Oireachtas Joint and Select Committees
Thursday, 9 October 2014
Joint Oireachtas Committee on Health and Children
Concussion in Sport: Discussion (Resumed)
I remind Members, witnesses and those in the Visitors Gallery to ensure their mobile telephones are switched off or on airplane mode as they interfere with the broadcasting of equipment and they are unfair to members of staff. We have apologies this morning from Deputies Robert Dowds, Regina Doherty, Eamonn Maloney and Ciara Conway.
This is our third in a series of meetings of the joint committee that has been convened to discuss the issue of concussion and concussion in sport. I welcome Dr. Sean Moffatt, technical adviser on medical matters to Cumann Lúthchleas Gael, Mr. Ger Ryan, chairman of the Medical, Scientific and Welfare Committee to the GAA, Dr. Rod McLoughlin, Head of Medical Services at the Irish Rugby Football Union, IRFU, Mr. Omar Hassanien, chief executive of the Irish Rugby Union Players' Association, IRUPA, Dr. Joe McKeever, medical adviser to the Irish Amateur Boxing Association and Dr. Mary Flannery, honorary medical officer of Horse Sport Ireland.
I thank all the delegates for being here this morning. I apologise for delaying them up at the beginning. It was necessary to do a small bit of private business. As Members will be aware following last week's meeting, there was considerable interest from the media and public and there were many inquiries from members of the public to the office of the committee. I thank people for taking time to contact us since last week's meeting. For those who watched the proceedings or read the transcripts of last week, it was a very thought-provoking and interesting meeting. Many different issues concerning the issue of physical activity, in particular regarding sport, were highlighted. I will single out Michael Dara Macauley for the ambassadorial role he played which has resonated with people across the county and I thank him for that.
Before we commence, to remind people on privilege, witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if the witness is directed by the committee to cease giving evidence in relation to a particular matter and the witness continues to do so the witness is entitled thereafter only to a qualified privilege in respect of evidence and the witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice that where possible they should not comment on, criticise or make charges against any person or entity by name in such a way as to make him or her identifiable and Members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that Members should not comment on, criticise or make charges against any person outside the House or an official either by name or in such a way as to make him or her identifiable.
As this is the first of two parts of today's meeting, I remind Members in particular that we need to have finished the proceedings by 11.20 a.m. because we have to allow time for turning around the room and the equipment. I also remind people that these proceedings are being broadcast live on Oireachtas TV which is available on Sky, UPC and on the Internet.
I call on Mr. Ryan to make his opening remarks.
Mr. Ger Ryan:
The GAA would like to thank the Chairman and the committee for the invitation to present here today on concussion. I chair the GAA's medical scientific and welfare committee which is responsible for advising the association on medical and general player welfare matters and driving policy in these areas. I am joined by Dr. Sean Moffatt who is the technical adviser to us on medical matters and has extensive experience dealing with sports injuries and as a GAA team doctor. Dr. Moffatt will give an overview of the GAA's guidelines on managing concussion injuries and safe return to play. I will conclude with the actions we have taken in relation to policy.
Dr. Sean Moffatt:
Concussion is a brain injury which the GAA believes must be treated seriously to protect players in the acute and long-term periods following this important injury. By definition, it is a complex pathophysiological process in which forces are transmitted to the brain and result in temporary impairment of brain function. In considering this definition of concussion, there are four key strands to be considered. Concussion can be caused by either a direct or indirect blow to the face, head, neck or elsewhere in the body with forces transmitted to the head. Concussion typically results in a rapid onslaught of short-lived impairment of brain function that resolves spontaneously. In some cases, symptoms can take longer to develop. Typically, concussion is a functional disturbance rather than a structural disturbance. Therefore, typically, on neuroimaging such as CAT scan or MRI, there will be no abnormality detected. Contrary to popular belief prior to an increased awareness of concussion, a person does not need to lose consciousness to have a concussive injury.
Since 2007, the GAA has focused on raising awareness on concussion in three key areas. These are education and knowledge transfer to our players, coaches, managers, team doctors and physiotherapists, highlighting, in particular, the diagnosis and on-field management of concussion, and the ongoing management of concussion and safe return to play. In terms of diagnosing concussion, an index of suspicion is required. The team doctor needs to closely monitor play, in particular collisions. It is necessary to be able to recognise the symptoms and signs of concussion which can vary from the very obvious to the subtle and hence the difficulties sometimes in diagnosing concussion. The typical symptoms and signs range from balance difficulties, such as dizziness, to headaches, drowsiness, confusion, irritability, noise and light sensitivity and the more obvious signs and symptoms, such as loss of consciousness or concussive seizure.
It is the GAA’s position stand that if there were a detection of any one of these symptoms or signs, a player must be safely removed from play following medical evaluation. The player should be brought to the side-line, serially monitored by the team doctor or responsible adult. If no team doctor is available, they should be brought for immediate medical attention, whether at an accident and emergency department, GP or out-of-hours services.
The GAA has advised that while the use of concussive assessment tools such as SCAT 3, sport concussion assessment tool, are useful in making the diagnosis of concussions and assessing their initial severity, the assessment of the symptoms, neuro-cognition and balance should be done after a 15-minute rest period, therefore excluding the effects of exertion and fatigue. However, it remains a clinical judgment for a medical doctor. There is no other diagnosis tool, bar a doctor’s medical knowledge. Hence, the drive by the GAA to educate our playing population, coaching staff, team doctors and physiotherapists.
With regard to return to play, the cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve. Typically in uncomplicated cases, the acute symptoms resolve after a rest period of 24 to 48 hours. Our protocol following a concussion follows a step-wise process where a player should only continue to proceed to the next level if asymptomatic at the current level. Generally, each step would take 24 hours.
The GAA has taken on board the consensus expert opinion on concussion and the advice from our medical opinion to advocate and adopt a much more conservative return to play in our child and adolescent population where the emphasis is on return to learn and safe schooling. For the five to 12 year old cohort of players, we have adopted a minimum rest period of two weeks and the child SCAT 3 as an assessment and management tool for concussion.
Other modifying issues that we have discussed at length and at education meetings with our team doctors that may predict longer return to play are more serious or persistent concussion symptoms, players who suffer recurrent concussion injuries, players who have suffered a loss of consciousness for greater than one minute as part of their concussion injury, concussion injuries that occur repeatedly with less traumatic force and being aware of the comorbidities of players who suffer from migraine, depression or children with attention deficit disorder or learning disabilities.
The GAA has adopted and advocated a comprehensive educational tool since 2007 that is in keeping with best practice internationally and we continually review for players, managers and team doctors.
Mr. Ger Ryan:
In 2007, the GAA produced a position statement on concussion and this position was subsequently updated in 2013. A multifaceted educational programme was devised earlier this year which aims to transfer knowledge to players, coaches, parents, referees, administrators and medical personnel on concussion, as well as the GAA’s guidelines in this regard. This programme comprises concussion workshops, seminars, a specific e-learning course and information leaflets designed to get to as wide an audience as possible.
The GAA has teamed up with Acquired Brain Injury Ireland on awareness campaigns which saw posters being distributed to each club, video campaigns featuring high-profile players and wallet cards being produced for coaches. The association has operated a national injury database since 2007 in conjunction with the University College Dublin’s School of Public Health, Physiotherapy and Population Science. It informs us on the incidence of concussion injuries associated with playing senior inter-county football and hurling, while trends in numbers and impact of such injuries can be monitored and reported.
The GAA has worked closely with the Gaelic Players Association, Gaelic Games Doctors Association, UPMC Beacon Hospital and the Department of Education and Skills to ensure our guidelines are up to date. The GAA recommends consideration be given to establish a task force with representations from sports organisations, sports medicine bodies and primary and post-primary schools to devise an appropriate educational programme to improve awareness of sports-related concussion, its management and possible consequences among players, parents, coaches and medics.
The GAA believes there is scope to provide education and training for all GPs, out-of-hour GP services and accident and emergency departments in post-traumatic brain injury assessment and management to limit the chance of players receiving varying advice. There is scope also for additional research.
The most important message for all stakeholders is that players with symptoms that indicate a concussion be removed from play - If in doubt, sit them out. Thereafter, appropriate management is essential for reducing the risk of long-term symptoms and complications.
Dr. Rod McLoughlin:
The IRFU welcomes the Oireachtas Joint Committee on Health and Children’s invitation to address the committee on sports concussion. I am here in my capacity as head of medical services with the IRFU. I am also director of medicine at the Irish Institute of Sport and medical officer at the Olympic Council of Ireland, as well as having been a member of the GAA’s medical scientific and welfare committee.
Medical information about concussion in sport has already been presented to this committee. For this reason, I will present how the IRFU is managing concussion in rugby. Concussion education and management sits at the very top of the IRFU’s player welfare strategy aimed at educating, supporting and protecting players at all levels of the game. The strategic vision of the IRFU is that all players, coaches, referees and medical personnel involved in rugby union understand the importance of concussion, how to recognise concussion and manage it, therefore enhancing player welfare. The union is providing leadership to change the culture in rugby. The culture to which we aspire is one in which concussion is considered a serious injury, actively monitored for, recognised and proactively managed with player safety the ultimate consideration. We are working to achieve this vision and culture change by concussion education, regulation, prevention, management and research.
Education is at the heart of driving awareness and cultural change. The IRFU is delivering its educational programme in concussion roadshows. Almost 2,000 people have attended 54 concussion roadshow talks nationwide. Almost 900 participants have attended one of 46 SAFE rugby courses, a one-day practical course with one instructor to every six participants. These courses include concussion management protocols, basic life support, defibrillator training and first-aid management of sport injuries. Up to 30,000 concussion education wallet cards and posters were distributed last season to every club and school in July 2013 and January 2014. The medical section of the IRFU website was redesigned with educational content on concussion. We are developing child-friendly material. The IRFU's medical staff has presented educational talks to the emergency medicine, sports and GP doctors. The IRFU is targeting schools, adolescent children, coaches and referees with educational material specific to each group to inform them of their role in concussion management with specific guidance for each.
Rugby recognises the association between concussion and CTE, chronic traumatic encephalopathy. Regulation which includes mandatory components, coupled with strong education, is key to mitigating the risks. Concussion management strategies have been supported and reinforced by the following mandatory components. The IRFU introduced mandatory time out of the game for those with a suspected or confirmed concussion of 21 days for adults and 23 days at underage level. All coaches attending an IRFU coaching course must complete an online concussion educational module. Club and school funding has been linked to completion of concussion education by coaches. Referees report all concussion and suspected cases of concussion in the Ulster Bank League.
In the area of prevention, coaches are being educated on proper tackle techniques and appropriate training schedules, while referees are being educated on their role in injury prevention and the dangers of foul play. A medically supervised graduated return-to-play protocol that recognises the importance of treating youths more conservatively is at the heart of our approach.
The IRFU operates a zero-tolerance stance towards playing with concussion or suspected concussion. The message is, Stop – Inform – Rest – Return.
Any player with any symptoms of concussion must be removed and cannot return to play that day. Under IRB law 3.9, the referee may order an injured player to leave the playing area. Referees have been reminded of their powers under this law and its use in suspected concussion.
The IRFU is continually updating its concussion management strategy in line with new developments in this evolving area of sports medicine. We are at all times guided by the Zurich guidelines of 2012 and ongoing research. As I have already said, we have introduced mandatory time out of the game for those with a suspected or confirmed concussion and the linking of funding to coach education and we are monitoring compliance with these things. The IRFU is also developing bespoke adult education videos for Irish coaches.
Research drives IRFU’s concussion policies. The IRFU is currently supporting a study of schools rugby injuries, including concussion, in Ulster rugby. The union have developed an online reporting system to allow referees to advise us on any suspected or confirmed concussions during a game in the all-Ireland league. This enables us to audit the incidences and engage directly with the player and the club to ensure they follow the return to play guidelines. The research will inform the IRFU about how effective our concussion strategy has been and guide future developments in concussion management.
We recommend the following considerations. They include the development and distribution of concussion education material throughout the schools system and the development of "return to learn" guidelines for schools, similar to the return to sport guidelines and education of teachers and parents on the importance of this part of management. We have "return to sport" guidelines but we do not have any "return to learn" guidelines. Other recommendations include concussion education and training of all medical personnel who are involved in managing this issue, improved access to specialist care and a consensus on minimum return to play timelines across all sports nationally.
The IRFU is leading the drive to change the culture within Irish rugby with regard to concussion and its management. The union has been proactive in driving a concussion awareness campaign, which has been underpinned by an initial broad-based educational programme. This is now moving to focused education at multiple levels of the game supported by mandatory components. The IRFU operates a zero tolerance stance towards playing rugby with concussion and the message to all is "Stop - Inform - Rest - Return". The IRFU has been proactive in its management and continues to evolve its strategic approach to managing concussion which is based on the most up-to-date scientific evidence.
Mr. Omar Hassanien:
I thank the Oireachtas joint committee for allowing me to speak on the hugely important area of concussion in sport. To provide some degree of background, I am a former professional player who currently acts in the role of chief executive of the Irish Rugby Union Players' Association, IRUPA, a body whose underlying mandate is to protect and promote all aspects of player welfare in the professional side of the game in Ireland. To be clear, IRUPA is a body that sits independently from the IRFU, employing a primary focus of protecting players' interests whilst also promoting the broader game.
In addition to my domestic obligations to the Irish professional player group, I also act as a director on the board of the International Rugby Players' Association – a role that is perhaps more relevant here given the global nature of the issue. While I do not come from a medical background, my experiences both as player and my involvement in these collective player representative bodies would hopefully qualify me to offer a unique perspective in this area.
This forum presents us with a wonderful opportunity to analyse the issue of concussion not only in promoting the dangers of mistreating head injuries from a medical perspective but also in discussing the mechanisms by which we are promoting education and awareness in our respective sports. Generating this awareness is crucial with respect to those within the sport as well as members of the broader public who play the game and who idolise those in the professional game - looking up to them as role models.
While my colleague, Dr Rod McLoughlin, has spoken more about the management and research side of concussion, I will focus more so on the educational and awareness building side. Also, while Dr McLoughlin has addressed the game of rugby in its entirety, I will be focusing on the professional game only – the group of players for which we are responsible as a players' association.
Education and general awareness are such important aspects here as essentially they are the keys to mitigating risk. When addressing this aspect, it is important to recognise that we are talking about a cultural change of attitude, which Dr. McLoughlin has also touched on. Along with educating medics at the highest level, all other stakeholders including players, coaches, management and referees must understand their respective roles in the ongoing management of head injuries.
The education of players is critical in driving the overall cultural shift required here. IRUPA works closely with the IRFU in ensuring that players are well aware of the risks. During the most recent 12-month period, the IRFU, with the involvement and cooperation of IRUPA, has been around to all provinces in Ireland taking leading neurosurgeons with it to provide the players with an in-depth presentation on concussions, the symptoms and effects. Additionally, wallet cards have been issued and informative posters are at the respective provincial training bases. In its quarterly magazine, IRUPA promotes awareness of the potential long-term effects of head injury mismanagement so we are constantly trying to inform our players.
We also believe that there must always be a focus on loud vocal messaging from the right type of people. Obviously, the medical advisers in the sport need to be active here but equally and perhaps even more significantly, it involves the senior players themselves speaking out and breaking down long-held attitudes of "tough it out" and "you'll be right" that perhaps have been culturally embedded in the past prior to us developing the knowledge we have today about concussion. Players being vocal is perhaps the quickest and most effective way of breaking this down.
As an indicator of how productive these educational measures have been in the past two to three years, we can refer back to an IRFU survey carried out in the 2011-2012 season. Of those players who said they suffered from concussion and remained on the field, 95% did so because they did not think concussion was a serious issue. Only two years later after the work carried out by the IRFU, we conducted our own survey which revealed that 80% of the players were now concerned about concussion – a statistical turnaround that was no doubt based on increased awareness campaigns in the sport both globally and domestically.
Moving on to other stakeholders in the sport, it is important to emphasise the importance of team coaches and management in this. Under no circumstances should these people have any influence over the decision of whether to remove a player from the field or not. The game has addressed this by not only educating coaches about the dangers of head injury mistreatment but also by linking it to performance. Leading medical experts in rugby are constantly preaching to coaches that a team's best player concussed is not as effective as a lesser player who is not concussed. They have supported this statement by highlighting video evidence of even mildly concussed players who show an inability to perform the more fundamental skills such as running the right support lines in attack or aligning in defence. The management of coaches is another crucial area in this cultural progression.
The role of the referee in the responsible treatment of head injuries should also not be understated. Often the referee is in a better position than anyone to see the impact of a collision at close range - sometimes even better than the use of video technology, which may not pick everything up. As Dr. McLoughlin mentioned, IRB regulation 3.9 gives the referee the power to remove players from the field of play. Referees should not be afraid to exercise this right for fear of the repercussions that removing an influential player might have. Quite simply, the health of the individual must take priority in all cases.
The IRB educates elite medical staff around the rugby world in various ways. In November of each year, it hosts its annual medical forum and medical advisors from all international teams are invited to Dublin to listen to leading practitioners present. I have personally attended this conference the past two years and have found it to be a very informative and interactive environment. The IRB Player welfare website, which is dedicated strictly to player welfare, has a very clearly laid out "Learn Online" concussion management tool in which medically trained visitors to the site can enter the interactive learning modules at various stages. There are modules for doctors, match day medical staff and elite match day medical staff. There is also a module available for the general public to access.
I will speak very briefly about the management of concussion in professional rugby. I will not speak for too long as Dr. McLoughlin has addressed this area, as did Dr. Falvey last week on behalf of the IRFU. Rugby is at all times guided by the Zurich guidelines of 2012, which we believe to be best practice in this area. Under the guidance of IRB Chief Medical Officer, Dr. Martin Raftery, the IRB has managed a working party over the past two years dedicated to pitch side concussion assessment, which is now referred to as head injury assessment. We as a players' association internationally have had a seat on that throughout. The fact that rugby has come out and recognised the association between concussion and chronic traumatic encephalopathy, CTE, is a positive step. While a conclusive link may not be formed at this point in time, the fact that an association or potential association has been recognised in the US is positive in bringing a focus to this matter.
As players, we also acknowledge that the game is adopting a strong preventative policy.
Rugby has shown itself to be a world leader in the promotion of correct playing techniques, as well as the implementation of laws that ensure that dangerous play - such as high tackles and tip tackles - is outlawed from the game as best possible. We compliment the IRB and the IRFU for giving this greater focus they have placed on this matter in recent years.
At professional level in Ireland, the IRFU complies with all guidelines set out by the IRB and takes a very serious approach to the management of concussion, particularly in the past few years. The IRFU has implemented an instantaneous video review system at all home international matches, which allows their medical advisors to assess the mechanics of the injury at that point in time and thus hopefully better understand the severity of that particular concussion on the spot. This puts them in a leading position throughout Europe in this regard and is a strong step forward from a player-welfare perspective.
The role of the players association in respect of all of this could be described as being twofold - first, understanding and influencing players and, second, interacting with the governing bodies of the sport. In the context of understanding players, our role is to represent them in a number of capacities. No matter how we represent them, we take on the role of being the key influence on many occasions. We are able to influence and shape opinion on the general approach to particular matters. With respect to managing head injuries, we educate our players in understanding their role in society and the degree to which they are revered as role models by a generation of youngsters. Players need to understand how closely their actions are being watched and, for this reason, they should not be seen publicly to be having any influence over medical staff in trying to remain on the field of play. They need to demonstrate, through both words and actions, that the entire decision is in the hands of the medical advisers. In order to understand our players better, last year we completed a survey of our membership specifically in the area of concussion. In the past month we have issued our more extensive biennial survey to players which questions them on all aspects of their employment. Concussion is obviously an important part of this survey in the context of the questions asked. We are awaiting the results of the survey, which will be processed by an independent body over the next month.
Our interaction with the governing bodies is sometimes conducted by me or by other members of the staff of IRUPA. On other occasions it is conducted through industry leaders. We employ Dr. Niall Hogan as our medical representative of the players and he acts as a conduit between ourselves and medical experts in the game such Dr. McLoughlin. At international level we as a collective international player body and, as stated earlier, we are involved in the IRB working parties. We have also been involved in concussion education videos with the IRB as part of the "Recognise and Remove" programme. Overall, our role in interacting with the governing bodies of the game is critical to both parties. The players need to be well informed and represented by their associations in this process and equally the governing bodies of the sport need to understand player attitudes and how they view this all important area.
As representatives of the players, we welcome being invited to forums such as this in order to discuss the important player welfare issue of concussion. We also welcome any studies and research which might lead to further advances in this particular area.
Dr. Joe McKeever:
My name is Joe McKeever and I work as a trauma specialist and a day surgeon. I thank the committee, on behalf for the IABA, for the opportunity to take part in this meeting. We are very grateful for the opportunity to make a presentation on the implications of concussion in sport and how the issue is being addressed by the IABA.
The welfare and safety of our boxers is of the highest importance to us and their welfare and safety is always our top priority. Established in 1911, the IABA's main role is to develop, foster and control boxing in Ireland. As one of its rules, the IABA lists the fact that any person who enters a boxing club must first undergo a medical examination to ensure they are fit to box. A boxer will not be allowed to partake in competition or in full training-sparring sessions until he or she receives a medical record book from the association. This book is used to record any competitive bouts the boxer is involved in and any medical information that would need to be recorded about the said boxer, including any periods the boxer has been restricted from taking part in competition or sparring. This book will accompany the boxer for the duration of his or her domestic boxing career.
The IABA is governed by the International Amateur Boxing Association, AIBA, or the world body for amateur boxing. Historically, the IABA self-regulated but was also governed by the AIBA. In the early 1970s, the relevant rules - which are listed at appendix 8 of my presentation - were introduced into Irish boxing. The AIBA in its Medical Handbook for Boxing, Eighth Edition, 2013, has set down rules in respect of concussion. The IABA is obliged to comply with AIBA rules and is happy to do so as they are strong than those which were previously in place. If the committee so desires, I can read out the relevant rules.
Dr. Joe McKeever:
Provision is made for minimal suspension periods after knockouts. If a boxer suffers a knockout with as a result of blows to the head or if the bout is stopped by the referee because the boxer has received heavy blows to the head, then the boxer may not take part in boxing or sparring for a period of at least 30 days afterward. If there is a loss of consciousness for less than one minute, the boxer may not take part in boxing or sparring for a period of at least 90 days afterward. If there is a loss of consciousness for than one minute, the boxer may not take part in boxing or sparring for a period of at least 180 days afterward. If, during a period of 90 days after a boxer's suspension for knockout, the boxer is knocked out a second time or if the referee stops a contest as a result of the number of heavy blows received to the head, then the boxer may not take part in boxing or sparring for a period of 90 days after the second occurrence. If the first suspension was 90 days, the repeat suspension will be 180 days. If the first suspension was 180 days, the new suspension will be 365 days.
Every year, each boxer who is set to represent Ireland in international competition must take an annual medical screening. All details of these screenings are recorded in the AIBA medical and competition record book for boxers. These medical booklets or passports contain the history of all individual bouts undertaken by boxers at international level and a history of all previous medical checks. Three months prior to every major international competition - the European and world championships and the Olympics - each boxer must undergo a medical by the IABA-registered doctor. Boxers are also fully medically examined at the weigh-in at international competitions and are passed to compete at competition. Before a boxer enters the ring for each competitive bout, a doctor will examine and make a decision on whether the boxer is medically fit to take part in the bout. As he or she leaves the ring, the medical doctor will always check the fighter again at ringside before he or she returns to the dressing room.
The IABA is of the view that all sporting organisations should report to a specific centre for concussion and be kept updated by same on advances in respect of detection or on regulatory matters regarding concussion in sport. The primary objective in the IABA's medical rules is to reduce the risk of severe injury and limit the long-term effects of repeated brain injury. The organisation has an excellent track record with regard to the control of boxers access to competitions as their medical record books must record all prior fight results. As members will appreciated, there is a need to ensure that a physician be available to oversee all national and international boxing championships. The IABA has adopted the AIBA rulings with regard to boxer exclusion following a concussion superseding its own measures that were in place since the 1970s. However, the need for a suspended boxer to have a MRI scan gives rise to a financial cost which may be difficult for all boxers to meet. We hope to be able to secure public funding to cover this increased financial burden.
Vigilance is the watch word of the IABA in regard to signs of serious head injury of any boxer in competition. The rules I have set out not only preclude participation in boxing competitions, they also exclude a boxer from sparring while training at his or her club or with his or her squad.
These rules, introduced in the mid-1970s, have proved to be far-sighted and ahead of their time. This is evidenced by the fact that no AIBA boxer has suffered a severe head or brain injury in the last 40 years. Finally the medical examination now required to be undertaken before a suspended boxer is allowed to compete has been upgraded by IABA to take into account advances in medical imaging. As set out in the AIBA rule, an MRI or CT scan is required before a boxer is re-licensed following suspension. The IABA remains open to any suggestions that may improve the health and safety of its boxers as a result of medical research and studies carried out across a range of other contact sports.
Dr. Mary Flannery:
As honorary medical officer to Horse Sport Ireland, I thank the Chairman and the committee for inviting me to present on concussion in equestrian sport. In 2006, I was appointed to first medical committee of the Fédération Equestre Internationale, FEI, the international equestrian federation based in Lausanne which oversees all equestrian sports across the world. This committee was chaired by the late Craig Ferrall, who had a particular interest in concussion, and during my term of office it became very aware, from evidence-based medicine, that all concussion is serious and the terms "mild" or "moderate" concussion are no longer acceptable in medical circles. As a result, we introduced legislation with a mandatory suspension following any diagnosis of concussion and also making wearing of protective head gear compulsory. This has gone through right across the world in the various countries subject to the FEI. Horse Sport Ireland is unique in this sporting sphere, in that it encompasses many different disciplines of equestrian sport. It involves somewhere between 9,000 and 10,000 competing individuals on an annual basis, but with an enormous range of age, capabilities and experience. We have four year old children on lead rein ponies and we have people up to 100 years of age breeding horses for competition. It also embraces those who do not compete and who are involved with horses for leisure, pleasure, or commerce.
The FEI has advised on risk-management policy. Helmets are mandatory at all times and fortunately we have adopted a standard, which Dr. Adrian McGoldrick last week said he aspired to for all racing people, kite-marks on competitors' helmets, so that they are checked regularly. Cross-country competitors must wear medical armbands. These armbands show not only the individual rider's name, contact number and next of kin, but also their previous medical history, in particular any history of concussion or falls, any medications they are taking and any allergies they might have. If a horse or rider falls, they must leave the field of competition - hopefully walking and not on a stretcher - and they are not allowed to re-mount until seen by a medical officer. All falls are recorded in a medical book at events and a record of these falls is maintained by the individual disciplines within the sport. Competitors and horses are monitored regularly by stewards at competitions to ensure that they are competing at a level for which they are qualified and capable. Stewards are advised that they may tell people, parents or individual competitors that they should be downgraded if necessary for their own safety. Tack and saddlery must be of a safe standard and are inspected regularly. The field of competition and courses are also checked by stewards and must be passed safe for competition.
Diagnosis of concussion has also been dealt with very specifically by various medical professionals, both this morning and in the last session, but it is important to get through to competitors, riders and members that concussion is an alteration in brain function secondary to trauma. It is not structural damage and may not be obvious. We use the SCAT tools, which were very eloquently dealt with in last week's meeting. This SCAT tool is not an expensive piece of medical equipment, but rather a sensible series of questions put to the patient - for example what horse they were riding, which fence they fell at, etc. - and clinical observations. We have put a copy of this in the cover of the more recent medical books, so that medical officers and paramedics can refer to it. The importance of diagnosing concussion cannot be stressed enough because the real problem is ensuring that patients or riders have a sufficient recovery-rest period. An interesting North American study has shown that those who suffer brain injury and concussion and are undiagnosed and not allowed to rest are three times more likely to have a second episode within a year. Those who have a second episode are eight times more likely to sustain a third during that period.
Return to sport is therefore very important. Competitors sustaining concussion are given printed information on head injuries. Most doctors acting at an event will carry these, but in case they do not have them we are now putting them into the medical books which go around from one event to another. Those who have sustained a concussion are not allowed to ride on the day of diagnosis because suspension for 21 days is mandatory. This suspension can be amended to ten days if the rider is asymptomatic and is passed fit by a qualified medical practitioner. The suspension can be reduced to seven days if the rider has had previous neurogenic or psychometric testing and attains that level. Unfortunately, very few - in fact, none that I know of - in Irish sport have actually had psychometric testing. This is because of both the cost and the difficulty in having it done. All suspensions are recorded in a rider's medical armband and repeated episodes of concussion must be reviewed by a consultant neurologist.
Education, as my colleagues said earlier, is of the utmost importance. We must educate riders, handlers, parents, trainers, coaches and medical officers of the significance of concussion. Our coaches must undergo an equine-related first aid session before qualification as coaches, and this entails a module on concussion. We must ensure that our medical officers and paramedics are always in attendance and that medical records are kept in date. This is something to which we very seriously aspire in Horse Sport Ireland.
I join the Chairman in welcoming all our panellists this morning and in thanking each of them for their very well-prepared and informative presentations. It strikes me - and I can be corrected on this - that boxing and horse sports each have very specific rules applying that are immediately enforceable, and I commend that. Individual performances in these sports are perhaps, from my layperson's perspective, easier to follow, and to identify where an issue may present or may have presented. As a result, my questions will concentrate a little more on the team sports, where we are dealing with a much greater platform. We are talking about a pitch. It is a very big area, and one is not always able to see everything in quite the same focused way that one can in boxing and various horse sport activities. The poor referee, if too much responsibility is placed on one set of shoulders, will also not be able to do so.
I put my hand up as a parent. My young lad would be of a mind, as are many young people wanting to excel in what they undertake, that the helmet is a protection, but it was said to us here last week that it only protects the scalp. The helmet has no protective value in regard to the brain and offers no protection against the potential consequences of a severe impact. They might take up on that point. Is that impressed on players of all ages because it undoubtedly gives that extra degree of self-assurance, bravery and willingness to go the extra distance to put oneself in the gap of danger?
I thank the GAA. Dr. Flannery described well that this is a functional disturbance rather than a structure injury. For a lay person, it is immediately understandable. That simple phrase tells us all about this matter and how difficulty it is to identify.
When talking about those in charge, Dr. Moffat and Mr. Ryan state in their presentation that where a team doctor is present, he should advise the person in charge. Often that might not be a single person. Is it the practice that there is an identified person in charge who makes the call? We do not always have team doctors. Certainly, in juvenile football, it is not always the case. Who is the person in charge? Who, in the absence of a doctor, has that responsibility? In my own ignorance of everything, I learned last week that SCAT 3 was a piece of paper. This has been an informative exchange, even to that extent. With no biomarkers to make a diagnosis, what instruction can one give to that person in charge?
Dr. Moffat and Mr. Ryan state that certain individuals believe the GAA should relax substitution rules. I would think that such is a common sense approach to deal with the issue of having to assess, if it is at all possible to assess definitively, a suspected case of concussion. There are only X substitutions over the course of the game. It puts enormous pressure on the team mentors and players. Without question, in the heat of play there is an unwillingness to come off to let the side down. If there was a relaxation on substitution, that might take some of the pressure off. There might be a greater willingness for compliance in relation to coming off the field of play where a suspected concussion has taken place. I wonder would they elaborate on that. Are there prospects of that being done?
There seems to be a slight difference between the GAA and the IRFU or, in this instance, the Irish Rugby Union players' Association, as to who that person in charge might be. Of course, I get the sense that the referee has a role to play but the GAA presentation seems to place some degree of responsibility on making the call to the person in charge whereas it is clear from the presentation this morning from the rugby fraternity that, "Under no circumstances should ... [team coaches and management] have any influence over the decision of whether to remove a player from the field or not". Am I reading correctly that they believe it is the referee, wholly and solely, who should make the call in this regard? It is open to that interpretation. I invite Mr. Hassanien and Dr. McLoughlin to elaborate on that point. The IRUPA presentation states that the referee has the power to remove players from the field of play whose health he or she believes in is danger, and there seems to be that reliance. On a last point to the rugby representatives, the recognised association between concussion and chronic traumatic encephalopathy is not conclusive but would Dr. McLoughlin elaborate on that and give us a greater understanding of it?
I thank all the witnesses for their presentations. It builds on the presentations we heard last week also. We are on a journey of learning on this.
Using the experience from the United States, we learned last week that the protocol is that an independent person will make the decision. Deputy Ó Caoláin referred to that also. I am confused with the different sports about exactly who is making the decision because I hear different stresses on who exactly is making it. How does one deal with off-the-ball tackles, especially in team sports? One can say it is the referee but when the incident is not where the referee is watching, how does one deal with those instances?
We are dealing with the elite sporting levels and I am also concerned about how that filters down into the practice and culture of schools, clubs and counties so that the same culture and roles exist. One of the proposals put to us last week was that there should be training on pitch-side injuries but that a similar training would be given. I am concerned, if each of the sports is developing its own training, that often someone who is volunteering at a school or club level may volunteer with other sports and there may be slight differences in approach which could lead to problems. Last week we heard examples about New Zealand and South Africa. In New Zealand, there is one certification. How do we ensure that there is a consistent message for dealing with pitch-side injuries so that, whatever the sport, the same approach will be given? I believe that at the top level it will be looked after. I am more concerned that, at the schools and clubs level, the same approach filters down.
The mandatory reporting of injuries was raised with us last week. Dr. McKeever mentioned a reporting centre for concussion. How would that be done? Dr. Flannery mentioned that they keep their records but they are kept by the individual disciplines. One point we learned last week is that we do not have enough evidence and records to build up a picture of Ireland. How should we bring all those records together? Is it a matter for a sporting body or must we set up something else? As a legislator and policy-maker, I am asking for direction. What should we look for when we are making our final report?
Deputy Ó Caoláin also raised the issue of helmets. It was interesting for us to hear last week about the risk compensation that sometimes a young person may make because he or she has a helmet on. I am also concerned about the issue of bulking up. I have seen it in rugby in the past ten years since the sport has become professional, but we have also seen it in the GAA. I am concerned about the sale of products, particularly to children. We heard last week that it is all about nutrition, but at the weekend I returned to the sports shops and they do not mention nutrition. There are sporting heroes linked to these bulking-up products, including protein and creatine. I have a problem with that. I take issue with it and I wonder is there something that we should be doing as well. Whether it is the helmet or the bulking up, it makes players feel they are more invincible which will change the nature of the sport and lead to more cases of concussion because it makes for a much more barging-through type of play.
Do the witnesses believe legislation us needed and that we as legislators should be doing something?
Last week we were told to wait for two or three years to allow the different bodies to bring in their own rules and see how that goes. I would certainly be interested to hear whether there is something we should be doing at a national level, on a legislative basis or at policy level. Is there anything that the witnesses would ask we ensure is in our final report?
I welcome the witnesses and thank them for their presentations. Over the course of last week's and today's discussions, we have been learning a lot about concussion in sport. A number of issues came up during the discussions. It is obvious that we need clear protocols to adhere to best practice and that there are no national structures or guidelines available in schools. Many other issues also came up regarding, for example, proper concussion clinics and the need to set up an international centre of excellence, the lack of neurosurgeons and the lack of science around it all - how to recognise and treat concussion. It is also necessary to invest in education. Who do the witnesses think should be responsible for rolling out the awareness and education programmes? Should it be the schools, the sporting bodies, the Department of Health or the Department of Education and Skills? Who should ensure that a player is forced to leave the field following concussion or suspected concussion? We have heard about the team doctors and medics, but they are really only available at the highest level. Up and down the country week in, week out it is either coaches or parents who are responsible for many of the juvenile teams. We mentioned the SCAT3 test. Are all parents and coaches trained in first aid and if they are carrying a first aid kit to a match, do they have a copy of this SCAT3 paper? If it is used, how is the data collated? I believe there is no national database either. How often is the SCAT3 test taken, particularly at lower level? Would the witnesses agree that all parents and coaches should be trained in first aid? The GAA has been rolling out education programmes since 2007 and I believe they have an app now that most clubs can use. However in the all-Ireland final of last year, one of the players played the last 20 minutes concussed. Were all the guidelines adhered to on that day? Was the SCAT3 test taken? If so, how come he did not come off the pitch and how come the concussion was not identified? Regarding boxing and equestrian sports, the protocols and rules are very clearly identified. I go to a lot of boxing tournaments as I have a fierce interest in the sport and am actually attending a match on Saturday night - Katie Taylor is going to be boxing in Fermoy. Perhaps concussion is easier to identify when there is a referee and two players, but I do like the idea of the medical record books.
I welcome the witnesses. I have been very lucky over the years in that I have been involved in a lot of sport and have received no serious injuries, except for four months ago when I fell off my bike and broke my hip - these things do happen. My focus is players' concerns. Players have to be educated and informed about the research and the culture change. As far as I am concerned there are two types of sports - the sports for the elite professionals like the Gaelic players who represent their country and go over to Australia or the rugby players or the boxers. To me that is the elite. They seem to be the ones who are being looked after most of the time. The people who are my concern would be the amateurs, club players like wee boxing clubs in very small towns or horse riding clubs. I think they are the ones that should be looked after really well. The committee received a letter from Mr. Cliff Beirne, who is a consultant surgeon in the sports clinic in Santry. When I started to read through his letter, I realised that the media is getting all these reports and there is nothing really being done about it. He stated that concussion is a traumatic brain injury. We all accept that. Repetitive concussion may result long term in degenerative brain diseases. In this country we have seen a lot of bad incidents over the last years. I will mention a few examples if the Chairman will allow it. In 2009 Lucas Neville, a young St. Michael's student who suffered a second brain bleed----
A young student, then, from St. Michael's, who suffered a second brain bleed, was selected to play while still symptomatic with an undiagnosed initial brain bleed. There was also a young rugby schoolboy who tragically died from second impact syndrome, and a young schoolboy from Tralee who, if not for the prompt action of his mother in bringing him immediately to hospital, would have had extremely adverse outcomes. Most referees get paid to referee a game and look after the game. I think it is the referee's responsibility to take action if a person takes any kind of a knock. This year we have had fantastic weather and the grounds have all been very hard. I am sure there has been a lot of hard and heavy hitting and falling. Sport is played in a good way, but someone has to look after the amateurs, like the GAA, rugby, boxing; there is plenty of money there. These people have given up their time for absolutely nothing for the love of the sport. It is very important that a referee reports the incident. If the referee, manager, a person on the sidelines, or a player gets any kind of impact he or she should automatically be sent to the local accident and emergency clinic or the minor injuries unit. It is the responsibility of that organisation to monitor the situation going forward. Concussion is getting to be a big thing at the moment. When we saw Brian O'Driscoll getting the wallop in the Six Nations we all panicked that our chances might be gone. Concussion is a big thing. A large number of people and voluntary organisations are putting the effort into it. I think the players should be looked after and the onus is on the witnesses' organisations to look after these people.
Some of the issues that I wanted to raise have been covered, so I will be brief. One of the very precise recommendations from the GAA concerns setting up a task force. Has the GAA been in correspondence with the relevant Departments on that matter, and has it received a response? If a task force involving all the sports organisations is set up, which Department would be most appropriate for it to come under? This area covers the Department of Education and Skills, the Department of Health and a number of others. There is no point in it being answerable to a number of different Departments because that will not work. The GAA's recommendations are very well and very precisely set out. Mr. Ryan referred to the public health campaigns in Canada and the United States. If we were to do a public health campaign in Ireland, which one should be prioritised and fast-tracked that would be effective and would be of benefit for everyone involved in sport?
My last question concerns rural areas in particular. It is not physically possible for every sports club to have a medic available immediately. Where an event takes place 30 to 50 miles from the nearest hospital, is there any procedure in place to ensure that it is known where the nearest available medic is and who is on call before the start of the match? Many GPs are not on call at weekends. One is dependent on the call-out service from hospitals. Is there any procedure available for clubs to see where the nearest person who can be summoned to give assistance is, should something serious happen?
While all the clubs have people with training and expertise, sometimes additional assistance is required. Is there a procedure for it?
I thank the witnesses for their testimonies. While I am not primarily a rugby fan, over recent years, I have been impressed by the obvious attention the sports organisations, especially rugby, have paid to the safety of players. Apart from motor sports, I guess rugby and equestrian sports were historically the two leading causes of seriously neurologically damaging sports injuries in the British Isles, particularly neck, spine and brain injuries. Obviously, the responsibility of the sporting organisations ends when a medical decision is made that a person needs medical care. In Ireland, we have a more serious problem with our system’s ability to deal with head injuries. We have very few neurosurgical units. They are bizarrely centralised. Huge hospitals that designate themselves as major trauma centres are not equipped to do rudimentary brain surgery following somebody falling off a ladder or in a pub, or suffering a head injury while playing rugby, soccer or Gaelic football.
Are the witnesses happy with the level of service they get in general following the decision that somebody needs to be referred for specialist hospital-based assessment acutely? Are they happy with the availability of scans? From my practice I know that in some cases the waiting list for scans appears to be longer than the life expectancy of the illness one suspects the patient may have. I would be especially interested to know if anyone who sits on an international body has any sense as to whether our system is as agile and flexible in dealing with these demands as other, somewhat more sophisticated medical systems.
I have a particular question for Mr. McKeever. People who are on the interface of medicine and boxing face this argument constantly. Boxing is a special case in that the sport has gone to great efforts to ensure the safety of its participants. However, one can win a boxing match by killing one's opponent or by knocking one's opponent down and causing brain injury. To knock the person out is one of the ways to win at boxing. It is in the rules of the game. There should be absolutely-----
The technique and skill of boxing should be rewarded, not the effect it has on the recipient of the blow. Is Dr. McKeever happy that the game at an international level is putting sufficient effort into having zero tolerance for injuries in the sport?
Dr. Mary Flannery:
I reassure Deputy Ó Caoláin on the issue of helmets. Although equestrian helmets are much stronger than those used in football and rugby, as we found out last week they provide very little protection against concussion. However, they provide immense protection against structural brain damage and trauma, which is very serious. All disciplines of equestrian sport are governed by the Horse Sport Ireland board, which holds all the records, which are available for scrutiny. It would be very easy for each sport to have a stated policy on concussion. Funding for sport in this country, under the Irish Sports Council, is dependent on each sport being signed up to the World Anti-Doping Authority, WADA. Equally, perhaps sporting organisations that do not have concussion policies should not get any money either. Education is important, and, as I said in my presentation, we have gone to lengths to ensure all coaches, at whatever level, participate in an equestrian-related first aid course, which includes a concussion module.
Dr. Mary Flannery:
Yes. We should not forget that responsibility lies with the rider, who must prove he or she is capable and qualified to compete in such a competition. This is also very important in three-day eventing involving cross-country riding in which, unfortunately, there have been many fatalities over recent years. These were not due to concussion but rotational falls, when a horse hits a fence, its back end goes up in the air and the horse rolls over and falls down causing a traumatic crush. Unfortunately, these are very serious and have been fatal.
Dr. Joe McKeever:
The Senator did. There is probably a stenographer here. Because boxing has a background of support that traditionally comes from the working class and, ironically, the aristocracy, as it was a public school sport, it tends to particularly inflame people of middle class backgrounds with better incomes. There are no boxing clubs in Foxrock-----
Dr. Joe McKeever:
As a sport, it has always been hyper-vigilant in defence of those who are injured because it is very topical in the media, hence the example just seen. Boxing has extraordinarily close-proximity observation. The referee is less than 1 ft. away from the boxer. It is the art of self defence, not of killing one's opponent. In this country, there has been no significant injury for 40 years. On the skills levels ensured internationally, everybody here should hold his or her head high, because we have 16 out of the 28 medals that have been awarded to Ireland in the Olympic Games. In the history of Ireland's involvement in the Olympic Games, boxing has accounted for the highest number of medals. Among the people who are very much in charge of amateur boxing, Joe Christle, Mel Christle and Terry Christle, one is a former professional boxer and a surgeon. He is the only person I have every heard of worldwide who is a surgeon and a former professional boxer. Part of his hippocratic oath is to first do no harm to others.
Dr. Joe McKeever:
There is. In 2013, the international organisation adopted the view that headgear should be removed and I agree with this. Incidentally, I came here on a 1,200 cc motorbike and I will put on my helmet when I leave. However, with regard to helmets in boxing, they do not prevent concussion but prevent blood injuries that often look quite dramatic but actually are quite trivial. There is, if anything, a move towards the removal of helmets, which I believe we probably will see in the context of the Commonwealth Games of 2014. Those games just this year have been studied and it was found there were no significantly higher levels of concussion with the removal of helmets.
Given Dr. McKeever's remarks on the demographic and social background and his comments in his presentation regarding magnetic resonance imaging, MRI, availability and the costs thereof, has there been discussion with the Sports Council or the Department of Health regarding public funding or the financial issue he has raised, because it is an issue of concern?
Dr. Joe McKeever:
Absolutely. In my own capacity, of the 753 fights I have done, I have organised a scan of any boxer that ever was knocked out. It was not always an MRI scan but could have been a computed tomography, CT, scan. However, quite often nowadays, MRI scanning is employed. One must remember that the rules in boxing regarding concussion, for example, were written in the 1970s when such scans did not exist. The radiology and the safeguards are evolving and improving all the time and therefore these rules will evolve. As they do, there probably will be a new mandatory radiological test, which I believe would transcend boxing and would apply to any sport, be it football or rugby. In other words, if one is concussed, one is concussed and if it is the case that the best test to diagnose the level of concussion is a radiological test, that should be applied across the board to all the sports here.
Mr. Ger Ryan:
First, on the person in charge, as we are an organisation with 420,000 players, we cannot always presume on the presence of a medical doctor. Consequently, there is always a clearly identifiable person in charge and the guideline to coaches, referees and parents is to go to that person in charge. As part of our guidelines and our training, this point is made clear to referees, that is, they can insist that somebody be removed from play by going to the person in charge of a team. Related to this at intercounty level, where one always will have a team doctor present, if that team doctor suspects concussion, it is his or her duty to go to the person in charge, namely, the team manager, who must act on the doctor's instructions in that regard. The incident in the 2013 all-Ireland final has been raised a number of times. We have updated our guidelines since then and as a specific part of that, we went to the GAA's central council, its supreme governing body, which approved and reiterated this approach. This has been communicated to all team managers and in this year's championship, I recall a game involving a Derry player in which the required action did take place. Consequently, I believe we have learned from the aforementioned incident and have updated our guidelines accordingly.
The issue of independent doctors was raised and we believe that because our doctors do their work pro bonoand because we are an amateur association, they effectively are independent and have demonstrated this over a long period. There was a question on the mandatory reporting of injuries. Since we established our injury database in 2007, we have found that voluntary compliance with that from more than 20 teams each year is the best approach, because we work directly with the medical people. That gives us an excellent database for research from which we identify a number of programmes for both injury treatment and injury prevention. We have had a number of success in that area, one in particular being the whole area of anterior cruciate ligament, ACL, injuries or cruciate injuries as they are more commonly known. This is an approach whereby one gets together a good research database after which one can then take actions on foot of that. As to whether this is something that can be combined from all sports is a matter I will leave to members to decide but we certainly would be willing to co-operate with some sort of database in that regard. We recommend the education route, rather than legislation at this point. Compulsion through legislation is not necessary at present and I believe we could work on education. As for first-aid training, we certainly would support any initiatives in this respect but as an organisation, we encourage it and there is appropriate first-aid training at every club in the country.
Finally, there was a question on the task force that we recommended and we have met representatives of the Departments of Education and Skills and Health on this matter. It actually was initiated by the Department of Education and Skills but we suggest it should be driven through the Department of Health. We consider it to be a matter of public health and we recommend consideration of the programmes in Canada. As for prioritisation, we suggest that awareness and prevention should be the focus of any initial campaign. In addition, there is no formal policy in respect of call-out procedures but every club in the country has trained first-aid personnel, maintains a list of local emergency services and has easy access to it. At any significant games, even at club level, there are trained personnel, who again are volunteers, from the Order of Malta and such like. In addition, there also will be ambulances present. Consequently, I believe there is a high awareness of that.
As for the rule change for Cumann Lúthchleas Gael, I am aware it takes a motion at congress or a county convention to get change. However, in the context of the blood substitute, which has been introduced successfully, has consideration been given to concussed players being part of the blood substitute change, as opposed to being another substitute?
Mr. Ger Ryan:
Yes, this is something at which we are looking continually. We had quite a lot of debate on it before introducing our present system and is something we continue to review. There is a balancing act in this regard. As it fundamentally is a player welfare issue, somebody should be taken off. Were someone to break a limb, that player would not be able to continue even if all the substitutes had been used at that point and this case is comparable. The priority here is that somebody be removed as a player welfare issue. Other than that incident to which reference was made, we have not seen a situation in which somebody did continue. It is something we are monitoring continually and absolutely is something we are willing to consider but we have not decided to change it at this point.
Dr. Sean Moffatt:
I thank members for their important questions on and interest in concussion. I will take up on three key areas, the first of which is the concussion substitute. There is an awareness within the association of the medical resources. In many of the under age and club games, no doctor is on site. Consequently, the GAA has tried to have the same uniform message for both elite and club players. As we have been coming from a low base since 2007, it is very much based on education, whereby if one recognises a sign or symptom of concussion, the message is "if in doubt, take them out". As for players getting the best medical attention and safe return to play, the key consideration has been discussed but in considering the guidance of players, we did not want a situation in which they may be left in a vulnerable position whereby they remain on the field and sustain a second injury, hence the issue of the second impact.
In respect of specialists and with my general practitioner and sports physician hat on, I agree there is a general lack of neurologists and further to that, there is a lack of neurologists with an interest in sports concussion. As a team doctor and a GP, I am very much reliant on favours, personal connections and using the private health sector to get the opinion for players, particularly for those who have sustained their second and third concussion or, as we have highlighted, the concussion with modifiers. Each concussion is unique, a lot of concussions are not the same and for a lot of them, particularly for the second or third concussion, one will need specialist opinion. This is an area of public health to which we must give consideration. If we are to bring into place concussion policies, we will need those specialists to be in place in order to not leave players in limbo.
The third area on which I will focus is the SCAT 3 tool. All health care professionals, including doctors and physios, have been aware of the tool, the first medical part of which is recognition of the injury and a medical examination, namely, the Glasgow coma scale, as well as making sure there are no other injuries. The second part for doctors is a tool to assess symptoms, to outline return to play and to allow players to be serially monitored. I believe all players, coaches and schools should have access to the pocket concussion recognition tool, which is a more miniature version of it that is easily readable. It will give players, coaches and managers the tools to detect it and to be confident in this regard. It highlights that the key message is, "if in doubt, sit them out and get medical attention". That is where the SCAT 3 is a useful tool but it remains a clinical diagnosis for team doctors like me and it can be difficult. At times during the game, we do not have the benefit of video analysis or what spectators and television audiences would have. It is a clinical diagnosis and we have emphasised very much today our role in respect of education of the playing population.
Mr. Omar Hassanien:
Many of the questions relate to the amateur game and I will leave those to Dr. McLoughlin. I would like to clear up one misunderstanding regarding the question around with whom the ultimate decision lies. The simple answer is with the team doctor. The GAA and rugby are the very much same in this regard.
Issues were raised around coaches and management. When I refer to management, I refer to team management and administration, not medical management. Coaches and management should not be involved because they should not have influence over the decision. With more money coming into the game in countries such as France and owners coming in with their money, we need to ensure they are separated from medical decisions. Coaches who want their star player for a particular game or in subsequent weeks should be separated 100% from that decision. There should not be any pressure, therefore, from coaches or management. It may have existed in the past but it should not exist in this day and age. With regard to subsequent weeks, we have the gradual return to play policy in rugby. The coach should be separated from getting into a medic's ear or a player's ear to say, "You're okay, mate".
I refer to the issue raised around referees. The team doctor and not the referee is the final decision maker. However, the referee is often in a better position. I reiterate my colleague's words: "If in doubt, recognise and remove any doubt" or "If in doubt, sit out". The referee might often recognise that doubt having seen the collision and, therefore, he should advise the team doctor but, ultimately, the doctor will always be the final decision maker in that regard.
Dr. Rod McLoughlin:
We see that the referee is the person with the authority. We say to our referees that even if there is a consultant neurosurgeon on the sideline, if they doubt that somebody is fit to play or suspect they have a concussion, they should be off. We do not want clinical discussions on a sideline. The other important thing we are doing is that we are saying it is the responsibility of all. We are educating players that if the player inside them is concussed, they have a responsibility for their safety because, as has been clearly shown during this meeting, no one can see everything and we need to keep this in mind. People also need to understand that we are educating them for their health, not for our health. That is a culture change, which takes time.
The association between concussion and CTE was mentioned. I cannot tell the committee the association. A recent article in the British Journal of Sports Medicinerefers to 158 cases worldwide. All we seem to know is that traumatic injury to the head may have a connection with CTE. We do not know that yet and, therefore, what we need to do to mitigate that is manage concussions well now in order that people do not suffer repetitive concussions.
Training was another issue raised. All our trainers are pre-hospital care trained. We give standard medical approach training to all our people. It is not that they are getting different training. This is what doctors have been trained in; it is pre-hospital level training.
The IRFU has a clear policy on supplements. No supplements should be taken by under 18s. If somebody has evidence to suggest that policy has been broken, they should tell us.
I refer to the issue of whether legislation is needed. Zurich talks about medical clearance. I would look for clarity and help on this. My understanding is medical clearance can only be given by a doctor whereas in America allied health care professionals who have been specifically trained in concussion management and assessment are used. That may be worth looking at. Do we have the ability to use trained physiotherapists or others similar to practice nurses who have expertise in a particular area?
The pocket SCAT is included in our handout. Let me be clear that I do not want people to become doctors. If this helps make the diagnosis, that is fine, but, as has been reiterated, if someone has any doubt, he or she should not even take out the pocket SCAT and just take the player off.One of the kick backs we get is fear on the part of referees about taking responsibility for a decision they may get wrong and where they stand legally. We would prefer if they put off lots of non-concussed players rather than the other way around.
I estimate 97% of the time I spend managing concussion, which is two to three days a week in terms of policy setting and overseeing it, relates to the amateur game. One of the cases mentioned was a result of failure to follow the guidelines. Everyone mentions education and I will not argue with that but implementation studies tell us that for education to be effective, it has to be proactive, user specific, instance specific and impact orientated. For example, we have a six minute video that all our referees must watch. It specifically tells them what they have to do on the pitch and in handover with specific sentences of guidance. It is specific to referees, specific to an incident and it impacts outcome because we are telling them what to do. It is the same with our coaching and, therefore, we are moving on from education to looking at how education has a greater impact. We are also beginning to look at whether we are having an impact. We will come back and tell the committee because we do not know.
We give guidance to all clubs on the terms of basic first aid content and so on and we have taken our safe rugby programme nationwide. That is getting down and into the clubs. We are very much trying to drive this within clubs. Two weeks ago we gave a talk to 60 schools coaches because we have proactively gone after people. We rang and e-mailed schools to get names. We are going out there because one can produce the material but it can sit there.
I would like to acknowledge the presence in the public gallery of Mr. Stephen McNamara, IRFU director of communications; Mr. Feargal Carruth, chief executive officer of the Irish Amateur Boxing Association; Mr. Feargal Mac Giolla, Ceannaire Riarcháin na gCluichí-Imreoirí, GAA ceannaire; Ms Karen O’Boyle, communications manager, Acquired Brain Injury Ireland; and Mr. Damian McDonald, chief executive officer, Horse Sport Ireland.
I thank our witnesses for attending and for their expertise and time.
We will resume in public session on the issue of concussion in sport. I apologise to the witnesses for the absence of some committee members due to votes in the Seanad, conferences, by-election canvassing and a Fine Gael Parliamentary Party meeting. I request that those attending today switch off their mobile phones.
I welcome Dr. Tony Holohan, chief medical officer; Dr. Miriam Owens and Mr. Ronan Toomey of the health and well-being programme in the Department of Health; Dr. Tony Gaynor of the curriculum and assessment policy unit in the Department of Education and Skills; and Mr. Seánie McGrath of the inspectorate unit in the Department of Education and Skills.
Witnesses are protected by absolute privilege in respect of the evidence they give to this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of the proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and rulings of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I invite Dr. Holohan to make his opening remarks.
Dr. Tony Holohan:
I greatly appreciate the opportunity to speak to the committee this morning on the implications of concussion in sport from the perspective of the Department of Health. I am joined today by Dr. Miriam Owens, specialist in public health medicine, and Mr. Ronan Toomey, assistant principal officer, both of whom are working on the implementation of the Healthy Ireland project, which I will outline in a few moments.
First, I take the opportunity to commend you, Chairman, and your committee for raising the profile of this important issue which I have no doubt will make an important contribution to the awareness raising that must happen in relation to concussion. We have all seen some very public examples of concussion at major sporting events recently. We are also very aware that it is not just at major sporting events that the dangers of concussion arise. We know that there is always a risk of injury in every aspect of daily living. Normal day-to-day activities, whether in the school, while commuting, at home or in the workplace can result in injury. An injury such as concussion, wherever it occurs, presents particular challenges which we recognise need greater attention. Wherever incidents occur, during sport or otherwise, the Department of Health recognises that more can be done to respond in a manner that ensures the safety and health of the person experiencing concussion.
I understand that a number of medical experts presented considerable detail on concussion to the committee at last week’s hearing so I will not repeat it again but it is appropriate to recall a few particularly important points. First, it is important that we describe concussion as what it is in order to convince everybody of the severity of the problem. Concussion is mild traumatic brain injury. If those with responsibility for responding to incidents are convinced of this very real trauma to the brain, I think they will be more likely to respond in an appropriate manner. The symptoms of concussion may not be immediately apparent but may evolve over a longer period of time and it is important that somebody who may have experienced an incident is monitored to see how they are affected.
Concussion is not specific to any one activity and can occur anywhere. The management of concussion includes evaluation, removal from active participation, medical assessment of symptoms, and physical and cognitive rest until the acute symptoms resolve, followed by a gradual return to participation. The second important point to stress is that the risk of further complications is increased if an initial concussion is not properly diagnosed and treated. Members of the committee will be aware of Healthy Ireland, the framework approved by Government for improved health and well-being. The framework provides for new arrangements to promote effective co-operation between various sectors involved in protecting, promoting and improving the health and well-being of the population. The requirement to work together across sectors and across society is at the heart of what Healthy Ireland is about.
If the issues that influence the health and well-being of people are left to be dealt with by the health sector alone, we will fail to deal with them as we should and we will limit not only the health and well-being of our people, but also their ability to play a full and active part in the economy and in society at large. Healthy Ireland aims to provide a strong focus for modifying unhealthy lifestyle habits and, in particular, promoting awareness of the benefits of physical activity. These benefits are seen not just in physical and mental health, but also through participation and community involvement.
One of the priority actions under way is the development of a national physical activity plan, which will encourage greater levels of participation in physical activity. Mr. Ronan Toomey, who is present, co-chairs a group tasked with developing the plan with the Department of Transport, Tourism and Sport. It is a novel way of approaching something in which we have a shared interest and it is a very good piece of work which we look forward to being finalised in the near future. We all want more people to participate in sport and physical activity, but we want to encourage that in a way that keeps people safe and healthy and provides appropriate responses when an injury such as suspected concussion occurs. We must also ensure that we do not discourage anybody from participating in sport either directly or as a volunteer because of fears about sustaining injury or concerns about how to respond when in a position of authority or responsibility.
The health and well-being programme in the Department of Health, together with the Department of Education and Skills, recently began to explore the issue of concussion in school settings. The two Departments brought together a small group of relevant experts from key organisations to have an exploratory discussion about the implications of concussion and to identify current shortcomings in concussion awareness. Many of the experts have already contributed to the deliberations of the committee. A number of issues have been identified, many of which were also discussed by the committee last week - there is a need for a change of culture, particularly among coaches, players, officials and all others attending matches to remove a player suspected of having concussion from the field of play immediately and if concussion is suspected, a player should not be allowed to return to play until he or she has been properly assessed and medically cleared to return.
There is a lack of data on the incidence of concussion in this country. The need for cognitive rest is not fully appreciated and implemented. That has considerable implications for learning and engagement in school settings. There is a need for greater education and training of emergency medical personnel and general practitioners on the assessment and management of concussion. Without that, there is a danger of concerned parents and others being unable to access appropriate medical assessment and evaluation of possible concussion. It is vitally important that there is also education and awareness training for coaches, parents, teachers and all others involved in sport.
I acknowledge the work of a number of sporting organisations, Acquired Brain Injury Ireland and the faculty of sports and exercise medicine which have been very proactive in this area and have developed guidance on concussion, as they outlined to the committee, for participants, coaches, officials and others. The Department of Health believes there is an opportunity to build on this work and develop a uniform approach to understanding and educating people about concussion and creating a better awareness about injury prevention, risk reduction and response and treatment for concussion. While concussion is a complex issue, initially we intend to work with the Department of Education and Science and the group of experts from the key organisations to which I referred earlier, to raise awareness of the implications and responses necessary when dealing with suspected cases of concussion. We want to reflect best international practice, which is well set out, to ensure physical activities and sport can be undertaken in the knowledge that if an injury occurs it will be dealt with in a safe manner.
One way to progress the matter is the development and distribution of common information materials to reiterate that the management of concussion includes the elements I outlined. We hope the material will be widely distributed to everybody with responsibility for providing sports and physical activity opportunities. In our deliberations on concussion, we have recognised that we need to explore further what more needs to be done to ensure concussion is addressed in a safe manner. It is clear that the national governing bodies have a very important role in demonstrating an appropriate and adequate response to concussion when it occurs in public view. It is important for children and others involved in sport to see that what happens on television is in compliance with good practice and does not provide poor or bad example for them. It is through a greater public visibility of such actions that everyone can be aware and appreciate the dangers and consequences of concussion. Many instances of concussion are happening at events away from the public limelight and without medical or paramedical attention available. That clearly demonstrates a need for greater awareness among match officials, coaches, teachers, parents and players when concussion happens at minor events and in recreational settings and also the need for those routinely involved in such settings to have adequate training in the early management of injury.
While many organisations have developed excellent guidance materials for their individual sports - the committee has been made aware of them - there is an acceptance that there is not widespread adherence to guidelines. While in no way criticising the excellent progress made by a large number of organisations in recent years, a singular process will be beneficial in encouraging everyone to understand the true importance and implications of concussion, which as I outlined is a mild traumatic brain injury. Medical practitioners have the same duty of care when dealing with sporting or other injuries as they do in a formal clinical setting. That is important in terms of the visibility of events portrayed on television. In saying that, I also recognise that no medical or paramedical expertise will be present at the vast majority of occasions where people are participating in sporting and other recreational activities that take place every day of the week.
My colleagues in the Department will continue to liaise with the relevant experts to identify what we can do to develop a more effective and uniform approach to understanding and educating people about concussion through the singular mechanism we advocate and on which preparatory work has begun. I acknowledge the ongoing interest demonstrated in this issue and the evidence presented to the committee last week which clearly signifies the value and potential of the initiative on which we are about to embark. I would be happy to return in the future to provide an update to the committee if members so wish. I again acknowledge the commitment to this important public health issue shown by the committee and particularly by you, Chairman, in conducting these hearings.
I welcome the inclusion of player representatives at these committee hearings, as their experiences provide a valuable perspective. We look forward to the conclusions of the committee and to the continued ongoing engagement with relevant stakeholders.
Dr. Tony Gaynor:
I thank the Chairman and the members of the joint committee for giving me an opportunity to contribute to the committee’s consideration of the issue of concussion in sport from the perspective of the Department of Education and Skills. I work in the Department's curriculum and assessment policy unit. I am accompanied by Mr. Seánie McGrath, who is a post-primary subject inspector for physical education.
The Department recognises the seriousness of concussion and its potential impact on an individual's well-being. It is aware that concussion can happen to anyone, at any stage of life and at any time. It is not the case that it only happens during school time or on school premises, or that it only arises in the context of sports or other physical activities. The Department's focus is on ensuring school authorities are equipped with the appropriate knowledge and skills to enable them to promote pupil safety during school time or during the many extra-curricular activities that are supported by schools. We assure the joint committee of our willingness, in conjunction with other relevant stakeholders such as the Department of Health, to take any measures necessary to further promote pupil safety.
Each board of management of a school, or the relevant education and training board in the case of such schools, is responsible as an employer for ensuring as far as reasonably practicable the safety and health at work of its employees, pupils and anyone else on school premises. In particular, each school is required under section 20 of the Safety, Health and Welfare at Work Act 2005 to have a school safety statement. These statements are intended to ensure each board of management has the appropriate procedures in place to safeguard safety and health at school level. These include procedures in relation to first aid, accidents and dangerous occurrences and instruction, training and supervision.
The Department of Education and Skills and the Health and Safety Authority have co-operated to produce guidance to assist the boards of management of primary and post-primary schools in developing their safety statements. One of the key steps in this process is an assessment of the potential risks to safety and health within schools. When these risks have been identified and assessed, boards of management are expected to reflect in their safety statements the means by which such risks will be eliminated or prevented as far as possible. Safety statements should be regularly reviewed by boards of management to ensure they address any new risks identified at school level. We believe the structures in place at school level, through the safety statement process, are sufficiently flexible to allow schools to respond positively to any new pupil safety and health challenges they are made aware of.
The Department of Education and Skills is actively contributing to the Healthy Ireland agenda, which is being led by the Department of Health. To this end, we support a number of programmes and initiatives to promote physical activity and contribute to tackling the growing problem of obesity. As well as the physical education programme in primary and post-primary schools, the Department of Education and Skills also promotes the active school flag and active schools week, as well as a number of innovative pilot initiatives such as the Points for Life project, which focuses on improving the physical literacy of pupils. We are also centrally involved in the development of the national physical activity plan, which has been mentioned and is being led by the Departments of Health and Transport, Tourism and Sport.
The latest data, which were collated from schools through a life skills survey published by the Department of Education and Skills in January 2014, indicate that schools are very active in supporting extra-curricular activities among their students. These data indicate that 81% of primary and 96% of post-primary schools promote physical activities outside the school day. This encompasses a range of pursuits, including Gaelic games, soccer, rugby, athletics, swimming, hockey and horse riding. According to the same survey, 98% of primary and 86% of post-primary schools that responded to the survey promote physical activity during break-times. It is clear, therefore, that schools are playing an important role in the overall Healthy Ireland agenda. As we develop guidance for schools on the topic of concussion, the Departments of Education and Skills and Health are conscious of the need to ensure such guidance does not discourage schools from continuing to promote physical activity among their students.
The Department views the issue of concussion in sport or otherwise very seriously. The potential dangers are clearly illustrated by the tragic case of Benjamin Robinson. Following an initial approach to the Department from Benjamin’s father, Peter, officials spoke with him via teleconference in January 2014. Mr. Robinson outlined the progress being made at that time in raising awareness of concussion-related injuries in Scotland and Northern Ireland. Following that meeting, the information provided by Mr. Robinson was circulated by the Department of Education and Skills to the Physical Education Association of Ireland and the well-being team of the Professional Development Service for Teachers. Such information will enhance the ability of physical education teachers to deal with suspected incidences of concussion. Officials from the Department of Education and Skills made contact with their counterparts in the Northern Ireland Department of Education. The Northern Ireland officials agreed to share the work they were undertaking in this area, which subsequently formed the basis of the "Recognise and Remove" leaflet that was circulated to all school boards and other relevant bodies in Northern Ireland in May 2014. Mr. Peter Robinson's concerns were also raised by Mr. Seánie McGrath with the members of the national physical activity plan at a working group meeting on 12 February 2014.
The Department of Health made it clear at that time that it was concerned about this issue and was interested in promoting awareness of the signs and symptoms of concussion. Both Departments agreed to ascertain whether organisations providing information on concussion were interested in collaborating on an awareness raising campaign for schools. Such organisations include a number of major sporting bodies - many of them, including the IRFU, the GAA and the Turf Club, were mentioned earlier - and Acquired Brain Injury Ireland. Contact was made with the medical representatives of each of these organisations and a meeting was arranged in the Department of Health in July 2014. This meeting was attended by representatives of Acquired Brain Injury Ireland, the IRFU, the GAA, the FAI, the Turf Club and both Departments.
There was broad consensus among those present at the meeting about the seriousness of the issue of concussion. It was agreed to draft a concussion awareness leaflet for discussion among the group, with clear and concise messages to support everyone providing and participating in sport or physical activity in schools and elsewhere. There was broad agreement on the type of issues that would need to be covered in such a leaflet, including material on the sports concussion assessment tool, links to the resources produced by various sports national governing bodies and Acquired Brain Injury Ireland and references to the consensus statement on concussion in sport that was produced at Zurich in November 2012. While there is broad agreement on the main principles that should inform the leaflet for schools, some additional work is necessary. As this is primarily a medical rather than a pedagogical issue, we would defer to the expertise of the relevant health experts in the Department of Health, the national sports governing bodies and Acquired Brain Injury Ireland in drawing up the final content of the leaflet. We will be more than happy to advise on any education-related issues that arise in the course of drafting the leaflet. We envisage our primary role to be to circulate the guidance to schools as part of a communications strategy.
I will conclude by assuring the joint committee of our willingness to raise awareness of this important issue in schools. We will continue to co-operate with the Department of Health and other relevant health experts to ensure appropriate advice issues to schools. I would be happy to respond to any questions the members of the committee might have.
I welcome all of those present and thank them for their presentations. We have learnt a great deal about sport-related concussions since last week. It is obvious that we need to introduce clear protocols and to adhere to best practice. I would like to pick up on one or two points that were made in the presentations. Dr. Holohan said, "we want to reflect best international practice... to ensure physical activities and sport can be undertaken in the knowledge that if an injury occurs it will be dealt with in a safe manner". What is international best practice? What model or country should we be following in that regard? We were told that broad agreement was reached at the meetings that took place about an awareness raising campaign for schools. When will this be ready to circulate?
I would like to refer to a few of the issues that have been discussed over recent sessions. Who should be responsible for ensuring a player is forced to leave the field on foot of a concussion or suspected concussion? Given that medical personnel will not be present at all amateur and juvenile games played across the country, should the referee, the linesman, the coach or a parent have to do this? Should a person with first aid skills always be present before a match is allowed to start? Should all officials be trained in first aid? I was surprised to hear we have no national database to collate information. What do we need to do in that regard? The lack of proper concussion clinics is another issue that came up in the course of our discussions. How do we rectify this? We do not have an international centre of excellence. There is a lack of neurosurgeons. How can we change things so that we have the neurosurgeons we need?
Regarding education, who should be responsible for rolling out awareness campaigns? We have heard about a campaign that the Department of Education and Skills intends to roll out, but is the Department of Health planning to roll out a campaign? Are the sporting bodies going to initiate campaigns? Who should be responsible for this?
Many of the other questions I intended to pose have been asked and answered already so I will leave it at that.
I welcome all of the witnesses and thank them for their presentations. I apologise for not being here earlier, but there was a vote in the Seanad and a number of other committee meetings were taking place this morning. At the last session, the GAA raised the issue of a task force. I understand it has been in correspondence with the Department of Health on the subject. Is the Department of Health going to give serious consideration to establishing a task force which would have representatives of various sporting organisations and sports medicine bodies as well as primary and post-primary schools? Such a task force could devise a programme for dealing with the general issue of sports injury. Can we proceed with establishing such a task force, as called for by the GAA, and could the witnesses outline the timescale for its establishment? What is the thinking within the Department on this?
The next issue I wish to raise relates to primary schools, particularly those in urban areas. Where I work, on the north side of Cork city, one of the schools had more than 400 students but no indoor sports facilities, which was problematic given the Irish climate. The school fought for over 15 years before it got an indoor facility that could accommodate the students for physical education. Has the Department of Education and Skills carried out an audit of primary schools, particularly in urban areas, in terms of indoor sports facilities? In fairness to the Department, I know it must prioritise areas in which there are no schools at all or where there is a sudden increase in demand for primary school places. That said, perhaps it could roll out a five to ten year programme to provide or improve indoor sports facilities in primary schools. Has an audit been done to identify where the deficiencies are at present? What information is available in that regard?
A point was made in the previous session about equestrian and boxing organisations having a lot of strict rules and protocols. Reference was made to a medical record book that all participants in those sports are required to have. Is it practical or feasible to roll that out in other sports?
Dr. Tony Holohan:
In response to Deputy McLellan's question on best international practice, the consensus statement on concussion in sport of 2012, known as the Zurich statement, describes the assessment and management of concussion, and most international observers would regard that as the statement of best practice. In terms of where we look to for examples of best practice, we are talking about countries as well as individual sporting organisations. Some sporting organisations, at both a national and international level, are better than others. There are particularly good examples of best practice in rugby in South Africa. In terms of public health initiatives on the wider issue of concussion in sport, Canada is an example of best practice. We are looking at all of those examples and have material on them to build into what we are trying to do here.
We are at the initial stages of our engagement with the sporting bodies. We would like to be in a situation in which we have a singular message. We are all agreed on the science behind the message but we must reach agreement on how it looks and feels and how to promote it. The Department of Education and Skills will be assisting us in the promulgation of the message to the school setting, which is very important because the question of children returning safely to learning is a big part of the management of concussion. We still have some work to do in this area. While a lot of good work has been done by individual sporting bodies, we are some way away from the point at which we have agreement on a singular mechanism and are actually putting it in place. It would be hard for me, therefore, to predict how quickly it will be done. There is no lack of willingness on our part or on the part of the Department of Transport, Tourism and Sport to engage, and that is also the case with the sporting bodies themselves.
Deputy McLellan also asked who is responsible for the player leaving the field. That is a complicated question and I will offer her my personal view, rather than a departmental one. I am very involved in coaching myself, and when one gets down to a certain level it is difficult because the level of official engagement varies in the sports in which large numbers of young children participate. There are generally referees for games - in GAA, for example, there are Go Games referees, but they are only trained to a certain level. One of the big challenges for all sporting organisations is to get the volunteers and mentors trained to a sufficient level so that they understand their obligations as trainers. Issues such as child protection come into the equation here. There must also be a singular view among parents, which can be challenging. We believe that having a singular communication mechanism, a tool or a leaflet, that has the same look and feel whether it comes through the school or through the GAA clubs, boxing clubs, rugby clubs and so forth, will help in terms of consistency and implementing the message.
In terms of training requirements, the coaching courses that most of the major sporting bodies run have content on concussion. However, getting people to participate in those courses is challenging and we must recognise that fact. It would be very easy for us to sit in criticism of the sporting organisations, but we know they are doing their best to overcome the difficulties involved in getting the message out to very large numbers of people.
We do not want to introduce any artificial requirement that might raise the standard from a participation point of view only to see people dropping out. We must remember that it is predominantly volunteers who get children out onto the playing fields at weekends and so forth. Were they to drop out, even in small numbers, that would have a profound impact on the number of children participating in sport. Indeed, if we reflect on the wider issue of children's participation in sport, that is something we as a Department are concerned about. We are particularly concerned about the level of participation in sport by girls in their teenage years and about their access to sporting and physical activity opportunities. We do not want to do anything that will interfere with that. We must promote awareness and so on while preserving a lot of what is already in place that is good. We do not want the volunteers to drop out either, because there is considerable evidence that volunteering yields significant physical, emotional and mental health benefits, irrespective of the actual activity.
Reference was made to a concussion database, but one of the challenges is that a lot of concussed individuals never formally present to our health services, so capturing the data is difficult. We have national data on those presenting and being admitted to hospital following concussion, but that is not representative of the total body of people who are being concussed. My information is that most of the good information available in places such as the US is generated through special surveys as opposed to routine reporting systems, which would be very difficult to put in place to capture a full picture on concussion.
Concussion clinics were referred to earlier and neurosurgery was also mentioned, both of which are important. However, concussion per seis not something we will deal with effectively through the provision of neurosurgical services. That is not where the gap lies.
Again, I am not suggesting that the Deputy is saying that. Neurosurgery is required for people who have significant brain trauma as a consequence of whatever mechanism. We must promote awareness among first responders who are going to be dealing with the vast majority of people, particularly children, who are concussed. They must understand what they have to do. The provision of extra neurosurgeons, with all due respect to them, will not help us significantly in terms of dealing with the public health impact of concussion.
Senator Burke asked about the task force. I understand the suggestion was made by the GAA and I had a very quick chat with Mr. Pat Ryan, the chairman of the player welfare committee, whom we know and work with. This is something that is very resonant with the kind of idea we already have going. There is a meeting of minds there. We are already involved in an exercise and can look to how we might structure it in a way that addresses the specific GAA suggestion. Our door is completely open in terms of working with our colleagues in the Department of Education and Skills and with sporting bodies to address these issues and we would be very happy to look at what the GAA is proposing. The idea we have already outlined to the committee this morning - the work we have put in train with the Department of Education and Skills with regard to its initiative - to develop a common information tool is an expression of our commitment to the way of working that the GAA was calling for this morning.
There was a question on the medical record book in other sports. I cannot provide the committee with an informed answer to that. It seems to me that many sports have a great deal to teach other sports. There appears to be an increasing awareness or understanding of the value of the cross-fertilisation of ideas between sporting bodies. Outside this arena, we see the use of yellow and red cards. Some sporting organisations have demonstrated an ability to learn from others. While there will be questions around the practicality of some of those things when one gets into the very large numbers of people, particularly children, in certain large-scale sports, we will do anything we can to facilitate and encourage cross-fertilisation of learning in the approaches to dealing with concussion and the implementation of the standard guidelines.
I hope I have not left any question out.
I am sorry to come back on the task force issue, but in fairness, witnesses came in this morning with a very structured set of recommendations. One of the important things about meetings and public hearings such as this is to ensure we get something out of them and follow through. I accept fully that a great deal of work has been done by both the Department of Education and Skills and the Department of Health on this area. However, a complaint I have about a different area in the Department of Health involves nursing homes and home care, where there has been a failure to get everyone to sit around the table at the same time. It is fine to have the GAA come in and meet the Department of Health or the Department of Education and Skills, but they are doing so on a one-to-one basis. By getting everyone around the table, which is the advantage of a task force, everyone's view is out there at the same time and it is possible to come forward with a far more comprehensive solution. I wonder if their proposals and recommendations will be given serious consideration.
Dr. Tony Holohan:
I can provide the Senator with complete assurance on that. The process of sitting around the table, as we have outlined, is already happening. We will look at the specifics of establishing a task force and consider what has been recommended and why. We completely support the principle behind it, but the Senator will understand the position on the establishment of a task force without reference to the Minister. I am quite happy to reflect on the matter, advise the Minister and have him make a decision. I am sure he will be willing to update Senator Burke on that at a future point.
Dr. Tony Gaynor:
A few of the questions were directly for the Department of Education and Skills. In terms of the timing of the report, the findings and discussion by the joint committee have been very useful in informing our thinking, identifying issues and filling in the gaps. To echo Dr. Holohan, we are very committed to concluding a process which we have started already. We are also of the view that what we want out of this is a single resource. We do not want duplication of resources out there, as it would lead to confusion among relevant stakeholders. We want one common resource that can be used in any setting, although it might have to be tailored to specific instances. That can be covered in the common resource, but what we do not want is a different resource for each sector. We want the schools sector and the education sector to fold into the overall resource so that the final guidance developed by the Department of Health with co-operation from ourselves and the sports bodies will be applicable to schools as well. Our role will be to disseminate that across the education sector and to schools. We do not want to be involved in drafting a specific resource for schools, however. A common resource that crosses sectors is important and that is what we support.
Concussion is a society-wide issue and schools have an important role to play in that regard. However, we do not want schools to be seen as a panacea for all of society's ills. Children spend a limited amount of time in school in comparison to out-of-school time. Parents have a huge role to play, and the information campaign that is launched and of which schools will be a part should be targeting parents and coaches, among other groups. We have heard from the joint committee's proceedings over previous days of the importance of education for GPs and other medical practitioners also. These are all sectors of society that must be informed and subject to awareness-raising. One member of the joint committee indicated that she had had a fall in the bathroom and learned about the dangers of concussion the hard way, and that there is sometimes a time lag before symptoms manifest themselves. We see it, therefore, as a society-wide issue. We are committed to and supportive of playing a role in relation to schools, but will row in behind the overall expertise of the health experts.
The question of first aid was raised. In the safety statement schools must produce as part of their assessments of risk, one of the matters that must be taken into consideration is the extent to which first aid exists within a school. If there are gaps, or if inadequate numbers of staff have received training, those will be identified in school training plans. We leave it to boards of management of schools and to whomever responsibility for safety has been delegated within a school to make the call. Boards of management are autonomous in terms of how they govern the schools and we leave the decision as to how many people are trained in first aid to them. That is most appropriate.
Senator Burke asked about sports facilities. As new schools are built, sports facilities are provided. The Senator is right that we have a huge capital budget that is spent on building schools, and within that the priority is on new school placements, which has to be the case. However, it is open to schools to apply for funding. If there are schools in urban areas which have deficiencies in relation to sports halls, they can apply to be considered as part of the capital programme. Within the application process there is prioritisation across different sectors, so such applications will be considered. While the Department must make a call on priorities, it is open to schools to apply and be considered for capital funding for sports halls. Applications will be considered in due process as part of the overall capital budget available to the Department.
Mr. Ronan Toomey:
It is worth putting in context some of the work that is ongoing in the Department on physical activity, which will add to what Dr. Holohan and Dr. Gaynor have said. As Dr. Holohan mentioned, we are in the process of developing a national physical activity plan and are engaging to a significant extent with a range of stakeholders to identify the best means by which we can get the population of the country more active. While these stakeholders include the Departments of Education and Skills and Children and Youth Affairs, the sporting bodies, the Irish Sports Council and a range of other stakeholders are key to the implementation of what is a significant challenge for us. Our primary message is that physical activity is one of the most significant decisions anyone can make that benefits their own health. That message must filter down to everyone. Of course, we must do that in a way that ensures the safety and security of any individual who chooses to participate in physical activity.
The ongoing discussions we have had with the sporting bodies on developing a physical activity plan show that they are fully committed to working with us. As Dr. Holohan mentioned earlier, one of the innovative aspects of Healthy Ireland is that it calls for genuine cross-sectoral engagement. That is not just with the Department of Education and Skills, with which we have had a very good relationship on the delivery of the plan, but also the Department of Transport, Tourism and Sport, which is co-chairing the group.
That is also the case outside our own areas of responsibility in the sports bodies and working with community and voluntary organisations to try to identify the best means of doing it.
I will make one further point about what Dr. Gaynor said about facilities in schools. One of the engagements we have had with sports bodies is attempting to identify how best to use the facilities available in communities across the country. Many sports facilities are available for particular single organisations, for example, football, soccer, rugby and athletics clubs and so on. There might be an opportunity to better share these facilities at local level and we have been trying to identify how we can encourage this and ensure the sharing of facilities becomes a priority agenda in local communities throughout the country. I hope it will add to the ongoing work the Department is undertaking.
I thank Mr. Toomey.
I want to make one or two comments in response to Dr. Gaynor. I could not agree with her more that children do not live in schools; they live in communities. Therefore, we all have a responsibility in that regard.
Mr. Toomey spoke about getting all stakeholders involved. I wish him luck in trying to have facilities shared, as it can be difficult to achieve. I know that at local level we try to submit a municipal application for sports capital grants, but people want to make their own applications. However, Mr. Toomey is right. There are examples up and down the country of schools, in particular, opening their facilities in the evening which is hugely beneficial to communities.
I am very involved in ladies football and since last weekend the very proud mother of a county champion, but ladies football and ladies' sport in general are often forgotten. We talk about the GAA, but the GAA is not the Ladies Gaelic Football Association. We use the GAA as an umbrella brand, but it only deals with men. We have to remember the Camogie Association and the Women's Football Association.
On how to deal with cases of concussion, we had a scary incident in a semi-final some weeks ago in which a young girl was concussed and there was not even a bottle of holy water available. There is an onus on clubs which are struggling, particularly in women's sport, to raise money because they do not capture the same generosity from communities as men's football to provide first aid facilities, training and so on. If we are serious about women participating in sport, we have to make sure they are resourced.
I thank everybody for his or her informative and challenging presentation. This was our fourth meeting focusing on these important and challenging issues. The delegates' submissions will be important to us as we continue our deliberations and prepare a report for the Minister for Health. I thank everybody for his or her contribution.