Policy Research Programme - The feasibility of routine screening for gambling-related harm within mental health and drug and alcohol services

Timetable and Budget

Description	Deadline/Limit
Deadline for Stage 1 Applications	04 October 2022, 1 PM
Notification of outcome of Stage 1 Application	December 2022
Deadline for Stage 2 application	24 January 2023, 1 PM
Notification of outcome of Stage 2 Application	June 2023
Project Start	June 2023
Project Duration	18-24 Months
Budget	£250,000 to £500,000

Introduction 

The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for a single research project to look at the feasibility of routine screening for gambling-related harm within mental health and drug and alcohol services. 

Screening for harmful gambling (see The PHE gambling related harms evidence review glossary) in healthcare settings has the potential to improve early intervention through access to effective treatment and support, an area identified as a concern in a recent Section 28 Coroner’s Prevention of Future Deaths Report, following the inquest into the death of Jack Ritchie (1).

The Office of Health Improvement and Disparities (OHID) is committed to ensuring those impacted by gambling-related harm are able to access appropriate advice, support and/or treatment in a timely manner. This will be an opportunity to assess the feasibility of strengthening identification of those experiencing gambling-related harm and to support the development of robust referral pathways. 

Background

In England, 0.5% of people (approximately 245,600 people) experience problem gambling and a further 3.8% (approximately 1.8 million people) are gambling at levels of increased risk (2). There is currently limited screening and access to services for harmful gambling throughout England. In 2020-21, 7,726 people accessed specialist gambling treatment, representing just 3% of people experiencing problem gambling (3), indicating that the majority of people experiencing problems are not being adequately identified and then referred through to services.

In England, during 2020/21, 275,896 adults were in contact with drug and alcohol services (4) and around 1.46 million people were referred to Improving Access to Psychological Therapies (IAPT), 1.02 million of whom entered treatment (5). 

The PHE evidence review on  gambling-related harms (2) analysed Health Survey for England (HSE) data which showed that the risk of gambling-related harm is associated with psychological health. People describing poorer psychological health (i.e. those scoring 4 or more on the short general health questionnaire - GHQ-12) had the highest prevalence of gambling at increased risk (5.1%) and problem gambling (1.4%), while those scoring 0 (no evidence of probable mental ill health) had the lowest prevalence of at risk gambling (3.0%) and problem gambling (0.3%). 

Similarly, there was a clear pattern of  gambling risk increasing as the number of alcohol units consumed per week also increased; with 10.0% of people who consume over 50 units a week gambling at increased levels of risk and 1.4% experiencing problem gambling, compared to 1.6% of non-drinkers gambling at-risk and 0.5% experiencing problem gambling (2).

Given the overlap between harmful gambling and mental health issues (6-8), and harmful gambling and harmful alcohol and drug use (6, 9), screening people accessing mental health and drug and alcohol services for harmful gambling may represent a major opportunity for effective identification and treatment of those most in need. Community mental health and drug and alcohol services are likely well placed to identify people experiencing gambling-related harm and are settings where either referral or first-level interventions can occur.

There is currently no standardised screening assessment for harmful gambling routinely employed across healthcare services. This creates a barrier to the provision of early intervention and harm minimisation activities, as well as to onward referral for treatment, where this is appropriate. This could be addressed with the introduction of screening. 

Screening for gambling-related harm is a topic which has received little attention, however there is currently some research underway to identify a gambling ‘trigger question’ for adult social care (10). There is a substantial body of literature which has looked at the feasibility of screening for alcohol use in a variety of settings including primary care (11, 12) and emergency departments (13), as well as for tobacco use (14) which can provide important insights for screening for harmful gambling.

Research priorities

The overarching need is for research to facilitate understanding of the appropriateness of mental health services and drug and alcohol services in England for identifying,referring, and treating people experiencing harmful gambling.

There are 2 broad groups of questions:

• Is it feasible and acceptable to introduce gambling screening in these settings? What factors may influence the successful implementation of gambling screening, and subsequent referral, in these settings? That is, what is likely to be the most appropriate and effective way to screen for harmful gambling, and refer people experiencing gambling-related harm for treatment and support?

• Is screening in these settings likely to identify substantial proportions of people who would benefit from treatment and support (i.e. people experiencing harmful gambling)? 

Understanding the views of those working within and using mental health/ drug and alcohol services on the feasibility of, and their attitudes towards, screening for gambling-related harms within these services.

We are interested in understanding the views of service staff and service users regarding the appropriateness and feasibility of screening for harmful gambling in community mental health services and in drug and alcohol services. Compared to drug and alcohol services, there is greater diversity in the delivery of mental health services. We are, therefore, interested in identifying which setting types (e.g. IAPT, Community Mental Health Teams) are most appropriate for the introduction of gambling screening. 

Research may consider issues such as, but not limited to, staff attitudes, service user attitudes, referral pathways, and how screening for harmful gambling may fit with other screening that services undertake. Qualitative methods may be most appropriate for this.

The research will explore factors likely to influence the success of screening for harmful gambling, that is, the likely barriers to, and facilitators of, the successful implementation of such screening in these settings. This may be factors relating to the screening tool, service users, service staff, the setting, or other relevant influences. It may also explore which of these factors are specific to individual settings, and which are common across several mental health service and/or drug and alcohol service settings. It will explore potential issues with      the screening itself, and with the onward referral to treatment. 

Previous studies have suggested that common facilitators to implementing alcohol screening and brief intervention were knowledge and positive beliefs regarding the intervention, while barriers often related to cost of implementation and lack of self-efficacy (12). GPs perceived a lack of training, support and busyness as barriers to engaging in the prevention and management of alcohol problems (15). Lack of training, and therefore having to rely on individual experience, was also identified as a barrier to developing a mental health screening tool and referral pathway in individuals with mental health issues in police custody (16).  

Piloting the introduction of screening for harmful gambling

A pilot study will further explore the feasibility of introducing screening for harmful gambling, and produce indicative figures for the proportions of:

1. users of mental health services experiencing harmful gambling
2. users of drug and alcohol services experiencing harmful gambling 

Researchers are required to identify the most appropriate screening tool for these purposes.

The pilot will test feasibility and collect data in a range of service sizes, configurations, geographic locations (including areas which represent the north and south of England, urban and rural areas, and areas of higher and lower disadvantage) to reflect the breadth of services across England. 

Applicants will need to justify the suitability of their chosen methodology, including their data collection methodology and sample design, for producing insights into the feasibility of screening, which include assessments of the scale of harmful gambling likely to be identified across these settings.

New Guidance on Health Inequalities data collection within NIHR PRP Research: 

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data, if appropriate for the research. Our goal is to collect information on health inequalities in research and data relating to the main outcome(s) of the proposed research. Please clearly identify in this section whether or not your application has a health inequalities component or relevance to health inequalities and detail the core set of health inequalities breakdowns that will be reported; if none please explain why. We understand that research projects have different methodologies and focus on different populations, so please explain what data will be collected and reported for the methodology you plan to use. If a health inequalities component is not included, please explain why this does not fit within your proposed research. This should only be a few sentences.

For quantitative research we would ideally like researchers to provide one-way breakdowns of their main outcome(s) by the following equity-relevant variables: age, sex, gender, disability, region, 5 ONS Ethnic groups, and the 5 IMD quintile groups. If more detailed cross tabulations are appropriate, please include these. This table should be submitted to NIHR PRP at the end of the project. Due to data limitations, judgement calls may be necessary about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgement calls yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies.  More details and an example table can be found in Appendix A. 

For qualitative research projects, this can be purely descriptive statistics giving the number of observations against the various variables.

Further details about this new request can be found in Appendix A. 

We will also be holding a Health Inequalities in NIHR PRP Research Q&A Event on 19 September 2022, more details in APPENDIX B. 

Areas out of scope for this programme of work 

The project is looking at the feasibility of routine screening for gambling-related harm within mental health and drug and alcohol services only. Other settings where gambling screening may be appropriate have been considered, however, at this stage the feasibility of screening needs to be tested in the areas where there is significant overlap with gambling-related harm.

Technical requirements

The research team applying requires expertise in both quantitative methods and qualitative methods to be able to undertake this project.

The process of this project should be open and transparent by sharing information on objectives, protocol, timetable, and reporting with stakeholders and the general population, where appropriate. 

NIHR is a signatory of the Concordat to Support Research Integrity. Researchers must declare, and act accordingly to manage, conflicts of interest. Applicants are required to demonstrate the independence of their research from influence by, or interaction with, the gambling or alcohol industry (please see PHE’s definition of unhealthy commodity industry stakeholders for more detail).

Outputs 

Technical reports detailing the findings from the project should be delivered in two stages, as detailed below. We encourage applicants to pre-register their study, to make their data openly available, and to aim for peer-reviewed publications as an output of this piece of work. 

Stage 1: Qualitative insights, using methods such as interviews, focus groups, or other creative methods, from service providers and users within mental health and drug and alcohol services. We are interested in the suitability of and attitudes towards, routine screening for harmful gambling. This should capture the opinions of a diverse range of service users and clinicians to ensure coverage of groups who may have differing perspectives. A range of service types (i.e. IAPT, CMHT, community drug and alcohol settings) should be included to help us understand the appropriateness of screening in different settings. To be reported within 6-12 months of start date.

Stage 2: Reporting on pilot study, which includes indicative figures on the proportions of users of mental health services and drug and alcohol services experiencing harmful gambling. This should include the settings determined at stage one and include a range of geographies to be representative of England. To be reported within 18-24 months of start date.

A set of recommendations which include:

• Guidance on the suitability of implementing routine screening within different mental health and drug and alcohol settings
• Considerations on the design and implementation of a proposed screening intervention to ensure this can be introduced to have maximum effect
• Barriers or difficulties in introducing screening in these settings and potential mitigations to these difficulties     
• How screening for harmful gambling could sit alongside existing screening which takes place in mental health and drug and alcohol services, such as ASSIST-Lite screening in mental health services (18)

Applicants are asked to consider the timing and nature of deliverables in their proposals. Policymakers will need research evidence to meet key policy decisions and timescales, so resource needs to be flexible to meet these needs. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting. 

Budget and duration

The budget for this project is between £250,00 - £500,000.

The duration for this project is 18 – 24 months. 

Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning panel members will assess applications against.

Management arrangements

A research advisory group which may include representatives of DHSC and OHID, other stakeholders with expertise in gambling, mental health and drug and alcohol treatment, people with lived experience of gambling-related harm, and the successful applicants for the research, should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:

• Provide regular feedback on progress

• Produce timely reports to the advisory group

• Produce a final report for sign off

Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

References and key documents

1. Jack Ritchie (2022). Prevention of future deaths report. [Accessed August 2022]
2. Public Health England (2021). Gambling-related harms evidence review. Quantitative analysis of gambling involvement and gambling-related harms among the general population in England. [Accessed August 2022]
3. GambleAware (2021). Annual Statistics from the National Gambling Treatment Service 1st April 2020 to 31st March 2021. [Accessed August 2022]
4. Office for Health Improvement and Disparities (2021). Adult substance misuse treatment statistics 2020 to 2021: report. [Accessed August 2022]
5. Baker C (2021). Mental health statistics: prevalence, services and funding in England. [Accessed August 2022]
6. Afifi TO, Nicholson R, Martins SS, Sareen J (2016). A Longitudinal Study of the Temporal Relation Between Problem Gambling and Mental and Substance Use Disorders Among Young Adults. Can J Psychiat. 2016;61(2):102-11. [Accessed August 2022]
7. Scholes-Balog KE, Hemphill SA (2012). Relationships Between Online Gambling, Mental Health, and Substance Use: A Review. Cyberpsych Beh Soc N. 2012;15(12):688-92. [Accessed August 2022]
8. Pavarin RM, Fioritti A, Marani S, Gambini D, Turino E, Piazza A. Who Are the Subjects with Gambling-Related Problems Requiring Treatment? A Study in Northern Italy. J Clin Med. 2018;7(4). [Accessed August 2022]
9. Cowlishaw S, Merkouris S, Chapman A, Radermacher H (2014). Pathological and problem gambling in substance use treatment: A systematic review and meta-analysis. J Subst Abuse Treat. 2014;46(2):98-105. [Accessed August 2022]
10. Caroline Norrie EF, Wardle, Shearer, Bramley, Anna Hemmings, Jill Manthorpe (2021). Can a 'trigger' question to identify gambling harms to individuals or affected others be validated and used in three local authority (LA) Adult services departments (ASDs)? NIHR Funding and Awards 2021. [Accessed August 2022]
11. Kaner EFS, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Db Syst Rev. 2018(2). [Accessed August 2022]
12. Chan PSF, Fang Y, Wong MCS, Huang JJ, Wang ZX, Yeoh EK (2021). Using Consolidated Framework for Implementation Research to investigate facilitators and barriers of implementing alcohol screening and brief intervention among primary care health professionals: a systematic review. Implement Sci. 2021;16(1). [Accessed August 2022]
13. Drummond C, Coulton S, Bland M, Cassidy P, Crawford M, Dale V, et al (2014). The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial. Plos One. 2014;9(6). [Accessed August 2022]
14. Spaducci G, Richardson S, McNeill A, Pritchard M, Sanyal J, Healey A, et al (2020). An observational study of system-level changes to improve the recording of very brief advice for smoking cessation in an inpatient mental health setting. BMC Public Health. 2020;20(1). [Accessed August 2022]
15. Wilson GB, Lock CA, Heather N, Cassidy P, Christie MM, Kaner EF (2011). Intervention against Excessive Alcohol Consumption in Primary Health Care: A Survey of GPs' Attitudes and Practices in England 10 Years On. Alcohol Alcoholism. 2011;46(5):570-7. [Accessed August 2022]
16. Noga HL, Walsh ECL, Shaw JJ, Senior J (2015). The development of a mental health screening tool and referral pathway for police custody. Eur J Public Health. 2015;25(2):237-42. [Accessed August 2022]

Appendix A: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk. 

Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.  

For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group. 

For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.

We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used. 

We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section. 

* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.

** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.

*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.

Example data table for submission at the end of the funded research project

(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.

Variable	Outcome (an appropriate average for this subgroup, usually the mean)	Number of observations	Additional information about variation if appropriate, e.g. range, standard deviation
Age	-	-	-
Sex	-	-	-
Gender	-	-	-
Disability	-	-	-
Ethnic Group	-	-	-
IMD Group	-	-	-
Region	-	-	-

Appendix B: Health Inequalities in NIHR PRP Research Q&A Event

This event will take place on Monday, 19 September 2022 from 2:00 - 3:00pm. There will be a discussion from the NIHR PRP, the Department of Health and Social Care and other panellists followed by the opportunity for a Q&A session to help applicants navigate this new request. Please register for the event using the registration form for the event. Any questions that are not answered during the session will be anonymously answered and published in a FAQ document on the health inequalities webpage.