Front Line Health and Care Staff
At the very best of times staff on the front line delivering health and care face enormous stresses. During the Covid crisis the stresses have stretched staff to breaking point.
Professional health staff are further faced with bureaucracy, cascades of new initiatives, training and frequently unrealistic demands. Gambling harms and addiction are one example of how services are asked to deal with what are essentially complex social problems as much as health disorders. Similar pressures apply to auxilliary health providers, carers and social workers.
We hope that this site as a whole, even with a quick browse, suggests the scale of harms that can result from gamblling need acknowledgement. This applies too to debt advisors and all citizen advice and support services. The acknowledgement and awareness asks no more for most than to recognise gambling difficulties and where appropriate refer people to the most suitable services. In the case of health staff it will also need to be recognised that health issues such as anxiety, depression and anxiety may be factors in a complex nexus of illness related to gambling.
Problems such as addiction are often not volunteered by patients who may either not accept they have a problem or feel embarrassed and ashamed to talk about it. Doctors now routinely screen for alcohol and drugs problems as do many other services.
Gambling issues are not always – or usually? – so screened.
Health and social care settings are ideal for advertising awareness. Posters in waiting rooms and booklets are useful. For staff, an awareness of the need to screen, refer to appropriate services and consider co-occurring health problems is all that is required.
While much of this page is aimed at GPs and other primary heathcare staff, most of it is relevant to all levels and fields of health and social care support. It should be especially relevant to secondary and tertiary mental health staff.
The call for greater recognition of gambling’s relationship to health is neither new nor rare. A British Medical Association report of 2007 recommended:
• should be aware of the types of gambling and problem gambling, demographic
and cultural differences, and the problems and common co-morbidities associated
with problem gambling.
• should receive education and training, within GP training, in the diagnosis,
appropriate referral and effective treatment of gambling problems.
• should understand the importance of screening patients perceived to be at
increased risk of gambling addiction. They should be aware of the referral and
support services available locally.
In 2010 GP Journal noted:
Problem gamblers experience high rates of physical symptoms (cardiovascular, musculoskeletal, gastrointestinal and other non-specific psychosomatic symptoms) and psychiatric comorbidity (such as depression, anxiety and substance misuse, especially alcohol and tobacco).
Such indirect presentations can result in gambling disorders going unrecognised and unaddressed, resulting in numerous adverse consequences to the patient, family and society….
It is seldom that patients will present to their GP with gambling problems and we do not recommend that GPs routinely screen all their patients for gambling behaviours.
However, it would be worthwhile screening high-risk patients such as those presenting with psychosomatic symptoms, stress-related symptoms and those with psychiatric morbidity.
Patients suffering from depression, anxiety-spectrum disorders and substance misuse (especially alcohol and tobacco) all tend to have higher rates of co-existing problem gambling.
In 2011 British Journal of General Practice discussed the role of GPs in addressing gambling and health, and while acknowledgingg difficulties recommended:
GPs have a crucial role in addressing problem gambling in primary care, both as treatment providers at present and as treatment commissioners in the near future. We hope this paper will help to catalyse further debate among key stakeholders and arouse interest in this largely ‘hidden’ addiction.
Current drives to involve health staff include The Lancet Public Health Commission on Gambling and a growing consensus that gambling be located as an urgent public health issue. A growing number of articles is appearing in journals for doctors and nurses, all in the context of growing public concerns about gambling. There are various initiatives from organisations chiefly funded by the gambling industry to ‘train’ primary care staff
There are also calls from several quarters to integrate gambling disorders with alcohol and drugs services, though this has logistical problems, not least those accruing to training staff and paying for service expansion at a time when addiction services generally are facing defunding.
GROWING FRONTLINE AWARENESS AND SKILLS
Awareness and skills bases are growing among frontline staff. There is a need for them to grow more. This will be achieved and hindered within the following factors:
- Training, awareness and education by health boards, professional journals and associations.
- Growth in general cultural awareness of gambling harms.
- Impact of anti-stigma initiatives.
- Public health and third sector campaigns to provide public with information and assurances of respectful sources of support.
- Health and care staff are all different, real individual people! They work in different settings differentiated by things like geographical community, rates of social deprivation etc. Staff will attend to things relevant to their frameworks of practices, understanding, values and priorities. Calls for attention to gambling harm need to demonstrate the urgency, be illuminating (that is, identifying an area not previously considered), be useful and practical, deliver advice briefly and powerfully. Each place of work will have differing emphases upon and within mental health, and particularly upon addiction. Some, while admitting the importance of gambling treatment provision will feel a need to put existing priorities over importance. Individual staff will each have their own, perhaps unconscious, ideological frames including morality, and possibly be subject to institutionalised stigma around addiction.
Gambling with Lives was set up by bereaved parents whose children completed suicide because of gambling. The organisation states;
Gambling with Lives was set up by the families and friends of young people who have taken their own lives as a direct result of gambling. These were all very normal, bright, popular and happy young folk who had great futures ahead of them … gambling was their only problem. We’re starting to get evidence from neuroscience that gambling on electronic machines affects mental health and even creates suicidal thoughts. Our children had all struggled with their gambling addiction for years, often being clear for many months at a time … but always dragged back in by an industry offering “free bets” and other give-aways. They all felt that they could never break free.
Their site contains excelllently researched papers. It is possible that as many as 600 people a year complete suicide eachc year, many more attempt to, and most consider doing so. This briefing paper focuses on the research. Gambling with Lives announced in March 2021 the setting up of a pilot project to help people in Glasgow.
Screenings, referrals, materials
Articles of Interest
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.  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.
Nursing in Practice
Gambling harms have only recently started to gain much-needed attention as a significant contributor to poor well-being and the ways in which they accentuate inequalities in society. The country is now starting to take this issue more seriously and adopt a public health approach to tackling it. Nurses have an important role to play in helping to identify people who are experiencing gambling harms, respond appropriately and develop care pathways to match individuals to the help that they need.
Gambling disorder is sometimes described as a hidden addiction, as the more visible indicators of intoxication or disintegration common to other addictions are often missing. But it is also hidden in another way. Some forms of gambling, including online, can be done discreetly in the presence of others, who often remain totally unaware of this behaviour and its impacts (poor mental health, relationship problems, and debt can all be indicators of a gambling problem).
See more at Nursing in Practice 29 October 2020
NHS Fighting Back against Gambling Harms
Frankly no company should be setting kids up for addiction by teaching them to gamble on the content of these loot boxes. No firm should sell to children loot box games with this element of chance, so yes those sales should end,’ said Claire Murdoch, National Mental Health Director for the NHS.
Despite the daunting scale of the problem, it does look like the NHS is getting ready to respond properly.
‘Our NHS is fighting back against a rising tide of gambling related ill health as more people than ever before are being egged-on by shameless gambling firms not just to take a chance with their money, but with their health too,’ said Claire Murdoch.
‘While the NHS will always be there for people – adapting, improving and increasing different and new treatments as our patients need them as part of our Long-Term Plan – the gambling industry, which takes upward of £14 billion a year from punters, must take the blame for this increase and ensure a fair amount of its profits help its customers who may suffer from addiction.’
Independent Nurse March 2020
Gambling related harm is no longer in the shadows
We spend significant time as social workers listening to and understanding the issues, traumas and concerns of individuals and families. Sometimes these issues fly under the radar of statutory health and care services.
Gambling addictions are a case in point – not helped by society’s tendency to stigmatise, judge or misinterpret the actions of those who find themselves gripped by them.
These compulsions have multiple causes, cutting across mental and physical health, financial and domestic difficulties and problems in work or education. It makes effective analysis, treatment and support a complex, delicate and nuanced business.
gov.uk blogs, Social Care with Adults 1 March 2019
If We Do Nothing
Gambling, as is now widely accepted, can become a disorder comparable to that of drug or alcohol addiction. Representing a significant public health problem, it should rightly sit within addiction treatment services, both in commissioning and treatment delivery terms.
If we do nothing now, we not only turn away from the needs of nearly half a million Britons living with gambling disorder (and many more carers and family members), but will also ignore a preventable future trend in addiction that we are ill equipped to treat.
Royal College of Psychiatrists 2014 RCP report on gambling addiction
Good primary care networks go beyond health: they are about community
As a GP, I felt a failure. I was frustrated because I could see that Anna was quite typical of many of my patients who could not get joined up care. When the idea of primary care homes came around, I was very interested. This joined up model, where community health trusts, mental health trusts, acute trusts, social care and voluntary organiations come together around the needs of a community, seemed like a practical way to address the gaps in service delivery.
There are four key characteristics that make up primary care homes:
- an integrated workforce, with partnerships spanning primary, secondary and social care
- a focus on personalisation of care and improvements in population health outcomes
- aligned clinical and financial drivers through a unified, capitated budget
- a registered population of between 30,000 and 50,000.
The point on population size is particularly important. A population of between 30,000 and 50,000 works particularly well because of the staff numbers. If there are about 100 to 120 staff then people know each other quite well.
So, in the example of my patient Anna, rather than writing a referral letter to someone anonymous. I could pick up the phone to Rosie the physiotherapist, who I know, working as part of a multidisciplinary team.
Dr Farzana Hussain is a GP at the Project Surgery, Newham and Co-Chair of the National PCN network at the NHS Confederation.
This from 2007. What’s Changed?
Launching the report, the BMA’s head of science and ethics, Vivienne Nathanson said: “Problem gambling is associated with a number of health problems and the BMA is concerned that there are insufficient treatment facilities available. Psychological problems can include anxiety, depression, guilt and suicidal thoughts. There needs to be treatment for problem gambling available on the NHS similar to drug and alcohol services.
“Doctors should be thinking about problem gambling when they see other addictions. They should also link it with other problem behaviours in adolescents, such as truanting. We can’t afford to wait and see if the numbers spiral upwards, as is predicted by every expert in the area.”
The report’s co-author, Mark Griffiths, professor of gambling studies at Nottingham Trent University, said gambling had only been recognised as an addiction since the 1980s.
“GPs routinely ask how much people drink or smoke, and if they take illicit drugs, but they never ask about gambling. Last year’s government white paper on health didn’t even mention it. The NHS as an entity hasn’t recognised gambling as an addiction.”
Guardian 16 January 2007
PRIMARY CARE GAMBLING SERVICE
This service in South London operates an integrated network of support with GPs playing a key role
We are pleased to announce a new service to help you manage patients who have problems with gambling. This new service will be led by Dr Clare Gerada and supported by a multidisciplinary team of mental health nurses, GPs, treatment practitioners and therapists.
The Primary Care Gambling Service is working in partnership with GamCare to provide integrated support services to anyone experiencing gambling harms across South London.