In the next instalment of our Q&A series, the Scottish FA’s Chief Medical Consultant, Dr John MacLean, discusses his involvement in the COVID-19 Joint Response Group, and how the Hampden Sports Clinic are working with PFA Scotland to offer support to players struggling with mental health during the Scottish football shutdown.

1. Dr MacLean, can you outline the role you are playing in the daily Joint response Group meetings and explain how you keep Scottish football informed of the government’s evolving medical advice through the pandemic?

My role initially was to keep the group informed of the most up to date information from a medical perspective to allow the group to plan for the implications that this would have on playing football in Scotland. The information was gathered from speaking to medical colleagues in Scotland, and the rest of the UK, as well as contacts within UEFA and the World Health Organisation, particularly through their weekly webinars.

In addition, I give a daily summary of the medical aspects of the information from Scottish and UK Governments. This information has helped to guide the group in making decisions around the likely timescales and issues around a resumption of training and playing matches in Scotland, both at professional and recreational level.

More recently, the group has focused on what is required to start playing football in Scotland. In addition to following Government regulations, it is important to look at the hurdles and issues which need to be resolved. I will chair the medical group with experienced colleagues from both football and health.

2. The government advice has been clear but what additional considerations need to be applied to professional footballers – and athletes in general – when we talk about resuming football?

The safety of players, staff and supporters is paramount in everything we discuss. From a medical perspective, we will look at the issues in the journey back to training and eventual matches. Our remit will look at the practical aspects of returning to training as a squad, such as maintaining social distancing, personal hygiene, ensuring the safety of club environments such as the gym, medical areas and changing rooms. We will discuss the practicalities of testing, protocols for unwell players and staff, as well as using facilities shared with other groups.

When you list all the different aspects, it’s quite a task but we have a group motivated to find solutions and take advice from others around the UK and the world, in both football and other sports. Shared knowledge is key and leads to better solutions.

Another important aspect is the management of athletes who have had COVID-19. Evidence is emerging of the potential heart and lung complications of the illness so evidence based rehabilitation protocols and screening for complications have already begun with, as always, athlete safety paramount.

3. Mental Health must be a major consideration at a time like this - can you explain the role of Support Within Sport and the work undertaken with the help of PFA Scotland?

Those of us involved in football had become aware over recent years of an increasing number of players reporting issues with their mental health but there was little scientific evidence to substantiate this. In 2015, my colleague at Hampden Sports Clinic, Dr Katy Stewart was awarded a research grant from UEFA to ascertain the extent of such issues in Scotland. In partnership with PFA Scotland, we contacted all players in the SPFL and asked them to complete an anonymous survey. We had an excellent response and the key finding was that 64% of players reported that they or a teammate had had issues with their mental health.

Reassuringly they reported that in addition to their family and GP, they would speak to club medical and coaching staff, as well as PFA Scotland. Out of this realisation that assistance was required, Support Within Sport was formed in 2016.

4. What have you identified as the main mental health risks for players during the football shutdown?

Our initial study identified key triggers for mental health issues in football. These include players at the beginning or end of their career with uncertainty around their new contracts and the prospect of having to find employment and finance outside professional football. This is where the partnership with PFA Scotland has been so successful through their practical support and advice and access to training programmes and we are grateful to the Chief Executive, Fraser Wishart, and his wider team for their support.

At times like this, some players already considered to be at risk will potentially feel further impact. Players who play distant to their family home are one such category, with such players seeing their family infrequently and being socially isolated, perhaps living alone. This is a particular issue with foreign players who may have an additional language issue. Also, players who are injured, especially with a long-term injury, are considered to be at risk too. In some circumstances, not all clubs integrate such players into the squad and they are often left training alone, perhaps at times when the rest of the team have left for the day. During the football shutdown and given social distancing, rehabilitation will be affected.

5. How can players come forward if they are not aware and what can they expect?

Players can self-refer or be referred by family or club staff through a dedicated confidential phone number or App. The doctor then contacts the individual and does an initial assessment over the phone or in person at a convenient location in Scotland. Following this the player can be referred to one of the specialist practitioners for further input and support. The service is free, completely confidential and immediate – there is no waiting time or limit to the number of sessions.

One of the key aspects of Support is the uniqueness of the service. In our experience mental health is complicated and a one size fits all approach doesn’t work so the beauty of Support is access to a range of services both quickly and tailored to each individual’s needs from clinical psychology to psychiatry.

When we return to training and eventually playing a service such as Support will be even more valuable. Whether from the trauma of losing a loved one, the need for isolation from our wider family and teammates, the loss of valuable social interaction and the uncertainty over finances and contracts Support will be on hand to help.

6. The virus has spread across Europe at different rates and timescales, how big a challenge is this not just domestically, where players from abroad may have returned home to be with families, but also for European and international fixtures?

Understandably players from abroad have returned to be with their extended families in this time of a worldwide pandemic. Many players will have lost family members and for them returning to playing football will not be a priority. There is also the practical issue on when international travel and medical regulations around leaving and entering countries will be relaxed to enable players to return to their clubs. In addition, with countries at different stages of the outbreak, fairness will dictate not starting European or international matches until participating countries have reached an appropriate stage of the relaxation of regulations.

7. How important is it for Scottish football to have a member of UEFA’s medical committee advising and how beneficial have you found it to be ‘plugged-in’ to the wider European strategy?

My mentor in football and indeed life, the late Professor Stewart Hillis, taught me the importance of developing networks with colleagues around the world to learn from their experience and from their self-confessed mistakes. Being Vice Chairman of UEFA’s Medical Committee has not only allowed me to do this but also allowed me to drive forward policy related to player safety. Two good examples relate to the management of concussion and education medical colleague in UEFAs 55 National Associations in emergency pitchside care.

The Medical Committee has driven forward the agenda of better concussion management through educational resources and protocols, videos and so on. Importantly, UEFA have driven the recommendation of head injury substitutions currently being considered by FIFA and the International Board. We are rightly proud in Scotland that the advanced pitchcare course developed and run by my colleague in the international team, Dr Jonny Gordon, has been adopted by UEFA and that our Scottish group of medics teach this course to doctors from all UEFA members.

8. What do you think will be the biggest challenges for players and fans from a medical perspective in emerging from this pandemic as safely and as efficiently as possible?

Ensuring player and supporter safety is key in order to avoid an increase in COVID-19 numbers, especially when we are seeing encouraging signs with the flattening of the curve and a plateau in numbers of hospital admissions, and most importantly deaths.

The challenge will be twofold. Ensuring a safe environment for players to return to squad training and secondly to ensure that our football grounds are safe for supporters to enter when regulations allow. Both are significant challenges but the people and determination are both there to achieve this.

9. In your many years as medical consultant and national team doctor, has anything come close the impact COVID-19 has had on the game?

Fortunately nothing in my 37 years of working in professional sport has come close to this world pandemic and the impact it has had on people’s lives and the tragedy of the deaths which has resulted. Any anecdotes of unusual experiences are not worth mentioning in the current pandemic.

10. Before COVID-19 you had been a co-author of the study into the incidence of dementia in professional football. What impact has the virus had on the roll-out of the heading ban?

Many of us involved in professional sport, and many of the general public, have long had the belief that there may be a link to playing contact sport and dementia. The FIELD study published last year was the first to scientifically show a link between former professional football players and a range of neurodegenerative diseases including dementia and Parkinsons Disease. I am proud to be one of the Scottish researches who carried out the study in Scottish players and using our excellent Scottish health records.

The key and yet unanswered question remains why? Is it related to repetitive heading of the ball or to head injury or both? Further studies are needed to answer this question. However, given the time required to find the answer, the Scottish FA believed that the heath of players, particularly young players, was paramount. The decision to implement the heading regulations are based on the best evidence available and a pragmatic approach which rightly errs on the side of caution.

11. To what extent can we expect a different kind of game, or approach to the game, when it returns?

Life in general will be different going forward. Perhaps the understanding of good personal hygiene and the benefits of physical activity will become part of everyday life. We will certainly have a better respect and understanding for those who work in jobs in the health and social care sectors.

As for football – it too will mirror the importance of hygiene, as well as player and spectator welfare. Facilities will need to be improved before we return so will present an important legacy. However, football is an important part of our society and daily lives, so I have no doubt we will come out of the pandemic with the game intact.

As an optimist, and as someone who was part of the Scotland backroom staff at EURO 96 and France 98, I look forward to the Israel match and then that hope of qualification for the EURO finals in 2021, seeing Scotland playing at Hampden again, and of course that match that would follow at Wembley.