Concussion in sport Contents

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5The need for a coherent approach

63.Constant refrains within our evidence have been:

• the need to better understand how brain injury happens;
• how it might be treated; and
• the need to help those currently suffering from the effects of brain injury.

One of the major issues that has become apparent is the lack of any one responsible body to take charge of the issue and drive a solution for any of these issues. We considered each of these during the course of taking oral evidence.

Research activity

64.The need for more conclusive evidence that links brain injury to increased neurological diseases such as dementia is evident for a number of reasons. While the FIELD study showed a significant correlation between injury and incidence of disease, this was a population level study that explained neither why there was a correlation between brain injury and neurological disease nor what caused it. There is a need to understand the mechanisms by which neurological disease occurs to allow for the development of treatments that might mitigate the severity of disease or even prevent it happening at all. Knowledge of the mechanisms would also aid in making changes to the rules of sports to minimise the risks of brain injury in the first place.

65.Professor Stewart told us that the problem was not a lack of research activity but that “well-designed, focused studies that are directly towards answering application questions and do it with robust methodology are incredibly important, but they are few and far between in this field”.94

66.There is also the problem that some research is never published95 or planned research fails to deliver results for one or more reasons.96 One of the criticisms we heard about the Concussion in Sport Group (and its Consensus Statements) was that it looked at such a small sample of possible research to draw its conclusions.97 Dr Cowie of the Football Association told us that the availability of subjects to study was a greater barrier to conducting research than getting the necessary funding.98 All of the research groups are likely to be fishing in the same pool for subjects to study.

67.Another issue raised with us is that, because funding has mainly come from the sports themselves, there is the potential for the findings to exhibit confirmation bias, whereby the results reflect what the commissioning organisation wants to hear. Dr Grey of the UK Acquired Brain Injury Forum said:

I would like to see more independent research, more transparent research, and more funding for research. Rather than leaving it to the non-government bodies, Government could be taking a leading role. Public Health England and some of the various ministries could be contributing to that research. I think together we can do much better than when we are doing this separately.99

The same charge was made against the Concussion in Sport Group (which issues the Consensus Statement and is funded by sport) by the Head for Change group:

From an extensive review of the composition of the CISG, together with their consensus statements, Head for Change agrees that the CISG presents an ultra-conservative perspective emanating from a group of researchers significantly funded by sporting governing bodies. Comments have been made as to the obvious potential for conflict of interest within this group.100

More pointed criticisms of the state of research in this area were made by academics from Newcastle University, who said that “It is striking that in the UK there is almost no independent research into rugby injuries, research is almost exclusively funded by the rugby unions”,101 and Durham University, who said:

We have found it challenging to secure funding for research in this field. Few grant calls are open to concussion research, particularly in sport. To date, most of our research has been conducted with no, or very little external funding.102

The Minister for Sport and Tourism subsequently indicated that, if there was suspicion that research was compromised by where the funding came from, he would be open to considering an alternative method of disbursing research money.

68.While we made no analysis of the amount of money that has been made available for research into dementia, or more specifically into how sports-related brain-injury might lead to neurological diseases, written evidence from Alzheimers Research UK,103 the Drake Foundation104 and the Love of the Game105 outlined significant funding being made in this area. It is indubitable however that there is a greater demand for funds than there is money available, and a number of written submissions outline the list of unknowns that the right research projects might begin to address.106

69.Whilst we have seen evidence of third-party organisations seeking to gather resources and people together to address this issue,107 we have had no evidence of the Government taking action or funding research. We recommend that the Government uses its power to convene interested parties and establish a single research fund that will co-ordinate and fund research. The allocation of funds should follow the model of the research councils to ensure it is seen to be independent and excellence-driven and to ensure that the available funding is coordinated to cover the research requirements most efficiently. All research funded in this way should be required to return all results and analysis to a central database that should be freely and publicly accessible. We also recommend that the Government incentivise sport and other groups to contribute to this fund by offering a degree of match-funding.

70.We also recommend that the Government convene its own specialist group on concussion, drawing on campaign groups, relevant scientific expertise and sporting institutes to assess, every four years, the emerging science on this issue. This group should take a broader view of the existing science than the Concussion in Sport Group, with its priority on taking a precautionary approach to safety.

Clear messaging and advice

71.There is a lot of online information and sources regarding concussion and what should be done. There is, however, no obvious single source of the truth. Each sport has to develop its own rules and protocols, campaign groups produce their information and while the NHS provides information on concussion it is, understandably, lacking any of the necessary detail on return to play.108

72.From our first evidence session with Professor Ritchie and Professor Stewart through to the final evidence session with UK Sport, sportscotland and Sport England, we heard of Scotland’s example in bringing all the relevant bodies together to produce a coherent campaign for concussion in grassroots sport. sportscotland told us that their campaign was focussed in grassroots and had limitations:

We are talking about Scottish rugby, we are talking about Scottish football, we are talking about shinty, we are talking about lawn bowls, equestrian, cycling. We have had support from Government Ministers, the Education Minister, Sports Minister, and at the moment around the table sits the Scottish Chief Medical Officer included in that, and academia. We have been able to bring this group together, led by colleagues like my colleague Jonathan Hanson, James Robson and Willie Stewart, who you have heard from. That collaborative approach has allowed us to bring one grassroots-level recognise and remove education tool. We have not got it right and there is a lot more education to go forward and that is very much our next drive.109

73.The value of a coherent approach has been strongly represented. Professor Stewart told us that a great success in Scotland is:

this single policy on concussion management, which applies to every sport across the sports and grassroots. That has not been replicated in any other country and I would ask why not. It is not difficult to put the tools for brain injury and concussion recognition and management in the hands of parents and coaches, but no other country has done that.110

This was endorsed by the Alzheimer’s’ Society, the UK Acquired Brain Injury Forum and Headway.111 Doctor Sylvester of the Institute of Sport Exercise and Health and Doctor Etherington of the Faculty of Exercise and Sport Medicine also endorsed the Scottish approach.112 In contrast, Public Health England told us that they did not have anything to contribute to the inquiry, much to the surprise of the medical experts we spoke to.

74.We find it difficult to see any downside of a coherent UK-wide protocol for concussion and recommend that the Government look to the Scottish model and then work with the devolved governments in Scotland, Wales and Northern Ireland to develop, in the next 12 months, a UK protocol for concussion across all sport. This should be used by National Governing Bodies as the minimum standard in creating the rules for their sport and should take account of, and be consistent with, the national framework for the reporting of sporting injuries we recommended earlier in this Report. This protocol should be refreshed every two years.

75.Once this protocol is in place we recommend the Government deliver a comprehensive communications campaign to ensure that everyone involved in sport, from the athletes to coaches and doctors, is aware of best practice. This campaign should signpost where people can find the most current, well-evidenced advice on what action to take in the event of head trauma.

The Government’s role in regulating sport

76.The Government regularly flirts with the concept of greater statutory regulation of sport. The Culture Secretary will often threaten legislation, which rarely materialises. Given this failure to act, we were interested in the potential efficacy of DCMS’s recent roundtables on concussion in sport, the 2017 review into duty of care in sport conducted by Baroness Grey-Thompson113 and DCMS’s 2002 report on improving safety in sport.114

77.While we were taking evidence, the Government held two roundtable events on concussion in sport. Written evidence from DCMS said that:

The first DCMS roundtable on 2 February involved current and past sportspeople, and gave a valuable insight into the culture around - and effects of - concussion in sport.

[…]

The second roundtable on 25 February was attended by chief executives and medical officers from various sports, along with selected academics, plus the Department for Education (DfE) and NHS England.115

78.We were surprised that the roundtables made no mention of the various campaign groups, and witness after witness told us that they had not been invited to participate. The Government did not invite the player representative bodies116 or even the specialist Faculty of Exercise and Sport Medicine.117 NHS England confirmed to us that it had not been part of the roundtable:118 although the consultant at the roundtable worked within the NHS, he did not represent the organisation.119 As such, we are puzzled that the Government, in its evidence to this inquiry, should be confident enough to conclude that:

The two roundtables demonstrated that sports are committed to taking safety issues seriously. There may be commonalities across the sector, but it is for each sport to determine the best protocols for their sport.120

79.It is encouraging that the Minister, in oral evidence, was more open to the Government’s potential overarching role:

We need to make sure that we have a convening role in Government to co-ordinate this in a more effective way, and sharing learnings and best practice is a route out of that.121

Whilst the Minister said that the current roundtable exercise was the first time this issue was being considered by the Government, we are aware of two previous pieces of work that address the issue of concussion.

80.Baroness Grey-Thompson’s 2017 review should also be considered. That review explicitly mentions concussion several times, including recommendations on: communicating best practice to schools, coaches and players; better enforcement of return to play protocols; the potential for all-sport insurance to cover catastrophic injury; and the need for a co-ordinated policy on concussion.

81.Professor Nick Webborn also wrote to us, highlighting a 2002 DCMS Working Group that considered improving safety and medical provision in sport. He wrote that:

This working group, of which I was a member and co-author while Medical Adviser to the National Sports Medicine Institute, set forward a pathway to “to assess, monitor and advise on the improvement of standards of safety and medical provision within organised sport” but government failed to act to bring this about.122

The key findings of the 2002 report included the establishment of a UK-wide body to “improve the standards of safety and medical provision for participants in organised sport”. The report also indicated that the proposed body, which would be embedded within UK Sport, would collate data, spread best-practice and maintain a national database.

82.We are concerned that there is history of the Government looking into issues of sporting safety and failing to follow through with practical interventions that would make a difference to the safety and health of those participating. The reports of the 2002 Working Group and by Baroness Grey-Thompson in 2017 both suggested ways to address the issue of concussion in sport and yet the Government has not progressed these. We urge the Government to grasp the nettle this time, move past the concerns about how regulation may change sports, and take real and effective action.

83.It will never be possible to ensure that sport is one hundred percent safe. It should, however, be expected that participants are aware of the risks involved and that there is a precautionary approach to risk management. The Government cannot avoid taking a proactive role in ensuring that this occurs.