What do paediatricians need to know about the Nationality and Borders Bill?

Sinead Phelan
RCPCH Insight
Published in
6 min readApr 4, 2022

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Migration been a feature of the history of mankind that has enriched the culture and prosperity of the UK across its society. It has become a dominant way of 21st century life with, in 2020, an estimated 35 million forcibly displaced children and young people, more than the total number under the age of 18 years old in England and Wales.

But the terms ‘migrant’, ‘refugee’ and ‘asylum-seeker’ are often used interchangeably and described in different ways. Amnesty International uses migrant to describe people staying outside their country of origin, who are not necessarily asylum-seekers or refugees, and may have left because they want to work, study, or join family. A refugee is a person who has fled their own country because they are at risk of serious human rights violations and persecution there. An asylum-seeker is a person who hasn’t yet been legally recognized as a refugee and is waiting to receive a decision on their asylum claim. Unaccompanied asylum-seeking children are children and young people who are seeking asylum but who have been separated from their parents or carers. Seeking asylum is a human right.

“…age will have implications for the outcome and ability to access health services, education, and welfare support.”

The UK saw 26,903 asylum applications in the year ending March 2021. Since children, particularly those who are unaccompanied, have additional rights under the United Nations Convention on the Rights of the Child, the entry requirements for asylum claims are lower. This means age will have implications for the outcome and ability to access health services, education, and welfare support. This is why determining asylum-seeking children’s age is currently under discussion as part of the Nationality and Borders Bill.

Refugee child health

Children arriving in the UK claiming asylum will have specific healthcare needs. They may have come from an adverse health setting- war or famine with little or no access to care. This means malnutrition, infectious diseases, lack of immunisations and treatment of day-to-day and long-term conditions like eczema or asthma. This is on top of the trauma and mental health implications of what they have experienced in their short lives. Following that, unaccompanied asylum-seeking children have to navigate the UK legal system and their new surroundings alone.

“Many asylum-seekers will have no documentary evidence of their birth date, so the UK has put in place processes to establish age.”

“Refugee children usually come from an awful situation through an awful situation,” says Dr Vicki Walker, a consultant paediatrician on the RCPCH Child Protection Committee. As part of her work with looked after children, Vicki sees unaccompanied asylum seekers for an initial health assessment after their age has been determined. “The age assessment can be a gateway into two very different journeys in the UK,” says Vicki, “If an unaccompanied asylum-seeking child is assessed to be under 18 years old, they will immediately move into the looked after children programme of care and are protected by that legislation.” However, this changes when they turn 18 years old and they will need ongoing support to navigate the asylum system to be granted leave to stay in the UK.

Nationality and Borders Bill

Many asylum-seekers will have no documentary evidence of their birth date, so the UK has put in place processes to establish age. Currently, when the declared age is in question, an assessment is conducted by Border Agency staff based on a person’s appearance and demeanour with possible further thorough assessment by a social worker to determine levels of maturity. The Nationality and Borders Bill will introduce the use of new ways to determine age. A scientific advisory committee has been set up by Government to look at a range of scientific methods for estimating age, and will be considering their accuracy and reliability, as well as ethical and medical issues. A child’s physical, emotional, and developmental presentation is influenced by a myriad of factors including but in no way limited to their ethnicity, socio-economic environment, and nutritional status. The margin of error can sometimes be as much as five years either side, especially around the time of puberty.

“The statement on age assessments from RCPCH does not support paediatricians being asked to carry out age assessments of asylum-seeking young people.”

Home Secretary, Priti Patel, has said that two thirds of age disputed cases have found that the individual claiming to be a child is actually over the age of 18 years, and that the Home Office is providing resources to local councils to apply “vigorous and robust tests to check the ages of migrants”. However, a High Court case in January criticised the short time taken for the assessment and found the age assessment process to be unlawful after two teenage refugees were deemed to be 21 and 20 years of age.

Concern from paediatricians

The statement on age assessments from RCPCH does not support paediatricians being asked to carry out age assessments of asylum-seeking young people. It highlights concerns about the accuracy of methods, such as bone and dental X-rays as proposed in the Nationality and Borders Bill, and the ethical considerations relating to the impact on children. “It’s always been the Royal College’s position that paediatricians shouldn’t be involved in age assessments,” says Vicki, “If the Bill is passed and professionals are expected to use X-rays or dental and puberty assessments, it falls in the health arena. Our concern is that doctors will then be asked to undergo or contribute to those age assessments when we disagree on scientific and ethical grounds.”

“In the interests of those children, paediatricians would never want them to undergo a medical procedure that isn’t for the benefit of their health…”

The issue of age assessments was specifically raised in an RCPCH briefing to MPs, calling for further detailed scrutiny as the Bill continues to move through Parliament. It also drew further attention to the ethical concerns of paediatricians and workforce capacity practicalities as well as the accuracy of proposed age assessments methods: the British Dental Association has vigorously opposed the use of dental X-rays to determine whether asylum seekers have reached the age of 18 years, stressing they are not a reliable way of establishing age.

“Most importantly, the health, wellbeing and circumstances that refugee children have gone through have to be taken into account…”

Importantly for paediatricians, the age assessment processes conflicts with a child-centred approach to care. In the interests of those children, paediatricians would never want them to undertake a medical procedure that isn’t for the benefit of their health, particularly when concerns are raised about the outcome and as the process could potentially cause further trauma to an already vulnerable group. “That is the very core belief for paediatricians. You would be asking us to do something that is not directly linked to supporting the health of the child,” says Vicki, “in terms of ethics and professionalism, whether these young people know what they’re consenting for is a huge concern. Do they feel like they have to go through this process? Are they under duress to consent?” Given this, and the lack of evidence regarding the accuracy of age assessment, RCPCH believes that young people should be given the benefit of doubt with regards to their age.

Moving towards a solution

The scientific advisory group will look at the accuracy of each scientific method of assessing age to see how far they provide an evidence-based holistic opinion. However, each method must not be taken in isolation and rather as part of a range of ways to estimate age. Most importantly, the health, wellbeing and circumstances that refugee children have gone through have to be taken into account, firstly in terms of how that affects the roll out of these methods, and secondly in terms of safeguarding and consent. “Certainly, at this point in our health and science world, there is no single thing that is going to determine age,” says Vicki, “and we shouldn’t forget everything else in the search.”

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