Gambling Harm Treatment and Support in Scotland: Current provisions and future directions

Chapter 5: System assessment and implications for development

5.1 From mapping to system assessment

Chapters 3 and 4 have outlined, respectively, the current evidence base on effective interventions for gambling harm and the configuration of treatment and support provision in Scotland.

This chapter moves from mapping to assessment. It evaluates the extent to which the current system of gambling harm treatment and support in Scotland aligns with two complementary frameworks:

1) the priorities identified by Public Health Scotland (PHS) for the development of further services, which articulate key principles of healthcare delivery to address gambling harms in Scotland; and

2) the evidence base on intervention effectiveness summarised previously in Table 1 (page 17).

The aim is not to provide prescriptive recommendations, but to identify areas of alignment, tension and potential development within this system.

5.2 Alignment with PHS priorities and the evidence base

5.2.1 Be provided locally and integrated with existing trusted services

PHS emphasises that services should be provided locally and integrated with existing trusted services. Findings from Chapter 4 suggest that, in the Scottish context, elements of local provision are already present both through the work of Scotland-based treatment providers (who operate primarily remotely) and, more prominently, through the work of non-specialist support providers and peer support networks.

Non-specialist support providers, often embedded within communities and working across related areas such as housing, mental health and substance use, play an important role in identifying and engaging individuals who may not access specialist gambling services. Similarly, peer support organisations are characterised by strong community embeddedness and in-person engagement, and currently account for some of the largest volumes of support across the system. These forms of provision align closely with the emphasis on accessibility and trust underpinning this priority.

However, the major peer support networks currently operating across Scotland are unlikely to integrate into an emerging formalised system as they aim to maintain full organisational independence. Furthermore, the recovery model adopted by the two major peer support networks across Scotland may not be suitable for all individuals seeking support for gambling harms.

Local embeddedness alone does not necessarily translate into a well-integrated system. As discussed in Section 4.5, pathways between services remain weakly defined, and coordination across the system is often informal and relationship-based rather than structurally embedded. In particular, integration with statutory health services remains limited, with NHS-based provision represented at the time of this study only by one England-based remote specialist treatment provider. Engagement with primary care across Scotland is also minimal. A palpable distrust among surveyed organisations towards NHS-led secondary care clinics emerged as a recurrent theme in the interviews. While not always explicitly articulated (see Section 4.5.4), this scepticism appears to shape expectations about the future role of the NHS within the system and may act as a barrier to deeper integration. Addressing this dynamic is likely to be an important consideration as the ecosystem develops further.

This has implications for the population’s access to evidence-based interventions. As outlined in Chapter 3 (Table 1), interventions with the strongest evidence base, such as cognitive behavioural therapy (CBT), are concentrated within a small number of specialist treatment providers operating primarily remotely. They also form the major treatment type provided within NHS Secondary Care Clinics. More locally embedded services generally lack appropriately qualified staff to deliver such interventions. While 81% of the Scottish population have ‘good’ access (live within <10 miles) to in-person services, the main service type for the majority is peer support meetings rather than more structured interventions.

These findings suggest that while the system demonstrates some strengths in terms of local presence and community engagement, it falls short of the level of integration envisaged in the PHS model. Local provision exists, but it is not consistently connected to evidence-based care through coordinated and accessible pathways.

5.2.2 Be flexible to ensure equitable, person-centred care

PHS recommends that services be designed and delivered in ways that are flexible, person-centred, as well as responsive to the diverse needs and circumstances of those experiencing gambling harm.

Across the current system, there is clear evidence of flexibility in how support is delivered, particularly within non-specialist support providers. These parts of the ecosystem tend to adopt relational and context-sensitive approaches, working with individuals in light of broader circumstances such as housing instability, financial hardship, mental health and substance use. In this respect, they align closely with a person-centred model of care, offering forms of engagement that may be more accessible and less stigmatising than formal treatment settings.

Peer support organisations similarly provide flexible modes of engagement, combining structured meetings with more informal and ongoing support. As discussed in Chapter 4, these organisations currently account for some of the largest volumes of engagement across the system, suggesting that such approaches resonate with at least part of the population experiencing gambling harms.

However, the presence of flexible and person-centred approaches does not in itself ensure equitable access. As outlined in the epidemiological overview in Chapter One, gambling harms are socially patterned across Scotland with higher prevalence among more deprived populations. While some elements of the current system, particularly community-based and peer-led provision, appear to reach some representatives of these groups, overall service utilisation remains low relative to estimated need (Section 4.4). This indicates that flexibility in delivery of these services has not translated into comprehensive population-level coverage, even despite 81% of the population of Scotland having good access (living within <10 miles) to these in-person services.

While remote delivery is framed by specialist providers as way to provide more flexible specialist care and to reduce stigma and barriers for access, digital access and digital literacy are themselves barriers disproportionately concentrated among more deprived populations.^[31]

Findings from Chapter 4 further point to uneven provision for specific population groups. Although over half of the surveyed organisations reported some form of specialist provision (e.g. for women, LGBTQ+, ethnic minorities, etc.), these services are generally modest in scale and not systematically embedded. At the same time, certain populations appear to fall largely outside the scope of the current system. Under-16s, for example, are engaged only as affected others. This suggests a gap in early intervention.

Thus, while person-centred and equitable approaches are present in, or at least discursively recognised by participating organisations, these approaches are unevenly distributed and not consistently aligned with patterns of need. As a result, the system does not yet deliver equitable access across the population limiting its capacity to address gambling harms at scale.

5.2.3 Have a clearly defined pathway to access services

PHS recommends the establishment of clearly defined pathways to access services to support consistent and coordinated movement through the system.

Currently, access to support is characterised by multiple entry points, including specialist treatment providers, non-specialist support providers, peer support organisations and the national helpline. While this plurality of entry routes may increase the likelihood of initial contact with services, it does not fully translate into a coherent or consistently navigable system.

As discussed in Section 4.5, onward pathways between services are often unclear or inconsistently applied. Organisations’ referrals are typically based on informal knowledge, personal relationships and ad hoc arrangements rather than on clearly defined protocols or shared frameworks. As a result, movement through the system is not systematically structured and may depend on the specific knowledge and connections of individual staff members.

This lack of formalisation has implications for continuity of care. In the absence of clearly defined pathways, individuals may experience fragmented support with limited coordination between providers and no consistent progression across different levels or types of intervention. While practices such as ‘warm referrals’ partially mitigate these issues, they remain dependent on local relationships rather than being embedded within the system as a whole. The limited availability of Tier 3 provision and a complete absence of free-at-the-point-of-access Tier 4 services in Scotland further suggest that individuals experiencing higher levels of harm may not be progressing to the types of support from which they could benefit.

Limited involvement of primary care further constrains pathway development. As noted in Chapter 4, participants reported GPs playing a limited role in identifying and referring individuals experiencing gambling harm, and there is little evidence of systematic integration with broader healthcare pathways.

Lack of a clearly defined and consistently applied pathway structure represents a key limitation in the current ecosystem’s ability to provide coordinated, equitable and effective support.

5.2.4 Be evidence-based and follow up-to-date clinical guidance (including NICE Guidelines)

PHS recommends that healthcare delivery to address gambling harms should follow an evidence-based approach, aligned with current clinical guidance, including NICE Guidelines.

Table 1 (Chapter 3) summarises the current evidence base on the effectiveness of different intervention types and provides an assessment of their availability in the Scottish context. Read alongside the findings from Chapter 4, the table points to a clear and systematic mismatch between the strength of the evidence supporting particular interventions and their adoption within the current ecosystem.

At the level of structured psychological treatment, e.g.CBT - assessed as effective and recommended in NICE guidelines, is available only in a limited form. Strong evidence of delivery by appropriately qualified professionals is confined to a single specialist treatment provider with only partial or non-specialist-provided forms of CBT-type interventions identified elsewhere. Internet-based CBT shows a similar pattern, with clear provision in only one setting and limited evidence of equivalent provision across the wider system.

A similar pattern is observed for motivational interviewing (MI) (see footnote on p.15 for definition). While MI is assessed as potentially effective by NICE, its provision is uneven. Strong evidence of MI delivery is limited to a single specialist treatment provider, with partial or unclear use elsewhere.

By contrast, lower-intensity interventions are both more widely available and more central to current provision. Brief interventions, despite being associated with relatively small effects, are the most commonly delivered form of support. A similar misalignment is evident in the prominence of voluntary limit-setting and self-exclusion within current support offers. While widely used by providers as part of harm-reduction strategies, these measures have mixed or context-dependent evidence of effectiveness. Their impact in the UK is likely constrained by a fragmented regulatory environment, including the absence of mandatory limit-setting and the coexistence of multiple self-exclusion systems across different gambling products.

Peer support, including mutual aid groups, represents one of the most extensive forms of provision in Scotland with comparatively high levels of engagement across the country. NICE Guideline 1.5.11 recommends offering peer support ‘as an integral part of the support and treatment for gambling-related harms for people who wish to engage with it’. However, as reflected in Table 1, the evidence base for such interventions indicates relatively small effects. Whilst there are benefits associated with the scale and accessibility of this form of support within the Scottish ecosystem, its current prominence is, in part, a result of limited alternative provision and should not be interpreted as evidence that it is adequately meeting need.

Educational and awareness-raising interventions occupy an intermediate position. While potentially effective depending on implementation, their presence in Scotland appears limited and uneven with few clearly identifiable, industry-independent programmes operating at scale, and a certain degree of duplication (e.g., in prisons and armed forces).

On balance, these patterns indicate that the current system is weighted towards interventions that are more easily scalable or accessible, rather than those with the strongest evidence of effectiveness.

5.2.5 Be evidence-generating through robust data collection and evaluation

This priority underscores the importance of gambling harm support and treatment delivery being also evidence-generating, with robust data collection and evaluation supporting system learning and development.

Findings from Chapter 4 suggest that this remains an underdeveloped aspect of the current system of gambling harm treatment and support in Scotland.

Across provider types there is no shared framework for data collection, outcome measurement or evaluation. While some organisations collect routine data on service use, these practices vary considerably in scope, quality and purpose. Specialist treatment providers tend to have more developed data infrastructures, including the use of standardised assessment tools. Non-specialist support providers and peer support organisations often operate with more limited or informal data collection practices. In some cases, data collection is minimal or absent reflecting capacity constraints and the prioritisation of service delivery over monitoring and evaluation.

This fragmentation limits the system’s ability to produce a coherent picture of service reach, user characteristics and outcomes. As discussed in Section 4.4, even basic parameters such as the number of individuals accessing support and the scale of provision across different intervention types can only be approximated. There is no integrated dataset that would allow for systematic tracking of individuals across services or for assessing continuity of care and long-term outcomes.

The absence of shared outcome measures further constrains evaluation. Although some providers report using evaluation tools, there is no common approach to measuring recovery, improvement,or sustained reduction in harm. This makes it difficult to assess the relative effectiveness of different service models or to compare outcomes across provider types.

The implications of these gaps are significant. As highlighted in Section 5.2.4, the current system is not fully aligned with the available evidence base on effective interventions. At the same time, it lacks the capacity to generate robust evidence on what works within the Scottish context. This creates a situation in which both the application and the production of evidence are constrained.

Strengthening data collection, evaluation capacity and the use of evidence across the system would be a necessary condition for more effective and coordinated service development.

5.2.6 Be designed and provided with meaningful involvement from people with lived experience

The meaningful involvement of people with lived experience is identified by PHS as a core principle for the development of services. Findings from Section 4.8 indicate that lived experience is present across the Scottish gambling harm support ecosystem, but that its role varies significantly across provider types.

In specialist treatment providers and non-specialist support providers, lived experience is most commonly incorporated in a consultative or instrumental way. By contrast, peer support organisations are fundamentally organised around lived experience, with governance and delivery all driven by individuals with direct experience of gambling harm. As discussed in Chapter 4, this represents a qualitatively different model of involvement in which lived experience is not an input into service design but the basis of the intervention itself. This distinction may be relevant to understanding why some individuals do not pursue formal treatment routes as the ‘nothing about us without us’ ethos is missing in those settings.

Thus, while people with lived experience of gambling harms are visible within the current ecosystem, their experience is not consistently recognised as a form of expertise with equal standing in decision-making processes.

5.2.7 Be free from the influence of the gambling industry

Independence from gambling industry influence is a key principle of a public health approach to gambling harms. Findings from Chapter 4 indicate that, historically, the organisation of services in Scotland has been shaped by funding arrangements linked to industry-derived sources, most notably through GambleAware. This funding model has played a central role in enabling the development of specialist treatment providers and, to a slightly lesser extent, non-specialist support provision.

At the same time, interview data suggest that this model has had important implications for system dynamics, including the emergence of competition between providers, pressures related to client retention and limited incentives for collaboration (Section 4.9). In this sense, funding arrangements have not only supported service provision but also shaped relationships within the system.

However, the system is now entering a new phase whereby funding for treatment and support has transitioned towards a publicly governed funding model. This represents a significant structural shift with the potential to reshape commissioning practices, system coordination and the overall configuration of services. The effects of this transition are not yet fully visible. Many of the dynamics identified in Chapter 4, particularly those related to funding uncertainty, short-term cycles and competitive pressures, were observed during a period of transition and may continue to influence the system in the short term. As such, while the move away from industry-linked funding creates conditions for greater independence, it does not in itself guarantee changes in how the system operates.

Scotland is at an important juncture in the development of its gambling harm support ecosystem. The shift towards a levy-funded model provides an opportunity to align the system more closely with public health principles, but its impact will depend on how funding is structured, allocated and translated into practice.

5.3 Implications for system development

The analysis presented in this report points to a system that remains uneven in its provision and fragmented in its organisation, with a number of structural limitations. The following areas emerge as particularly important for further system development.

Future directions for system development

• Strengthening pathways and coordination
• Improving alignment with evidence-based interventions
• Developing workforce capacity and competency frameworks
• Expanding early intervention, especially for underserved groups, and improving awareness of support pathways
• Building data and evaluation infrastructure
• Clarifying roles across the ecosystem
• Embedding lived experience structurally into system-level decision making
• Stabilising funding and commissioning arrangements

Strengthening pathways and coordination

While access points into support are multiple, movement across the system remains largely informal and dependent on individual relationships. Developing clearer and more consistently applied pathways between provider types would support continuity of care and improve access to appropriate levels of intervention. This includes strengthening formal connections between specialist treatment providers, non-specialist support providers and peer support organisations, as well as improving integration with primary care and broader healthcare pathways.

Improving alignment with evidence-based interventions

The current configuration of services does not consistently reflect the relative effectiveness of different intervention types. Interventions with the strongest evidence base, particularly structured psychological therapies such as CBT, remain limited in availability while lower-intensity and peer-based approaches account for a substantial proportion of provision. Strengthening alignment with clinical guidance would involve expanding access to evidence-based interventions while retaining the accessibility and engagement strengths of existing models.

Developing workforce capacity and competency frameworks

The analysis also points to significant variability in workforce composition, qualifications and training across the system. Specialist treatment providers, non-specialist support providers and peer support organisations operate with different expectations regarding professional competencies and experiential knowledge, reflecting the diversity of service models. However, there is currently no shared competency framework for practitioners working in gambling harm treatment and support in Scotland. This variability reflects a deeper structural issue. There is no dedicated pathway into gambling treatment specialism within the Scottish context. Furthermore, general practitioners receive little or no formal preparation in identifying or responding to gambling harms, and no routine screening protocols are in place. As a result, gambling-related expertise is often acquired incidentally rather than through formalised training routes. This has implications not only for the consistency and quality of care, particularly in relation to the delivery of evidence-based interventions, but also for the longer-term reproduction of the system as workforce development remains contingent on ad hoc rather than structured pathways. In this context, the absence of a common framework makes it more difficult to define roles, support workforce development and ensure coherence across different parts of the system. Strengthening workforce capacity, including through clearer competency expectations and training pathways, would support more consistent delivery of care and better alignment with the evidence base.

Expanding early intervention, especially for underserved groups, and improving awareness of support pathways

Access remains uneven across the population. Service utilisation is low relative to estimated need and gaps persist for certain groups, including younger people. However, our findings suggest that this may not only reflect insufficient service provision, but also limited awareness of available support, uncertainty about where to seek help, and reliance on non-specialist or peer-led routes among the population. This points to the importance of strengthening early intervention, while also developing more systematic approaches to making support pathways visible, accessible and trusted among populations currently underserved by the system.

Building data and evaluation infrastructure

The absence of shared data frameworks, outcome measures and evaluation practices limits the system’s ability to assess effectiveness and adapt provision. Strengthening data collection and evaluation capacity across provider types would support both service improvement and strategic planning, and would be necessary for the development of a more evidence-generating system. This would also align with recommendations in the PHS healthcare needs assessment, which highlighted the need for more consistent routine recording of gambling harms across different types of services, improved understanding of service demand and pathways into support, and evaluation of newly developed services against agreed outcomes and measures.

Clarifying roles across the ecosystem

Specialist treatment providers, non-specialist support providers and peer support organisations each contribute distinct forms of support reflecting different service logics. However, their roles are not yet clearly defined within a coordinated model of care. Greater clarity regarding how these components interact and what their role will be within the PHS-proposed model of care to address gambling harms, including referral relationships and areas of responsibility, would support more effective use of existing resources and reduce fragmentation.

Embedding lived experience structurally

Lived experience is visibly present across the system, but its role varies significantly across provider types and is not consistently embedded in system-level decision-making. Strengthening its meaningful involvement would require moving beyond consultative uses towards more structured forms of participation in service design, evaluation and governance, recognising lived experience as a form of expertise alongside clinical and professional knowledge.

Stabilising funding and commissioning arrangements

The transition to a statutory levy-funded model represents a significant shift in the funding landscape, with the potential to reduce the influence of industry-linked funding and support a more coordinated system. At the same time, many of the dynamics identified in this report, including funding uncertainty, short-term cycles and competitive pressures, are products of the previous funding model and may persist in the short term. The effectiveness of the new system will depend on how funding is structured and translated into commissioning practices that support collaboration, integration and long-term planning.

Taken together, these areas point to the importance of moving from a system characterised by parallel forms of provision towards a more coordinated, evidence-aligned and population-oriented model. This does not require replacing existing approaches, many of which demonstrate clear strengths, but rather integrating them within a more structured and strategically developed framework, as already proposed by PHS.