The role of the GP in maximising school attendance

School is integral to the long-term wellbeing and aspirations of children, so it is a cause for significant concern that school absence has increased markedly since the COVID- 19 pandemic. It is especially troubling that children from deprived backgrounds are most likely to be persistently absent.

The Royal College of General Practitioners (RCGP) is part of the Education Secretary’s Attendance Action Alliance in England, where national sector leads from education, social care and health, alongside parent and child representatives, are working together to tackle the underlying causes of school absence.

Education is arguably the single most important factor in reducing trans- generational inequalities, and poor school attendance can negatively impact a child’s future both socially and developmentally as well as through reduced educational achievement. A paper titled, ‘GP Role in Maximising School Attendance — Addressing the Growing Problem of “Ghost Children”’, was brought for discussion to this June’s (2023) RCGP UK Council. The subsequent vote strongly endorsed the call for the RCGP to raise awareness among GPs about their vital role in promoting school attendance.

GPs have close and trusted relationships with children and their families, who will often turn to their doctor first when they have concerns. GPs can use this opportunity to reinforce the health and wellbeing benefits gained from a good school attendance. The paper acknowledged that GPs will not be the only group addressing this, but early support to emphasise the importance of school attendance can be key to enabling parents to make the best decision for their children.

Every child has the right to a good education. We want our children to thrive, and to be healthy and happy. For this to happen the majority of young people need to be attending school, seeing their friends, and learning in the classroom. Most children in England agree with this assessment. The Children’s Commissioner for England’s ‘Big Ask’ survey from March 2022 gathered over 550 000 responses from children and demonstrated during the pandemic how much they had missed face-to-face teaching, spending time with their friends, and the extra-curricular activities that brought joy and excitement to their lives. The benefits of school are many. It offers positive adult role models and gives children a strong foundation for their interactions in society. School helps young people build confidence, which is crucial to healthy self-esteem. It encourages independent critical thinking and self-expression. These skills translate to every area of life, whether it is in academia, the workplace, or relationships. School widens a child’s horizons and influences their aspirations. Schools are more than just classrooms, they are communities.

WHY ARE CHILDREN MISSING SCHOOL?

Despite the demonstrable importance of school for children’s development, there is an increasing number of children in the UK who have fallen through gaps in the education system and struggle to attend school regularly. The latest figures show that more than 125 000 children were missing more school days than they attended for the first term of this academic year. This is double the number before the pandemic. Pupils eligible for free school meals are twice as likely to have persistent absence, while those with an Education, Health, and Care Plan (EHCP) or a Statement of Special Educational Needs (SEN) are three times as likely.

There are many disadvantaged children in the UK. The National Youth Agency says that in the UK there are 1 million young people from vulnerable families, and many more with hidden or unforeseen consequences from the pandemic and the cost-of-living crisis.

In addition to learning loss, a systematic review prepared for Scientific Advisory Group for Emergencies (SAGE) found evidence that the impact of school closures on mental health and wellbeing was substantial and consistent across the range of emotional, behavioural, and restlessness/inattention problems. The paper acknowledged there are many systemic issues that are not the role of primary care. Discussion with patient representatives highlighted the need for schools to find a way to engage young people in education who are neurotypical and physically healthy, but not traditionally academic. There is also a need for children and young people with physical disabilities, mental health issues, or who are neurodiverse to have more support to access school, and a trauma-informed approach is often valuable.

The reasons for absence are complex; for some the pandemic has led to disengagement, others are waiting for a Special Educational Needs and Disabilities (SEND) assessment, and for some it is lack of appropriate provision. There may be a particular medical complaint that affects attendance while the child is ill, and reintegration back into the school environment may require support. Long waits for Child and Adolescent Mental Health Services (CAMHS) input can exacerbate attendance problems for children with poor mental health.

Despite this, there are examples of excellent practice, such as the Single Point of Access (SPOA) Children’s Emotional Wellbeing Panel in Aneurin Bevan University Health Board in Wales. Here, acceleration of the referral process to mental health support services has led to shorter waiting times. Other children are affected by caring responsibilities or financial difficulties that make attending school difficult. School refusal is challenging for families to manage, and some opt to take the path of least resistance, asking the GP to support their child’s reluctance to attend school. Persistent absence grew during the pandemic due to increased illness. On their return to the classroom in autumn 2020, pupils were on average around 1.8 months behind in reading and 3.7 months behind in maths compared to similar pupils in 2019/2020. The evidence suggests that the higher the percentage of sessions missed, the lower the level of attainment at the end of the key stage. Disadvantaged pupils have been more adversely affected than their peers by time out of the classroom, falling 0.5–1 month further behind than other pupils.

VULNERABLE CHILDREN

Vulnerable children were more likely to be absent from school in England: 33.6% of pupils receiving free school meals (FSM) were persistently absent in autumn 2021, compared to 20% of pupils not in receipt of FSM.

While looked-after children are statistically less likely to miss school, children living in care homes are a particularly vulnerable group. They may have experienced abuse, neglect, and trauma. Moving between care placements or in and out of care will often impact on their school attendance. Children in care are also more likely to go missing.

Children missing education can be a precursor to a range of safeguarding issues including neglect, sexual abuse, and child sexual and criminal exploitation, including involvement with county lines where children are groomed and manipulated to act as runners transporting drugs and cash across the country. In 2021, the National Crime Agency reported that over 2000 county lines were active across the UK and 90% of English police forces had seen county lines activity in their area. The Home Office reported in 2021 that 27 000 young people were known to be involved in county lines, while 450 000 are exposed to risks associated with gangs.

When a child is in care or goes missing from care, their increased emotional, behavioural, and mental health needs place them at increased risk of being groomed or exploited by people offering them the attention, affection, or support that they have struggled to find elsewhere. Being in school offers them some protection against this. Evidence also suggests that children with a positive attitude to school are less likely to become involved with recreational drug-taking activities. The Children’s Commissioner for England issued a report in 2022 showing that children attending the first week of school is a strong indicator that a child will go on to attend regularly throughout the term. Children who had an unauthorised absence on any day in the first week of term experienced an overall unauthorised absence rate of 25% compared to 2% for pupils who attend. If GPs are aware of the importance of that first week, they may be able to support anxious children to attend during this key period. Home schooling is not an inherent safeguarding risk; when done well it can be excellent. It cannot be ignored, however, that vulnerable children who are home schooled are hidden from view and miss protective factors such as regular contact with their teachers or access to free school meals. Any safeguarding concern is less likely to be recognised.

Patient representative groups have highlighted the role of social media in discouraging school attendance for children with neurodiversity issues and described pressure being placed on parents to home school. The family may then find this challenging, but by then it may be a hard decision to reverse. Supporting these families with help and resources to enable their child to stay at school may lead to better outcomes.

Historically, children not attending school for a prolonged period have been viewed from a medical model perspective, which locates the problem as being ‘within the child’. This perspective limits consideration of the environmental factors playing a role in contributing to the absence. It is important to have a holistic view of the child’s needs, considering family, social, and school factors, as well as the child themselves.

Each case is different and complex, and the school multidisciplinary team, including the educational psychologist, is better placed than the child’s GP to gain a broader perspective of extended school non-attendance and then to offer support at both individual and family level. For many vulnerable children, school is a place of sanctuary, a place to escape from dysfunctional homes or violent streets. These missing children are not spending their days in bedrooms filled with books and parents supporting their schoolwork. Many of them turn to gangs for their physical, financial, and emotional needs. GPs may feel that their focus is their patients’ health, not their education. But this issue also concerns safeguarding and addressing societal inequalities. It will become a national disaster if it is not turned around.

Trusted family practitioners have a role to play doing what they do best — practising curiously, asking the right questions, and supporting parents to make the best decision for their child. Education is crucial for individual children but also for the future of our country.

RCGP COUNCIL APPROVED THE FOLLOWING FIVE PRINCIPLES:

1. Be alert to when it is better to encourage a child to attend school rather than take time off. Consistently promote school attendance, emphasising the importance of attendance for every child’s long-term outcome, while continuing to support the child and their family.

2. Reassure and have sensitive conversations with pupils and parents about anxiety, particularly at the start of new school terms, recognising the importance of minimising time missed during the first week of school.

3. Remind ourselves that some schools have mental health support teams, and most have a range of self-help resources and organisations to which we can signpost.

4. Encourage parents and carers to speak to school staff about any worries their child may have, enabling them to work together to support their child and improve attendance.

5. Make it practice policy to try and schedule routine appointments to minimise time taken off school. Although broader in scope than just GP appointments, in 2020/2021 there were 4.6 million school sessions interrupted due to medical appointments.