All unaccompanied minors have access to the public healthcare system in Ireland. Unaccompanied minors in the care of Tusla are entitled to a medical card issued by the Health Service Executive (HSE), which provides for access to public health services free of charge (Quinn et al., 2014). This includes basic medical care, including through a General Practitioner (GP) and access to prescription medication free of charge, as well as emergency treatment.
All unaccompanied minors who are referred to Tusla undergo a medical assessment as part of their needs assessment, with referral to specialist services where necessary. A general screening appointment with a GP is organised for unaccompanied minors on being taken into care (Quinn et al., 2014).
The medical card also provides for access to specialised services for victims of torture, sexual violence or other conflict-related trauma. On identification and referral to Tusla, child victims of trafficking have access to assessment and treatment services for sexual assault, full medical screening and psychological and counselling services (Department of Justice and Equality, 2012). Health and Information Quality Authority (HIQA) however reported in January 2018 that, while medical screening was provided on admission, a comprehensive assessment of emotional needs was absent from some of the care plans of unaccompanied minors in residential care, and therapeutic needs of all children were not adequately assessed and addressed through referrals to specialist services (HIQA, 2018a).
Practitioners note that services to respond to the unique needs presented by individuals, including children, in the context of migration are not routinely available in the Irish health system (Royal College of Physicians of Ireland, 2016;
College of Psychiatrists of Ireland, 2017). Spirasi, an NGO providing rehabilitation services for victims of torture or inhuman treatment, is the only organisation in Ireland providing rehabilitation services for victims of torture on behalf of the State; it provides intake assessments, therapeutic services, psychosocial support and medical legal reports on referral from the client’s GP.217 A Remit Panel, comprising the director and senior staff, reviews all referrals made to the service to determine eligibility for support.218 Spirasi’s family therapy service, which was established in 2015, offers a structured and specialised service to families and unaccompanied minors.219
As the sole provider of such services, Spirasi has highlighted how the service is limited in its ability to provide for all individuals in need of specialised services due to resource constraints and the fact that the service is based in Dublin, which poses a barrier to accessing the service for those living outside of Dublin (Spirasi, 2017). In particular, Spirasi has expressed concern at the lack of specialised rehabilitative services and therapeutic support for child and adolescent victims of torture in Ireland (Spirasi, 2017). Spirasi has recommended that legislation be enacted to establish concrete mechanisms and programmes for the provision of holistic rehabilitation to victims of torture and ill-treatment, including in particular for child and adolescent survivors of torture (Spirasi, 2017). Research on unaccompanied minors has recommended that provision be made for comprehensive and culturally appropriate mental health screening for all unaccompanied minors in Ireland (Abunimah and Blower, 2010).
Research finds that covering costs for medical expenses that are not covered by the unaccompanied minor’s medical card can pose a challenge to social workers caring for unaccompanied minors (Quinn et al., 2014). Research also highlights that social workers can face difficulties in obtaining Personal Public Service Numbers (PPSNs) for unaccompanied minors who have not submitted, or received a decision on, an application for international protection, and those who have not applied for an alternative immigration status or registered with the Irish Naturalisation and Immigration Service (INIS) (Quinn et al., 2014). PPSNs are required to access public services including healthcare.
In practice, timely access to a medical care is dependent on the basis on which an unaccompanied minor is in the care of Tusla. Research has highlighted how social workers, residential care staff and foster carers caring for children under section 4 of the Child Care Act 1991 are precluded from giving consent for medical procedures on behalf of children under the age of 16. In cases where consent from the child’s parent or guardian cannot be obtained, social workers must go to court
217 Spirasi, ‘Spirasi Client Services’, http://spirasi.ie/healthcare-professionals/sub-healthcare/. 218 Correspondence with Spirasi, February 2018.
in order to obtain permission to give such consent, which is time-consuming and costly (Arnold and Sarsfield Collins, 2011; Arnold, 2013; Quinn et al., 2014; Corbett, 2018).
As previously outlined, unaccompanied minors who have submitted an international protection application and have not received a decision on their status prior to turning 18 years of age, or who submit an international protection application on turning 18, are transferred to Direct Provision reception centres. As with all persons seeking international protection residing in a Direct Provision reception centre, aged-out minors are still entitled to a medical card. In some cases, foster families are reported to have continued to provide accommodation to aged-out minors so they do not have to be transferred to a Direct Provision reception centre (Sirriyeh and Ní Raghallaigh, 2018). However, in such cases, they will not be automatically entitled to basic supports, including a medical card, provided to residents of Direct Provision reception centres (Tusla, 2017b).