Dr. Fiona O'Reilly:

I thank the committee for the invitation to appear before it. I am joined by Dr. Alva O’Dalaigh. Safetynet is a medical charity providing quality health care to vulnerable patients without access to mainstream services. At the same time, we advocate for an inclusive health system for all. Safetynet's services are commissioned by HSE social inclusion and, in the national transit centre, by HSE health and well-being. We provide primary care services, including GP and nursing clinics and health assessments and screening.

Over the past year and a half our migrant health service has increased significantly. Initially we provided pop-up clinics for beneficiaries of temporary protection fleeing the war in Ukraine and the increased numbers of international protection applicants. Now, our migrant clinics mainly see international protection applicants who are faced with more structural barriers to care. We continue to provide GP clinics for Roma without medical cards.

Of the 6,500 beneficiaries of temporary protection, BOTPs, and international protection applicants, IPAs, from more than 85 countries seen by our migrant health service last year, 800 were children. This year so far, we have seen almost 800 migrant children in our clinics.

I will now talk about the main challenges facing refugee and migrant children, seeing this through the health lens and understanding it in the broad social determinants of health model. The first and quite a new challenge that we have seen is children or young people on their own being deemed adults and therefore not being protected. These age-disputed minors present to us as children. However, the State may not recognise them as such. While they are deemed adult, they are not protected as children as they should be in accordance with international, EU and national law. Often, these minors are not able to provide documentary evidence of age at the time of their initial assessment. It can take months for a reassessment, after which their child status may be accepted. In the interim, they can be extremely vulnerable - as those we have come in contact with have been - and unprotected and placed in adult accommodation. At least one of our 17-year-old patients in this situation was given no accommodation and slept on the streets. Later, his reassessment of age was accepted and he was taken into care.

In the briefing document Safetynet submitted to the committee, we describe eight case studies of young people between the ages of 15 and 17 placed in adult accommodation. The GPs engaging with these people concurred that they were likely to be the ages they claimed to be based on their physical and behavioural maturity. All minors requested a reassessment and waited months for one, and most of those with whom we have been in contact recently are still waiting. The two 15-year-olds - one of whom was 14 when she came here - continue to be very vulnerable, with one not managing to feed herself adequately and the other’s mental health suffering. Common themes emerging from the conversations with these young people are the lack of information they receive about the process, the lack of certainty about whether they have been age-assessed, the desire to go to school, the desire to be among their own age group and their feelings of fear and anxiety.

It is our understanding that the International Protection Office relies on the eligibility for services assessments done by Tusla to decide whether to treat the young person as a child or an adult. However, Tusla has separately been clear to us that its assessment should not be used for this purpose. The principle of benefit of doubt in favour of the child’s age does not appear to currently apply. At the very least, we believe that in the interest of child protection, the young person should be placed in safe accommodation until the age assessment has been fully concluded, including the appeal. We welcome the provision in the new Tusla protocol stating that benefit of the doubt will apply and we recommend this be implemented immediately.

I will touch on other barriers because I know some of my colleagues and Dr. Walsh will expand further. The barrier to health integration is significant. Migrant children require access to primary care 24-7, just like Irish children. Importantly, they require immunisations to protect them against disease and often catch-up immunisations. Community healthcare organisations, CHOs, have set up vaccinations, which vary across the CHOs. The medical card application process is slow and does not cater for parents of migrant children with low or no income who cannot provide evidence either of means or no means. Migrant children, including migrants from the Roma community, have been here for years and still do not have access to mainstream medical care. The lack of communication ability, particularly interpreting, is a serious barrier. Unlike the rapid establishment of Ukrainian interpreting, access to interpreting in other languages is still not available as a standard for primary care across CHOs.

There is also a lack of system-wide co-ordination and communication. Migrant families are not given any notice, or 24-hour notice, when they will be moved. Their public health nurses are not told when newcomers are coming into the area and they are not told when they will be moved out of the area, so it is difficult to co-ordinate care. In addition, poverty, inappropriate accommodation, inappropriate food and the impact of cramped living conditions without cooking facilities have been well described and are a constant barrier and challenge for children's physical, mental and emotional well-being.

In conclusion, migration in and of itself imposes challenges for children, including loss, trauma and fear. The State's response to migration and efforts to welcome, accommodate and integrate children and their families can create or remove further challenges. Some migrant children are in Ireland for years and still do not have access to mainstream health services. We saw through Covid and the response to the Ukrainian crisis just how quickly the health system can respond when there is a will and an urgency. A co-ordinated emergency response approach is required when usual systems cannot cope any longer to ensure people receive safe shelter and have basic needs met, including healthcare. Children should always be prioritised within this response. We should never again be in a situation whereby people and, on occasion, unaccompanied minors applying for international protection are forced to sleep on the streets.