Concussion in sport Contents

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4Professional sport

41.Professional sport has a different context and particular issues. The profile of football and rugby dwarves that of other sports and the coverage of concussion in these sports has overshadowed media coverage of the issue in other sports. Much of the written evidence we received related to these two sports and our inquiry has been conducted in the knowledge that there are currently court proceedings regarding head injuries and rugby. In line with the House of Commons resolution on sub judice, this Report will refrain from commenting on what may or should have happened in the past with regard to these cases.

42.A key difference between professional sport and elite sport is that professional sportsmen are paid to play their sport, under contract to commercial organisations who seek to profit by selling tickets and broadcast rights to fans and media organisations respectively.

Professional football

43.The media narrative on concussion in sport is heavily weighted to the effects on footballers. This is partly due to the 2020 FIELD study mentioned earlier in this Report which was “the first peer-reviewed research to determine that having played professional football correlated with an increased rate of dementia within its sample group”64 and found risk rates for former footballers were 5 times greater for Alzheimer’s disease, almost 4 times greater for motor neurone disease and 2 times greater for Parkinson’s disease. This solid scientific evidence gave greater weight to those who have campaigned on this issue for years.

44.Jeff Astle’s daughter, Dawn, founded the Jeff Astle Foundation after a landmark coroner’s court verdict in 2002 that “[Jeff Astle’s] type of dementia was entirely consistent with heading a ball. The occupational exposure has made at least a significant contribution to the disease which caused death”.65 Dawn Astle told us that she was frustrated that:

For almost 20 years now football has failed to act and failed to protect its players—men, women, children, all at risk, potentially, with no restrictions, unprotected, uninformed. If the sport is left to its own devices as it is, it will just do what it wants to do. If there was a body overseeing the sport 20 years ago when my dad had died, it would have been saying to it, “You need to take these steps, you need to take these steps,” and those steps would have been taken.66

45.Chris Sutton, a former professional footballer, has also campaigned for changes in football. His father, who was also a professional footballer, recently died of dementia and he told us that football should be held responsible:

It is really important that the Government take ownership of this because the [Football Association] and the [Professional Footballers’ Association] have not done anywhere near enough. They have not been interested in it because it does not benefit them in any way, shape or form.67

46.Both the Football Association (England’s National Governing Body for the sport) and the Professional Footballers’ Association (the body that represents players) engaged strongly with our inquiry and listed a number of studies and programmes that they have funded and run, including, most pertinently, the FIELD study.68 The Football Association’s Chief Medical Officer, Dr Charlotte Cowie, told us that it had put no limit on the funds it would award to research that sought to provide answers to the questions surrounding concussion in football, even if that meant reaching out to the global football community for the necessary financial support.69

47.The importance of robust concussion protocols has continued to be demonstrated even now. During the drafting of this Report, the UEFA Euro 2020 football competition was under way. The UEFA Concussion Charter, which was agreed for that competition, indicates that any suggestion of loss of consciousness should lead to the player being removed: a point more explicitly stated in the awareness video on the UEFA website.70 Early on in the competition, a French footballer sustained a head injury that the player reported had left him unconscious on the grass for a short time (though this was later denied by UEFA).71 Within minutes he was allowed to return to the field of play, much to the criticism of media campaigners, though UEFA said that they were content the protocols had been followed.72

48.Football’s engagement with the issue of concussion, both in England and internationally, has taken too long and its current prominence is due to the campaigning of organisations like the Jeff Astle Foundation and prominent spokespersons like Chris Sutton. We would have expected the Football Association, as the National Governing Body, to have taken a stronger, sustained interest in the issue after the coroner’s verdict of Jeff Astle’s death. We would also have expected the Football Association to have been publicly hounded by the Professional Footballers’ Association, whose key concern should be player welfare. Over the past 20 years neither the Football Association nor the Professional Footballers’ Association have fought hard enough, or publicly enough, to address this issue within the broader football community. They are, however, only part of a broader failure to address the issue of acquired brain injury in sport.

Professional rugby

49.The game of rugby football intrinsically features more player contact than association football, and has had to consider how to monitor and manage the injuries, including head injuries, that derive from that contact. Professor Stewart told us that while rugby has good protocols for reporting and assessing injuries, the incidence of head injury in rugby is unacceptable:

There is about one brain injury per match in professional rugby, and English rugby has been very good at monitoring the levels of injury. That level of one brain injury per match has stayed the same for about four or five years now and that is an unacceptably high level.73

50.Kyran Bracken, ex-England player, speaking for the campaign group Progressive Rugby, thought that the game’s current trends might not be helping the issue:

The game of rugby, since it went professional, has changed hugely. First, the players are bigger and stronger. You are likely to see the likes of Jonah Lomu all over the place now in the backs. The rules in the game have changed so that the ball is in play 30% more than it ever used to be because of the rule of kicking it outside the 22. Effectively, that means there are more tackles and there are more head injuries. Every single team has a professional defence coach and their job is to basically cover any space on the pitch. Rugby has now become a game of collision and not evasion. I am not saying that is a bad thing but that is the truth of it. The third change in the laws allowing lots of substitutes to come on to the pitch and change the direction of the game means the impact and the intensity is huge. Recently, Italy said that it put its best front row on the bench so that they could come on to the pitch in the second half against a tired front row.74

51.Progressive Rugby laid out its concerns and challenges for the game in an open letter to Bill Beaumont, a former player and current Chairman of World Rugby.75 The campaign seeks to improve how the game adapts to the challenge and potential long-term health consequences of head trauma, including limiting contact in training, reducing the number of games per year for international players, extending the minimum number of days before ‘Return To Play’ to at least three weeks and establishing a Concussion Fund to provide post-retirement welfare. Dr Falvey, chief medical officer for World Rugby, welcomed the interest of groups like Progressive Rugby:

I understand the frustrations of some groups where they feel the pace of this is not quite what it should be, but anyone who is involved with science knows that good science takes some time. It takes time to do it properly and we need to ensure that any science that is implemented does not have unintended consequences. That is not an excuse for acting on the information that we have, which we are doing and we will continue to do.76

52.The problems faced by both football and rugby are common to a multitude of other sports which do not have the same media attention or the same resources to apply to possible solutions. One of the biggest problems is the apparent lack of clarity on who is responsible for driving change. Change has not happened quickly enough and while the science currently available to us describes the problem it does not provide solutions.

Professional employment or sporting endeavour

53.We were interested in finding out how professional sport was responding to the increasing scientific evidence of how a sporting career might affect an athlete’s later health and the role professional sport was playing in developing good practice.

54.Professional athletes are not simply competing for glory or sporting achievement, they also have the motivation of signing extremely lucrative contracts. Moreover, the clubs employ these sportsmen, creating a distinct relationship that it was important for us to consider.

55.Our attention was drawn to the Management of Health and Safety at Work Regulations 199277 as a fundamental framework for workplace injury.78 The Health and Safety Executive submitted a memo to the inquiry,79 which indicated that:

It is the governing bodies and the rules of the sport that dictate how the sport is played. The rules will look to ensure that the sport is a positive and enjoyable experience for the athletes and those spectating whilst also looking to reduce risks to participants or potential for injuries by use of specified equipment e.g. headguards for certain levels of contact and high speed sports. The relevant sporting bodies in the governing of their sport and its management of risk must, or should, consider the element of reasonably practicable controls that would reduce the potential for injury while at the same time not serve to prevent the sport from continuing. Any measures introduced need to be focussed on practical controls and ensuring participants are informed, and their health in monitored.80

It went on to indicate that reports for concussion injuries under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 201381 are unlikely, as they would not fit into the specified diseases or injury criteria.82 The closest equivalent under the Regulations would instead be to report “any crush injury to the head or torso causing damage to the brain or internal organs in the chest or abdomen”.83 The HSE concludes that “sports’ governing bodies are best placed to make judgements on the risks and we would expect them to regularly review their rules and procedures as appropriate”.84

56.When asked whether sport might benefit from the Health and Safety Executive casting a critical eye over how it manages player safety, Paul Struthers of the Professional Players Federation said:

I certainly see some value in that overarching role, because you are right: the sports governing bodies are left to their own devices and mark their own homework.85

57.The issue of work-related disease and whether a condition might be classed as an industrial disease (and therefore engage an entitlement to compensation such as that paid to miners for pneumoconiosis) is determined by the Industrial Injuries Advisory Council.86 The Professional Footballers’ Association told us that it had applied to the Council after the Jeff Astle coroners verdict in 2003 to have dementia in footballers classed as an industrial disease but that the Council had:

published a report87 which concluded that there was “currently insufficient evidence to recommend prescription of dementia in boxers or footballers”. The report also found no research on dementia following head injury in jockeys.88

The Professional Footballers’ Association, after publication of the FIELD study, applied again to the Council to have neurodegenerative diseases in footballers classed as an industrial disease but the outcome of that, at the time of writing remained unclear.

58.When questioned on the issue of greater involvement of the Health and Safety Executive, the Minister for Sport and Tourism, Nigel Huddleston, said:

I think you are making a fair point. There are lots of jobs that are dangerous or potentially dangerous, and you are right that the health and safety regulations in the workplace highlight those.89

While he considered that there were differences in sport when compared to other sectors, he noted that the lack of any statutory requirements to report injuries, which exist for other sectors, was “one of the areas of concern for me. I am not at all convinced that there is accurate recording of all concussion injuries at the moment”.90

59.Many of the witnesses to our inquiry, when talking about rugby or football, thought that the sport should cover or contribute to costs related to acquired brain injury. For example, Chris Sutton suggested that the Premier League, Football Association and Professional Footballers’ Association should be paying out.91 The Professional Footballers’ Association suggested, in written evidence, that it would like to see:

an industry-wide fund set up to pay for care home fees and other associated costs for former players who receive a neurodegenerative diagnosis. Due to the overall cost of care, it is simply not financially viable for the [Professional Footballers’ Association] to solely fund this support provision. Other football stakeholders such as [the International Federation of Association Football (FIFA)], [the Union of European Football Associations (UEFA)], [the Premier League], the [Football Association] and [the English Football League] should contribute to a joint fund.

Another potential consideration is a Football Care Home that could help support former players who have dementia. For instance, this could be at the FA’s Training Centre at St. George’s Park or another suitable place. A feasibility study would need to look into the need, cost and management issues of such a project.92

While such an endeavour is financially feasible for football, and possibly rugby, due to the amount of money these sports receive, it would probably not be for many of the less well-funded sports such as bobsleigh and ice hockey. The Minister indicated that the NHS was there to support those in need, including ex-sportsmen and women, but that the principle of putting an obligation “on the institutions, bodies or groups that caused that damage in the first place” would be a valid one.93

60.The protections afforded by the state to workers apply as much to footballers and jockeys as they do to miners and construction workers. The Health and Safety at Work Act 1974 was a landmark piece of legislation to protect the health of workers and, along with subsequent Regulations, places a duty of care on employers. The extent of that duty has been established through numerous court cases in many other sectors. We are astounded that sport should be left by the Health and Safety Executive to mark its own homework.

61.Our inquiry into concussion has demonstrated that the long-term effects of acquired brain injury are not simply those events that lead to a diagnosis of concussion. Therefore, any impacts that impair clear thinking or involve a heavy impact could contribute to acquired brain injury.

62.We recommend that the Government immediately mandate the Health and Safety Executive to work with National Governing Bodies of all sports to establish, by July 2022, a national framework for the reporting of sporting injuries. Within a year of the framework being published, all organised sports should be required to report any event that might lead to acquired brain injury.