Inflating the harms of gambling

Ideologically-driven government departments are playing fast and loose with gambling statistics to further their own agenda, argues Dan Waugh.

In January 2023, the Office for Health Improvement and Disparities (OHID) published ‘The economic and social cost of harms associated with gambling in England: Evidence update 2023’. The report was billed as a ‘review and update’ of an earlier set of estimates produced by the now defunct Public Health England (‘PHE’) and claimed that harmful gambling was associated with either £1.05bn or £1.77bn of social and economic costs. It also offered a choice of either 117 or 496 suicides associated with problem gambling.

In a Structured Critique published this month, we show that the OHID ‘review’, produced under the aegis of the Department of Health and Social Care (DHSC), is deeply misleading. It raises four questions of honesty and integrity which we examine here:

Why was the OHID review undertaken?
Was it a review?
Is it accurate?
Is factual accuracy still important in public policy?

Below, we address each of these questions in turn.

Why was the OHID review undertaken?

According to the OHID, the decision to review the PHE cost estimates was ‘a standard approach to previously published reports’ – but this claim stretches credibility for a number of reasons. First, the review was announced by the DHSC on 2nd August 2022, barely ten months after the publication of the PHE report. The idea that the government routinely reviews the work of its agencies at such brief intervals is implausible (or else hints at egregious profligacy). Second, if such reviews are ‘standard’, why was only one report from PHE’s suite of six on gambling harms – the one dealing with economic and social costs – reprised?

It seems far more likely that the review was undertaken because the claims made in the PHE report were demonstrably inaccurate – and people were starting to take notice. On the same day that the Health Minister Maggie Throup announced the review, the DHSC admitted (in response to a request made under the Freedom of Information Act or FOIA) that PHE had made a significant ‘mistake’ in its analysis of data relating to suicide. The DHSC’s decision to review was made at a time when the PHE report was coming under growing scrutiny through Parliamentary Questions, FOIA requests and articles (including on Cieo and in the Racing Post).

One consequence of the ‘review’ is that the PHE report has now been expunged from public record. It has been withdrawn from the government’s website and DHSC officials have stated that they ‘will not be publishing anything further relating to the old report’. In this way, a study released to a fanfare of publicity in September 2021 – with the explicit intention of influencing policy on market regulation – has been quietly removed from view. This suggests that the OHID’s actions were motivated by something other than ‘standard practice’. If the DHSC has been less than honest about the reasons for review, what other deceptions might have been contrived?

Was it a review?

The OHID report claims to be a ‘review and update’ – but is this an accurate description? It is undeniably an update. Where PHE claimed that the ‘annual economic burden of gambling in England’ was £1.27bn, the OHID offers a choice of either £1.05bn or £1.77bn. Every single line item in the cost analysis is altered – in some cases dramatically. Although the OHID neglects to mention the fact, its estimate of direct costs to the government is 36 per cent lower than PHE’s (while total costs – including intangible costs to society – are 20 per cent lower on a like-for-like basis).

Cost calculations are based upon the estimated number of cases of each harm ‘associated with gambling’ (with a unit cost applied to each case). In aggregate, the ‘excess’ cases of harm in the OHID review total around 110,000 individuals (1) (although this is an overstatement as some individuals may be assumed to suffer more than one category of harm) compared with around 267,000 individuals in the PHE report. In other words, the OHID review suggests that 59 per cent fewer people experienced harm in association with problem gambling compared with the PHE report, but assumes that the cost per individual of these harms is more than three times greater.

What is striking when considering the differences between the two sets of estimates is that the OHID’s access to research or data was almost exactly the same as PHE’s. (2) That two DHSC reports, featuring a number of the same researchers and published just 15 months apart, should produce such different estimates requires an explanation – but none is provided. It seems disingenuous to describe the OHID report as a ‘review’ when it contains no critical analysis of PHE’s cost estimates at all. The DHSC has now admitted (in response to FOIA requests) that the PHE estimates (and the suicide estimates in particular) were based on a misunderstanding of gambling disorder diagnostics and mathematically incorrect calculations; but these admissions are nowhere to be found in the OHID ‘review’.

Looked at in this light, the OHID exercise looks rather less like a review and rather more like a cover-up. As documents released under the FOIA reveal, PHE possessed a hidden agenda – to use research ‘to support advocacy and action’ in order to justify tobacco-style controls on betting consumers. In August last year, the same OHID-PHE researchers published a ‘delphi study’ in the Lancet Public Health, recommending a swathe of restrictions – to ban consumers from placing bets during sporting events (in-play betting); to ban them from drinking beer or wine in bingo clubs, casinos and at racecourses; to ban all forms of advertising and sponsorship (including at racecourses); and to raise taxes each year above the rate of inflation (i.e. to extinction).

The study’s most revealing proposal was for the introduction of ‘plain packaging for all gambling products’ – defined as ‘standardised design and packaging for gambling products so that no brands; colours; imagery; corporate logos and trademarks are displayed’. This measure would, for example, require that playing cards could only be printed in black and white; Jacks, Queens and Kings would be overthrown and the suits replaced by a more utilitarian system of classification. In this way, card manufacturers might be required to replace the Queen of Hearts with something plainer, such as ‘12B’ – a truly ‘Heartless’ public health policy.

Is the OHID report accurate?

Given the way in which the DHSC abandoned wholesale the PHE cost analysis, it seems appropriate to adopt a healthily sceptical attitude towards the OHID claims of costs associated with gambling harms. Our 61-page structured critique of the OHD and PHE reports reveals the presence of factual inaccuracies, speculative and unscientific methodologies, basic mathematical errors, subjective bias and issues of questionable governance and integrity. The deeply sensitive issue of suicides ‘associated with problem gambling’ (which represents either 23 per cent or 54 per cent of the total cost estimates; but which also has a salience that cannot be expressed in monetary terms) highlights the nature of these flaws. The OHID estimate of either 117 or 496 excess deaths per year is based on a 2018 study of data from Swedish hospital records, by the researchers, Anna Karlsson and Anders Håkansson. While the study itself is of high quality, OHID’s application of its findings is not.

In short, OHID assumed that people receiving treatment in Swedish hospitals for a wide range of mental health conditions (60 per cent diagnosed with anxiety, 51 per cent with depression, 41 per cent with substance use disorders, 29 per cent with alcohol dependence and so on) and physical health conditions (40 per cent with diseases of the musculosketal system, 31 per cent with diseases of the digestive system, 25 per cent with diseases of the respiratory system etc) face the same health and mortality risks as people in England who may have poor control over gambling behaviour but have no diagnosed psychiatric disorders or physical health problems.

This approach – which ignored explicit warnings from the Swedish researchers whose work OHID co-opted – is speculative at best. It requires the rejection, for example, of the widely accepted view that risk of self-harm is linked to both breadth and severity of disorders. Indeed, the OHID report acknowledges that its approach is open to question. Its decision to proceed is justified solely by reference to the opinion of its ‘expert panel’ – a group of public health researchers convened to provide guidance on difficult matters. There are, however, three major issues with the role of this panel.

OHID fails to mention that at least one member of its expert panel is actively involved in anti-gambling activism (and has lobbied, amongst other things, for mandatory state scrutiny of personal bank accounts as a condition for buying so much as a single lottery ticket).

According to documents released under the FOIA, ‘there was no agenda or papers shared before the meeting or minutes circulated afterwards’ for the expert panel. In other words, the meeting to determine the single most significant, sensitive and contentious issue in the entire report is entirely undocumented. It is difficult to understand how this ‘expert panel’ arrived at a considered opinion under such circumstances. The fact that there is no record of how the decision was made indicates, at best, poor governance.

In September 2022 (i.e. during the OHID ‘review’ period), one member of the expert panel, Dr Henrietta Bowden-Jones directly criticised the PHE-OHID approach, saying ‘we cannot extrapolate from Swedish studies, from Norwegian studies – it doesn’t work’. It is impossible to reconcile this opinion (with which we agree) with the decision of the expert panel.

It is not simply the case that the OHID approach is unscientific or accompanied by slipshod governance; it also appears to be mathematically incorrect. The ‘review’ (unhelpfully and contrary to ministerial pledges) does not contain the actual calculations used to produce the cost estimates – but last month we managed to obtain the relevant figures from the OHID. This new information suggests that the researchers got their sums wrong (again) by overstating age-standardised suicide rates (by as much as 40 per cent in some cases). This is not an isolated gaffe – the estimate of costs associated with homelessness is also overstated by 40 per cent due to mathematical error. These are illustrations of a systemic laxity (or worse) that runs through the entire OHID ‘review’.

Why do so few people care if the OHID review is accurate?

The OHID ‘review and update’ of the social and economic costs associated with problem gambling is – as we document in our Critique – methodologically unsound, demonstrably biased and based on factually and mathematically incorrect assumptions. What is strange is that so few people want to talk about it.

Documents obtained from the Gambling Commission under the FOIA, reveal that the market regulator was highly critical of PHE’s cost estimates, describing claims in relation to suicide as ‘inaccurate’ and ‘not based on reliable data’. For reasons that are unclear, the market regulator suppressed this opinion (which must also apply to the OHID review, given its use of precisely the same data). The Commission has now adopted a position of not commenting on research produced by government departments or other state agencies – a remarkable self-denying ordinance that closes off its ability to include a wide range of studies and statistics in its work (including, for example, the entire output of the Office for National Statistics). Caught between an unwillingness to endorse flawed research and an inability to criticise the DHSC, the Commission has adopted a chilling vow of silence.

Others have been less scrupulous than the Commission. The OHID cost estimates (and particularly the higher of the two suicide figures) have been widely cited in public policy discourse. This is understandable (if not necessarily laudable) where campaigners are concerned; but academic researchers, journalists and parliamentarians should be above such behaviour. It is a simple fact that anyone who has quoted the PHE or OHID figures has either not bothered to scrutinise the manner of their production or does not care much for factual accuracy. Some organisations – the parliamentary group, Peers for Gambling Reform, for example – continue to parrot claims from the PHE report despite its withdrawal.

Perhaps most surprising of all, the gambling industry has (with a handful of exceptions) remained silent. This is illogical. While the PHE-OHID estimates are demonstrably unreliable, they are based on legitimate areas of inquiry. People with gambling disorder are, for example, at elevated risk of self-harm and depression (although the nature of association is complex). In the interests of customer wellbeing, operators should be paying much closer attention to these issues – and at the same time insisting that state-funded research into them is conducted with greater rigour.

‘Scaring the pants off’?

The saga of the OHID-PHE reports on social and economic costs associated with problem gambling is an unedifying one; symptomatic of how the ideology of Critical Social Justice has come to pervade academic research and infiltrate public institutions in this country. Problematic or disordered gambling can involve a range of harmful consequences – and some of these are severe. The manufacturing of spurious cost estimates based on unsound methodologies is unlikely, however, to alleviate these harms – and may, in some cases, make matters worse. That state agencies and government departments should be involved in such enterprises, at the expense of the taxpayer and in pursuit of a hidden ideological agenda, ought to be a matter of concern. As with Isabel Oakeshott’s ‘Lockdown Files’, the absence of outrage (or simple curiosity) about a state department’s attempts to ‘scare the pants’ off the public and policy-makers is perhaps the most worrying aspect of the entire affair.

(1) Corrected for the OHID error in the section on homelessness where excess cases were overstated by around 40% (or c.5,000 individuals).
(2) The one difference is Allami et al.’s meta-analysis, published in November 2021 and which OHID uses in preference to Afifi et al. (2016) when estimating costs associated with depression.

Dan Waugh is a partner at the global strategic sports and leisure advisory firm, Regulus Partners. You can read his full report on The Economic Cost of Gambling-Related Harm in England here.

Photo by Jamie Street on Unsplash.