Football Lens

Dr. Charlotte Cowie’s FA Covid-Lens to Return to Play

A guest for this episode is Dr. Charlotte Cowie. She works in English football, and is Head of Medicine at the Football Association. We discussed a range of themes including the FA's approach to testing and venue biosecurity. And we started by asking Dr. Cowie about her work with the UK Government. They created a group to bring elite sports together to respond to COVID-19, Dr Cowie explained this approach was coordinated by the Department for Culture, Media and Sport, which is known in the UK as the DCMS.

I think the really useful thing with the DCMS group is that it feels very collaborative. So what has been really helpful Is that CMO’s from different sporting organisations have collaborated to try and put together the DCMS guidelines. And I suppose one of the things that has been really useful to understand is how important it is when you’re encountering something that is entirely new, to collaborate with people. A because you will always find no matter how much you think that you understand what’s necessary, and you’ve got everything sorted out, it is always helpful to have a second view where somebody can just point out a different experience or something that they’ve learned that you haven’t learnt yet, or just where they’ve tried to implement something and it hasn’t worked so well on the ground and to use that experience. The other thing I would say is, within sports medicine, I think we’re really used to working within a multidisciplinary team or interdisciplinary team. So that feels like a very familiar thing. But what I would say is that the COVID multidisciplinary team is actually a little bit different. By using people like public health consultants, people who are specialists in biology, that kind of thing has also been really useful, epidemiologists, those people actually start to become part of your MDT in terms of managing how you prepare for return to sport from Covid.

In terms of monitoring, symptoms and the testing for symptoms, what do you what are your thoughts about the relationship and intimate interdependence between those two things, monitoring and testing?

Yeah, I think there’s been a lot of debate about this and this is something where different sports and even different organisations within sports, are going to be taking different approaches. And I think everybody will be really familiar with the testing approach that the Premier League and the EFL took as really apart from horse racing, which has its own separate issues., and also has done PCR testing but you know, the first, you know, sport back with a very obvious potential risk in terms of breaching of social distancing guidelines and I think it was really important for those organisations to monitor the effect of returning to training and playing. It’s been incredibly helpful that the PCR testing that was put in place by those leagues has really successfully demonstrated the apparent lack of risk of returning to both training and too match play as a result of their testing programmes. So I think that’s really helpful. The only thing I would say is obviously the DCMS guidance does not include testing as a mandatory part of screening players to participate. I think everybody who’s been involved including Premier League and EFL staff would agree that the day-to-day symptom screening of players and particularly the attention to hygiene, the attention to distancing but it’s absolutely the key risk mitigator in all of this, it is the important bit in terms of ensuring that your testing programme doesn’t show a spike and increase in COVID cases.

In terms of risk, you mentioned risk, in terms of that, how have you monitored that and managed that when it comes to things like medical and legal liability throughout this whole COVID period?

I think that’s one of the things that the FA has added to a lot of its guidance, not just in the elite professional game, but in the sort of the semi-professional game and now coming down into grass roots. Because everybody has a degree of liability. And obviously, the extent and the sums involved differ from one level to another, but it doesn’t, nevertheless, exclude anybody who takes liability for supervising or providing facilities for people who are doing sports. And it is really important for people to ensure that insurance they have in place and procedures that they have in place, a) follow the new guidelines that the government have put in place over and above the usual health and safety guidelines. And also the insurance they have in place does cater for this and they do need to contact their insurers and make sure that they are indemnified for the work they’re taking on. It’s a horrible thing to have to do. Nobody wants to think that something might go wrong or that somebody might get sued. And obviously, the chances of that happening, I think, particularly in football, are relatively low because we’ve already successfully demonstrated that the risk of infection is low with football, but nevertheless, I think it’s important that people establish those principles before they set out.

You mentioned venues and I know you may not yourself have had direct involvement at this stage. But could you give us an overview of how you yourself and your colleagues are perhaps planning to manage medical and biosecurity of venues and training At such time as you have to...

From an FA point of view, obviously, what I have observed is the EFL, the Premier League and various organisations abroad as well, going back to training and going back to match play. And so the really exacting testing and bio secure environments, the zoning of stadiums that’s been put in place has been a massive part of ensuring that that return is safe. So that is something that I think now has set a precedent in terms of how people do manage sporting venues. And again, it is really about the flow of people, and the contact with people that that is absolutely key. I think the other thing that I would say both in terms of planning FA events and seeing other people working in this area, is it’s all very well to have plans on paper, but it’s really the implementation and then compliance that is that is key. So firstly ensuring that people, I know this has been fed back for a number of CMO’s, that people rehearse what they’re doing on the ground, so that what they’ve put in place in terms of plans has been run through before the critical point when athletes and support staff and everybody else start to arrive is one area where you know, you have a run up and there is opportunity to rehearse and go over on the ground and make sure that the paper plans work in practice. And the opportunity to review that as well. And then I think the other thing, again, that I think particularly the Premier League have done well and which we’re working on with England teams is compliance. It’s really difficult if the support staff and the medical staff and the coaches who have a day-to-day relationship with athletes are put in the position of also policing measures that have been put in place because that can be difficult. I think once players get used to being in an environment where they feel like Relatively cocooned and saved is incredibly tempting to let go of those social distancing guidelines, particularly if they are letting go of them on the pitch anyway. And so it is helpful if you have extra support in terms of compliance officers or people who’ve been given the role of policing things and pointing people in the right direction, not necessarily in a horrible way. But just, you know, the feedback that we’ve had from the Wembley match that occurred earlier this week is that where somebody politely points out to somebody to wear their masks rather than having it around hanging around their tune or you know, to wash their hands rather than walking past a hygiene station, people generally are compliant, but they do need reminding, and having that compliance monitoring in place is probably also an important part.

Again, that ties in with our next question, actually, and obviously the nation's league calendar already for the men's team. Perhaps some fixtures for the women's team in the near future too, we hope. So how are you and your colleagues planning to support players who have concerns maybe about their own health and their family's health when they do return to the training and playing environment?

I suppose there’s two questions there, isn’t there that one is the sort of England team’s return and I think one of the things that we’re fairly confident is that the ground has already been laid in terms of training and playing, because that’s already been done not just in this country, but abroad as well in terms of making sure that that’s the safe environment. What happens then, is that players return to their household. And what hasn’t really been done until international matches start, is a situation where rather than returning to their household, players return to a camp. And so we’re very aware that there’s not many wheels, we’re inventing this wheel, I guess. So, in terms of putting in place social distancing, we are erring on the side of caution. I know the government is moving to one metre plus, but it’s clear for all the scientific evidence there is that is that, you know, the closer you get, the higher the risk. And so in actual fact remaining to two metres where we can and where it feels like there might be a risk of going closer to one metre plus, putting in other mitigating factors, like ensuring that people are not face-to-face that they’re wearing face coverings, that areas are really well ventilated, or activities occur outside. Those kinds of mitigating factors become really important when you’re relying on social distancing, rather than zoning or bio secure areas. So, we’re putting together a plan where we’ve constructed what we call a ‘COVID-lens’. So, this is looking at me Everything that an England team might do, for instance, and you could apply this to any area of sport and apply three principles, one is social distancing. One is hygiene and the other is screening. So those three lenses screening, including testing, hygiene includes fomites and distancing includes PPE as well. So within those three buckets of activity, which we call our COVID lens, we could feel we can view every single activity that there is on a camp and add those extra pieces in to try and make sure the environment is safe. So we’ve got quite a complex piece of work to do in terms of looking at every activity within an England camp through that three point COVID lens and making sure we’ve got things in place. We hope to put together a document that really shows the work that we’re doing from that time Point of View. Doing a risk assessment for each area of England activity and sort of reassuring players, reassuring parent clubs, and reassuring various international organisations that what we’re putting in place is safe enough for people to enter into.

Have you perhaps picked up any differing opinions, beliefs or ideas from players about COVID and mitigated those reservations they might have or differences when you've had communication with any squads or anything of that nature?

I think the difficult thing from an England team point of view is that we cover so many different areas of football. So, the very obvious area that is probably the highest profile would be the men’s senior team. When we’re talking about experienced professionals, you have already been through testing and you know, red zones and you know, really understand this landscape, as well as anybody. The women’s teams at the point that we meet up for our first international window will only really just be back in training and it’s unlikely they will have played any matches. So, this will be relatively new for them. But they have got a testing programme in place. So they will be familiar with testing. And then our age group teams will be coming from academies, which may not have started on the women’s side yet or may only just started on the men’s side. And so may not be familiar with testing and with some of the things that we’re putting in place in terms of protocols. So we’ve got to manage all those groups and their expectations separately. Throughout all of this, obviously, everybody is aware that there are groups of individuals that might be more vulnerable or might see themselves as more vulnerable to COVID-19. And so we have to manage all those issues with regards to people opting-in and out with regard to consent and most importantly, ensuring that people really have an understanding of what they’re signing up to and that they feel safe.

Yeah, yeah. how she's probably The kicker question but with what you've experienced so far, do you have a view on how you and your colleagues, coaches, medics, trainers can come together to ensure that where possible this, this massive disruption doesn't have too great an impact on performance and preparation? It might be impossible. I don't know. What do you think?

Yeah, that’s a massive question and I think we still don’t know yet. And I think, you know, there are issues, for instance, around long periods, not training and then go back into quite concentrated Match-play. And I think there was some conflicting mainly anecdotal evidence in terms of what the injury rates have been on the initial returns to football. It seems as though it’s possible that maybe in the first couple of matches, injury rates are high and then they steady out we don’t really know. I don’t think there’s any definitive stats out there at the moment. So again, everyday’s a school day with this, you know, I think nobody can look back at a time when they experienced this before and say, I think this what’s likely to happen. And it’s a great leveller in that lots of experienced sports physicians or people who worked in sport, have no better idea of how this might pan out, and people, you know, who are relatively early on in their careers. But I think that’s where, you know, the intelligence that’s out there in terms of people who are doing this already is so important and, and partly why, you know, I feel it’s important to speak about my experiences we all should do, we all should try and share experience as much as possible because that’s where the knowledge is, at the moment. The knowledge is in the live community at the moment. It’s not in papers that have already been written or textbooks that have been written a long time ago. You know, this is all new and it’s all out there and being communicated mainly verbally and in meetings by people who are living it at the moment.

All that fantastic sentiment about altruistic brings us neatly on to the last couple of quick questions. I'll just ask you. What do you feel the main learning points or useful experiences are that you would share with fellow practitioners?

Um, no, I think that there’s an extent to which it feels as though, some things have changed forever. You know, I think that you know, doing this podcast, and the fact that I’ve come on to it from a series of online meetings over the whole day, which have actually been incredibly effective in lots of situations and new ways of Working but do reinforce how important hygiene is and how important it is to really look after not just injuries, but the overall health and wellbeing of athletes that are probably things that we’ve learned that a long term lessons and then I think some of the really inconvenient stuff of not being able to see people and not being able to meet people face-to-face I do hope will change soon, but it’s very, very difficult, you know, this all supposes the trajectory of the virus is gradually downwards again, which seems to be the case at the moment, but everybody is aware that, you know, second spikes, you know, we’re starting to hit across the world. And also aware, I guess that, you know, this is not the only virus in the world and the only virus is able to mutate or change or develop into something else. And so I think if I’m looking at how prepared some countries were for this That was as a result of previous viruses that hit particularly, you know, in Asia and prepared people really well for this. So I think that if we have some, if we have an awareness of this in the future, then I can’t say that even when this virus, you know, becomes commonplace, and we’ve got the kind of herd immunity that means we don’t have to take these precautions. You know, there are still things that we’ll probably be aware of in the long term.

Yeah, fantastic. I think everyone involved in Sport and Exercise in whatever capacity would certainly share that view. Just one final question. Could you look into the future for us and perhaps predict how long you feel the situation might continue for? Or do you have a view on how it might develop in the mid to long term, difficult to answer, but do you have any sense at all at this point in time?

One of the things that I would say is that I don’t want to downplay the importance of this. It’s not possible, certainly at the moment in terms of DCMS guidelines, to return to elite sport without putting in place a really structured set of safeguards. And I think that DCMS guidance has been really helpful for two reasons. One is that it sets out a framework for people to be able to look at what they’re doing and check against. But also, it sets out a framework where if somebody looks at that and they can’t match it, they know they’re not ready to go back. People have been cautious and I think that’s right, and they have got a structure in place and people have to stick to that. Having said that, I guess one of the take homes would be, that if you’ve got that structure in place, this is possible. So I think it’s just going through with your COVID lens and with your DCMS guidelines and with all the things that are out there that are just written up and ready to roll, and implementing those in the simplest way possible. And I think in some ways, simplicity is probably the key in this, if you make it too complicated, you set yourself up to fail. And so I think one is, only going at the pace you feel you can safely go and that’s okay. And the second would be to say, don’t get too caught up in this. It is possible to put in place relatively simple protocols that allow people to socially distance, keep to hygiene guidelines and stick with very simple screening protocols. Which allows you that three point process to take all of your, all of your sporting protocols through, check through and make sure you’ve got those covers. And then I think it’s okay. And I think particularly where sports are outdoors, and obviously I am relating this all to football, but I think when you’re outdoors, it’s clear the risk is lower, and where people can get back exercising. I think the thing that we don’t know yet and which is looming ahead of us, is the cost of people not engaging in sport and losing their activity. You know, I think, you know, even visually and personally within groups that people know people can see people losing fitness, putting on weight, getting anxious about returning to sport and all those things and we know how important regular physical activity is for people generally, in terms of their mental and physical health. So I think where we can facilitate people getting back to sport, then it is really important and I think their long term benefit of doing that will balance against a degree of risk in terms of returning back to activity.

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