 16 and over except for NGS, Gordon Moody, Derman and NECA who offer support to those aged 18 and over.

Most treatment providers offer support in addition to structured treatment. Some of this support includes training, such as providing:

• gambling harms training to other services or the wider community (Ara, Aquarius, Beacon Counselling Trust, Breakeven, Krysallis, Leeds Community Gambling Service, NECA)
• training and teaching on university programmes (NPGS, NGS)
• primary care training (PCGS)

While individual GamCare treatment providers do not offer training, the GamCare programmes team does.

Other support offered

A number of providers said they provide holistic care, but some providers offer specialist support for other health issues, such as:

• substance use (NPGS, Ara, Aquarius)
• mental health and bereavement from suicide (NPGS, NGS, Ara, Aquarius, Beacon Counselling Trust, Derman)
• Parkinson’s (NECA)
• attention deficit hyperactivity disorder (NGS)
• trauma (NGS)

Some providers also said they offer support for social issues such as:

• homelessness and criminal justice (Ara and Beacon Counselling Trust)
• domestic abuse (Aquarius and Beacon Counselling Trust)

Referrals

All treatment providers said they accepted people who self-referred to their services, with NPGS reporting that most of their referrals were self-referrals. Both NHS specialist clinics (NPGS and NGS) and the PCGS said they received referrals from:

• third sector treatment providers
• GPs
• other healthcare services
• other professional services that the respondents did not define

Third sector treatment providers reported referrals from the National Gambling Helpline and statutory services (for example social care, criminal justice). Other less common referral routes included debt advice services (who refer into GamCare) and community outreach programmes (who refer into Ara).

Established referral pathways between gambling treatment providers and other gambling and non-gambling services were not always present. GamCare has developed a referral pathway document for their services, although it is not used consistently across the GamCare network of providers. Some specific pathways reported by services included:

• third sector treatment providers (Beacon Counselling Trust, NECA, Gordon Moody and Breakeven) referring to individual NHS treatment providers
• third sector providers referring to other third sector providers (Gordon Moody and Breakeven)
• third sector providers referring to mental health and addiction services (Gordon Moody)
• PCGS referring to third sector providers
• general signposting as needed

Time to access treatment

We asked treatment providers about waiting times at their services between:

• point of contact and triage
• triage and assessment
• assessment and treatment start

Some treatment providers reported triaging patients themselves, whereas others said they were triaged by the National Gambling Helpline. Some respondents gave us the time taken to access treatment in the number of days. Other respondents gave a range or an earliest estimate. So, we reported average days where available or the highest value for ranges that were provided. It’s worth noting that some treatment providers did not specify if access times included working days only.

The range between first point of contact with the service, or triage, and accessing treatment was between approximately 4 days (Breakeven) and 54 days (Leeds Community Gambling Service). However, 12 of the 16 treatment providers had a period of 3 weeks or less. Time between contact or triage and accessing treatment was not clearly associated with NHS or third sector treatment providers. We found that:

• NGS and PCGS had access times within 3 weeks
• Leeds Community Gambling Service, NPGS and the residential treatment service Gordon Moody took longer than 4 weeks
• the remaining third sector community providers ranged from within a week to within 4 weeks

Some respondents attributed longer access times to service users choosing to delay assessment or first treatment appointment. All NHS and third sector community providers said they did not have waiting lists. They thought this was due to the flexibility in how they designed their services, such as having staff available on-demand and scaling up staff recruitment when caseloads increased. Similarly, 5 treatment providers, including third sector organisations and the PCGS, said they did not have a maximum capacity due to how they are structured and contract their staff. The residential treatment provider Gordon Moody reported an average of a 100-person waitlist.

Caseloads and staffing

Like access times, data reported by treatment providers on caseloads was not uniform. So, we report a combined measure of either the current service user caseload or the maximum service user caseload treatment providers can accommodate at any given time. If a treatment provider gave information for both measures, we report the higher value.

Current or maximum service user caseloads reported by services at a given time ranged widely, including:

• NHS treatment providers had caseloads of 144 (NPGS) and 340 (NGS)
• PCGS had a caseload of 76
• third sector treatment providers ranged from 9 (Derman) to 304 (Breakeven) - however the second smallest caseload for the third sector was 62 (Gordon Moody)

Aquarius and GamCare London reported service users in their caseload that, although there may be some concern about them, were not actively being seen by a worker. So, the numbers of service users receiving gambling treatment may be lower.

NECA reported a current caseload of 136 service users but only held 25 service user appointments each week. NGS, Gordon Moody and NPGS provided a maximum annual service user caseload which were 450, 264 and 200 respectively.

Treatment provided

We asked treatment providers for information about their staff and treatment they provided, which included:

• occupational qualifications of staff and treatment types
• care for comorbidities
• the number of treatment sessions provided to each person
• support for specific groups and other support provided
• follow-up after treatment

Occupational qualifications and treatment types

NHS treatment providers employ a wide variety of disciplines, including:

• people with clinical expertise, such as GPs, psychiatrists and registered nurses
• mental health professionals who were on a professional registry
• mental health professionals not on a registry
• peer support experts

Gordon Moody, Breakeven, Derman, Krysallis and Beacon Counselling Trust said they employed mental health professionals who were on a professional registry. But this was not consistent among other third sector providers where occupations and minimum qualifications of staff varied.

NHS treatment providers delivered psychologist-led or registered therapist-led CBT and pharmacological interventions where pharmaceutical drugs are used as medication. CBT is a specific, structured psychosocial intervention that aims to help people learn more helpful ways of thinking and reacting in everyday situations (linking their thoughts, actions and feelings) which is why it is reported separately from other psychosocial interventions. Few third sector providers offered CBT.

All third sector treatment providers described delivering brief interventions and structured psychosocial interventions. These interventions ranged broadly in their structure, techniques and practical help to support people achieve their treatment and recovery goals and may involve elements of therapeutic approaches like CBT or motivational interviewing.  

Most NHS and third sector services provided motivational interviewing. Other interventions varied depending on the provider. Examples included:

• general counselling
• group therapy,
• couples or family therapy
• the 5-step model for affected others
• other forms of treatment (including psychodynamic therapy, preparation for change, social behavioural and network therapy)

Gordon Moody offers single-gender residential services, recovery houses and a ‘retreat and counselling’ programme for people who cannot attend residential treatment for whatever reason.

Care for comorbidities

Many treatment providers identified that comorbidities were common among their service users, including:

• mental health issues
• substance use problems
• experience of trauma

NHS treatment providers reported that they deliver treatment for people with complex needs and comorbidities. This is because they had access to staff, like psychiatrists and clinical psychologists. Some providers said they specialise in a particular comorbidity, such as NGS which offers assessment and treatment for attention deficit hyperactivity disorder (ADHD). PCGS and NECA reported providing case management or care co-ordination for service users needing access to a range of different services.

In the third sector, some providers said they would refer service users with complex needs or comorbidities to NHS treatment providers or other services where there are referral pathways. Others offered gambling treatment support to people with comorbidities but then would refer people to other services to meet their needs, such as:

• mental health
• social prescribing
• substance use services
• general practice

Number of treatment sessions

Community treatment providers did not uniformly report the number of treatment sessions service users receive. Also, the GambleAware data reporting framework splits treatment data according to tiers of service received, which is used by third sector providers but not the NPGS or PCGS (Hickman and Chakraborty, 2022).

GamCare East Midlands and GamCare South West provided data, but this was based on part year data as their services opened in 2021 to 2022. These differences prevent meaningful comparisons, so we have not reported the number of sessions.

Support for specific groups

Several treatment providers said they have specialist support to meet the needs of specific groups.

Many providers had support for women available, including:

• Breakeven
• GamCare London
• Gordon Moody
• PCGS

NECA specifically offered support for prisoners who were women and had working relationships with a local women’s centre. Other GamCare locations are developing specific support for women.

Several providers offered language and cultural-specific support to service users. This included offering therapy in languages other than English (Breakeven, Derman and PCGS) with Derman offering gambling support in an existing Turkish-language health and wellbeing service. GamCare providers, Leeds Community Gambling Service and Breakeven offer service users access to an interpreter and NECA has produced leaflets in Mandarin in collaboration with the North East Chinese community.

‘Breaking the Sharam’ is a project offered by Ara and Beacon Counselling Trust that provides culturally sensitive support to people in the South Asian community.

Some treatment providers offered other types of support.

Ara provides support workers to service users to address practical challenges, like debt or legal issues, as well as community engagement work with their local area.

All GamCare providers and the Leeds Community Gambling Service said they provide referrals for and access to debt and financial support.

Beacon Counselling Trust said they provide support for veterans.

Follow-up after treatment

All treatment providers described providing aftercare or contact with service users after their formal treatment.

The most common follow-up schedule with service users was 3, 6 and 9 months after treatment. One provider reported follow-up beginning at one month, another reported follow-up starting at 6 months. Gordon Moody reported outreach recovery workers who follow up with people after they have left treatment but did not specify how often.

Peer support and lived experience engagement

Apart from one treatment provider, all others said they offered some form of peer support to their service users. This was either during treatment or as a part of aftercare and recovery.

Gordon Moody, GamCare providers, PCGS, Leeds Community Gambling Service, Krysallis and Breakeven offer peer support through their collaboration with the charity Betknowmore UK. Gordon Moody, Breakeven and Ara referred people to general mutual aid or other specific peer support groups such as the EPIC Restart Foundation, WhySup and Changes.

Another way services provide peer support is having people with lived experience being involved formally in services. This could include:

• being a peer worker or peer mentor
• supporting staff recruitment
• providing advice about service development
• helping to improve services

Treatment providers that have this type of lived experience engagement include:

• Ara
• Aquarius
• Beacon Counselling Trust
• Breakeven
• GamCare
• Leeds Community Gambling Service
• Gordon Moody
• Krysallis
• NECA
• NGS

3.3 National Gambling Helpline data

National Gambling Helpline

The National Gambling Helpline is a service operated by GamCare that is available across Great Britain by phone and online chat 24 hours a day. It offers:

• advice
• information
• practical tools
• referral to a gambling treatment service

In 2021 to 2022, the National Gambling Helpline received 71,267 total calls or chats. Out of these, 42,070 calls or chats received a brief intervention (a call under 20 minutes offering structured feedback on gambling risks and harms) or extended brief intervention (a motivational session longer than 20 minutes, usually with a scheduled follow up call). Of these calls, 81% were categorised as brief interventions.

Table 1 lists the resources and services that the National Gambling Helpline has signposted callers to. It can signpost a caller to more than one type of support. Also, signposting is only recorded for calls that are logged on GamCare’s case management system so does not include callers who want to remain anonymous. Callers were most often signposted to self-exclusion options, followed by being given advice on blocking software.

Table 1: type and count of resources and services the National Gambling Helpline signposted UK callers to, 2021 to 2022

Category	Signposting type	Count
Gambling harm reduction	Self-exclusion	20,027
Gambling harm reduction	Blocking software	10,303
Information	GamCare’s other services (for example, self-assessment tools, chatroom, website, forum)	8,811
Gambling treatment	GamCare partner treatment services	2,576
Gambling treatment	GamCare’s treatment services (regional treatment)	1,512
Gambling treatment	Other providers within NGSN (including Gordon Moody, PCGS, NHS NGS and NPGS)	214
Gambling treatment	GamCare’s affiliated partners (Isle of Man, Guernsey and Northern Ireland)	24
Peer support	Mutual aid (such as Betknowmore UK, Gamblers Anonymous, GamAnon)	1,636
Financial	Debt management	2,077
Other health and social care	Non-gambling health and social care (GP, housing, other health professionals)	1,868
Other health and social care	External non-gambling counselling and support services (for example, Samaritans, food banks, Cruse bereavement support)	1,152
Other health and social care	Domestic abuse services	142
Other health and social care	Emergency services	132
Other	Commissioners (GambleAware, Gambling Commission)	93
Other	Other	7
Total		50,574

Source: internal data provided by GamCare

Referrals from the National Gambling Helpline to treatment

In the following section, we do not report on referrals to PCGS, NGS or NPGS as the National Gambling Helpline did not provide this information.

In 2021 to 2022, the National Gambling Helpline referred 6,155 people calling from England to a treatment provider based in England. We excluded callers with unknown postcodes from our analysis.

The National Gambling Helpline refers callers to either the nearest treatment provider based on their location or to a provider based on their preference. We do not know how many people went on to access treatment.

Most people calling the National Gambling Helpline who were referred to treatment lived in:

• the South East (1,203)
• the North West (1,045)
• London (1,023)

The East Midlands had the lowest number of referrals (304).

The largest number of referrals went to:

• GamCare London (1,315)
• Beacon Counselling Trust (924)

The fewest number of referrals went to:

• Leeds Community Gambling Service (127)
• Derman (3)

Some regions had a main treatment provider the National Gambling Helpline would refer people to. These were:

• GamCare in London which received 91% of all referrals for London callers
• Beacon Counselling Trust in the North West which received 86% of referrals
• Aquarius in the West Midlands which received 91% of referrals
• NECA in the North East which received 77% of referrals

However, in the South, East of England and the East Midlands, larger proportions of people were referred to different treatment providers. This was often to services in neighbouring regions, including GamCare treatment providers in London, the South, South West and East Midlands and Breakeven.

3.4 Gambling treatment and trend statistics

While we do not have national thresholds of harmful gambling, we do have some understanding of who is showing up to gambling treatment from the NGSN annual reports, which we summarise below.

Notes for interpretation

NGSN reports treatment episodes rather than the number of individual service users receiving treatment. This means that, if during the reporting period a service user attends more than one service, they could be double counted in the figures. In 2021 to 2022, GambleAware estimated the overlap was 1.7%.

Reported figures do not include referrals to the PCGS because this provider was operating as a pilot programme and did not submit data to the GambleAware data reporting framework used to develop NGSN reports.

NGSN annual reports provide 2 indicators that aim to be routinely collected at all appointments and are used to assess the outcomes of treatment, which include the PGSI and the Clinical Outcomes in Routine Evaluation 10 (CORE-10). CORE-10 is a brief questionnaire used to measure common signs of psychological distress and to track treatment progress, with items covering anxiety, depression and risk to self. While these are useful indicators, it’s worth noting that the PGSI was not designed as a clinical outcomes tool. Other than total number of treatment episodes that are reported for England, the 2021 to 2022 reports figures for Great Britain. So, unless specified, figures reported below are for Great Britain and 2021 to 2022.

Referrals

In 2021 to 2022 there were 7,072 episodes of treatment in Great Britain, of which 6,467 were for residents of England (91%). The number of treatment episodes in Great Britain increased between 2015 to 2016 and 2019 to 2020, followed by a decrease that coincided with the COVID-19 pandemic.

Of the people engaging in a treatment episode:

• 57% were referred from the National Gambling Helpline
• 26% self-referred
• 8% were referred from GamCare or partner network member
• around 6% were referred from wider services such as healthcare, social care, criminal justice and debt or finance management

Of treatment episodes where people self-referred, they heard about services through:

• other sources (36%)
• internet searches (30%)
• GamCare’s website (14%)
• a family member or friend (10%)

People in treatment

Most treatment episodes were for people with a gambling problem or for people who reported being at risk of developing a gambling problem (86%). The other treatment episodes were for affected others (14%). The proportion of people being referred to treatment as an affected other has increased from a low of 9% in 2016 to 2017.

Around a quarter (24%) of treatment episodes were service users who had previously received treatment for gambling harm.

Demographics

Most people accessing treatment were men (69%, or 4,881 episodes). On average, men were also younger than women, with a lower median age of 34 years compared to 39 years. The percentage of women accessing treatment has increased from 19% in 2015 to 2016, to 30% in 2021 to 2022 (2,113 episodes). This may reflect an increase in the percentage of women identifying as a gambler (13% compared to 21%, respectively) rather than as an affected other (80% compared to 81%, respectively). There has been less difference between the number of women accessing treatment compared to men in recent years and appears to be the result of less men accessing treatment. For example, the number of men accessing treatment decreased 28% between 2019 to 2020 and 2021 to 2022, while this decrease was only 5% for women over the same period.

The majority of treatment episodes that collected ethnicity information were categorised as white (88% of 6,565 total episodes), which is a slight decrease from 2015 to 2016 (91% of 5,819 total episodes). In 2021 to 2022, the NGSN started collecting data on sexual orientation, and was collected for 52% of episodes (3,701 episodes) that year. Of these, 96% identified as straight or heterosexual.

Gambling history

Of the treatment episodes associated with someone’s own gambling (rather than affected others), people reported a median of 10 years of gambling before coming to treatment.

Treatment engagement

In 2021 to 2022, there were 55,853 total appointments across all treatment episodes. GambleAware’s data reporting framework specification defines an appointment as “a scheduled interaction with a client with the objective of making a contribution to the overall health of the client”.

Appointment purpose was recorded for 78% of appointments (43,822). Of these appointments, over three-quarters were for treatment (78% or 34,295) and nearly a fifth were for assessment (18% or 7,839).

Treatment lasted a median of 10 weeks, with half of all episodes lasting between 6 and 16 weeks. Interventions delivered during appointments included:

• structured psychosocial (58%)
• CBT (19%)
• motivational interviewing (12%)
• other therapies (7%)
• brief advice (4%)

Treatment episodes

Among all treatment episode types recorded in 2021 to 2022, 27% (1,895) continued treatment into the next year while 73% left treatment (5,177). Of those who left, 63% (3,247) completed their scheduled treatment and 30% (1,525) had an unscheduled discontinuation or exit. This is a decrease in unscheduled exits from 35% in 2015 to 2016. For the remaining 7%, other reasons for people leaving treatment included being referred to another service and being discharged following advice and support.

For people referred to gambling treatment services for their own gambling (5,996 episodes), a PGSI score was recorded at earliest assessment for 94% (5,614 episodes). Of this group, 90% (5,039 episodes) reported a score of 8 or more out of a possible 27, indicating problem gambling.

For people leaving treatment who had a PGSI score recorded as they left treatment and at least once during their treatment (4,333 episodes):

• 28% had a score of 8 or more (1,232 episodes)
• 22% had a score of 3 to 7 indicating at moderate risk (942 episodes)
• 22% had a score of 1 to 2 indicating at low risk (954 episodes)
• 28% were assessed as no problem (1,205 episodes)

Between the earliest and latest assessments, people in treatment improved their PGSI score by an average (median) of 12 points.

For all types of treatment episodes that recorded a CORE-10 score at earliest and latest appointment (5,123 episodes):

• 74% experienced an improvement in their score
• 17% reported no change
• 9% reported a worse score

For both PGSI and CORE-10 scores, any improvement was substantially higher for treatment episodes that completed scheduled treatment (92% and 86%, respectively) compared to an unscheduled discontinuation or exit (62% and 53%, respectively).

3.5 Interviews

We conducted 30 interviews with 36 participants.

We identified the following 6 themes with stigma coming up as a cross cutting issue.

Strategic prioritisation of gambling

Participants told us that gambling and addressing gambling-related harm is not a strategic priority nationally or locally when compared to other health areas. They thought that a contributing factor to this was not enough awareness among the public, healthcare professionals and parliamentarians of gambling’s addictive nature and harms. They also said this lack of awareness kept the problem hidden and prevented gambling treatment being prioritised.

Participants thought other reasons for gambling’s low prioritisation included:

• inadequate research on intervention effectiveness and gambling harms
• poor data collection by local services and on service user’s treatment journeys

They went on to say that without data, it was difficult to justify trying to increase funding for treatment provision. Stakeholders believed that increased funding was important for:

• improving capacity
• expanding services and specialty services (for example affected others, ethnic minority groups and the LGBTQ+ community)
• reducing time to access treatment
• offering more types of treatment
• improving staff training and expertise

Some stakeholders thought that more data is required to understand the rates of unscheduled treatment exits, which they believed is an issue for NHS and third sector providers.

Participants noted that progress has been made to increase the strategic prioritisation of gambling treatment and in general as an important area of public health by:

• OHID and DHSC
• NHSE
• some local authorities

Participants pointed to the recent expansion of the gambling treatment system by NHSE as evidence.

Several participants discussed the need for a national cross government strategy to address gambling harm. A lived experience stakeholder discussed the need for local authority gambling strategies. Another suggestion was for a national training co-ordinator role to help prioritise healthcare training and development on gambling-related harms.

Current relations between third sector and NHS treatment providers

Third sector providers discussed having positive relationships with each other and some reported good individual relations with NHS treatment providers. But generally, participants viewed relations between NHS and third sector providers as poor. They thought this resulted in a lack of both strategic and routine co-ordination and communication. Participants also felt the current funding model and perceived conflicts of interest were central to this issue, particularly since NHSE ceased their funding arrangement with GambleAware in March 2022. For context, a funding commitment was made in the NHS Long Term Plan in 2019 to expand the number of NHS run gambling treatment providers.

Several lived experience, NHS and public health stakeholders felt that because gambling causes harm, it is a conflict of interest to take industry money to fund treatment, directly or indirectly. This was because industry profits from these harms, as stated by a lived experience stakeholder. Other stakeholders believed accepting money from industry would negatively influence progress to reduce gambling harm. One participant noted conflict of interest concerns extended to research as some researchers were unwilling to work in this area.

However, some third sector providers felt taking industry money was better than not having services. They also did not view funds distributed by GambleAware as being ‘industry’ funding, so did not believe their services were being influenced by industry. One third sector provider said they would prefer to receive funding from public health bodies, whereas others were less concerned about this.

Some third sector providers said they felt undervalued and unhappy because of NHSE’s public criticism of their services. This perceived criticism related to the funding third sector providers received through voluntary financial contributions from the gambling industry. Some viewed the public criticism as hypocritical of the NHS and reputationally damaging to the third sector, which caused concern that it would prevent people from accessing services when they need them.

Some third sector providers said how hard it was to build working relationships with NHS clinics who limited engaging with the third sector based on their funding. Examples included not:

• referring service users
• attending meetings with the third sector
• responding to formal communications

These relationship issues contributed to a lack of understanding of what each other’s service provides. Most stakeholder groups expressed a need for providers to work together and communicate better to help make system improvements including:

• basic minimum standards for governance
• increased quality assurance
• having clear pathways between treatment providers for service users
• improving experiences for complex service users

Participants thought the current funding model was a barrier to achieving good relations. Views on what would be an acceptable model varied. Some participants were not concerned about funding sources, but others felt any industry funding was inappropriate or supported funding services through general taxation like other health and social care services. In between these views, some participants supported a ring-fenced statutory levy with an independent statutory board to manage the funding. Participants suggested learning about this type of model from the experiences of other countries.

Other recommendations to fix existing relationships included having part of the NHS clinical lead role dedicated to improving relationships or hiring an external mediator to do something similar. Participants thought the NHS, national or local government could develop:

• guidance to help engage industry-funded partners in the current system
• principles for how providers can work together in the future

A stakeholder suggested that improved governance and transparent commissioning processes across third sector providers would help NHS engage with third sector providers and lead to better co-ordinated efforts.

Governance

Lived experience and public health stakeholders felt there was a lack of transparency around commissioning of the third sector treatment providers. They also felt it was inappropriate for commissioning to be non-statutory without a clinical backstop (or independent regulator) like CQC.

One participant said the current regulatory settlements added further complexity by funding services in a way that did not feel systematic. Other participants raised concerns about the quality of gambling treatment, particularly within the third sector, including:

• using non-evidence-based treatments
• differing levels of qualifications among staff
• inconsistent treatment quality between providers
• a lack of service standards
• inadequate recording of outcomes

Some participants thought the current gambling treatment system lacked strategic co-ordination (see ‘Current relations between third sector and NHS treatment providers’) which was:

• reflected by a lack of clarity on how the NHS and third sector systems fit together (impacting referrals and time to access treatment)
• partially a result of disjointed oversight of gambling across national government

There were varying views on who should be accountable for gambling treatment. Several stakeholders said DHSC should be accountable for oversight and standards at a national level. A public health stakeholder felt that directors of public health or integrated care boards specifically should be accountable for commissioning services. A third sector stakeholder said there should be joint strategic commissioning between NHSE and GambleAware.

Several third sector participants said that governance within GambleAware’s commissioning process was improving.

To further improve the system, participants felt aligning commissioning processes between NHS and third sector providers could help:

• establish joint working agreements and data sharing protocols
• develop minimum standards on data collection for treatment
• develop occupational standards

Participants believed the upcoming NICE guideline on harmful gambling would help inform the future model of care and minimum treatment standards.

Access to treatment

Participants said barriers to accessing treatment included:

• stigma
• low public and professional awareness
• unclear treatment pathways
• lack of resources for the treatment of more complex cases

Lived experience stakeholders thought that in general, the public did not see gambling as harmful or a health issue, so gambling harms are stigmatised. They said this resulted in:

• some people feeling too ashamed to seek support
• public and professionals being unaware of available treatment, including initial points of contact like GPs
• issues in social care and criminal justice systems so some people having to find gambling services by themselves

Stakeholders reported that people with complex needs were increasingly presenting to gambling treatment services. They said this caused issues as people with complex needs generally require linked-up support from other services across the wider healthcare system. But the links between the gambling treatment system and these other services were often inadequate. So, this resulted in service users being referred between many different services and experiencing long waits for appropriate support.

Participants said that gambling treatment providers had limited understanding of what services other providers within the system were delivering, and what their referral criteria was to access these services. Some felt that referral decisions were not always centred on patient need and that other factors influenced their decisions, such as the working relationship between providers or financial incentives.

Participants said that limited resources within the gambling treatment system had an effect on the availability of treatment and support for some service users. They saw NHS as the preferred service for service users with a higher PGSI score. But one NHS treatment provider pointed out that the NHS did not have the capacity to see everyone fitting that higher PGSI criteria.

The high demand for NHS treatment providers and third sector residential treatment providers meant that people sometimes had to wait to access treatment. Several third sector stakeholders felt that NHS capacity issues were partly due to some NHS clinics seeing people with all levels of need. They thought NHS clinics should see just the people most severely affected by gambling harm. Some lived experience stakeholders reported accessing private treatment because they could not get the treatment they needed in the NHS or third sector system.

To improve access to treatment, participants supported:

• raising awareness of and training on gambling harm for non-gambling frontline professionals
• giving financial incentives for GPs to screen for gambling harm or integrating gambling into initiatives like Making Every Contact Count
• standardising the triage system so that there is clear referral criteria for accessing treatment
• offering flexibility for service users to choose how they engage with treatment
• having a broader range of services available in each region to better support people accessing treatment, for example offering interventions in-person or remotely and for specific populations
• clarifying the role of the National Gambling Helpline and how well its staff triage and refer callers, and deciding who is best placed to fund and deliver this service

Treatment model

All stakeholder groups highlighted the talented and passionate people working in the gambling treatment system. They said there were good support services available when people could access them, and some lived experience stakeholders indicated that treatment was sometimes lifesaving care.

Other considerations to improve the treatment model were raised by participants. Some said that local commissioning and planning of services should be flexible to meet the different requirements of their community. They wanted treatment to be:

• easy to access
• holistic
• centred on service users’ needs

Lived experience stakeholders wanted there to be more focus and visibility on recovery.

Several participants said increasing professional capacity in the gambling treatment system could help increase the numbers of sessions with service users. More trained professionals could also provide a wider variety of evidence-based treatment options. Some participants told us that CBT, the gold standard treatment for gambling, was not always appropriate for people with additional needs such as ADHD or complex mental health conditions. So, providers needed to offer other treatment options.

One participant suggested learning from the drug and alcohol treatment system about the importance of the first 90 days in recovery and providing aftercare support throughout this time to minimise the risk of relapse. Lived experience stakeholders strongly emphasised the importance of peer support and aftercare as part of a sustainable treatment system. They said this type of support helped address the long-term harms from gambling that could not be fully dealt with in treatment.

NHS stakeholders disagreed about whether their services should only see gambling service users with complex needs or also treat people with lower levels of complexity. They said third sector providers sometimes treated people with complex needs, but they had conflicting opinions on why this was. Some stakeholders wondered whether:

• there was a lack of more appropriate NHS services in some areas
• third sector providers purposefully kept people who really should be referred on

With some exceptions, stakeholders wanted a mixed economy of treatment options provided by the third sector and NHS. They said this approach would maximise service user choice since it would best use the different strengths of the providers.

Stakeholders said that NHS services’ connections with wider local systems, clinical governance and healthcare expertise made them best placed for services users with complex needs. But stakeholders recognised that NHS sometimes had slow response times, which were less suited to help people in crisis and they were viewed as less involved in communities, prevention and recovery work.

Alternatively, stakeholders generally viewed the third sector as not fully equipped to treat service users with complex needs. But stakeholders acknowledged that their quick response times and flexibility was beneficial to supporting people experiencing a crisis, with good links to peer support groups and outreach work in communities.

Treatment as one part of reducing gambling-related harm

While improving gambling treatment provision was seen as important, participants raised other areas of action to prevent and minimise gambling harm, such as:

• improving research
• increasing action on prevention and harm reduction (particularly from lived experience stakeholders)

Participants suggested the need to improve the evidence base through research on:

• intervention effectiveness
• prevalence of harm
• mechanisms of harm
• how harm is experienced in different populations

Some felt this research needed to be independent of industry funding and others said that data from the financial and gambling industries could aid future research.

Lived experience stakeholders said that the treatment system needed to be improved. But they also recognised that we needed to fix the wider issues around gambling harm and stop people needing treatment in the first place. They supported prevention activities to raise awareness of gambling harms, including:

• public health campaigns
• low-risk gambling guidelines
• independent education programmes for children and young people
• training for frontline professionals and community leaders

Lived experience stakeholders felt gambling adverts were unavoidable because of how common they were. They said the pervasive nature of advertising could:

• trigger a relapse for someone in recovery
• normalise gambling to young people which in turn creates new users

So, some participants suggested that regulating marketing could help to reduce the risk of relapse and reduce normalisation. Others felt that a ban or strict regulation of gambling advertising was needed.

Lived experience stakeholders supported improving harm reduction interventions as some felt existing support like self-exclusion schemes were sometimes inadequate. Ideas included:

• regulating gambling product design, such as having maximum stake limits on online slot machines
• mandating affordability checks
• making online searches for gambling support services safe from adverts or links to gambling websites

Lived experience stakeholders wanted increased accountability for the gambling industry, including:

• enhanced industry standards with strengthened obligations to prevent and reduce gambling harms
• mandatory training on gambling harm for all staff attached to licencing conditions
• better identification and referral of people experiencing harms by operators
• compulsory safer gambling tools clearly visible on all gambling websites

One stakeholder wanted increased accountability from the financial industry, with another advocating for mandated delays for people wanting to reverse self-imposed blocks on their accounts using banking tools.

Participants thought prevention and harm reduction interventions were helpful to reducing stigma as well, which is important to increasing access to treatment.

Many participants felt that gambling should be approached with a focus on both treatment and regulation in a similar way to tobacco and alcohol. One stakeholder suggested moving the remit of gambling from the Department for Digital, Culture, Media and Sport (DCMS) to DHSC, as this would be better to make progress from a public health perspective.

3.6 Deep dive case studies

Physical access to gambling treatment providers varied by local authority. When our deep dive process took place, Derbyshire, Gloucestershire and Wakefield did not have a gambling treatment provider locally. But all areas had links to treatment available in nearby regions, though access was sometimes limited to remote-only. Since then, NHS treatment services have opened in Derbyshire and Gloucestershire.

Treatment available for harmful gambling

In all deep dive areas, staff working in non-gambling frontline services were often unaware of the treatment available locally for harmful gambling. Participants in Wakefield said they had never received training on gambling treatment services. Awareness was higher in Sunderland, which has multiple treatment providers. And at least one of the gambling providers reported strong relationships with non-gambling services, for example housing, citizens advice bureau and food banks. However, some of the non-gambling participants were not aware of this local gambling treatment provision.

In all areas except Sunderland, stakeholders were generally unaware of which organisations offered treatment for people experiencing gambling harms. This included not knowing about what the pathways into support were. Some stakeholders were aware of Gamblers Anonymous or GamCare, sometimes from internet searches.

The low awareness of available treatment services among non-gambling frontline services may partially relate to a lack of integration between gambling treatment services and wider healthcare, social care and justice services. For example, in Newham participants reported not receiving referrals into their non-gambling services for additional support from gambling treatment providers.

Working with people experiencing gambling harms

There was a mix of local authority staff who reported working with or meeting people experiencing gambling harm. Derbyshire and Gloucestershire had some services reporting contact with people who could benefit from treatment. And drug and alcohol services staff in Newham reported seeing someone every 4 or 5 months who needed support for harmful gambling. Wakefield was slightly different as more participants reported meeting people experiencing gambling harm through their services. Few non-gambling frontline services reported screening for gambling harms or collecting local data on gambling.

In Gloucestershire, participants from one non-gambling service felt that gambling was not an issue for people accessing their services.

Hidden gambling harms

When gambling harms were discussed, most felt this was a hidden issue. Participants in Derbyshire, Sunderland and Wakefield described secrecy around gambling. Participants in Sunderland said gambling harms remain hidden until “things get bad”. Participants in Wakefield said this hidden harm contributed to people not being referred to support earlier and preventing some of these harms.

In Newham, participants did not explicitly address hidden gambling harms, but they did talk about shame and stigma surrounding gambling issues. Other potential barriers to accessing treatment related to:

• gambling being such a part of the local culture, such as in Sunderland
• cultural beliefs on gambling, such as in Newham

Addressing gambling harms

For participants who meet people experiencing gambling harm, there was little proactive or regular work on gambling harm at a local authority level. One exception was licensing staff in Newham. They told us that gambling harm could be considered as part of their gambling policy and that they could provide information to gambling venues to encourage them to identify people experiencing harm earlier and refer them to support. They also said that prison was a local setting that could use more gambling specific support.

Barriers to take on additional work to address gambling harm included:

• limited resources or lack of staff capacity, particularly if local authorities do not get funding to do this work
• feeling limited in the effect they can have locally for certain gambling issues like online gambling

Raising awareness and training

All areas felt a need to raise awareness and have training about gambling harm for non-gambling treatment frontline staff, particularly around how to have a conversation or ask questions about gambling. They saw this training as important for people in all frontline posts.

Some participants in Sunderland suggested gambling should be part of the Making Every Contact Count e-learning programme. Participants in Newham suggested GPs should receive training to help them identify people experiencing gambling harms.

Participants in one area specifically asked for guidance on whether to refer people to treatment providers that are partly funded by the gambling industry. Many local areas felt they needed advice on where they could refer people for treatment and support, including for specific groups like young people. Some participants asked for self-help and signposting materials.

Participants in Derbyshire supported having national campaigns about gambling harms to raise the public’s awareness as well as having better gambling education in schools.

Commissioning gambling services

Some areas raised the need for locally based gambling treatment services, such as Gloucester.

Other suggestions specific to commissioning included a participant in Sunderland who spoke of the need to have non-industry funded treatment options available.

Participants in Wakefield suggested that adding gambling to drug and alcohol commissioning specifications could help with identifying gambling harms locally.

Cost of living

Some areas were concerned about the current cost of living situation and how this might affect gambling behaviour, such as more people gambling to try and top up their income.

4. Challenges and areas for improvement

We identified clear strengths of the current system, such as:

• a passionate workforce providing helpful services
• an increasing priority of gambling as a public health issue

However, we identified several areas which need improvement, including:

• treatment data collection and reporting
• the structure of the gambling treatment model and referral pathways
• co-ordination in the gambling treatment system
• governance
• awareness of gambling harm and available support
• prioritising gambling harm and treatment
• further research on gambling treatment

We also identified:

• other recommendations by stakeholders
• limitations to the assessment

We will describe the challenges in each area, which were identified from across all data sets. We then describe recommendations made by stakeholders in the interviews and deep dives for how to address these challenges to the gambling treatment system.

4.1 Treatment data collection and reporting

Many stakeholders thought the collection, monitoring and evaluation of gambling treatment data was currently inadequate. We encountered some of these issues in our analysis due to inconsistencies in reporting data in the questionnaire. This made it difficult to compare certain metrics.

Gambling treatment data in the GambleAware data reporting framework reports episodes of treatment only. It does not report the number of individual service users receiving treatment, with estimated levels of double-counting service users at 1.7% in 2021 to 2022. Also, the reporting framework can only provide a partial picture as it does not collect data from all providers, such as PCGS. NHS services have also stopped reporting into the reporting framework as of April 2022. NHSE is currently reviewing its approach to data collection.

Consistent reporting across third sector and NHS treatment providers would give a better understanding of the treatment system. For example, to understand the system’s capacity, they could use standardised metrics such as:

• number of service users and treatment episodes
• number of referrals
• waiting times
• numbers in treatment
• numbers finishing treatment

Any data collection system for gambling treatment should report these metrics and provide clear definitions for all metrics. Currently, the GambleAware data reporting framework reports treatment episodes and some metric definitions, so the data collection system has room for improvement.

An important part of improving future evaluations of the treatment system is longer term monitoring and centralised reporting of service user journeys. This would include analysing the number of people leaving treatment before their scheduled end date. Service users who leave treatment early are less likely to get the full benefit of treatment (Pfund and others, 2021). This is reflected in the 2021 to 2022 NGSN statistics where fewer people who had an unscheduled exit had an improvement in their PGSI or CORE-10 score, compared to people who finished treatment. So, in future, we would want to see more people completing treatment rather than the nearly one-third who left before their treatment was complete in 2021 to 2022.

Developing a clinical outcome measure would also help improve our understanding of service user outcomes. PGSI is a frequently used outcome measure for treatment, but it was not designed for this purpose.

England has an established National Drug Treatment Monitoring System, which provides monthly and annual statistics on a number of important metrics and service user characteristics. This system could be helpful in informing a future gambling treatment monitoring system for all gambling treatment provision.

4.2 Structure of the gambling treatment model and referral pathways

Integrating gambling treatment and other healthcare services

People we interviewed wanted a treatment system that:

• is holistic
• is centred on the service user
• offers a mix of provision because NHS and third sector providers were viewed as having different strengths

There was wide support for better integrating the gambling treatment system with the broader healthcare system, given the perceived levels of complex needs in this treatment population. PHE guidance Better care for people with co-occurring mental health, and alcohol and drug use conditions already encourages commissioners and service providers to work together to improve access to services. Also, commissioning bodies could learn lessons about integrated care from the drug and alcohol treatment system. A number of stakeholders supported a regional service delivery model across providers.

Improving referral pathways

In the deep dive areas, we found many non-gambling frontline staff did not know what support was available, which was confirmed by our interviews with people with lived experience. However, even in the gambling treatment system there appeared to be no standardised referral pathways or referral criteria, which could limit access. Stakeholders commented on how this issue is acute for service users with complex needs.

The questionnaire, National Gambling Helpline data and interviews demonstrated that referral sources were different along treatment provider lines, with NHS providers receiving mostly self-referrals and third sector providers receiving referrals from the National Gambling Helpline. This means that accessing services may not be done in a systematic way based on the level of need and puts unnecessary burden on the service user to navigate the system on their own.

So, stakeholders wanted standardised triage processes to direct people to the right support. Whether standardised triage processes are at a national or regional level requires further exploration.

Stakeholders thought that the role of the National Gambling Helpline was not clear, including whether it should triage service users. They said that commissioning bodies should review and confirm its remit. And if the National Gambling Helpline is suitable to triage potential service users, then minimum standards with clear referral criteria would be required.

OHID commissioned the University of Sheffield to estimate the levels of treatment need for people experiencing harms from gambling. The paper Establishing thresholds for support and treatment for gambling disorder: protocol for an e-Delphi consensus study is published on the Open Science Framework website. This work could be used to help develop clinical thresholds, which would outline what level of gambling harm using a specific measure indicates that a person would benefit from a specific kind of treatment. It could also inform triage and referral processes.

Accessing gambling treatment

It would be helpful to give further consideration for how to reach communities who are less likely to access gambling treatment. The NGSN statistics for 2021 to 2022 shows that most treatment episodes in Great Britain, of which 91% were for residents of England, were for men and people who were white. PHE’s gambling-related harms evidence review found that while problem gambling is lower among women, they are more likely to be affected others. And according to Health Survey for England data, people identifying as white had the lowest relative prevalence of problem gambling compared to other ethnic groups, indicating there may be an under-representation of these groups in the system.

The questionnaire and interviews highlighted some specialist support that was available from individual providers. But more tailored services for under-represented groups could be valuable, as well as more efforts targeting information about existing services to these populations.

Available interventions

Stakeholders describe CBT as the gold standard treatment for gambling. But treatment data shows that providers only delivered CBT in less than a fifth of treatment appointments in 2021 to 2022. This is likely because CBT is mostly only offered by NHS treatment providers, of which there are far fewer than third sector providers. Many third sector providers report using CBT techniques but not full CBT. Commissioning bodies should explore how to increase accessibility of CBT and other effective interventions.

Also, lived experience stakeholders strongly advocated for treatment pathways to include aftercare. Most treatment providers described having access to peer support workers for people in gambling treatment. However, this support is needed after people complete treatment to deal with long term harms resulting from gambling. Evaluation of these initiatives would be beneficial, because these are not currently represented in the research literature (Blank and others, 2021).

4.3 Co-ordination in the gambling treatment system

Stakeholders participating in our assessment thought the co-ordination between gambling services was inadequate. They thought this was a result of:

• structural reasons, such as not having formal mechanisms to enable co-ordination
• generally strained relationships between the third sector and NHS treatment services

These strained relationships related to people’s beliefs on conflicts of interest and how these beliefs have been publicly expressed. Addressing how gambling treatment is funded in England is a core issue to improving the system.

In April 2023, after we conducted this assessment, the government announced the introduction of a statutory levy to fund research, prevention and treatment of gambling-related harms in the gambling reform white paper.

We could learn lessons from other countries that have introduced similar gambling levies, such as New Zealand. This could include looking at how to maximise the efficiency of the scheme and ensure transparent oversight.

Similarly, interviewees and stakeholders in the deep dive areas supported having guidance or principles of engagement for dealing with conflicts of interest, which we could explore using resources available from other settings (Mialon and others, 2020).

Since relationships between third sector and NHS treatment services are difficult, they will need to strengthen these relationships under the new statutory levy funding arrangements. Suggestions included third party mediation or making relationship-building a core part of NHSE’s clinical lead role.

Some stakeholders we interviewed said that there was limited co-ordination on gambling harm between government departments. It may be helpful to further understand issues in this area and identify ways to improve national co-ordination.

4.4 Governance

Concerns around governance structures and the transparency of these structures further contributed to a lack of co-ordination across providers. Stakeholders felt that governance was inadequate, or at least inconsistent, in a range of areas, including:

• accountability
• quality assurance
• monitoring and evaluation
• standards of care
• occupational standards

We also heard that differences in minimum occupational standards between providers have direct implications for the type of interventions a service can offer. For example, only nationally accredited healthcare professionals can deliver CBT and not all third sector providers require those qualifications.

Stakeholders raised concerns about governance along with questions about the quality of treatment. This included using treatment without a strong evidence base and inadequate data monitoring, particularly in third sector provision. The upcoming NICE guideline will provide comprehensive, evidence-based guidance for the effective treatment of harmful gambling.

Other improvements to governance should be explored. This may include implementing independent quality assurance processes for treatment providers, potentially in line with other health and social care services under CQC, as well as formalised joint working and information sharing protocols. Creating occupational standards for staff working in the gambling treatment field would be beneficial.

4.5 Awareness of gambling harm and available support

There was low awareness of gambling harm and available treatment and support among healthcare professionals and other frontline staff who were not gambling specialists. These stakeholders in the deep dive areas also reported that they tend not to screen for gambling.

Some lived experience stakeholders reported that when they did try to seek help, they found low awareness among these professionals, particularly GPs. So, it’s not surprising that only 6% of treatment episodes in 2021 to 2022 were referred from wider health care, social care, criminal justice and debt or finance management services. The amount of referrals from wider health care, social care, criminal justice and other similar sources was much higher for alcohol and drug treatment for the same year. The report Substance misuse treatment for adults: statistics 2021 to 2022 shows that healthcare made up 18% of all referrals to alcohol and drug treatment and 13% came from criminal justice services.

There appeared to be an appetite to learn more about identifying and tackling gambling harm from the services that we spoke to. Lived experience stakeholders were strongly in favour of frontline professionals receiving relevant training on gambling awareness. Related to this, there were suggestions that non-gambling specialist frontline staff should be more active in identifying and screening people experiencing gambling harm, for example integrating gambling into Making Every Contact Count.

Stigma was a clear theme throughout stakeholder interviews and some deep dive areas. Service users felt high levels of shame and often hid issues they were experiencing with gambling. We were told that low awareness of gambling treatment and support by both gamblers and frontline professionals, along with stigma, made accessing treatment difficult. The treatment data showed that people experienced harm for a significant length of time before entering services, a median of 10 years.

4.6 Prioritising gambling harm and treatment

Some stakeholders felt that a combination of a lack of awareness about gambling harms, stigma and a lack of knowledge about gambling treatment means that gambling is not seen as a priority in national and local policy. And that this could have an effect on resource allocation for:

• commissioning
• research
• data gathering
• staffing

For example, few local authority non-gambling frontline services collect gambling data, which may lead to underestimates of gambling-related harms and the level of need for treatment, and a lack of evidence for additional funding. They reported it was difficult to work on gambling without dedicated funding.

The questionnaire showed that 35 of 153 upper tier local authorities in England have a treatment provider in their area, although since the assessment NHSE has opened 7 new clinics. Several lived experience stakeholders reported concerns about cost, despite having access to free treatment. They felt they had to access private treatment because of the lack of support in their area.

Increasing public awareness on gambling harms might help make addressing gambling as a public health issue more of a priority and bring with it increased resources. Stakeholders suggested public health information campaigns to raise awareness. There is a substantial body of knowledge across other health areas like substance use, sexual health, and diet and obesity that campaigns have been effective in increasing knowledge and awareness (Stead and others, 2019).

There is preliminary research from other countries that includes insights from people with lived experience of gambling harm on how to reduce stigma (Miller and Thomas, 2017; Miller and others, 2018). This research could be explored in future stigma-reduction work.

The gambling reform white paper has committed to improving messaging on gambling harm, shifting ownership from industry to DCMS, DHSC and the Gambling Commission.

4.7 Further research on gambling treatment

There is limited research on what interventions reduce gambling harm (Blank and others, 2021). However a Delphi study using expert consensus identified interventions which had the potential to be effective and implementable in a UK context (Regan and others, 2022). Piloting some of these interventions could provide a better understanding on what works in terms of prevention and regulation.

Stakeholders thought that more high quality research would improve gambling treatment and commissioning, and it could be funded by the levy proposed in the gambling reform white paper. They also said that research topics could include:

• evaluating the effectiveness of different gambling treatment
• peer support
• mechanisms of harm
• access to treatment
• how gambling interacts with new innovations like cryptocurrency and virtual environments

4.8 Other recommendations

Many stakeholders felt that to effectively reduce gambling harm and the numbers of people requiring treatment, it was important to have not just a good treatment system but also policy on gambling prevention, harm reduction and regulation.

Specific stakeholder recommendations included:

• exploring if user empowerment tools such as deposit limits should be mandatory or opt-out as default
• updating the licensing regime
• strengthening user consent regarding online gambling marketing
• DHSC and the Gambling Commission developing new lower-risk gambling messaging

4.10 Limitations to the assessment

We were limited in our ability to report certain metrics, due to inconsistencies in how they were recorded and reported. This was due to a combination of our questionnaire using free-text responses rather than pre-selected responses, and gambling treatment providers and commissioning bodies in England not reporting metrics in uniform ways (see ‘Treatment data collection and reporting’).

Interviews were conducted by one person and not transcribed verbatim, but instead were recorded through descriptive notes. We conducted fewer stakeholder interviews with local public health staff and treatment commissioners than with other stakeholder types. This was because there are few treatment commissioners in the gambling area and limited local authority public health staff who have knowledge of the gambling treatment system.

The local authorities selected for deep dives were chosen based on participants who were willing and had capacity to participate. So, they will not be a representative sample of local authorities.

We did not have capacity to analyse England-specific raw data from the National Gambling Treatment Statistics. However 91% of treatment episodes for 2021 to 2022 were for residents of England.

5. Conclusion

In recent years, there has been expansion and improvements made to the gambling treatment system in England. The introduction of a statutory levy to fund research, prevention and treatment announced in the gambling reform white paper offers a further opportunity to redesign the existing system to provide high quality, evidence-based treatment for those experiencing gambling harm.

This assessment set out to understand how the current system functions, where its strengths are, and what can be improved. All of which will provide useful context and evidence for considering the planned changes.

We found that the experience and dedication of staff working in the system are clear, but there are other areas which need development.

Some improvements can be achieved at commissioning and service level, such as a uniform governance process and standardised data collection and reporting. Structural improvements could be made that include:

• addressing the funding model
• integrating with existing services
• providing services that fit the needs of different populations, such as women and ethnic minority groups

Improved relationships and co-ordination in the gambling system are required to develop and implement these improvements.

Mobilising the suggested improvements in this report is an important next step and using a quality improvement methodology could be helpful. However, there are structural issues in the gambling treatment system, and improvements will be difficult to achieve within the treatment system alone. They require increased strategic focus, resource allocation and prevention activity.

6. References

Blank L, Baxter S, Woods HB and Goyder E. Interventions to reduce the public health burden of gambling-related harms: a mapping review. The Lancet Public Health 2021: volume 6, issue 1, pages e50-e63.

Cavanagh S and Chadwick K. Health needs assessments: a practical guide (pdf, 2.2mb). National Institute for Health and Care Excellence (Great Britain), 2005.

Hickman B and Chakraborty B. Analysis of NGTS treatment impact (tier 3 and 4 service users, 2018-2021) (pdf, 1.9mb). GambleAware, 2022.

IFF Research. Primary care gambling service pilot evaluation: final report. Prepared for GambleAware, 2022.

Mialon M, Vandevijvere S, Carriedo-Lutzenkirchen A, Bero L, Gomes F, Petticrew M, McKee M, Stuckler D and Sacks G. Mechanisms for addressing and managing the influence of corporations on public health policy, research and practice: a scoping review. BMJ Open 2020: volume 10, issue 7, article e034082.

Miller H and Thomas S. The “walk of shame”: a qualitative study of the influences of negative stereotyping of problem gambling on gambling attitudes and behaviours. International Journal of Mental Health and Addiction 2017: volume 15, pages 1284-1300.

Miller H, Thomas S and Robinson P. From problem people to addictive products: a qualitative study on rethinking gambling policy from the perspective of lived experience. Harm Reduction Journal 2018: volume 15, article number 16.

Regan M, Smolar M, Burton R, Clarke Z, Sharpe C, Henn C and Marsden J. Policies and interventions to reduce harmful gambling: an international Delphi consensus and implementation rating study. The Lancet Public Health 2022, volume 7, issue 8, pages e705-e717.

Stead M, Angus K, Langley T, Katikireddi SV, Hinds K, Hilton S, Lewis S, Thomas J, Campbell M, Young B and Bauld L. Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence. Public Health Research 2019: volume 7, issue 8.