Part II – Why did public health get things so badly wrong?
n the first in this series of articles, we examined the problems with claims made by state bodies – specifically Public Health England (‘PHE’) and the Office for Health Improvement and Disparities (‘OHID’) that up to 496 deaths by suicide each year in England are associated with ‘problem gambling’. We demonstrated that the basis for these claims is irretrievably flawed. Analysis of the Swedish dataset upon which they rely concluded that “gambling disorder did not appear to be a significant risk factor for the increase in suicide” (Karlsson, 2023). PHE and OHID researchers overlooked critical research findings and clear warnings about the advisability of their approach. While gambling disorder has long been recognised as a risk factor for self-harm, the estimates published by PHE-OHID are categorically unsound.
Read Part One: Lost in Translation?
In this second article in the series, we attempt to understand why PHE and the OHID persisted in following such a clearly problematic approach in the face of strong evidence of its unsuitability; we examine a number of issues of governance; and consider whether officials may have deliberately misled policy-makers and the public.
The Tobacco Road: why did PHE make such unsound claims?
In May 2018, at the conclusion of its review into gaming machines and social responsibility, the British Government’s Department for Culture, Media and Sport asked PHE to “conduct an evidence review of health aspects of gambling-related harm to inform action on prevention and treatment”. More than three years later, in September 2021, PHE responded with the publication of five reports on the subject. One of these reports (‘The economic and social cost of harms’) claimed annual costs of £1.27bn a year associated with ‘problem gambling’ – with roughly 50% attributable to deaths by suicide.
It was this rather speculative document, rather than PHE’s more robust quantitative review of evidence from NHS Health Surveys, that officials chose to emphasise – prompting Britain’s Gambling Commission to surmise that PHE’s goal was, “to ensure gambling is considered as a public health issue.”
The Gambling Commission had already been given a glimpse of what “a public health issue” would entail. In a draft press release (seen by the Commission), PHE officials called for:
“a public health approach to gambling…similar to how we tackle tobacco consumption or unhealthy food consumption…”.
In the summer of 2022, the PHE researchers (now transferred to OHID) spelt out what this tobacco-style offensive would involve. Their paper, published in the Lancet Public Health, contained 81 measures for state intervention in the gambling market. The list included prohibitions on: all gambling advertising and marketing (including at racecourses); all in-play betting; and the sale of wine, beer and spirits in bingo clubs and casinos. It also included limits on the number of people permitted on a website at any one time, annual tax increases above the rate of inflation and even ‘plain packaging’ for all gambling products (no colours, logos or images permitted on playing cards, gaming machines, National Lottery tickets and so on).
There were other indications that PHE’s endeavours were not entirely objective – or morally neutral. In 2020, for example, its project leader stated that “more research is required to support advocacy and action” against gambling – hardly a statement of impartiality or scientific rigour. Meanwhile, documents made available under the Freedom of Information Act (‘FOIA’) reveal that PHE had agreed to be part of a research group set up by the activist charity, Gambling With Lives (‘GwL’) during the review period – an engagement it failed to disclose within its report.
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Why did OHID publish its report…and did officials mislead?
In January 2023, the Department of Health and Social Care (‘DHSC’) withdrew the PHE report and published an updated set of cost estimates – this time in the range of £1.05bn to £1.77bn a year (underpinned by a choice of 117 or 496 deaths). OHID described the decision to review PHE’s work as “a standard approach for previously published reports ”; but this seems to be untrue. The decision to re-examine the PHE cost estimates alone (none of the other four reports was reviewed – despite the presence of errors) was taken in July 2022 and announced to Parliament shortly afterwards. We have found no evidence that reviewing state agency reports within ten months of publication is a “standard approach” or that any such policy exists.
Disclosures made under FOIA reveal the true reason for review. On 26th July 2022, an unnamed DHSC official circulated a memorandum, stating:
“We are going to need to make changes to two of the evidence review reports as an error has been spotted, and as it’s a change to results, its [sic.] probably what you would classify as a major change.”
Given that the PHE report contained quite a few errors, it is difficult to know which particular mistake prompted re-examination; but the decision was certainly not part of a “standard approach”. This raises the possibility that OHID may have deliberately misrepresented the grounds for review.
The Gambling Commission and the Advisory Board for Safer Gambling were both told by OHID researchers that “nothing in the report has changed substantially”; but this is incorrect. In fact, every single line item in the OHID cost estimate differed from the PHE version – in some cases substantially. Its estimate of direct costs to the Government was £234.1m lower than PHE’s – a reduction of more than one-third. This was masked by the introduction of a new area of intangible costs, relating to depression and several revisions to the suicide calculation. OHID’s estimates were also based on a ‘harmed population’ 59% smaller than in PHE. As chart 1 (below) shows, the claim that ‘nothing changed substantially’ appears misleading.
In August 2022, the then Health Minister, Maggie Throup MP advised Parliament that the PHE report would be reviewed and that the calculations underpinning its estimates would be published. The review however, has never been made public and – according to disclosures made under FOIA – no such document is held by the DHSC. Contrary to the minister’s pledge, the PHE calculations have still not been released. To do so would reveal a number of errors, such as the fact that PHE’s suicide figure was based on a 21% over-statement of the population prevalence of ‘problem gambling’.
The mystery of the OHID expert panel
OHID was at least prepared to admit – with a heavy dose of understatement – that its estimates were “uncertain”. It relied on a study of hospital patients in Sweden with a clinical diagnosis of gambling disorder (among many other health issues) to estimate the health risks for people in England with no diagnosed mental or physical health conditions whatsoever. In consequence, OHID leaned heavily on the opinion of its expert panel of health economists and academics who, it is claimed, approved the approach.
There are, however two problems where this opinion is concerned. The first is that one member of the expert panel, Dr Henrietta Bowden-Jones of the NHS had publicly criticised the PHE-OHID methodology. At a fringe meeting of the Conservative Party Conference in September 2022, Dr Bowden-Jones stated: “we cannot extrapolate from Swedish studies, from Norwegian studies – it doesn’t work”.
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The second issue is that the meeting of the expert panel – to discuss the most significant matter in the OHID report – is entirely undocumented. In February 2023, the DHSC admitted that:
“there was no agenda or papers shared before the meeting or minutes circulated afterwards”.
It is difficult to understand how this panel of experts might have been expected to review OHID’s work without access to any documents; and why officials did not consider it necessary to record the panel’s deliberations on this critical point.
Inappropriate behaviour?
The task attempted by PHE-OHID was always going to be challenging, given the dearth of actual data available. This does not explain or excuse the large number of errors and omissions made by researchers and officials:
- PHE and OHID ignored warnings by Karlsson & Håkansson about the representativeness of the sample in the 2018 Swedish study (upon which they relied);
- PHE and OHID ignored findings in the 2018 study of high rates of mental and physical health comorbidities.
- PHE and OHID ignored the follow-up study by the Swedish researchers (Håkansson & Karlsson, 2020), which found that risk of suicide attempt was significantly mediated by the presence of other disorders.
- PHE and OHID ignored the opinion of Dr Anna van der Gaag, chair of the Gambling Commission’s Advisory Board for Safer Gambling, that the PHE calculation was likely to be inaccurate.
A large number of issues with the PHE-OHID reports were brought to the attention of its Director-General, Jonathan Marron in July 2022 and again in September 2023. On both occasions, Mr Marron promised to investigate. Last year, he wrote that he would provide “a proper explanation” for the errors and methodological flaws; but more than seven months later, none has been forthcoming. In what may well be a breach of the Civil Service Code, OHID officials resorted to ad hominem disparagement of their critics – including one national news media outlet – rather than engage constructively.
What is particularly disturbing about the PHE-OHID scandal is not the fact that researchers (presented with an unenviable task) made so many mistakes; but that state officials proved so unwilling to confront them – responding with hostility to legitimate scrutiny.
Next week, in our third article, we will consider the behaviour of others in positions of political or moral authority who variously connived in the deception or turned a blind eye to it. We will reflect on what this means for their future involvement in research and policy-making.
Dan Waugh
May 17th 2024
Regulus Partners
Geoff Banks Online Reports 