A cross-sectional questionnaire study of the rules governing pupils’ carriage of inhalers for asthma treatment in secondary schools in North East England

Introduction

Asthma is the most common long-term condition in childhood in the UK (NICE, 2013), with 1.1 million children currently receiving treatment (NICE, 2013). The National Review of Asthma Deaths (Levy et al., 2014) found that 14% of all asthma deaths in the UK occurred in those aged under 20 years, and 75% of asthma deaths in this age group occurred outside of hospital. In addition to a high burden of mortality, asthma accounts for large numbers of hospital admissions: in the twelve months to May 2014, there were 54,300 emergency hospital admissions for asthma, of which 20,510 (38%) were in children (Health and Social Care Information Centre, 2014). Up to 70% of emergency asthma admissions may be preventable with appropriate early interventions (NICE, 2013).

The ability to improve outcomes in young people who suffer acute exacerbations of asthma in the community depends on high-quality emergency care in settings such as schools, where young people spend a large proportion of their time. Indeed, Asthma UK estimates that two thirds of children with asthma aged 5–18 years have experienced an asthma attack at school (Asthma, 2013).

The unpredictable nature of asthma requires that those aiming to deliver high-quality community care recognise acute exacerbations and promptly initiate acute medical management. In most cases, initial medical management will include use of a short acting bronchodilator delivered via an inhaler. Hence, if the exacerbation is to be controlled, rapid access to inhaler medication is a prerequisite.

Some variation in the method of achieving ready access to inhaler medication is to be expected since access will be affected by the wider context of school layout and competing policies. However, for older children, a simple method of facilitating ready access is to allow pupils to carry inhaler medication with them. The age at which a child achieves the maturity necessary to responsibly carry their own medication will vary from child to child. In England and Wales, under section 8 of the Family Law Reform Act 1969 (Government of the United Kingdom, 1969), those aged 16 years are presumed to be capable of consenting to their own medical treatment and any ancillary procedures involved in that treatment (though refusal of treatment may, in certain circumstances, be overridden by a person with parental responsibility or a court of law). As a result, it is probably reasonable for schools to presume that children aged 16 years are responsible enough to carry their own emergency asthma inhalers.

Under statutory guidance introduced in 2014 (Department for Education, 2014), schools are responsible for ensuring that appropriate policies are in place to support children with medical conditions. However, anecdotal evidence suggests that schools have adopted a variety of approaches to supporting children with asthma. In particular, the rules regarding storage of inhalers appear to vary, ranging from inhalers being locked in a central location to pupils being permitted to keep inhalers in their pockets. Location of reliever medication forms a key part of its level of accessibility in an emergency situation. Indeed, there have been a number of media reports of children in the UK (Buckingham, 2014; Farr, 2010) and elsewhere (The Canadian Press, 2013; Chaiyanhat, 2012) dying or becoming seriously unwell as a result of an asthma attack in school, with reports citing a lack of ready access to inhaler medication as a contributory factor. However, there is little published data describing the variation in practice. Having a better understanding of the rules governing carriage of inhalers in schools may highlight areas in which asthma management can be improved for young people.

As a result of extensive campaigning on the issue of inhaler availability in schools, the UK Government laid legislation before Parliament in July 2014 (Government of the United Kingdom, 2014) to amend The Human Medicines Regulations 2012 (Government of the United Kingdom, 2012) to allow schools to purchase emergency salbutamol inhalers. Such inhalers are for the use of children diagnosed with asthma and prescribed an inhaler, where parents have given written permission for the emergency inhaler to be used. The legislation (Government of the United Kingdom, 2014) permitted schools to purchase emergency inhalers from 1 October 2014. This regulatory change may represent a useful step in facilitating access to emergency asthma treatment in schools; however, there is no published data on the number of schools who have availed of this new power, and so no assessment of the impact of the legislation is possible.

This study aims to contribute data to two substantial knowledge gaps in asthma policy. Firstly, we assess the rules governing carriage of inhalers in secondary schools in North East England in aiming to gain a better appreciation of current practice. Secondly, we assess the proportion of secondary schools in North East England which have taken the opportunity to purchase an emergency salbutamol inhaler.

Methods

We compiled a list of all free-to-attend schools within the 12 Local Authorities in North East England using listings on Local Authority websites between October 2014 and February 2015. We reviewed the website belonging to each school, or (when no accessible website could be located) the latest Ofsted report. Schools whose website or Ofsted report indicated that they served 16-year-old mainstream pupils were included in our sample population.

We limited our study to schools which served 16-year-old mainstream pupils in order to aid interpretation of our results. Given the presumption of capacity to accept medical treatment in this age group, we felt that it was reasonable to presume capacity to carry inhalers in mainstream pupils in this age group. In addition, we excluded schools serving only pupils with special educational needs and educational institutions other than schools (such as Local Authority ‘pupil referral units’ for children with behavioral difficulties). Without these restrictions applied, results would be difficult to interpret: a policy allowing pupils to carry their own inhalers in a school catering only for young children or those with learning or behavioral difficulties may be considered irresponsible. We also excluded fee-paying schools as we were unable to locate a complete listing of these.

We undertook an initial pilot study in one Local Authority. Where available, the school policy governing inhaler carriage was accessed via the school website. As few schools had an available online policy, we sent emails to invite the remainder to supply their policy by email. As few schools responded to emails, we sent postal letters to invite the remainder to complete a brief online or postal questionnaire describing their school policy. Each questionnaire response was considered and categorised by both authors.

Since postal letters resulted in the highest response rate in the pilot phase, all included schools in the 11 remaining Local Authorities were invited by postal letter to complete an online or postal questionnaire. Postal letters were addressed to the head teacher of each school. The questionnaire consisted of two questions. The first question asked the responder to select a response describing the school’s policy regarding storage or carriage of inhalers for asthma. A free text box was also provided with this question to enable responders to describe any other arrangements for carriage of inhalers that did not feature in the prepared list of options. The second question asked if the school had an emergency salbutamol inhaler for use by any pupil in an asthma emergency. The questionnaire did not specify any age group of pupils to which the policies applied. A copy of the questionnaire is available as a File S1.

On receipt of the questionnaires, both authors considered the responses and entered the data into a central database. Discussion was used to reach a consensus where responses were not clear cut (such as where multiple responses were selected, and had to be considered in conjunction with clarifying free text). Responses which the authors felt unable to reliably interpret (for example, where multiple mutually exclusive responses were given) were categorised as invalid.

Data was collected during the period November 2014–May 2015.

Ethical approval was not required for this research as it was based solely on collation of policy information.

Results

Our review of 12 Local Authority websites found 1,133 free-to-attend schools for consideration. The number of schools per Local Authority ranged from 35 to 275 (mean 94.4). On review of the schools’ websites, 980 of these (86%) were excluded from further consideration in this study. The majority of these (n = 915, 93%) were excluded as the schools did not accept pupils aged 16 years. The remaining exclusions were due to: the school serving only pupils with special educational needs (n = 55, 6%); the institution being an educational institution other than a school, such as a Local Authority pupil referral unit (n = 9, 1%); or the school being a fee-paying private school mis-categorised on the Local Authority website (n = 1, 0%). Hence, the policies of 153 schools were included in this study, with the number per Local Authority ranging from 5 to 31 (mean 12.7).

Of 153 schools, we received responses from 106 (69%). 100 (94%) of these responses were received as postal questionnaire responses; 3 (3%) as electronic questionnaire responses; and 3 (3%) were answers derived by the authors from reviewing school policies. The response rate varied between Local Authorities, ranging from 43% to 100%.

The first question concerned the rules governing pupils’ carriage of inhalers at school. Of the 106 responses received to this question, we excluded 8 (8%) due to a lack of clarity: for example, selecting two or more mutually exclusive responses, or adding a free-text comment which was inconsistent with the selected multiple choice response. Hence, 98 responses were included in this part of the study.

Of these 98 responses, 75 (77%) indicated that children were automatically allowed to carry their own inhalers at school. 22 (22%) indicated that children were only allowed to carry their inhalers with parental consent. The remaining school (1%) indicated that pupils were not allowed to carry inhalers, but that inhalers were stored in a single central location within the school.

The second question concerned whether schools had a generic salbutamol inhaler for use by any pupil in an asthmatic emergency. We excluded the three schools whose response to the first question had been derived from policies since the policies were unclear in this area. We additionally excluded one questionnaire response due to a lack of clarity. Hence, 102 questionnaire responses were included in this part of the study.

Of these 102 responses, 45 (44%) indicated that the school had an emergency generic salbutamol inhaler available, while 57 (56%) indicated that the school did not. The proportion of schools in which emergency generic salbutamol inhalers were available varied by Local Authority from 0% to 71%.

Discussion

Within our study sample, 99% of mainstream secondary schools in North East England permitted pupils to carry their own inhaler medication: 77% without need for special permission or parental consent, and 22% with parental consent. Only 1 school (1%) stored inhalers brought in by pupils in a central location within the school, forbidding pupils from keeping them on their person.

Of the secondary schools in our study, 44% indicated that they held a generic salbutamol inhaler for use in an emergency.

Supplemental Information