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Winning Post: Gambling Review split by the two voices of Public Health

Regulus Partners dissects the recommendations and musings of an open letter authored by the Association of Directors of Public Health (ADPH) to DCMS, in which the organisation has provided conflicting guidance on how to establish a balanced public health approach to treat gambling harms…

The threat to licensed gambling in Great Britain was set out in stark terms this week in an open letter from the Association of Directors of Public Health (ADPH) to the minister in charge of the Gambling Act Review, Chris Philp MP. Its recommendations included the outlawing of gambling products and marketing; and the marginalisation of gambling as an adult consumer activity.

The letter was co-written by Greg Fell of the ADPH and Professor Maggie Rae of the Faculty of Public Health – and this co-authorship may explain why it appears to speak with two distinct ‘voices’. The first of these voices is intelligent and reasonable, capable of taking public policy discourse on gambling on a rare excursion beyond the intellectual shallows.

The second is the voice of authoritarianism and intolerance, determined to close down all debate in order to impose the will of ‘Public Health’. The letter shifts back and forth between these two competing monologues. While tempting, it would be a mistake to dismiss the missive on the basis of the manifest illiberalism of Voice 2; or to assume that its anti-business invective would make it unappealing to a Conservative government.

Fell and/or Rae are particularly insightful on the subject of a proposed ‘safer gambling’ levy, pointing out that the imposition of a mandatory or statutory levy risks deepening the reliance on industry of those involved in harm prevention. They write that “acceptance of gambling proceeds also leads to a situation where government and other organisations become dependent on the gambling industry, creating conflicts of interest that undermine policymaking and taking action to prevent harms as such action threatens this funding stream”.

In other words, organisations in receipt of funding inextricably linked to industry revenue might cease to be neutral on matters of market regulation precisely because they would have skin in the game. In such circumstances any support for greater market restrictions might be self-harming – unless of course the levy rate were to increase as its base dwindled (something that levy proponents have been at pains to deny).

For Fell & Rae, the entire point of a levy should be a reduction in gambling activity, whether achieved via behavioural change of consumers for whom gambling becomes too expensive (the authors acknowledge the inherent challenges to this logic), disinvestment by licensed operators as margins tighten or increased funding for public health initiatives designed to curb wagering. They argue that “if there isn’t a fall in [industry] profits then it might be assumed we aren’t reducing harm”. Taken at face value, this betokens a belief that population-level controls would force ‘harmed’ or vulnerable consumers out of the market first (a questionable proposition); and implies that profits must be put on a trajectory of terminal decline (on the basis that continued improvements in harm prevention must always be accompanied by margin squeeze).

This is prohibition by degrees – the authors later argue that “comprehensive approaches to improve public health impact” similar to those used with tobacco are required – but at least the authors are honest about their motivations. The letter rightly observes that for all the puff-talk about ‘a public health approach’, “this has still not yet translated into a coherent public health strategy” or indeed any cogent, joined-up attempt to tackle gambling harms.

It correctly identifies a paucity of governance in relation to “funding and delivery systems” (the most egregious example of which, we might add, has been the Gambling Commission’s ‘no strings attached’ largesse with £40m of ‘voluntary settlements’ in the last three years).

In a refreshing twist, the authors acknowledge that “the picture of gambling harms is complex” and set forth a reasoned case for a “framework of policies” including “limiting availability (including location, opening hours, and age restrictions) and marketing (including advertising, sponsorship, product design, placement, price and other promotions); providing information that is understandable, effective and covers all forms of gambling; and providing treatment services that are evidence-based, and independent”. They make valid observations about the expansion of “24/7 access to gambling” and other issues that have been insufficiently addressed to date. In short, the letter offers valuable insights in a number of critical areas of policy.

In other places however, Fell & Rae descend into anti-business demagoguery, replete with unsubstantiated allegations, hyperbole and highly controversial views dressed up as self-evident statements of fact. “Society”, we are told “should not be subjected to the marketing strategies of the gambling industry”; and “any person who gambles should be safe from preventable harm regardless of their ability to protect themselves” (a statement that relies heavily on how “preventable harm” is translated). The language is likely to be seductive to those of a particular moralistic bent – but what this means is the gradual eradication of betting and gaming as legal pastimes. In recent years, we have grown only too accustomed to public health’s presumptions of what is good for society.

At one point, there is a grudging acknowledgment that “there may be some instances when some people enjoy engaging with certain gambling products” but this is later countered by the suggestion that gambling may be harmful even if “people do it in a responsible way and for the right reasons”. It seems probable that even token acceptance of consumer enjoyment will in time be excised from the public health narrative.

Fell & Rae attack, without providing substantiation, the corrosive influence of licensed gambling operators on policy development and argue for the near-exclusion of licensees from any discussion of how the law should treat them or their customers. Predictably, it is in the area of research that this antipathy to business is most pronounced. We are told that the “industry has shown it does not act in a socially responsible way or respect high standards of evidence use”; and operators stand accused of “misuse and misrepresentation of evidence and the distortion of the scientific process”. No examples are provided to back up such claims – or at least none that extend beyond the behaviour of ‘Big Tobacco’; but substantiation is redundant where carefully nurtured articles of faith are concerned. Such declamations make what come next appear staggeringly hypocritical – but in recent years, we have become acclimatised to the chutzpah of public health.

For it is at this point that Fell & Rae share their definition of evidence-based policymaking. “Being evidence-led” they write, “involves (1) having a vision and set of values and principles that evidence can support on realising, and (2) a joined-up approach to gather this evidence…”. In other words, evidence-gathering is not an objective exercise undertaken in order to illuminate but rather a process designed to support a pre-determined “vision and set of values”. The authors continue: “We need to show how gambling harm is affecting our population individually, collectively, economically, socially, and how this influences and interplays with other health concerns such as mental health and violence.” Evidence is to be curated in order to support the a priori assumption that gambling is an inherently harmful (or perhaps sinful) pastime. It is evidence-gathering in the style of the ‘Sweeney’ – although that may be doing a disservice to the probity of DI Jack Regan and DS George Carter.

We have of course been here before. In 2020, the lead researcher on Public Health England’s review of gambling harms, wrote in advance of its report that: “more research and evidence are needed to support advocacy and action” – a statement that doesn’t exactly scream honest endeavour. Serious questions are now being asked about the extent to which claims made in the PHE report were manufactured – and to this are added suggestions of a cover-up by state agencies – but public health has an answer to this too.

In a paper published in the Lancet Global Health in April this year, research-activists set out a ‘public health playbook’ consisting largely of PR and lobbying tactics targeted at business (“tobacco, alcohol, gambling, pharmaceuticals, ultra-processed foods and beverages, firearms and weapons, automobiles, social media and technology, oil and gas, and chemicals”). One of the strands of this ‘playbook’ is to counter attempts to “undermine science”. The suggestion here is that there is one immutable scientific perspective (which conveniently happens to coincide with the views of public health militants); and any attempt to challenge that perspective should be resisted as an act of heresy.

And this is perhaps the bottom line for Fell & Rae. For all the insightful analysis, the overall sense from the letter is one of over-weaning self-service. Gambling regulation has long been underpinned by principles of public health, but the goal now appears to be public health hegemony. For example, the authors claim that “to take a public health approach, it is vital that people with sufficient public health expertise form part of that regulator at board level and within the staff team” (somehow they appear to have missed public health’s successful infiltration of the regulatory system over the last seven years).

Meanwhile, the gambling industry is to be exiled from policy discussion on the basis that it “does not possess public health competence”. We are informed that “the public health perspective” must not be undermined. The effect of these lines is to suggest two paradoxical ideas: 1) that all other perspectives (including those of psychiatry, economics, statistics, psychology and business) must be subordinated to public health; and 2) that while the “public health perspective” is hegemonic, it is at the same time so fragile that censorship is required to protect it from scrutiny. Drunk on Foucault, Public Health perceives ‘power structures’ everywhere and is determined to dominate all of them.

The open letter was addressed to the minister in charge of the Gambling Act Review, Chris Philp. In other times, one might have expected a Conservative minister (and particularly one who made his fortune in sectors that public health now wishes to destroy) to be able to home in on salient, constructive observations while giving the hard-left ideology a wide berth. These, however are strange times, as other events this week revealed.


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