Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice.

Asking about gambling

Why the committee made the recommendations

Recommendations 1.1.2 to 1.1.7

There was no evidence identified on the accuracy of simple (1 to 5 item) tools to identify people experiencing gambling-related harms in non-specialist settings such as primary care. Therefore, the committee made a recommendation for research on asking about gambling.

The committee discussed the barriers to people seeking help, including the stigma that can be associated with experiencing gambling-related harms, the lack of awareness that help is available and how to access it, and people recognising that they have a problem. The committee agreed that it is important to proactively ask about gambling to identify concerns and support people to access help. They discussed that most people are familiar with being asked questions about their smoking status, alcohol consumption and use of other substances when undergoing any health check or holistic assessment. Based on their knowledge and experience, the committee suggested that simple questions about gambling could be added to these routine assessments, which could include GP registrations and health checks in any setting.

There was evidence from several non-gambling specialist settings (for example, prisons, alcohol and substance dependence treatment settings and GP surgeries) that engaging in crime, having substance (particularly cocaine) or alcohol dependence, having mental health problems or concerns, experiencing violence or domestic abuse, having a family history of gambling, and experiencing homelessness may indicate an increased likelihood of gambling that harms. The committee were also aware that people on certain medications may be at increased risk of gambling that harms. The committee agreed that any of these factors should prompt practitioners to ask the person about their own or another person's gambling.

There was some evidence that veterans may be more likely to experience gambling-related harms. Based on their knowledge and experience, the committee were aware that people with some neurological conditions and other occupational groups may also be at increased risk. The committee identified, based on their own experience, that young people leaving home for the first time may be particularly at risk, and so they added this to the recommendations.

The committee noted that a self-assessment tool was already available on the NHS website (based on the Problem Gambling Severity Index [PGSI]) and that people could therefore be encouraged to assess their own level of harm using this tool.

How the recommendations might affect services

These recommendations will increase the number of people being asked about gambling, being identified as experiencing gambling-related harms and directed to sources of support and treatment. The number of people who may need treatment will therefore rise. However, effective early identification and treatment may reduce the number of people experiencing longer term or more serious harm from gambling, which may lead to savings for the NHS, and the wider public sector, including the criminal justice system.

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Referral and triage

Why the committee made the recommendations

Recommendations 1.1.16 to 1.1.19

Based on stakeholder feedback that the guideline needed to include advice to ensure that people were referred to an appropriate treatment or support service, the committee agreed, based on their knowledge and experience, that there would need to be a system of triage. The exact nature of this system of triage will likely be decided as part of the planned reconfiguration of gambling treatment services. The new statutory levy will provide a significant increase in investment for support and treatment services for gambling-related harm. This is likely to result in an increase in the amount of NHS-provided and NHS-commissioned services. The committee also added recommendations, based on their knowledge and experience, to alert professionals and practitioners to the fact that gambling severity can vary over time, and that affected others may benefit from referral too.

How the recommendations might affect services

These recommendations will increase the number of people being directed to sources of support and treatment. The additional time taken for referral and treatment will increase resource use for the NHS, but it will be part of a planned reconfiguration of funding and commissioning of gambling treatment services. However, effective early identification and treatment may reduce the number of people experiencing longer term or more serious harm from gambling, which may lead to savings for the NHS, and the wider public sector, including the criminal justice system.

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Assessment of gambling that harms

Why the committee made the recommendations

Recommendations 1.1.20 to 1.1.23

There was very limited evidence about the accuracy of tools to identify and assess gambling-related harms in people presenting to a gambling treatment service.

There was some evidence that a score of 4 or more on the South Oaks Gambling Screen had sensitivity and specificity both above 90% to identify 'problem gamblers'. However, the committee had concerns about the quality and applicability of the evidence because it came from small studies, some of which did not reflect the age range of most people seeking treatment for gambling in the UK. There was no evidence for the accuracy of the PGSI in people presenting to a gambling treatment service. However, the committee were aware that this is the most commonly used tool in UK practice and the one with which most practitioners providing gambling treatments would be familiar.

The committee agreed that a validated tool to assess severity could be useful, but the lack of evidence meant they could not recommend the use of a specific tool. The committee made a recommendation for research on tools to assess gambling-related harms.

Based on their knowledge and experience, the committee agreed some of the key factors needed to assess the type and severity of a person's gambling in a treatment service, to allow the development of a care plan for that person.

The committee also made a recommendation, based on stakeholder feedback, about types of pharmacological therapy that could be contributing to gambling. Reviewing or optimising this therapy may reduce compulsive behaviour caused by these medicines.

How the recommendations might affect services

These recommendations will increase the number of people being directed to sources of support and treatment. The additional time taken for providing referral and treatment will increase resource use for the NHS, but it will be part of a planned reconfiguration of funding and commissioning of gambling treatment services. However, effective early identification and treatment may reduce the number of people experiencing longer term or more serious harm from gambling, which may lead to savings for the NHS, and the wider public sector, including the criminal justice system.

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Information and support

Recommendations 1.2.1 to 1.2.5

Why the committee made the recommendations

There was qualitative evidence from people experiencing gambling that harms and from affected others about the information and support they valued. The committee used this evidence, in addition to their knowledge and experience, to make recommendations for both groups.

The committee had concerns about the influence of the gambling industry on information provided to people experiencing gambling-related harms. They discussed that information should be unbiased, and agreed a definition of unbiased information in the context of the guideline.

There was evidence from the qualitative reviews on access and what works best, that people who experienced gambling-related harms were not always aware of the addictive nature of gambling and what induced them to gamble. Nor did they understand the different types of gambling and the harm they caused. They may also be unaware of treatment services available to them or how to access them. There was evidence that people experiencing gambling-related harms would like to receive information about sources of support (such as informal support and practical issues). This information would help them understand that the harms they are experiencing due to gambling are not their fault, and that help and support is available to reduce these harms.

People experiencing gambling-related harms welcomed the opportunity to discuss the reasons why they wanted to change their gambling behaviour. They valued information about the potential for recovery and recognised that positive real-life stories of recovery could give them hope, and so encourage them to participate in treatment.

The evidence showed that affected others valued information on how they could help to support the person who was experiencing gambling that harms. However, there was also evidence that they wanted support for themselves, both for practical and emotional issues, and they wanted to know how they could access this help. Evidence also showed that they valued education and general information on gambling that harms to help them understand why the person close to them was gambling.

People experiencing gambling-related harms expressed a preference for accessing information in a variety of ways, including online – such as through apps and social media – as well as in face-to-face consultations. They also valued access to information through other routes in the community. The evidence highlighted the need for information about the risks and harms of gambling and the support available to be more visible and accessible. The committee agreed that it needs to be more widely promoted to raise awareness of the support available. They discussed where people might particularly benefit from being able to access this information, based on their experience, such as through the NHS website and NHS social media, in all health and social care settings, in the criminal justice system, and through other institutions, such as voluntary sector organisations. People also wanted to be able to access this information anonymously, so the committee agreed that service providers should prioritise this to ensure that people felt confident they could safely access information with their identity protected.

How the recommendations might affect services

The recommendations will encourage the NHS to develop systems to deliver information and support to people affected by gambling-related harms. To ensure that unbiased information is used, the NHS may need to develop sources of information, and this will have a resource impact.

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Models of care and service delivery

Recommendations 1.3.1 to 1.3.8

Why the committee made the recommendations

No evidence was identified for this review, so the committee made a recommendation for research on models of care and service delivery. They used their knowledge and experience of current gambling treatment services and other similar treatment pathways (for example, for alcohol and substance dependence, and NHS Talking Therapies) to produce recommendations on how gambling treatment and support services could be organised, commissioned and delivered in the future. The components of the service were also informed by the evidence from other quantitative reviews, as well as the preferences expressed by people experiencing gambling that harms and by affected others, which were reported in the qualitative evidence reviews.

Based on stakeholder feedback, the committee agreed that advice was needed to explain the future likely commissioning arrangements. This included the need to ensure that people were offered the level of support or treatment appropriate to their needs. Details were also needed on the role of specialist gambling clinics and community-based treatment services, and the role of gambling support services. The committee discussed that it was likely, with the planned reconfiguration of services, that the NHS would take over as the commissioner of treatment services, although these could be provided by the NHS or by other organisations (including the voluntary sector). The committee agreed that NHS commissioned services would be likely to be subject to the same clinical governance arrangements as other NHS services. Gambling support services are currently provided mainly by the voluntary sector and it was agreed that this was likely to continue.

The committee agreed that the commissioning and provision of all treatment and support services should be free of influence or conflicts of interest with the gambling industry and that there should be no link between the availability of funding for research, education and treatment and what those services provide. The committee agreed that the planned introduction of a statutory levy on the gambling industry would support this.

Based on their knowledge and experience, the committee made recommendations on what should be considered when commissioning and delivering gambling treatment and support services. They are designed to maximise entry to the service, ensure that people receive an appropriate level of treatment based on the severity of their gambling, increase engagement and optimise outcomes. As some people experiencing gambling-related harms will also have comorbidities and other needs, the committee agreed it was important that services for these comorbidities, including the support provided by local authorities and social care, were coordinated.

The committee agreed that having a range of competent practitioners to deliver these interventions would ensure optimal outcomes for people experiencing gambling-related harms. In addition, collecting standardised data would allow gambling treatment services to be properly evaluated.

How the recommendations might affect services

The recommendations will need revised commissioning arrangements for a range of gambling treatment services. This is likely to have substantial resource implications to reconfigure existing services and transfer staff or services currently provided by other providers into NHS-commissioned services. However, given the high excess costs to the NHS, wider public sector and society associated with gambling that harms (see the context for further details), the costs of NHS-commissioned services may be partly offset by cost savings if people experiencing gambling-related harms are treated and supported effectively.

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Improving access to treatment

Recommendation 1.1.1 and recommendations 1.4.1 to 1.4.8

Why the committee made the recommendations

Qualitative evidence showed that the following issues may discourage people from accessing gambling treatment services: lack of awareness of help available, difficulty with complex systems to access services, fear and stigma, concerns about lack of confidentiality and concerns about having to pay for treatment. So the committee made recommendations for positive actions that could help overcome these barriers.

The committee noted that stigma was a particular issue for people needing treatment. It may be a particular problem for people who gamble (compared with those who have alcohol or substance dependence) because gambling is normalised in society, and often perceived as an acceptable and harmless leisure pursuit. However, professionals and practitioners may not be aware of this, so they added a recommendation to the beginning of the guideline to highlight this issue. There was some evidence that stigma may be worse for some groups of people. These include women, migrants or people who are unfamiliar with NHS systems, and people from cultural backgrounds where gambling is prohibited. Stakeholders also suggested several other groups. The committee agreed that the recommendations should highlight that there were certain categories of people who may face additional stigma but that it was not possible to list all the individual groups.

The evidence also showed that special consideration may be needed when providing treatment services to certain groups to overcome stigma and support access.

There was evidence from women experiencing gambling-related harms, that they were often in a minority in treatment groups with men, and that they would prefer women-only groups. In addition, the committee were aware, based on their knowledge and experience, that people may be more likely to engage with treatment services that were focused on their needs and therefore more relevant to them.

The evidence also suggested that co-locating gambling services with alcohol or substance dependence services can increase stigma and reduce access. The committee agreed that having gambling treatment services available in separate locations might therefore encourage access.

There was also evidence that mental health problems may prevent people from accessing treatment services. The committee agreed that awareness of barriers such as stigma and mental health problems should be highlighted, alongside ways to improve access for people affected by these issues.

Qualitative evidence suggested that access to treatment for gambling-related harms could be improved by making information more widely available (see the recommendations on information and support), increasing signposting to treatment services, and having quicker and simpler pathways to treatment. The committee discussed how systems and pathways to access care could be simplified.

There was no evidence for any interventions to increase access to gambling treatment services and so the committee did not make any recommendations on specific interventions. Instead, they made a recommendation for research on interventions to improve access for under-represented groups.

How the recommendations might affect practice

The recommendations should increase access to and uptake of gambling treatment services, which will increase resource use.

Return to recommendation 1.1.1

Return to recommendations 1.4.1 to 1.4.8

Psychological interventions for gambling that harms

Recommendations 1.5.12 to 1.5.15

Why the committee made the recommendations

There was some evidence that motivational interviewing reduced gambling frequency; however, there was uncertainty around its effectiveness in reducing gambling symptom severity as a standalone intervention. Nevertheless, it was a cost-effective treatment under both an NHS and personal social services and a public sector perspective. An initial session of motivational interviewing was often part of the offered intervention in the included CBT trials. In the committee's experience, motivational interviewing is a useful technique to improve commitment to change and encourage participation for people who are uncertain about having treatment. However, it is unlikely to lead to the behavioural change needed to treat gambling that harms as a standalone intervention.

There was evidence that cognitive behavioural therapy (CBT) was effective and cost-effective for treating gambling that harms. The committee also looked at the differences between group CBT and individual CBT. In the network meta-analysis conducted to inform the guideline, group CBT showed a greater effect versus no treatment compared with the effect of individual CBT versus no treatment, in reducing gambling severity. Individual CBT showed a greater effect versus no treatment in reducing gambling frequency. According to the results of the guideline's economic analysis, group CBT was cost effective under both an NHS and personal social services and a public sector perspective. Individual CBT was also cost effective under a public sector perspective, which was given a higher weight when making recommendations. Group CBT was more cost effective than individual CBT.

The committee recognised there may be situations when a suitable group is not available, group CBT is not suitable for the person, cannot be provided, or there may be some people who prefer individual therapy. Therefore, they recommended that individual therapy be offered in these situations. The committee used information from the evidence on CBT, along with their knowledge and experience, to define how it should be delivered, for example, how many sessions and how many practitioners.

There was some evidence that behavioural therapy was effective and cost effective (under a public sector perspective) but the evidence base was more limited and there was uncertainty around the effectiveness evidence. The committee agreed that including a cognitive component was important because cognitive errors may increase the chances of experiencing gambling that harms, and therefore they decided not to recommend behavioural therapy.

There was limited evidence that individual counselling was cost effective under a public sector perspective but its relative effects versus no treatment in reducing gambling severity were lower than those seen for CBT. In addition, there was high uncertainty around the clinical-effectiveness evidence. The committee therefore agreed not to recommend counselling.

There was limited evidence about the long-term effectiveness of psychological and psychosocial treatments for gambling that harms, including their effectiveness at reducing suicide or self-harm or on recovery capital, and for some treatments known to be effective in other dependence, for example, the 12-step programme and on combination treatments. There was also uncertainty over the effectiveness of treatments for gambling that harms with comorbid conditions or when used in combination. The committee therefore made recommendations for research on the long-term effectiveness of treatments, psychological or psychosocial interventions to reduce symptoms and increase recovery capital, combination treatment, and treatment for people with comorbid conditions.

How the recommendations might affect practice

The recommendations will increase the number of people receiving motivational interviewing and CBT for the treatment of gambling that harms, which will increase resource use.

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Pharmacological treatment of gambling that harms

Recommendations 1.5.16 to 1.5.19

Why the committee made the recommendations

There was some limited evidence for the effectiveness of the opioid-receptor antagonists naltrexone and nalmefene in reducing the severity of gambling. There was also some evidence for the effectiveness of naltrexone in reducing depression and anxiety and improving functional impairment.

The committee agreed, based on the evidence and their knowledge and experience, that naltrexone should be available as a treatment option, even though it is not approved in the UK for this indication. The doses used in the clinical studies were similar to those used in the UK for the approved indication (prevention of relapse in people who were previously dependent on opioids or alcohol). The committee also had clinical experience of naltrexone used at these doses.

The committee discussed the possible use of nalmefene. However, the doses used in the studies had been much higher than those approved for use in the UK (for alcohol dependence) and the committee did not have clinical experience of its use and so they decided not to recommend it in national guidance.

The committee agreed that the evidence was not convincing enough to consider naltrexone for first-line use in people experiencing gambling that harms and that psychological therapies would be the usual first-line treatment. However, they agreed that naltrexone should be an option for people whose gambling had not sufficiently improved or who had had multiple relapses with psychological therapy. Based on their knowledge and experience, the committee agreed that naltrexone should not replace psychological therapy but that psychological therapy should usually be continued when people are started on naltrexone, although this would be an individualised decision. Also, as this is an unlicensed use of naltrexone, a specialist would need to be involved in starting and monitoring treatment, and the committee added details on the monitoring and safety concerns relating to the use of naltrexone. The committee were aware of a national prescribing guideline for naltrexone in gambling disorder, which provided more detailed advice and so included a link to this document.

Because of the lack of evidence for the place of pharmacological treatments in the care pathway or who would benefit most from them, the committee made recommendations for research about their use alone, as combination treatment with psychological therapy, use as combination treatment and use in different subgroups of people.

How the recommendations might affect practice

The recommendations may increase the use of naltrexone to treat gambling that harms, which will increase resource use.

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Relapse and ongoing support

Recommendations 1.6.1 to 1.6.5

Why the committee made the recommendations

There was evidence from the qualitative review on improving gambling treatment services that people valued addressing the risk of relapse as part of treatment. It can be a cause of shame and stigma, and discussing it and planning to reduce it can be helpful. The committee were also aware, based on their knowledge and experience, that relapse, although often part of a recovery pathway, may lead to distress and self-harm or suicide.

There was a very small amount of evidence that individual and group relapse prevention interventions based around stimulus control reduced the number of relapses at certain time points, as well as decreasing gambling severity and anxiety at 12 months. As the evidence was minimal, the committee agreed that they could not recommend this specific intervention for relapse prevention. However, based on their knowledge and experience, they agreed that some groups of people would need additional treatment or support to prevent or treat relapses, and suggested the types of interventions that could be considered.

As there was so little evidence, the committee made a recommendation for research on interventions and approaches for preventing relapse.

How the recommendations might affect practice

The recommendations may increase the number of people who have a discussion about relapse and who are considered for additional treatment. However, this may prevent people from relapsing, so it is likely to be cost saving in the long term.

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Interventions for families and affected others

Recommendations 1.7.1 and 1.7.2

Why the committee made the recommendations

Based on their knowledge and experience, the committee highlighted that affected others were likely to experience gambling-related harms and that the guideline recommendations in several areas applied to them, as well as those experiencing gambling that harms.

There was no evidence from the review of interventions for families and affected others demonstrating the benefit of any particular intervention for families or affected others to reduce gambling-related harms, so the committee made a recommendation for research on reducing gambling-related harms for families and affected others.

There was some evidence (from the qualitative review about what works best or what can be improved in gambling treatment services) that affected others appreciated the opportunity to receive help and advice by themselves or with the person experiencing gambling that harms. They also valued help to communicate with and support the person experiencing gambling that harms and to prioritise their own needs.

How the recommendations might affect practice

The recommendations will reinforce current good practice and improve the standard and uniformity of gambling treatment and support services for families and affected others.

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