28.The sporting landscape is reasonably complicated. There are arms’-length bodies in each of the four home nations responsible for grassroots sport, each of these arms-length bodies has its own Institute of Sport to provide scientific and medical expertise. UK Sport covers the whole of the UK but focuses only on the athletes and teams that have a significant chance of achieving international excellence. UK Sport also makes use of the English Institute of Sport to provide its scientific and medical expertise. On top of these funding bodies there is the wider collection of National Governing Bodies for each sport. Some, like the Lawn Tennis Association, cover the whole of Great Britain; others, like the Football Association and the Rugby Football Union cover England and have counterparts in the other home nations. There are also differing levels of overlap between grassroots and the professional games.
29.For an issue like concussion in sport, it can be difficult to see which organisation should have overall responsibility for coherence and compliance. When we asked about where oversight and regulation might lie, Sally Munday, Chief Executive of UK Sport, said:
It is important to be clear that we are not a regulator. UK Sport does not play that role, that is not our remit. What we are is a distributor of both Exchequer and lottery money to invest in Olympic and Paralympic sports and major events. Depending on the definition of your word “oversight”, we are definitely not a regulator.
All of the sports will run their sports in line with the rules and regulations that are set by the international federations. Those international federations will have their own medical Committees where they will set protocols that are then enforced by them at international competitions and it is what the governing bodies in the UK would respond to when they are running a sport in this country.
When funding depends on excellence and achievement, the focus of athletes, clubs and governing bodies on the safety of those athletes can easily be lost. Eleanor Furneaux, a former TeamGB bobsleigher, noted that
At the moment, there is too much onus on the athlete and then the coach. Realistically, as Monica mentioned earlier, an athlete is going to do everything possible to get back on that ice. You have a headache, you think, “It will be fine, I will just brush it off. I have to play, I have to get back, my team needs me,” or, “I need to do this race for myself.” It is difficult, but the coach is probably going to be on your side with that.
She also noted the potential resistance of those within the sport for anyone seeking to change rules or protocols around concussion:
I was not necessarily aware of the real dangers of concussion until after I had experienced it myself. I know that there are a lot of athletes that I speak to who are still in the skeleton programme in particular who think that all this awareness being raised of concussions and head injuries in sport and in skeleton is potentially damaging and going to ruin the sport, in their words. I don’t see it as that, but had I not had the injury myself, I think I probably would have.
30.Ex-England rugby player Kyran Bracken told us that grassroots players need better examples to follow:
The mode that they are in is exactly the same mode that you see in a Six Nations match, where the player will be knocked out and will stand up and say, “I’m not coming off, I’m absolutely fine”. What you see on TV is what you see on every single rugby pitch up and down the country. If you are at university and you are in the third team, you are not going to go to A&E when someone says you should, you are going to go out with the boys and you are going to train on the following Wednesday, aren’t you?
It needs a lot of education and I think it is the job of the ex-players like myself and other players who are struggling post-rugby to try to educate them. I feel that World Rugby is just too slow to respond to it all.
31.We heard strong support for the medical professionals working in this area. When asked about the pressures that doctors might face to certify that players are healthy and able to participate, Professor Stewart, said:
I know a lot of pitch-side medical doctors and national team doctors and healthcare staff who look after footballers and other players. To a man and woman I have not met one yet who strikes me as conflicted by their role. Their role is to ensure that no harm comes to the players and to look after them as best they can.
None of our witnesses cast doubt on the focus of doctors and other medical staff on the health of the people they looked after. What we did hear was that their job was made more difficult by: the “way the game is managed and the way that they are allowed to interact with the players”; sports failing to learn from other sports; a lack of knowledge about how trauma leads to long term injury; the contribution of training practices; the slow pace of change in the face of increasing evidence; rule changes that encourage more incidences of impact; and the fact that players are becoming bigger and more physically fit. Regardless of the difficulties, our witnesses consistently told us that sports had a responsibility to attend to this problem; especially in professional sports, which we will look at separately in this Report.
32.UK Sport and the English Institute of Sport told us that the incidence of concussion in elite sport is relatively low, that they provide guidance focussed on the individual rather than the sport, based on the Consensus Statement on Concussion, and that it has no remit to regulate or to commission research in this area.
33.The English Institute of Sport was the only organisation giving evidence to this inquiry that supported the use of the Consensus Statement on Concussion as the basis for dealing with concussion in sport. It told us its guidelines based on the statement have been “widely circulated” and are “routinely applied in concussion management”. Furthermore, it told us that:
While this resource has been designed to cover the range of sports that exist under the UK [high performance sport] umbrella, UK Sport and the [English Institute of Sport] acknowledge that most [National Governing Bodies] are likely to have pre-existing concussion management policies or guidelines laid down by their respective international federation, and that, at the point where consideration is being given to an athlete’s return to training, the [English Institute of Sport] guidelines may need to be customised so they are appropriate to each sports’ demands, environment and governance requirements. It is intended that the current [English Institute of Sport] Guidelines will be updated to reflect the recommendations of the 2021 [Concussion in Sport Group] Conference in Paris, which is due to be attended by the [English Institute of Sport’s] Deputy Director of Medical Services.
The English Institute of Sport recognised the problem of a statement that is only updated once every four years, and told us it addresses this in two ways:
First, we mandate that all doctors and physiotherapists go on a pitch-side trauma course that includes the immediate management of concussion and recognition of concussion, which is incredibly important. That is a pass or fail course and they do that annually.
Secondly, we run a quarterly medical meeting that includes discussion around difficult concussion cases. We invite national governing bodies of sports and chief medical officers to attend those meetings so that we are open about how to manage complex concussions and we educate ourselves and keep up to date on that.
34.The test of any system is in how it responds when things go wrong. Eleanor Furneaux’s evidence to us recounted an occasion when that happened:
My injury was January 2018. It was in the middle of a race. It transpires that I had had two knocks in three days. There was one knock where at the time it was not seen as anything particularly to worry about. I had cracked my helmet on my chin and I spent that evening sanding my helmet down to get the crack out.
I did not do a head injury assessment test that evening because I had spoken to my coaches, who obviously were aware of the knock but said they would give me the benefit of the doubt. I knew that I needed to train the next day in order to be in the best position possible for the race on the Friday, I think it was.
I ended up going into this particular corner very late, very badly, and I remember looking up very slightly, probably about this much, off the ice just to try to get my bearings and figure out what was going to happen. Then my head hit the ice and everything went black.
I was flown home the next day. I basically just spent the whole of that Friday—that was in the morning—asleep. I had had a phone call with our doctor from home. I had seen a track doctor. There was someone there, like a medic, who said, “She should probably go off to the hospital, she has clearly had a knock.” They did not have an ambulance there because they were just in an ambulance car or something—this was in Germany. They said, “We can call an ambulance but obviously that will take 10 minutes or so.” They said, “Don’t worry, we will speak to our team doctor back home in the UK so we’ll be okay.” He advised just to go back to the hotel and sleep. I went back and I slept for the rest of that day, that evening, and then I was flown home the next day. I cannot really remember the flight at all.
35.Dr Jaques of the English Institute of Sport told us that British Bob Skeleton and Bobsleigh Association’s rules state that “athletes are encouraged to have a second helmet and are not allowed to train or compete again unless they have a second helmet” but that on this occasion the protocol was not followed.
36.Further questioning revealed that while bids for funding from UK Sport would include information about the support that a sport will provide to athletes, it would have nothing specific to concussion. UK Sport was also clear that it invests “in the governing bodies, not in individual clubs”.
37.The current organisational structures in sport mean that there is no overall responsibility to mandate minimum standards for concussion and head trauma or to assess whether protocols are followed. The system allows sports to be funded as long as their protocols look good on paper with no effort put into assessing how those protocols work in practice. The fact that concussion does not occur at high frequency within the elite sport community means that little effort is made to drive numbers down even further. This means that, some preventable brain injuries are suffered, with the potential for long-term consequences for individuals.
38.It is no longer acceptable for concussion to be addressed in this fashion. We recommend that the Government mandate UK Sport to take a governance role in assuring that all sports it funds raise awareness on the dangers of concussion effectively. Those sports should not only have good protocols to mitigate the risks of such injury but proactively implement those protocols.
39.We are concerned that UK Sport, uniquely in our evidence base, considers the Consensus Statement by the Concussion in Sport Group as a satisfactory basis for concussion protocols. We recognise the value in the Consensus Statement that provides a baseline for what the science can say for certain and identifies a gold standard for science in this area of research. Scientific certainty is a worthy ambition, but it should not be a prerequisite for changing sporting rules to improve safety.
40.We recommend a more precautionary approach is taken and a greater proportion of the money spent on elite sport is focussed on protecting the athletes who are at the core of UK success in sporting endeavours. We also recommend that UK Sport fund a chief medical officer to attend events, like the Olympics, who will hold over-arching responsibility to assess the application of protocols and make decisions on who should be allowed to continue to compete in the event of injuries, including head trauma, sustained in practice and competition.
58 EIS and UK Sport supplementary ()