There is currently a real opportunity to establish an effective approach to preventing gambling harms, say Jenny Blythe and May Van Schalkwyk

In recent months, some of the now widely adopted online consultation questionnaires for primary care in the UK have started asking patients about personal or indirect exposure to gambling harms as part of their screening questions. A positive response to the question currently signposts the individual to organisations that can offer support and guidance.

This initiative is to be welcomed and is an important step in building greater recognition among the medical community of the harms associated with gambling. By including a screening question on all consultations, it recognises gambling as a potential public health problem—something that organisations such as the Faculty of Public Health and other independent bodies have been calling for—as well as acknowledging the role that primary care has in addressing public health issues. [1] By including reference to wider harms within the survey questions (e.g. asking about being affected by a friend or family member’s gambling), it also recognises the “all-cause harms” related to gambling. By signposting to national organisations that can provide more specialised support and treatment services, the intervention serves to promote recognition about the limited effectiveness of information provision alone as a way of addressing gambling harms.

Until now, capturing data on gambling behaviour has relied upon problem gambling prevalence surveys such as the British Gambling Surveys in 2007 and 2010. [2,3] However, there are limitations in this approach. Prevalence surveys rely upon people disclosing information about a highly stigmatised issue: furthermore, they are unlikely to reach those most at risk of gambling related harms and are poor surrogates for measuring all the diverse gambling harms. Other research has surveyed patients by anonymous questionnaires in GP waiting rooms, but again this makes assumptions about who attends general practices in person, and who would disclose gambling problems using this approach. [4]

Although it is good news that a screening question is being asked more widely, at present it is only being asked routinely via online questionnaires. Therefore this screening method does not capture those who are “digitally excluded” (more likely in older populations, the disabled, the homeless, migrants, and those living in institutions according to the recent reports [5,6]). There is significant overlap in the groups that are digitally excluded and the groups that are at increased risk of gambling related harms. As such, some of our most vulnerable patients who use “land-based” gambling such as bookmakers, arcades, lotteries, bingo and scratchcards as their primary form of gambling access, fall into demographic groups that suffer disproportionate gambling harm, and will not picked up by this current screening intervention. 

With the ongoing review of the Gambling Act 2005 focusing on online gambling by bringing “analogue legislation into the digital age,” the risk is that land-based gambling will not be given full consideration, and as such potentially widen the inequities that both public health and primary care strategies aim to reduce. [7]

Further opportunities to screen for gambling related harms must be sought to complement digital platforms in order to avoid widening of inequities. Possible solutions include: recognising that gambling problems “co-occur” with other mental health conditions, including alcohol and drug misuse. Clinicians could ask about the possibility of gambling problems when patients are reviewed for other mental health issues. Recognising the “all-harms” spectrum of harm caused by gambling, clinicians could ask directly about gambling in consultations when money worries are expressed. Gambling screening questions could be added to the appropriate annual review templates in primary care such as Learning Disability and Mental Health. We need to recognise that gambling problems can be shameful to disclose for those individuals and their families, and offer both support and signposting to the local and national services. With these digital and in-person interventions, and a review of the Gambling Act, there is a real opportunity to establish an effective approach to preventing gambling harms—a reality that in the not too distance future we hope will be reflected in an ever diminishing number of positive responses to these for now much needed screening questions.

National Gambling Helpline: 0808 8020 133

Jenny Blythe, GP and NIHR Doctoral Fellow, London School of Hygiene & Tropical Medicine 

May van Schalkwyk, Specialist Registrar Public Health, NIHR Doctoral Research Fellow, London School of Hygiene & Tropical Medicine 

Competing interests: JB is an independent researcher, based at LSHTM, funded by the NIHR ARC North Thames. She is also a Salaried GP at a practice that uses an online consultation platform that asks a screening question about gambling harms. 

MvS is funded by the National Institute for Health Research (NIHR) Doctoral Fellowship (NIHR3000156) and her research is also partially supported by the NIHR Applied Research Collaboration North Thames.

The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. 

References:

1. Faculty of Public Health (2018). Faculty of Public Health Gambling Policy Statement (online). Available: https://www.fph.org.uk/media/1810/fph-gambling-position-statement-june-2018.pdf (Accessed 27/5/21)
2. National Centre for Social Research. (2008). British Gambling Prevalence Survey, 2007. [data collection]. UK Data Service. SN: 5836, http://doi.org/10.5255/UKDA-SN-5836-1
3. Wardle H., Moody A., Spence S., Orford J., Volberg R., Jotangia D., Griffiths M., Hussey D., Dobbie F. (2011). British Gambling Prevalence Survey 2010. London, United Kingdom: The Stationery Office.
4. Cowlishaw S, Gale L, Gregory A, McCambridge J, Kessler D (2017). Gambling problems among patients in primary care: a cross-sectional study of general practices. British Journal of General Practice;  67 (657): e274-e279. https://doi.org/10.3399/bjgp17X689905
5. Office of National Statistics (2019). Exploring the UK’s digital divide (online). Available: https://www.ons.gov.uk/peoplepopulationandcommunity/householdcharacteristics/homeinternetandsocialmediausage/articles/exploringtheuksdigitaldivide/2019-03-04 (Accessed 27/5/21)
6. Doctors of the World (2020). A Rapid Needs Assessment of Excluded People in England During the 2020 COVID-19 Pandemic (online). Available: https://www.doctorsoftheworld.org.uk/wp-content/uploads/2020/06/covid-full-rna-report.pdf (Accessed 27/5/21).
7. APPG (2020). Gambling related harm (online). Available: http://www.grh-appg.com/ (Accessed 27/5/21)