‘School attendance is everyone’s business – that includes GPs’

Dr Saroja Forester on the importance of GPs’ role in improving children’s school attendance

It’s a typical mid-morning mid-week consultation. Eight-year-old L has been booked in by his mother, Miss W, who is worried about his cough. In they come, accompanied by a toddler in buggy and a six-year-old playing on a phone. It’s another mild viral upper respiratory tract infection. ‘Carry on with paracetamol if needed and drink plenty. Back to school tomorrow!’ 

It’s an easy consultation. I’m glad the family left happy – L got the day off school, and I had made his mother’s life easier by avoiding the trek to school with his siblings in tow. However, after they left, I noted that L had been in frequently over the past three months with minor self-limiting illnesses, therefore missing a fair amount of school. 

A month later, I was looking at the health inequity that exists across Stockport in my role as a Fairer Health for All Fellow. I found that people in the neighbourhood I work in have a shorter life expectancy by 7.5 years than those in another neighbourhood in the same borough of Greater Manchester. There was also a massive 13-year difference in healthy life expectancy. Delving into possible causes, I found evidence demonstrating that improved school attendance is good for children’s health. Remembering L, I wondered whether I had actually done him a disservice by legitimising his school absences. And why was Miss W making him appointments so frequently? Why were L’s siblings not in school or nursery either?

Standards for school attendance

The overall school attendance rate in England in 2023-24 was 92.9%, with 20.0% of children having persistent absence –  missing at least 10% of their schooling. The most common reason for poor attendance was ‘illness’.

Persistent absence is currently approximately double the rate it was before the pandemic, and is thought to have remained high after lockdown for several different reasons, including:

• Families’ perception that regular schooling is not a priority
• Increased anxiety, behavioural concerns and school avoidance in children 
• Increased socioeconomic stress in families leading to challenging home environments which may make maintenance of routine difficult; parental ill health; taking holidays during term-time 

On leaving primary school, children who failed to reach the expected standard of literacy and numeracy had missed an average of just 4 more days of school than their peers who met the standard expected of them. 60% of children with persistent absence failed to reach their expected level of attainment, compared to only 16% of children who attended school more often.

Education is a wider determinant of health. Greater educational attainment in primary school has been shown to increase the likelihood of growing up to be employed and have higher earnings, even after adjusting for the children’s socioeconomic deprivation. 

What does this have to do with GPs?

Good attendance leads not only to development of physical and cognitive skills, but also to greater emotional and social development which have been shown to improve long-term health due to psychological benefits, greater ability to adopt healthy lifestyle behaviours and also improved socioeconomic status. The chain goes: Improved school attendance → improved educational outcomes (social, emotional and social) → improved long-term opportunities (social, economic, employment and housing) → improved health equity.

With this knowledge, we made some simple but effective changes in our surgery which I would encourage other practices to take up too:

• Talking about how good attendance is for children’s health. Families are told by school what their attendance rate is, but it can be tricky to visualise what this percentage actually means. Missing an average of half a day a week – or one day a fortnight – leads to a persistent absence rate of 10%. Any improvement in attendance increases the likelihood of improved long-term health.
• Reviewing our appointments systems. In the month L was seen, 80% of children who booked acute appointments at our surgery were seen in school hours. Of these, 70% were actually fit for school – but none had been advised to return to school that day. We therefore made changes to our booking system – reserving 09:30am acute slots for children to be booked on the day. This would give Miss W time to take her other children to school and nursery first. Finding L well enough for school, he would have time to go to school for the rest of that day.
• All schools, nurseries and childminders use a document developed by UKHSA to guide what time off school is needed for different medical conditions. This same guidance was distributed to our GPs, meaning parents are given consistent advice.
• Explicitly encourage children back to school if they are well enough.
• Be curious. If children accompany others to their appointments, question it! No school today for L’s little brother? Does your toddler go to nursery or a childminder? Why not?
• Signpost families to further support for anything that may be hindering regular school attendance – e.g. parents’ mental health, school-based anxiety, family circumstances. This sheet has been developed for all practices in Stockport and can be texted to patients.

Will it work?

Consider an alternative end to L’s consultation if he had been seen at 09:30am. ‘Great news – L is well enough to go back to school today!’ ‘Your teachers will love to see you. Your friends will be missing you!’ That’s at least 10% of L’s school week saved, in addition to the 20% saved for each of his siblings (who will have already been dropped off prior to L’s appointment). It would have given Miss W the opportunity to discuss barriers to regular attendance – either in another appointment or by signposting to further support.

In the first school term of implementing the above changes at our surgery, 72% of children seen in acute slots were seen by 09:30am or after school, and 59% of these children were encouraged to return to school that day if well enough. Attendance at our local primary schools increased, and persistence absence fell. This was partly due to the timing and content of our GP appointments, but also due to the coordinated efforts to publicise the health benefits of improved school attendance with schools, early years providers, community pharmacies and of course the community themselves.

‘Attendance is everyone’s business‘, as stated by the children’s commissioner for England. Everyone who works with children has responsibility for playing their part in promoting improved school attendance and this includes GPs. We are well-placed to address attendance and its ensuing health benefits during consultations – as families have approached us and trust our advice. We can easily signpost to further support around this and give family members the opportunity to raise issues which are causing them problems in another appointment. A ‘how-to’ guide for GPs has been developed, and I encourage everyone to consider adopting some or all of these ideas in daily practice.

Miss W is now seeing us regarding her own anxiety and depression, and has support from other mothers in helping with the school runs. L and his brother are no longer missing so much school with minor illness, and their little sister is soon to be enrolled with a local nursery to give Miss W more time for herself. It is a powerful reminder in ensuring that children have an adequate education is a safeguarding concern which we must not shy away from. 

Dr Saroja Forester is a GP in Stockport and Fairer Health for All Fellow in Greater Manchester. She is interested in the role of primary care in population health and can be contacted on [email protected]