Health Bill: ICBs as strategic commissioners - equality impact assessment

Introduction

The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to:

• eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the act (equality aim 1)
• advance equality of opportunity between people who share a relevant protected characteristic and those who do not (equality aim 2)
• foster good relations between people who share a protected characteristic and those who do not (equality aim 3)

The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality but doing so is an important part of complying with the general equality duty.

In addition, the Secretary of State for Health and Social Care has a duty under the NHS Act 2006 to have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service.

This document therefore considers the impact of the Health Bill (‘the bill’) on people who share each of the 9 protected characteristics, as well as additional factors that have been strongly linked to inequalities related to the health service.

Summary of policy

The 10 Year Health Plan for England set out the ambition to create a new operating model for a devolved and diverse NHS, specifying the future direction for integrated care boards (ICBs):

ICBs will be strategic commissioners of local health services, responsible for all but the most specialised commissioning using multi-year budgets. This means ensuring that the money available to each local care system is put to the best possible use: to improve their population’s health, reduce health inequalities and improve access to consistently high-quality services.

Commissioning, sometimes referred to more simply as purchasing, is the process by which health services are planned, purchased and monitored.

Currently, the legal responsibility for commissioning health services lies with ICBs and NHS England. This includes NHS England carrying out the Secretary of State’s public health commissioning functions through delegation.

ICBs hold the legal responsibility for commissioning some secondary care services (for example, hospital care) and also commission certain other services, such as primary care, through delegation agreements with NHS England. The way ICBs run this process is constrained by a rigid legal framework underpinning these delegation agreements, which, in turn, makes service integration more challenging and inhibits long-term planning.

The bill proposes to place the legal responsibility for commissioning most health services directly on ICBs, except for:

• public health services, where the direct legal responsibility will remain with Secretary of State
• high-security psychiatric services, where the direct legal responsibility will be conferred on the Secretary of State

In addition, the bill proposes to enable regulations to allow the responsibility for commissioning certain specific services to sit with the Secretary of State, where it is appropriate to do so. These specific services are those that require:

• central commissioning due to lower volume of patients and higher complexity of disease (for example, treatments provided to patients with rare cancers, genetic disorders or complex medical or surgical conditions)
• cross-government working at a central level (for example, health services for members of the armed forces)

This shift in legal responsibility for commissioning will be reinforced by wider measures in the bill to support ICBs to become strategic commissioners.

Strategic commissioning

In November 2025, NHS England published a strategic commissioning framework in response to the 10 Year Health Plan, where strategic commissioning is defined as:

a continuous evidence-based process to plan, purchase, monitor and evaluate services over the longer term and with this improve population health, reduce health inequalities and improve equitable access to consistently high-quality healthcare.

The framework goes on to explain how ICBs are expected to fulfil this role, including placing a clear emphasis on accessibility of healthcare and the rights of patients, the public and staff:

ICBs, as strategic commissioners, are accountable for creating the best value for the public from their NHS budget. They do so by considering how this should be spent within their population to secure high quality accessible healthcare, now and in the future, and ensure that the health services they plan and commission uphold the rights and values outlined in the NHS Constitution for patients, the public and staff. ICBs will work alongside government, including local government, to address the wider determinants of health, such as employment, in line with the government’s health mission and the 4th purpose of ICBs to support wider socioeconomic development.

New commissioning responsibilities for ICBs

ICBs already control the commissioning of:

• secondary care services (for example, hospital and other accommodation, nursing and ambulance, and other services for the diagnosis and treatment of illness) - these have been the direct legal responsibility of ICBs since they were established by the Health and Care Act 2022
• primary care services (GPs, pharmacy, dental and optometry) through a delegation agreement with NHS England
• secondary dental services, such as paediatric dentistry, through a delegation agreement with NHS England

This means that when the legal responsibility for primary care and secondary dental services is conferred on ICBs through primary legislation and subject to Parliamentary approval, in practice, ICBs will be continuing with their existing work.

NHS England commissions a range of healthcare services that support children and adults throughout the youth justice and criminal justice systems in England, which includes sexual assault and abuse services. These services are referred to as health and justice services throughout this report.

The bill proposes to confer the legal responsibility for commissioning these services to ICBs, and this will be a new responsibility for ICBs.

There are around 170 specialised services for rare and very rare diseases. As of April 2025, when the delegation agreement came into force:

• ICBs control the commissioning of 70 these services through a delegation agreement with NHS England - see the ‘annex a’ PDF on Commissioning integration: delegation of specialised services to ICBs 2025 to 2026
• NHS England controls the commissioning of the approximately 100 remaining services

The bill proposes to place the direct legal responsibility for commissioning health services for the reasonable requirements of the public they serve on ICBs, except for the services that the Secretary of State will be explicitly responsible for commissioning.

This will ensure that, if appropriate, some very rare and highly complex services can be commissioned centrally. The exact split between which specialised services will be commissioned by the Secretary of State, and which will remain the commissioning responsibility of ICBs will be set out in regulations.

We expect to publish a list of which services will be commissioned by the Secretary of State during the passage of the bill.

Other legislative measures that will support ICBs to become strategic commissioners

Alongside legislative measures on direct commissioning responsibility described above, the bill proposes to introduce complementary measures that will support ICBs to become strategic commissioners. These are:

• removing the requirement for financial system balance, where ICBs and their local partner NHS trusts and NHS foundation trusts are required to jointly ensure how much they spend does not exceed their budget allocation within a year - this measure will place financial accountability with providers and allow ICBs to move away from more closely managing how providers spend their allocations to implementing value for patients and taxpayers through strategic commissioning
• removing the requirement for ICBs to have a member nominated by the NHS trusts and NHS foundation trusts that provide services in the area, and a member nominated by primary care providers in the area - this measure may lessen conflict of interest and clarify the role of ICBs as strategic commissioners
• introducing the requirement for ICBs to have a member nominated by strategic mayoral authorities - this measure will help ICBs be better connected to local populations
• removing the requirement for ICBs to produce a joint forward plan[footnote 1] and a joint capital resource use plan - this measure aims to allow more flexibility for long-term planning and increase resource for strategic planning by lessening administrative burden
• removing the requirement to establish integrated care partnerships[footnote 2] - this is intended to reduce complexity of the planning system and place more emphasis on local neighbourhood health plans

Intended aims

To inform the development of the policy described above, NHS England conducted a review of functions that are commissioned directly by their organisation to assess 2 policy options - that is, transferring these functions to either the Secretary of State or to ICBs (as the 2 possible commissioners of NHS services following the abolition of NHS England).

The following 4 design principles were used to inform decisions:

• subsidiarity - commissioning healthcare services should be devolved to the most local level of authority capable of effectively commissioning the services in question
• efficiency - the relevant body should be able to make efficient use of the limited expert commissioning resource and capability, currently sitting in NHS England
• accountability - the relevant body should be both legally accountable and responsible for commissioning healthcare services (avoiding delegation agreements where possible)
• alignment - the proposal needs to align with other work to design a diverse and devolved NHS, such as the Model ICB blueprint, the Model region and the restructured Department of Health and Social Care (DHSC) following the abolition of NHS England

The policy aims, therefore, to mirror the 4 principles.

The core objectives of the policy are to:

• improve the health of local populations
• reduce health inequalities
• improve access to consistently high-quality services

Allowing ICBs to take control of all but the most specialised commissioning will devolve decision-making to a local level, compared to when commissioning is controlled centrally by a national body. This means that healthcare services should be better tailored to the needs of local populations as decisions will be made closer to the people they serve, with a more intimate understanding of service users, patients and carers and family.

The complementary measures described above should support ICBs to perform this new function by:

• clarifying roles in the health and care system
• lessening administrative burden
• providing more flexibility for strategic, long-term planning

Supporting ICBs to achieve objectives

NHS England published the strategic commissioning framework to clarify expectations on ICBs and allow them to start preparing to take on new commissioning functions in anticipation of the bill progress through Parliament. NHS England has also committed to further support steps for ICBs and the launch of strategic development programme in 2026.

As part of the framework, each NHS region is establishing an office for pan-ICB commissioning, resulting in ICBs working together to commission specialised healthcare services to ensure economies of scale and the efficient use of limited expert resource. This means that ICBs will be able to:

• combine efforts to commission services across larger populations, where such services affect a small number of people with complex needs
• make best use of the small number of expert commissioners
• ultimately protect the accessibility and quality of specialist treatments for those who need them

To enable ICBs to implement strategic commissioning for specialised services, such as health and justice services and services for rare diseases, the bill proposes to introduce a Secretary of State general power of direction, which will be used to direct ICBs:

• as to which services they are responsible for commissioning are ‘specialised’
• to comply with nationally set standards, service specifications and commissioning policies in relation to those services
• to collaborate with each other on commissioning

This measure will support consistent access and outcomes for patients across all areas, ensuring all ICBs implement their functions to the same standards.

Wider work that may influence successful implementation

The fourth principle of policy development and its subsequent aim is to align with wider work to create a diverse and devolved NHS. The Model ICB blueprint introduced a redesign of ICBs, such that they could:

• grow those capabilities and functions necessary for them to undertake their role as strategic commissioners successfully
• selectively retain and adapt the governance and management functions that enable implementation of strategic commissioning, for example, quality management, board and corporate governance, clinical governance and core operations
• review for transfer to other parties those functions that are not core to strategic commissioning and may be better undertaken by others in future

Where ICBs are preparing to transfer functions to other parties, including through formally delegating statutory functions to another statutory body, they will only do so where there is another party ready and better placed than the ICB to discharge them. For example, such parties may be an NHS trust or an NHS foundation trust holding an integrated health organisation contract and the budget to meet the healthcare needs of the population.

This redesign work for ICBs, informed by the Model ICB blueprint and supported by the legislative changes in the bill, will enable ICBs to take on the role of strategic commissioner within the health and care system. This will mean a more focused mission for ICBs than before, centred around the needs of the population. ICBs will shape a wide range of services and work with a wide range of partners to secure the best possible services and outcomes for their populations with the resources available to them. As with any transition, it will be important to identify and manage risks to population groups and relevant services, particularly those that will be commissioned by ICBs for the first time.

The 10 Year Health Plan introduced an aim for ICBs to share the same geographic boundaries as strategic authorities, wherever possible. This means that there will be mergers and boundary changes to ICBs taking effect in April 2026 and April 2027. The ability of ICB leaders to manage such mergers and boundary changes at the same time as preparing to take on new commissioning functions will influence how successfully they can implement the policy. ICBs will also need to manage risks to the continuity of services, particularly those that will be commissioned by ICBs for the first time.

Effect on staff

As the bill proposes to introduce the legal responsibility for commissioning a wider range of healthcare services than ICBs do now, staff in ICBs will need to take on new responsibilities and may need upskilling and training.

The bill provides for NHS England staff to transfer to ICBs, which will help to ensure that there remains continuity and retention of expertise of the workforce carrying out these commissioning functions. There is an ongoing programme of work to develop and assess proposals for such a transfer, which includes:

• appropriate staff engagement
• consultation
• assessment of equality impacts (out of scope of this publication)

In addition, all ICB staff will be supported to develop their skills in strategic commissioning - the standard best practice way every ICB will discharge its commissioning duties - through a development programme launching in summer 2026.

There should not be any differential impacts on different groups of staff, such as those with protected characteristics or characteristics closely linked to health inequalities.

Effect on patients and service users

The effect on patients and service users may range from neutral, to positive if policy is implemented as intended, to negative if policy implementation is disrupted leading to unintended consequences. All 3 possibilities are discussed below.

Neutral effect of strictly legislative changes

Based solely on primary legislation, which proposes to expand the legal responsibility for commissioning a wider range of healthcare services on ICBs (where these services have previously been commissioned by NHS England), there should not be any differential impacts on different groups of patients and service users, such as those with protected characteristics or characteristics closely linked to health inequalities.

This is because ICBs must act consistently with the duty to promote a comprehensive health service, take account of reducing health inequalities in the exercise of their functions and must have regard to the public sector equality duty. The change of legal responsibility from one NHS body to another, where all else remains constant, is expected to have a neutral effect.

Positive effect if policy is implemented as intended

If assessing the impacts of the policy to make ICBs strategic commissioners, of which primary legislation is an integral part alongside complementary non-legislative measures, there should be positive impacts for all patients and service users.

This is because the principles guiding policy development and wider complementary measures to support the implementation of the policy act as safeguards to ensure ICBs can more successfully tailor services for patients and service users in their local areas. This would be beneficial for users of those services where commissioning is moving from NHS England, as a central body, to ICBs, as local bodies, such as health and justice services and some specialised services for rare diseases (compared with services which are already commissioned by ICBs, such as primary and secondary care).

Assigning ICBs the legal responsibility to commission health and justice services, alongside other complementary measures to support policy implementation, is expected to benefit those people who receive these services and those with particular protected characteristics who have greater health needs (see more information in the ‘Analysis of impacts’ section below).

Primary legislation will not specify which specialised services for rare diseases will be the legal responsibility of ICBs - because some will be commissioned centrally by the Secretary of State as set out in regulations - so it is not possible to assess which groups of people are expected to benefit at this stage. Subsequent equality analysis will build on this analysis, as appropriate, to inform the decisions about which specialised services should be specified in regulations to be commissioned by the Secretary of State and consequently which ones will remain the legal responsibility of ICBs.

While changes to who commissions services in the health and care system do not in themselves guarantee improvements for patients - as outcomes will depend on how such changes are managed and integrated with other parts of the system - the aim of the policy is to support ICBs so that they are in the best possible position to shape services to improve outcomes and value for patients and taxpayers.

Negative effect if policy implementation is disrupted

While our expectation is that the combination of legislative and non-legislative changes affecting ICBs will position them to make a positive impact on services and outcomes for patients, the challenges and risks of transition will need to be addressed and managed, particularly where transitioning services from one commissioning body to another for the first time.

To the extent that there is any disruption to the provision of health services during the transition, this is likely to differentially impact those people who receive health and justice services and those with certain protected characteristics who have greater health needs (see more information in the ‘Analysis of impacts’ section below).

As mentioned above, it is not possible to assess which groups of people may be differentially negatively affected by a disruption to the commissioning of specialised services for rare diseases.

Engagement and involvement

Officials in NHS England regional teams met regularly with all 42 ICBs when conducting the review of commissioning functions in summer 2025 to inform the development and assessment of options to transfer these functions.

All ICBs (36 as of 1 April 2026) continue to work in partnership with their respective NHS England regional team to shape the design of regional commissioning teams, which are expected to fund the offices for pan-ICB commissioning from April 2027.

Analysis of impacts

As indicated above, the most likely area of risk and potentially differential impact during the transition will be those services that are new to all ICBs as part of their commissioning responsibilities. At present, several services are delegated to ICBs, so the transfer of legal responsibility will have little impact on patients and service users in practice.

This section, therefore, covers analysis of impacts for people who receive health and justice services, as these are the only services that will be new to all ICBs in their commissioning responsibilities and, as such, carry higher risk during the transition.

No impacts are expected for people who will receive primary care services commissioned by ICBs, because these services are already commissioned by ICBs and primary legislation is introducing the legal responsibility without substantially affecting the ongoing service provision in practice.

It is not possible to analyse the impacts for people who will receive specialised services for rare diseases commissioned by ICBs at this stage, because the specific services are not set out in primary legislation, but rather will be set out through regulations, with accompanying equality assessment, as appropriate.

Disability

Research published by the Ministry of Justice (MoJ) in 2012, estimating the prevalence of disability among prisoners, showed that 34% of respondents to the survey thought they had a disability (compared with 19% in the general population). The research found that disabled prisoners were more likely to report having:

• used drugs and needing treatment and support for a drug or alcohol problem
• experienced abuse or observed violence as a child

It is important that ICBs appropriately consider the distinct needs of disabled people coming into contact with health and justice services. The policy intent is that ICBs, acting as strategic commissioners, tailor services to the needs of local populations and reduce health inequalities, including those experienced by disabled people.

Sex

As of September 2025, prisons data published by the government showed that 4% of the prison population in England and Wales were female and the remaining 96% were male.

The Chief Medical Officer (CMO)’s 2025 report on the health of people in prison, on probation and in the secure NHS estate (the CMO’s 2025 report) noted that there was an extensive national independent review of health and social care for women in prison and leaving prison in 2023. This identified 8 main findings and associated strategic recommendations, which are still current national priorities.

The report also found that:

Most women in prison and under the supervision of probation have experienced trauma at some point in their lives, including 2 in 3 identified as victims of domestic abuse and over half experiencing emotional, physical or sexual abuse as a child. This can be associated with a complex and cyclical pathway of poor mental health and substance use, both of which are more prevalent in women than men in prison and significantly higher than the general female population. Although data on wider health needs of this group is very limited, these factors directly impact on health, as well as engagement, access and experience of healthcare. There are many positive practice examples where services identify and respond to these holistic needs, including women’s centres and women’s health or primary health services working within probation. However, access to these services is very variable between areas, dependent on local commissioning arrangements.

It is possible that with the shift to ICBs acting as strategic commissioners and with support through nationally set standards and service specifications, there may be improvement to these services provided to women. This will be dependent on how successfully ICBs exercise their new responsibilities in the context of wider transformation.

Sexual orientation

His Majesty’s Prison and Probation Service (HMPPS) collects data on the sexual orientation of prisoners as part of an annual data collection exercise for its offender equalities annual report. The HMPPS offender equalities annual report 2024 to 2025 stated that, of those prisoners who declared a sexual orientation between January and March 2025, 97% were heterosexual, 1.3% were gay or lesbian and 1.4% were bisexual.

When considering these figures, it is important to note that the declaration rate for sexual orientation was 85%, based on an average of the prison population taken over the quarter (between January and March 2025). Data quality is assumed to be low for prisoner sexual orientation. Sexual orientation is self-reported by prisoners, and likely to be under reported as well as prone to bias towards heterosexuality.

There is no specific evidence on the health of LGBT+ prisoners in England.

Race

Compared with the general population, people from ethnic minorities are over-represented within the prison population. According to the House of Commons Library research paper on prison population statistics, in the prison population, 27% identified as an ethnic minority in 2024, compared with 18% in the general population.

There are health inequalities between ethnic minority and white groups, and between different ethnic minority groups. These are likely to be present among people who come into contact with health and justice services. A King’s Fund report on the health of people from ethnic minority groups in England noted that structural racism can reinforce inequalities in the criminal justice system, which in turn can have a negative impact on health. There is some evidence that older adults from ethnic minority backgrounds have complex health needs that may not be adequately met in prison[footnote 3].

The policy intent is that ICBs, acting as strategic commissioners, tailor services to the needs of local populations and reduce health inequalities, including those experienced by ethnic minority groups.

Age

As of September 2025, prisons data published by the government showed that of prison population in England and Wales:

• 27% were aged 15 to 29
• 55% were aged 30 to 49
• 18% aged over 50

HMPPS uses age 50 to describe ‘old age’ in prisons, given that age-related illnesses, dependency and frailty can begin at an earlier age than people of the same age in the general population.

The CMO’s 2025 report concluded that older people in prison have on average worse physical and mental health than older people of the same age in the general population, and frailty often begins earlier in prison populations (for example, affecting ability to climb stairs, wash independently and walk unaided). It is important that health and justice services can adequately include frailty services and represent the needs of older people in prison.

If ICBs can develop strategic commissioning plans that fully consider the age-related needs of local prison populations, there may be improvement in healthcare support provided to older people. This will be dependent on how successfully ICBs exercise their new responsibilities in the context of wider transformation.

According to the CMO’s 2025 report, 383 children aged under 18 were accommodated in the secure estate. The report stated that children and young people who come in contact with the criminal justice system often have very complex health needs relative to the general population of children and young people. This includes high levels of childhood adversity, poor mental health and neurodevelopmental and emotional difficulties. It also suggested that children often encounter the youth justice system when earlier intervention, including physical or mental health intervention, could have avoided it.

Effective prevention and diversion work relies on effective collaboration and integration of care services. It is possible that if ICBs are successful in becoming strategic commissioners, they will be able to enhance multi-agency work and promote integration of care services to prevent more children from coming into contact with the youth justice system. This will be dependent on how successfully ICBs exercise their new responsibilities and collaborate with other relevant bodies in the context of wider transformation.

Gender reassignment

HMPPS collects data on transgender prisoners as part of an annual data collection exercise for its offender equalities annual report. The 2024 to 2025 report states that there were 339 transgender prisoners in March 2025 and 9 additional prisoners were known to have a Gender Recognition Certificate.

There is no specific evidence on the health of transgender prisoners in England.

Religion or belief

According to the HMPPS offender equalities annual report 2023 to 2024, at the end of March 2024, just under half of the prison population was of a Christian faith (45%), just under a third declared no religion (31%) and 18% were of Muslim faith.

There is no specific evidence on the interaction between prisoners’ health and religion.

Pregnancy and maternity

According to HMPPS annual digest 2024 to 2025, each month in England an average of 47 pregnant women are in prison and, in the year prior to March 2024, 55 women applied and were approved to live in a specialist mother and baby unit within the prison, with their baby.

The CMO’s 2025 report concluded that pregnant women and mothers have excess risks to their physical and mental health during pregnancy and in the postnatal period than those in the general population. It identified several challenges that can be improved around the assessment of need on reception to prison, transitions back into the general population and significant variations in care in prison.

As ICBs shift to acting as strategic commissioners and commissioning health and justice services, they will be responsible for putting actions in place to improve health and justice services for pregnant women and women in the postnatal period.

Marriage and civil partnership

No data is available for this protected characteristic with regards to health and justice services.

Other identified groups

These are not covered by the Equality Act 2010.

Socioeconomic background and geography are routinely included in considerations on health and social care policy. This is due to health inequalities, which are differences in health outcomes that are unfair and avoidable and which are rooted in socioeconomic background and geography.

Poor mental health is considered to be closely linked to health inequalities and is therefore also routinely included in considerations of health and care policy.

Socioeconomic background and geography

Many people in prison come from disadvantaged backgrounds. The MoJ’s 2012 Accommodation, homelessness and reoffending of prisoners: results from the Surveying Prisoner Crime Reduction (SPCR) survey, found that of a representative sample of newly sentenced prisoners:

• 24% had been in care at some point while they were growing up
• 29% had experienced abuse
• 41% had observed abuse
• 37% had a family member who had been found guilty of a criminal offence - about 30% of these family members had been in custody
• 15% had been homeless prior to custody
• 44% had been in their prior accommodation for less than a year and 28% had been in their prior accommodation less than 6 months

There is evidence of a correlation between levels of local deprivation, as measured by English indices of deprivation for local authorities, and imprisonment rate, meaning that the prison population is more likely to come from areas of high deprivation[footnote 4]. This suggests that people who come into contact with health and justice services are likely to suffer from health inequalities and this is further exacerbated by entering the criminal justice system.

ICBs must take account of the duty to reduce health inequalities in the exercise of their functions, and a core policy objective of ICBs becoming strategic commissioners is to reduce health inequalities. This covers prison populations and the need to improve health inequalities experienced by those who come in contact with the criminal justice system.

Mental health

Mental ill health is more common across the criminal justice system pathway compared with the general population[footnote 5].

The CMO’s 2025 report found that many people in prison also have risk factors for poor mental health, such as experience of childhood trauma, domestic violence and concurrent substance use disorder. In addition, there are high rates of self-harm in prisons, higher in the female compared with male estate. The report cautioned about insufficient capacity in NHS mental health services to support the prison population.

This should be an important consideration for ICBs acting as strategic commissioners of health services, both for health and justice services and general mental health service provision (except for high security psychiatric services). The policy intent is to enable ICBs to address these issues strategically and reduce health inequalities. However, success for ICBs will also depend on other factors, including challenges in the wider health and care system and economy that are out of scope of discussion in this equality impact assessment.

Summary of analysis

Overall impact

The analysis looked at the impact of the bill conferring the legal responsibility for commissioning health and justice services on ICBs, as part of the policy for ICBs to become strategic commissioners.

Considering the 3 aims of the public sector equality duty, the analysis found:

• potential improvement in eliminating discrimination, harassment and victimisation with respect to the experience of healthcare services for people in the criminal justice system with the following protected characteristics: age and sex (neutral impact on other protected characteristics)
• potential improvement in advancing equality of opportunity with respect to access to healthcare services for people in the criminal justice system with the following protected characteristics: age, disability, pregnancy and maternity, and race (neutral impact on other protected characteristics)
• potential improvement in fostering good relations between people providing healthcare services and people in or at risk of entering the criminal justice system with the following protected characteristics: age and pregnancy and maternity (neutral impact on other protected characteristics)

The analysis briefly summarised evidence around poor access to relevant healthcare services for people in prison aged over 50 and women in prison, including pregnant women and new mothers. The analysis also showed that disabled people and ethnic minority groups are over-represented in prisons compared with the general population, and that these groups experience health inequalities, which may be exacerbated in prison.

In addition to protected characteristics, the analysis discussed evidence that people in prison are more likely to come from areas of high economic deprivation and disadvantaged backgrounds and to be at higher risk of poor mental health, all of which are associated with health inequalities, which may be exacerbated in prison. A core objective of the policy is to improve access to high-quality care for local populations in ICBs and, if implemented as intended, the policy should enable ICBs to develop measures to improve accessibility and quality of health and justice services for these groups.

Some of the evidence noted the importance of using health and justice services to divert women and children and young people from the criminal justice system, and to prevent new mothers from experiencing adverse health outcomes when leaving prison. These measures can broadly fit under the third aim of the public sector equality duty of fostering good relations. ICBs as strategic commissioners should focus on prevention, liaison and diversion services and may be able to achieve improved outcomes for these groups of people.

The potential improvements rely on how successfully ICBs will act as strategic commissioners. There is no specific evidence that can point to their likely success, as health and justice services commissioning will move to a local level for the first time. As such, there will be a need to ensure the effective implementation of strategic commissioning in order to address the inequalities highlighted in this analysis.

Addressing the impact on equalities

To mitigate the risk of unintended consequences that could have a negative impact on health inequalities, NHS England and DHSC are implementing multiple changes to how ICBs will operate and be supported. These are discussed in the ‘Summary of policy’ section at the start of this document and summarised below.

NHS England published a strategic commissioning framework in 2025 and has committed to a strategic development programme in 2026. This is intended to clarify objectives and expectations for how ICBs should carry out their new functions. As part of the framework, each NHS region is establishing an office for pan-ICB commissioning to allow several ICBs to work together and make the most efficient use of limited expert resources and capability for commissioning specialised services. This collaborative working is intended to ensure that ICBs have access to the right expertise to commission services and act as a safeguard for service provision.

NHS England is also considering what progress can be made during the legislative process to ensure ICBs are ready to exercise their new functions effectively once legislation takes effect. The options under consideration include running shadow arrangements or potential delegation of services as a step towards full legal responsibility.

The bill proposes to introduce several legislative measures to change financial system controls to:

• allow ICBs to focus on strategic commissioning
• clarify the role of ICBs and reduce conflict of interest with providers
• reduce administrative burden
• allow greater flexibility for long-term planning

The bill proposes to introduce a Secretary of State power to direct ICBs as to which services are ICB specialised services and to comply with national standards and service specifications in relation to those services, ensuring high standards and consistency of service provision. ICBs will procure services under the NHS Provider Selection Regime, acting as a single, accountable commissioner in compliance with rules for procuring healthcare services in England.

Monitoring and evaluation

There is an overarching monitoring and evaluation framework for the bill - see the ‘Monitoring and evaluation’ section in the Health Bill: equality impact assessment summary. Research conducted under this framework is expected to measure the impact of legislative change on health inequalities and may be used to assess whether there are any improvements in access to health services among the prison population groups with protected characteristics.

DHSC has oversight of ICB services and there will be enhanced oversight of ICB specialised commissioning to monitor compliance with national standards and service specifications. Monitoring how ICBs carry out their commissioning functions will be a part of the annual ICB performance assessment process.

1. ICBs and their partner NHS trusts and NHS foundation trusts have a duty to prepare a plan setting out how they propose to exercise their functions in the next 5 years.  ↩

2. The NHS organisations in an ICB and upper tier local authorities in the area run a joint committee called an integrated care partnership (ICP). This is a broad alliance of partners who all have a role in improving local health, care and wellbeing. They may also include social care providers, the voluntary, community and social enterprise (VCSE) sector and others with a role in improving health and wellbeing for local people such as education, housing, employment or police and fire services. ↩

3. Mulligan L and others. Ethnicity and older adults in the criminal justice system: a brief report from a nominal group The Journal of Forensic Psychiatry and Psychology 2025: volume 36, issue 1. ↩

4. Jones R and others. Chorley ‘Super Prison’: the case against (PDF, 637 KB) Cardiff University 2022. ↩

5. Fazel S and others. Mental health of prisoners: prevalence, adverse outcomes and interventions The Lancet Psychiatry 2016: volume 3, issue 9, pages 871 to 881. ↩