Lord Addington
To ask Her Majesty’s Government what advice they are giving to (1) sports national governing bodies, and (2) national medical services, regarding concussion sustained in sporting injuries.
Lord Addington (LD)
My Lords, I first thank everyone who bothered to put their name down for this debate. I would like to say why I felt that a discussion on this matter would be worth while. When we start talking about concussion and injuries and the areas around them it is important to try to get the whole situation in context. When it comes to head injuries there is always a great deal of fear within any organisation, and quite rightly so, because we are not entirely sure what happens. If your head goes, everything goes. Every time you talk about this, in particular when there is the idea that children will be involved, there is a fear reaction. Also, in sport—and this is probably very true of my own sport, rugby union—there is the machismo. “Well, it didn’t do me any harm”, a player will say as he twitches and staggers. However, that reaction always comes in.
I want to look at a debate which started at the elite level of the game. Here I pay tribute to Chris Bryant MP, who I first met on the Commons and Lords rugby trip about 10 years ago. Not a bad centre, likes to run straight and does not miss many tackles: that is my assessment of Chris. He has done a great deal of work at the professional end of the game. In the period of time since I had my flirtation with the top end of the game—and when push comes to shove it was a flirtation—professional rugby union players have got bigger, stronger and harder. They have gained weight and got fitter. They are now basically monsters. One of the biggest changes in the game is that they now take the defence more seriously and look for heavier collisions more frequently.
The other side is that those players are professionals. They have a structure which looks after them, which is aware of them and has invested in them on dozens of different levels to observe what is going on. At all levels there is a great incentive to make sure that people are functioning properly. Most of sport does not have that. It is also the case that most sport is played at an amateur or community-level basis, where people are not playing or training primarily because they are paid but because they want to be there. They enjoy the process. There are some, possibly not in this debate but quite frequently in other situations, who cannot understand this process and the fact that people enjoy what they are doing.
Virtually all sports have a danger of concussion and head injury. They involve people moving around and bumping into each other, and occasionally bumping into very hard balls travelling very fast. All sport has an element of risk. All sport will have to try to adjust and ensure it knows what it is doing. All of sport will have to interact with the National Health Service to make sure that these problems do not become chronic. As we become more aware of these problems we tend to discover more of them.
At the amateur, more participatory, casual end of sports, people frequently play more than one sport. The specialist at the top end will concentrate on one sport alone. That is why I frame this debate in these terms. Rugby union, rugby league and possibly gridiron football, although not that much of it is played in this country, look for a collision, as do the martial arts. In other sports it will occur as an inevitable part of the game at even the most casual level. In basketball, players are not supposed to hit each other, but people jump up for the ball and two of them can hit each other. If they do not clash heads and elbows, there is a nice hard surface to bang their heads on. It will occur. For example, in football, if the defender, goalkeeper and the forwards all go up for the same ball, all trying to head it—or the goalkeeper punch it—there is the possibility of impact. It has occurred at the top level of the game.
I have tried to look at how all sports manage to get the information running through themselves about what they should do and how they manage to get this down to the more vulnerable groups. In this case, children and the young are more at risk—more of them apparently have head injuries and more come into casualty. Much of this may be simply because the young climb trees, for instance, or cross roads less carefully than others, but it still occurs. They are more at risk not only from the one incident but the secondary incident. How do we take this on board and encourage the sports themselves to identify when somebody is at risk? How do we make sure that the people who are in charge of the organisations and of coaching know to tell the rest of them when to step down? How do we tell the medical services when they should take action and when they should tell you to go home? Very importantly, how do we tell them when not to overreact?
There is a general consensus that exercise is the wonder drug. It helps prevent types of cancer and even dementia. Most people take exercise, at least initially, through a sport. If we could all be trained to jog the 2.3 miles 2.4 times a week that are required to keep our bodies healthy, we all would and we would not have to worry about this—but we do not, as people find it basically fairly boring. How do we interact and make sure that this is going on?
When it comes to examples of good practice, the best culture I have seen for dealing with injuries is probably in anything to do with riding or the equestrian world. I live in Lambourne, the valley of the racehorse, and in National Hunt jumping, people come off the horses fairly frequently. I have seen quite an intimidating tea-towel about some old National Hunt jockey—I cannot remember which one, but he had X number of wins, rides and broken bones—which showed which bones he had broken flying off a horse. In that sport, a hard hat is the thing you absolutely always wear. The sport knows that people get hurt and it shares doctors now with rugby union. In rugby union, you probably have twice the amount of person to practise on but similar types of injury.
How do you get that culture down into the grass roots? Rugby union has a very good scheme, which seems to be a brand leader, called “Use your head”. It comes down to a culture of making sure that introductory-level coaches are taught how to deal with people who have head injuries. Will the Minister encourage all sports to get similar types of schemes going? We need to encourage people to take part.
Also, how do the medical services react? They should not just say, “Don’t do it for X number of weeks”. That would mean people will ignore you, because most of the time—statistics prove this—although you have a slight headache and feel slightly giddy, you are fine. We do not want to go back to assuming that you are not in danger, but most of the time you are fine. It is when this gets compounded and, on the odd occasion, the freak event and the panic occur. How do we square this circle of reaction? Can we please have some guidance about what are the best schemes? How can we address this and get through?
We are told not to go to accident and emergency all the time as we are clogging up the doors. Will the other elements of the National Health Service know when to refer you on, when to tell you not to panic, when to tell you to rest and when to come back? That is what I am trying to get at. If we overreact here and act inappropriately we get rid of the benefits of sport. If we do not react at all, we will have occasional cases of tragedy and then more commonly occurring cases of impairment and damage in later life. We have got to work these together. What are the best practices for what we are doing and how are we going to bring them together? That is what I am trying to get at here.
I hope that this is the start of a process in which the NHS and all the sporting bodies talk to each other. They need to ensure that there is communication at the grass roots, at the schoolboy—or schoolgirl—level, and that people know what is going on and what is best practice. If they do not, we are in danger of creating another case where overreaction, bluff and basic ignorance mean that we end up with slightly less competition—not just in sport but in any competitive environment—and a few tragedies are the result. We do not want that. We want to go forward with activity and safety. That is something that we can achieve and we should try to.
Lord Moynihan (Con)
My Lords, the Committee is indebted to my noble friend Lord Addington for securing this debate. It is both timely and important. It is timely because it comes on the eve of the screening next week at the Curzon cinema here in London of the world premiere of “Head Games: The Global Concussion Crisis”, which will spark nationwide comment and debate. From the acclaimed director Steve James, it is a revealing documentary featuring neurological findings related to rugby and soccer players that will serve as a wake-up call for those who think that the devastating and chronic effects of repetitive head trauma are found only in American football and boxing. The film is inspired by the book Head Games: Football’s Concussion Crisis, written by the former Ivy League football player and WWE wrestler Christopher Nowinski. I believe it will capture the attention of the sports world, and it is already causing a stir in the United States.
Concussion is increasingly recognised as a serious medical condition that is interesting legislators around the world. Indeed, it is the only medical condition whose treatment is currently mandated by legislation in the United States. This is the result of the Zackery Lystedt law, started in Washington state, home of the Seattle Seahawks, by the Seahawks’ doctor, Dr Stan Herring, after a terrible accident involving a teenager, Zackery Lystedt. There are now Zackery Lystedt laws in 49 of the 50 states of the union; Mississippi is the only one that does not have one.
The Zackery Lystedt law states, first, that concussion education must be delivered to parents, coaches and players in all sports, not just contact sports. Secondly, after a concussion the player must be removed from play and not allowed back on to the pitch. Thirdly, after a concussion the player cannot be allowed to return to sport until cleared to do so by a healthcare professional who has experience in concussion.
We have no legislation in the United Kingdom and, as my noble friend Lord Addington has highlighted, individual sports vary greatly in their attitude towards concussion management. That is the urgent issue that needs to be addressed. My noble friend mentioned horseracing, which is way ahead of the rest and started a management programme in 2004. The work that Dr Michael Turner, until recently chief medical officer of the Jockey Club, has done for jockeys has been world-leading and deserving of careful study and praise.
Rugby is still trialling new and appropriate codes; for example, the five-minute concussion timeout to allow doctors to assess and diagnose concussion. Speaking from a non-medical perspective, that seems a totally inadequate length of time and yet rugby has put many of the issues under consideration on the world stage. The highly controversial decision to allow Australia’s George Smith to return to action during his side’s third-test defeat to the British and Irish Lions last year, despite clearly having been concussed, has prompted one of a series of changes to the global trial of the pitch-side suspected concussion assessment, the PSCA protocol.
What is needed above all is education at the grass roots. At the moment there is nothing in this country that is structured for coaches, parents and clubs. That is a very serious state of affairs, which should concern all sports administrators and politicians. The South Africans have a great programme in this context called BokSmart, which should seriously be considered by all our governing bodies. The Canadians have Parachute and we have Headway.
The main source of information is the latest concussion consensus statement from Zurich 2012. It recently emphasised, once again, the need for education and in the United Kingdom all sports, not only contact sports, have faced the consequences of this. In soccer, there were changes to pitch-side assistance and medical requirements soon after the Reading-Chelsea match when Petr Cech sustained a depressed skull fracture and then the substitution goalie sustained a concussion, leaving John Terry in goal.
The Australians are probably the leaders internationally given the work being done in Aussie rules football in particular. Many sports are now caught up in the debate—NFL, ice hockey, FIFA, boxing, equestrian, rugby league and union. It is a global issue as well as a legal one.
What needs to be done? In this country we could create a national concussion and head injury research centre. This could address all of these issues, bring them together and ensure that what we are debating today is not a series of different practices across sports, clubs and schools but a centre capable of bringing together all research in this area and then disseminating it to all sports in this country. Above all, we need consistency in the approach of the national governing bodies of sport, both amateur and professional. Without it, and without such a voluntary approach working with the governing bodies of sport, there may be serious calls for legislation in the future, as there are at the moment in the United States.
Will the Minister, with his ministerial colleagues at the Department of Health, agree to a further meeting with interested members of the medical profession to discuss the establishment of a world-leading centre in the United Kingdom based on international co-operation, which I have called today the national concussion and head injury centre?
Perhaps I may set this in context. The current definition of concussion was first agreed in 2001 at the Vienna concussion consensus conference and has remained largely unchanged over the subsequent three meetings—the Prague concussion conference and then in 2008 at Zurich 1 and in 2012 at Zurich 2. It has been recognised that concussion is a complex neural process that does not involve any structural brain damage and does not produce any changes on conventional imaging—for example, an MRI scan. Normally it resolves spontaneously in seven to 10 days without medical intervention. However, it may linger on, and post-concussion syndrome may lead to long-term problems.
On the subject of long-term concerns, recent research published in the USA suggests that multiple concussions or sub-concussive impacts might lead to a serious brain condition called chronic traumatic encephalopathy. This has resulted in a number of law suits being initiated in North America against the governing bodies of professional sports, the NFL and the NHL, and unless we in the UK act, sports governing bodies must expect similar legal action in the future.
My noble friend focused his remarks on the sports with the highest incidence of concussion. We need to look at all sports. Dr Turner, to whom I have referred, recognised that if concussion does not involve any structural damage it is reasonable to suggest that a little more impact would lead to a few nerve fibres becoming damaged or dying. He refers to this as concussion plus. You cannot tell the difference between concussion and concussion plus. They are indistinguishable at present because the tools we have are not sensitive enough to pick up the microscopic structural and chemical changes involved.
This is the tip of a highly complex medical iceberg. It is vital that we bring together all the expertise available in order to ensure that, by setting up a national centre—which could be world-leading and could co-operate internationally with best practice—our athletes, our clubs and our governing bodies are best served. I repeat, I hope the Minister will accept that this kind of initiative is worthy of further study and that he will attend a meeting—I hope with his colleagues from the Department of Health—with medical experts in this field, including Dr Michael Turner, to see what can be done to ensure that we are world leaders in this context, above all because we will be protecting the interests of our athletes, both able-bodied and disabled, as our first priority.
Baroness Grey-Thompson (CB)
My Lords, I thank the noble Lord, Lord Addington, for tabling this timely debate. The issue of concussion has been gaining momentum over recent months. The journalist Anne Peters has written extensively about it and it comes on the back of the announcement last August of the case of the NFL in the USA, where 4,500 athletes took a class action suit and sued the league. The league agreed to pay out a total of $765 million to fund concussion-related compensation, medical exams and research.
I am very pleased that the noble Lord, Lord Moynihan, raised the issue of “Head Games”. Unfortunately, I cannot make the premiere next week, but I have read the book instead. It makes stark reading in terms of the information it lays in front of us. Who can forget the tragic case of Ben Robinson who died in 2011? He was a young man who died after being concussed on the pitch three times. I spoke to Ben’s father Peter this morning. It was very emotional. It is hard enough reading about Ben’s case, but it is incredibly powerful listening to a man talking about his son who died playing the sport he came to love. It is probably fair to say that Ben was not a natural rugby player, but he was really good at the sport and was one of the best players on the team. The hardest part was listening to Peter say that Ben’s mum Karen had been at the game and she realised that something was not right, but did not feel that she had any power to stop the game going ahead. When she did try to intervene, she was told to “calm down”.
This is a powerful argument in making us realise that we have to involve many people and governing bodies in the discussion. I absolutely do not want to stop children playing sport, because the benefits are greater than being inactive. Peter told me that Ben received advice on nutrition, training and absolutely everything except concussion. Peter also said that he has a younger son who does not play rugby, but he would let him if he felt that he could do so safely.
There is a lot of information out there, but would I have gone out and looked for it had I not been taking part in this debate? The answer is no, because I would have assumed that concussion would not be an issue in most sports that my daughter and I are involved in. Some of this comes back to how we educate people. Sport Scotland has issued a really good leaflet highlighting the issue of concussion and what you have to do if you see it in a young player. At the launch of the leaflet, Dr Willie Stewart presented a huge amount of information. He had interviewed 300 schools from the south-west of Scotland. The good stuff was that 90% recognised that concussion could be fatal. However, 30% of the schools said that they would still leave a child with suspected concussion on the field of play. Curiously, virtually all the 30% who would have left the child on the pitch would have then informed the parents that they thought the child had concussion, so there is a bit of a mismatch in terms of how young people were being treated. The survey also made it very clear that there was a need for a physical test in the first 24 hours after injury, but there was not the understanding that it was important for the brain to rest as well—that is a really important part of rehab.
It is also interesting that well known rugby players like Will Greenwood have spoken out on this matter and the need to take it seriously. However, it is really difficult for current players to speak out, because it is their career. How much time they spend on the pitch affects their sponsorship, media coverage and future contracts. So I think it is important that we engage retired players and, I hope, encourage more competing players to think about this.
Over the weekend, I was told the story of a professional club player who was very clearly concussed but refused to leave the pitch. The good news is that the referee refused to carry on. That might be easier to do at club level and it should be hugely applauded. But at a lower level, where there is a lot of pressure from parents and the children themselves who want to play, we should not be asking the children, “Are you okay to play on?”.
I have had a lot of help with preparing for this debate. The RFU has showed me a lot of information. Rupert Moon, a great Welsh rugby player and also a friend of mine, put me in touch with a lot of professional people within the sport who are trying to filter the information down. But we have to do so much more than we currently do. We have to recognise that, while there are many stories about rugby, the problem is about so much more than rugby. Yesterday, in the New York Times, there was a story about a young man, a 29 year-old former soccer player who died from chronic traumatic encephalopathy. He is the first named player to have died from this condition. On a four-point scale of severity he was considered to be at stage 2.
Part of all this is education and getting people to think about the issue, no matter whether it is lacrosse, hockey or any other sport we can think of. We also have to recognise that sport is dangerous. There were a number of concussion injuries during the recent Winter Olympics, while Maria Komissarova was injured during ski cross training. She has undergone a number of operations on her spine. My own husband broke his back cycling, and indeed many of my friends are in wheelchairs due to playing sport. I have twice been hit by cars while out training. By the end of my career I also knew that, despite all the benefits of doing sport, I would probably end up with some severe damage to my back, neck and shoulders, which has happened. But I still believe that the benefits far outweigh the risks.
I was trying to find some kind of context for this. Stories about sports injuries will obviously hit the headlines in lots of media outlets, but it is a question of trying to figure out what the comparable data are. Statistics from Headway using data extracted from the NHS show some massive figures for head injuries. During 2011-12, 213,752 people were admitted to hospital. There has been a 33% increase in UK head injuries over the past decade. The number of severe traumatic brain injuries is running at between 10,000 and 20,000 per year in the UK. Interestingly, men are twice as likely to sustain a brain injury as women, and if we look at the target groups, it is 15 to 24 year-old males and people aged over 80. Those figures are important in terms of putting the issue in context and showing how many people are injured. However, it is hard to find data for the UK, so measuring data is an area in which we need to do more work.
Mortality rates due to blunt trauma in the USA among athletes aged under 21 in organised high-school and collegiate sport show that there were 261 trauma-related deaths, 1,139 cardiovascular deaths and 427 deaths from other causes. If those numbers are broken down by sport, American football is responsible for 56.7%, track and field 10%, baseball 6.9% and then gymnastics at 1%, hockey at 1% and weightlifting at 0.4%. The average number of deaths per year is nine. Again, comparing these figures against deaths in the general population, some 12,000 are killed in road traffic collisions, there are 6,000 homicides, 2,500 young people die of cancer and, bizarrely, 50 are killed in lightning-related incidents, which is interesting. That is why we need some context in the UK.
I am also very conscious as a mum whose daughter plays a lot of sport that the temptation is to stand on the sidelines and say, “Come on, you are all right”. My daughter has never hit her head playing sport, but when they skid across the hockey pitch one says, “Come on, darling. Give it a bit of a rub and you’ll be okay. Get back out there”. That is because there is pressure on people to carry on playing, and that is much more the case for boys. We have a culture where it is cool to be a sporty boy but not so cool to be a sporty girl. I think that that kind of pressure on boys is huge.
I have received some interesting information from a colleague of mine, David Sutton, who is the strength and conditioning coach at Northants Cricket. He has worked in numerous sports. He sent me some information on fencing, which I had never considered to be a sport where there was a risk of traumatic head injuries. What is looked for is the natural position of the arms following concussion. Immediately after moderate forces have been applied to the brainstem, the forearms are held flexed or extended, typically in the air, for a period lasting up to a few seconds. It is interesting that there is a lot of work in this area through fencing. David Sutton said that this ultimately comes down to three simple things. We need to educate our PE teachers and coaches. We need to be unafraid of running a SCAT score in order to check whether a young person has been injured. It is not enough just to say, “Are you okay?”. We also need much more training through accident and emergency departments and GP surgeries so that health workers understand the realities of concussion.
I am really pleased that we are discussing this subject in a debate and I hope that we will return to it again in the future.
Lord Storey (LD)
My Lords, first, I thank my noble friend Lord Addington for initiating this important debate. I must say at the beginning that I am speaking on this issue while being aware that there are noble Lords here who have far more experience and understanding of the subject than me. I wanted to speak in the debate for a number of reasons, which will become apparent in the next few minutes. I am a former teacher, and the importance of sport in general, and team sports in particular, is there for all to see. I do not need to catalogue the details of that importance. We are becoming an increasingly sports-mad nation, with more and more people participating in sport in so many different disciplines.
Every parent wants to know that their child is as safe they possibly can be, whatever sport they take part in. Parents want to know that their child has the right and suitable advice, equipment and medical support if something goes wrong. Of course, accidents do happen, and I am mindful of that myself. Having taken up skiing late in life, I was standing at the side admiring the view, completely out of anybody’s way, when a snowboarder hurtled towards me. The next thing I knew I had broken my tibia and torn my cruciate ligament. I had to be rushed off to hospital through no fault of my own. These things do happen.
In contact sports, the problem of concussion must be taken seriously. A cursory browse through the newspaper headlines shows what a real issue it has become: “Brain Damage Fear Hits Junior American Football”; “Concern over the Effects of Heavy Knocks to the Brain is Rising among Contact Sports”; “Rugby Union Doctor Warns of Legal Cases over Brain Damage”; “Concussion is a Massive Problem for Rugby, Says Players’ Union Manager” and so on.
I have been rather disappointed by Answers to some Questions in the other place. Jim Shannon asked the Secretary of State for Health,
“what recent discussions his Department has had with the Rugby Football Union regarding the problem of concussion in that sport”.
The Reply was that there had been,
“no discussions with the Rugby Football Union regarding the problem of concussion in the sport”.—[Official Report, Commons, 27/1/14; col. 435W.]
Sir Bob Russell asked the Secretary of State for Culture, Media and Sport what advice players were receiving regarding head injuries and was told:
“It is a matter for National Governing Bodies”.—[Official Report, Commons, 20/11/13; col. 921W.]
I do not think it is a matter just for the governing bodies of those sports. We should not think is somebody else’s problem—it is an issue for all of us. I think that all of us would expect that the Government take these issues seriously and work with the national bodies and relevant partners to see what can be done.
One of the delightful—or less delightful—things about debates is that you have to do some research. The noble Baroness, Lady Grey-Thompson, mentioned Ben Robinson, who I did not know about until I did some research. I was saddened by the case of this lad who suffered a double concussion and died while playing a sport that he loved but, as in so many other cases like this, the parents immediately took up the issue, and a campaign was started. There was a meeting with the Scottish Government, there are leaflets available on what can be done and the message was developed, “If in doubt, sit them out,” which has been taken up by American football authorities. Out of this personal tragedy, a really important campaign has started. In my own city, a young boy called Oliver King died while swimming due to sudden arrhythmic death syndrome. He was 12 years old. As a result of that terrible tragedy, his father set up the Oliver King Foundation, which campaigns for defibrillators to be placed in every school. I am pleased to say that the Minister, the noble Lord, Lord Nash, is going to meet with the parents in the next few weeks. Again, some good has come out of a tragic sporting death.
It is not just a matter for sporting authorities. What should we do? First, we should not assign contact sports some sort of pariah status, but nor should we pretend that there is not a problem. We should not believe that there are quick and easy answers, such as a mandatory three-week rest that will solve the problems. Nor should we believe that we can spend 15 minutes looking at a cut as a result of a contact sport, but only a few minutes if there is concussion.
After doing the research, the person who best summed up for me what our attitude should be is the rugby player Dean Ryan, and I will leave his thoughts with you. My noble friend Lord Addington will know that Dean Ryan had six caps for England and is currently director of rugby at Worcester Warriors. Bizarrely, he was concussed not while playing rugby but in the victory celebrations after winning a match when somebody, in moment of hilarity, actually hit him. Examination showed that he had a large bruise on the side of his head. As he said in a newspaper article:
“The rule then was that concussion brought a mandatory three-week rest from the game, hence me missing that final league game at which the cup was presented”.
He had to give up the sport, as he started having 20 to 30 seizures per month and so on. I think that what he says is very telling and sums up my thoughts:
“To rid ourselves of the effects of a poisoned history and the macho culture which still pervades the issue of concussion, players have to believe in the guidance they are getting and this is where my frustrations lie. The game, the professional game, isn’t getting it. I’ve been to recent conferences on the subject hoping to learn the way forward, but instead came away with yet more conflicting views and argument. What the professional game needs is to be told what it must do. It must be authoritative and convincing. And until it gets that guidance there is little chance of persuading players that there is a way forward; that they can stop running away from the doctor, that they can stop hiding behind a wall of lies which prevents appropriate and sensitive treatment”.
Baroness Billingham (Lab)
My Lords, I thank the noble Lord, Lord Addington, for this debate. After listening to all the previous speakers, there is not much left to say. That is a good job because I have just been told that I have two minutes. Despite that, I am undaunted.
The purpose of this debate is to show that we are living in changing times. Only days ago, we were being thrilled by the Olympics and seeing people whizzing down slippery slopes on trays and so forth—all potentially lethal. At the weekend we saw the England and Wales rugby; if ever there was a clash of titans, that was it. In past times we would have accepted the odd bang or fall and expected play to resume fairly quickly. However, these are new times. The recent medical evidence has brought with it a far more cautious approach. The long-term effects cannot be ignored. In fact, the medical evidence has already affected the views of parents and participants in a whole range of sports. Rugby union, as has been said, is under more scrutiny than ever. It is now apparent that parents are refusing to allow their children to play that sport, which is something we all ought to be concerned about.
All sports played at either a competitive or non-competitive level share the possibility of injury. However, life is strange, and it is not only contact sports which have become the focus of public attention and apprehension. Three weeks ago, I went to the ballet at the Royal Opera House. Before it began, the house manager came forward and said that two of the dancers had collided at the matinee that day and had mild concussion. Previously, there would not have been an issue, but the manager said that he was very sorry but they were unable to dance tonight and the ballet was cancelled. In the old days, it would have been on with the show.
We have to be very careful now. This is a game-changing period. We cannot ignore advice, and we have to be sensible. The Government must take their responsibilities keenly. We do not want to spoil or lose the beauty and wonder of our sport, but we must ensure that people taking part are fully protected. I look forward to the Minister’s reply.
Baroness Jones of Whitchurch (Lab)
My Lords, I am extremely grateful to the noble Lord, Lord Addington, for tabling the debate today. As a couple of other noble Lords have admitted, I also have to admit that this is not an issue that I knew a great deal about prior to this debate but, now that I have looked into it, I agree with him that this is a serious problem. I very much look forward to hearing from the Minister about how the Government are acting to address the issue.
As the noble Lord has pointed out, growing awareness has occurred because of very sad deaths, particularly among several young people. It is particularly sad when that happens on a school playing field, where pupils ought to be properly supervised and protected by the highest standards of safety protocols. Parents should be able to feel assured that their children are being looked after in that context.
However, there is also growing awareness of the more insidious and widespread threat of longer-term damage for those who play sports, particularly professional sports on a regular basis. It is becoming increasingly clear that a number of sports players who have suffered concussion on a repeated basis are suffering from dementia and other longer-term brain issues. That is obviously a particular cause for concern. While it might not be possible to eradicate the danger completely, we owe it to amateur and professional sports men and women to invest in research to understand the dangers better; to provide rules for safe play; to ensure that staff are educated in diagnosis and response; and to ensure that there are strict regulations regarding return to play.
What does this mean in practice? First, we should welcome the latest Zurich consensus statement on concussion, mentioned by the noble Lord, Lord Moynihan, which provides a well informed and practical set of recommendations for those involved in the healthcare of sports men and women. Their advice provides diagnostic tools about what should happen should concussion be suspected, and emphasises the importance of standard emergency management procedures to ascertain the extent of the injury.
Importantly, the advice recommends that it should never be permitted for a player to return to play on a day where concussion is suspected, not least because, even if they get up and say, “I feel all right”, or if their mum and dad say, “Come along, pull yourself together and get back on the field”, there may be post-injury damage that is not immediately apparent. This is a particular challenge in high-level high-contact games such as rugby and football, where both the player and the medical team may be keen to downplay the injury and allow the player back on the field. However, as evidence grows of the longer-term health risks, it becomes more apparent that we need strict enforcement of the rules on the principle about returning to play.
The guidance that I have just referred to also makes it clear that any return to play should be on a graduated basis—over a period of a week is recommended—while tests continue. Again we need to ensure that this approach becomes standard practice. I would be grateful if the Minister would confirm whether his department is taking on board the Zurich conference recommendations and what discussions are being held with the Department of Health to ensure that health professionals are more aware of the dangers of this type of sporting injury and understand the signs that they should look for.
Secondly, we need a clear set of rules specific to children and adolescents, recognising the particular health dangers for this group whose brains can swell uncontrollably after a single bang on the head. All schools need to be aware of the dangers and the steps that need to be followed immediately an injury is suspected. Every PE teacher should be trained in the assessment procedures, and should be expected to carry a card that lists the nine red-flag symptoms that warrant urgent action. Parents and governors should be expected to check that the necessary staff training and awareness has taken place and should have a system for monitoring the responses to sporting accidents, as well as rules for rest, rehabilitation, and return to play. I agree with many of the points about the improvements in school procedures made by the noble Baroness, Lady Grey-Thompson. Will the Minister give details of any discussions held between his department and the Department for Education about the need to raise standards of care in sporting accidents, specifically on school premises?
Thirdly, at the professional end of sports, all players and coaches should be trained to understand the dangers of concussion and its diagnosis. This should follow the initiative already taken by the rugby union, to which the noble Lord, Lord Addington, referred, and should extend to other sports. This is increasingly necessary in the light of the rising number of concussions that have been recorded per 1,000 hours of play since 2011. Andy Hazell, who was forced to retire from England rugby after failing to recover from a concussion injury, rightly made this point, which was echoed by the noble Lord:
“Players are getting bigger and faster, and the collisions are getting a lot bigger”,
so the challenges in this particular sport remain high. It is not just rugby union, though; concussion remains the most common injury in premiership football. Training and awareness for both players and coaches across all sports have to be key to improving safety, so will the Minister give details of discussions held with the governing bodies to roll out a programme of training for players and coaches across the spectrum for all sports?
Lastly, there needs to be a review of what further preventive measures can be undertaken. It is not good enough to say that these games are inherently dangerous and that this is the nature of the sport. Where changes can be made to the rules to protect players from dangerous practices, they should be introduced. Most sporting rules are not set in stone; they are constantly being reviewed and updated by their governing bodies. For example, rugby union rules have been regularly updated to provide greater protection for individual players without taking away any excitement of the game, and that can be done across the board in other sports. We should be asking all sports bodies to review their rules to see what further steps can be taken to limit impact on the head, and what penalties should be introduced against those who flout the rules.
We should also be encouraging more research into helmets and other head protection to ensure that the best possible guards are available and permitted in the games. Will the Minister reassure us that dialogue is continuing with sports bodies to encourage research into safety equipment and to develop safer rules of play? Will he give serious consideration to the proposal of the noble Lord, Lord Moynihan, for a meeting to discuss the establishment of a national research centre? I thought that he made the case very well in his contribution.
The solution to many of the problems that we debate in this House is better liaison between departments and more joint working, and that is certainly true in this debate. The solutions lie in better education, better awareness among heath professionals and more responsible sports governing bodies. I hope that the Minister is able to persuade us that he is taking all these issues on board, and I look forward to hearing what the department is doing to liaise effectively and improve performance on this important issue.
Lord Gardiner of Kimble (Con)
My Lords, I, too, congratulate my noble friend on securing this debate on such an important subject. I thank noble Lords for this illuminating debate. As the noble Baroness, Lady Grey-Thompson, and my noble friend Lord Storey acknowledged at the outset of their speeches, participating in sports greatly benefits individuals and society, but we must ensure that risks are minimised and that appropriate medical treatment is available to all.
Any head injury sustained on the sports field must be treated seriously. Instances of serious injury are, thankfully, low, with many patients recovering fully without special intervention. However, a minority experience complications that must be minimised or avoided with early detection and appropriate action. The noble Baroness, Lady Grey-Thompson, spoke movingly about the tragic death of Ben Robinson and about his brave parents.
Instances of concussion are undoubtedly of concern to governing bodies. From what I have seen, I believe that they take this matter increasingly seriously, and responsibly. The Football Association and other sports with experience of head injuries, such as rugby, American football and ice hockey, are working together to establish appropriate internal guidance. This point was raised by my noble friend Lord Addington. The equestrian community, to which my noble friends Lord Addington and Lord Moynihan referred, is very much at the forefront of this. We need to ensure that the experiences of the equestrian world are incorporated into what other sports are doing.
The FA rules on head injuries are extensive but, in essence, a player suffering a head injury must leave the field of play and may then return only if he is given medical clearance to do so. My noble friend Lord Addington referred to the amateur and community level of sport—what I would call the grass-roots end of the game—where a medic may not be present. There, the default guidance to all affiliated clubs in the FA is that the player cannot resume play, and the reintroduction of the player to football in the following weeks should be tightly controlled. The FA emergency aid certificate provides club representatives and volunteers with crucial skills and gives prominence to head injuries and concussion.
As the leading body on concussion management in sport, the Rugby Football Union works proactively with the International Rugby Board and independent experts to raise awareness, stay at the forefront of research and promote best practice, to which the noble Baroness, Lady Jones, referred. My noble friend Lord Moynihan mentioned the importance of global exchanges of experience. I have the leaflet produced in Scotland and supported by Scottish Rugby, the Scottish FA and sportscotland, to which the noble Baroness, Lady Grey-Thompson, referred, entitled, If In Doubt, Sit Them Out. Rugby has taken specific steps to reduce risk in the game and these messages are being cascaded to clubs.
My noble friend Lord Storey referred to the “Don’t be a HEADCASE” initiative, which educates players and coaches—it is very important to mention coaches as well—below professional level to recognise and remove players with concussion. Some 200,000 concussion awareness cards have been distributed, and posters have been sent to every member club and newsletters to every member school. The “HEADCASE” website has also been adopted by the Medical Officers of Schools Association. The RFU’s first-aid course for volunteers, coaches and officials also gives prominence to concussion. Its pitch-side immediate trauma care course for healthcare professionals also includes specific concussion training.
The noble Baroness, Lady Jones, rightly raised the important issue of safety within schools. Many young people engage in sport at school. Indeed, the Department for Education expects schools to provide a safe environment for their pupils and they must ensure that their training includes child safety and well-being. There is, of course, also the DfE advice on health and safety. Indeed, the Association for Physical Education and the Royal Society for the Prevention of Accidents provide professional advice to schools on how to manage activities safely and reduce the risk of injuries. My noble friends Lord Addington and Lord Storey mentioned that advice.
The noble Baroness, Lady Jones, rightly referred to the need for dialogue. DCMS Ministers meet DfE Ministers monthly as part of the ministerial board on PE and sport. The board also includes external partners, such as the Association for PE, that play a lead role in health and safety in PE lessons. The departments continue to work together to ensure that schools have the necessary resources to deliver high-quality PE and sport, including through professional external partners such as the Association for PE, and provide guidance and advice on ensuring the safety and well-being of their pupils when playing sport. The Association for PE guidance on safe practice in physical education and sport is available online through the Department for Education. This comprehensive guide provides examples of issues that schools should consider in risk management for school sport, and advice on managing and applying safe practice.
All sports governing bodies working with schools should ensure that participation takes place in a safe environment. All national governing body coaches working in schools should obtain the level 2 coaching standard, which includes basic first-aid skills as a minimum requirement. Indeed, as part of the school games initiative, in which around 17,000 schools take part, national governing bodies have developed competition formats designed to ensure that schools can provide safe, meaningful and appropriate competition to all pupils regardless of age, ability or disability. As to guidance on sports-related concussion, the national governing bodies and schools do good work in disseminating advice to prevent injury and improve pitch-side care. However, it is clear from the examples given today that undoubtedly more needs to be done.
At an international level, my noble friend Lord Moynihan and the noble Baroness, Lady Jones, referred to the Zurich consensus of 2012. I am pleased to acknowledge and endorse what the noble Baroness said about the welcome for this statement, which of course forms part of the learning that is increasingly being developed in the area of head injury. This outlines that when an individual shows any symptoms of concussion they must either be assessed on site by a licensed healthcare provider using standard emergency management principles or be safely removed from practise or play for urgent referral to a physician. The statement also highlights that a player with diagnosed concussion should not be allowed to return to play on the day of injury; that sufficient time and adequate facilities should be provided for the appropriate medical assessment, both on and off the field; and that the final determination regarding a diagnosis of fitness to play should be a medical decision.
Standards in sport and exercise medicine are set and maintained by the Faculty of Sport and Exercise Medicine, a faculty of the Royal College of Surgeons and the Royal College of Physicians. The faculty works to develop and promote the medical specialty of sport and exercise medicine, and oversees the training and assessment of doctors working in this discipline. In November last year, the faculty outlined key messages of concussion management in sport at all sporting events for athletes of all ages.
The noble Baroness, Lady Jones, asked about advice to health professionals. The National Institute for Health and Care Excellence, established by the Government to provide evidence-based clinical advice, issued updated guidance last month to support clinicians on the diagnosis and treatment of head injuries, including concussion. The faculty helped to develop this guidance.
The noble Baroness, Lady Jones, asked about the rules for children and adolescents in these matters. The recent clinical guidance, CG176, is on the Triage, assessment, investigation and early management of head injury in infants, children and adults. So the guidance refers to it all.
My noble friend Lord Moynihan raised the issue of a research centre. The Department of Health’s National Institute for Health Research is supporting a research project in Birmingham that is looking at the effects of repetitive concussion on athletes from sports such as rugby, football, cycling and gymnastics. The institute has awarded a research professorship to Peter Hutchinson at the University of Cambridge to study head injury. The institute at the moment has an annual budget of over £1 billion and I hope that this will be an important resource. I shall of course be pleased to have a meeting with my noble friend to discuss his proposal and see how best we can all help on these important matters.
There is so much more to say. The noble Baroness, Lady Jones, mentioned guidance. A lot of this further public awareness, which is so important, is on the NHS Choices website.
Concussion is one of the most complex injuries to assess, diagnose and manage. Clinicians will make a diagnosis on a case-by-case basis, using their training and clinical judgment, and take into account the individual circumstances of each case. Much has been said in this debate. If there are any outstanding points that I have not raised, I will write to your Lordships. It is important to say that I have consulted officials from all three departments in preparation for this debate. It is clear that all three are working together. UK Sport, as part of DCMS, is working with the governing bodies. The system is working, but I think we can always work better. It is important that individuals engaged in sport, which is such a force for good and benefits society so much, are safe and secure. We must make sure that participation is in the right environment and that, in the event of injuries, all steps are taken to secure a full recovery.