Health Bill: equality impact assessments summary

Introduction

This document summarises the approach to assessing equality impacts of the Health Bill (‘the bill’) and provides an overview of identified impacts across all policies included in the bill.

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 equality impact assessment therefore considers the impact of 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 policies and intended aims

On 13 March 2025, the government announced plans to abolish NHS England and merge its functions into the Department of Health and Social Care (DHSC) by March 2027, subject to Parliamentary approval. This decision reflected the need for a new structure capable of delivering the scale of reform and ambition set out in the government’s health mission, Plan for Change, and was reinforced by the 10 Year Health Plan for England.

The 10 Year Health Plan set out the need for a radical change to address both:

• the immediate challenges the NHS faces
• longer-term demographic change, technological opportunity and an evolving workforce

It was formed around a large-scale public conversation, Change NHS, that involved thousands of staff and members of the public.

The bill is a critical part of this government’s health agenda, and it is an important step in enabling the required change in line with the 10 Year Health Plan and abolishing NHS England.

The bill is supporting 2 overarching aims:

• improve patient safety and experience through a new single patient record (SPR), enabling joined-up, proactive care and empowering patients
• put power and resources in the hands of NHS organisations providing direct patient care by abolishing NHS England and stripping back national bureaucracy

Improve patient safety and experience through a new SPR, enabling joined-up, proactive care and empowering patients

This overarching aim covers the creation of a legal basis for an SPR.

The bill proposes to allow the NHS to bring together patients’ health and social care records in one place through the SPR - a single, secure and authoritative account of patient data. This will enable people to see their own health record, securely, on the NHS App - empowering them to take informed decisions about their own health. Healthcare professionals will access the patient information they need from one single place too, supporting safer, quicker and more accurate care. 

Often patients’ experience of care is not joined up, and they must tell their story repeatedly each time they meet a new clinician. This puts patient safety at risk. When clinicians do not have all the relevant facts available, they cannot make the best decisions and patients lose out. By moving to a more personalised and proactive health and care system, we are giving people a bit more control over their lives. The NHS will revolve around patients, rather than patients revolving around the NHS.

Put power and resources in the hands of NHS organisations providing direct patient care by abolishing NHS England and stripping back national bureaucracy

This overarching aim covers abolishing NHS England and implementing the recommendations of the Review of patient safety across the health and care landscape (the Dash review) to:

• improve accountability and efficacy
• provide a better service to patients

The recommendations of the Dash review relate to:

• abolishing Healthwatch England (HWE) and local Healthwatch
• the role of the Health Services Safety and Investigations Body (HSSIB)

This aim also covers a range of measures to support clarity in relation to the new operating model for integrated care boards (ICBs) and NHS foundation trusts to support devolving decision-making to the local level.

Lord Darzi’s findings in the Independent investigation of the NHS in England were clear that the Health and Social Care Act 2012 has made the NHS rigid, overly centralised and bureaucratic. This can draw resources from where they are most needed - NHS organisations providing direct patient care - and slow down change to modernise the NHS.

Abolishing NHS England intends to cut bureaucracy and increase efficiency to support us in reinvesting resources in the NHS organisations providing direct patient care and restoring democratic ministerial accountability for national decision-making.

Through implementing the Dash review recommendations, the bill proposes to simplify the confusing landscape of arm’s length bodies (ALBs) with unclear and often overlapping roles, that ultimately do not best serve the public. This includes transferring the functions of HSSIB to the Care Quality Commission (CQC).

The bill proposes to abolish HWE and embed the voice of patients back into central government’s work, with a dedicated national director of patient experience. Additionally, the work of local Healthwatch will be transferred into ICB and local authority engagement functions, putting accountability closer to clinical teams and clinicians.

Empowering ICBs as strategic commissioners will support putting patients at the centre of care by devolving decisions to a local level where different services can better integrate. The bill proposes transferring responsibilities for all but the most specialised commissioning functions to ICBs. ICBs as local strategic commissioners are best placed to integrate health services such as primary care, dentistry, ophthalmology and pharmacy. This measure will refine the requirements for ICB memberships to better support strategic planning opportunities.

Strategic authority mayors rather than local authority representatives will be included as members and provider organisations (such as NHS trusts, NHS foundation trusts and primary medical care providers) will no longer sit as members on ICBs. The bill also proposes to remove the requirement to set up integrated care partnerships to allow for local decisions on how to most effectively put in place partnership working.

In addition, empowering ICBs as commissioners will be supported by financial accountability changes allowing ICBs to move away from performance managing to act as strategic commissioners.

Reforms to the NHS foundation trust model will give providers more flexibility to design and deliver healthcare around local needs. The reforms will introduce the basis for the criteria to convert failing NHS foundation trusts into NHS trusts, supporting the principle of earned autonomy with a higher price for failure for those foundation trusts that do not meet the necessary standard. They will also remove the requirement for NHS foundation trusts to have governors, allowing them to put in place more dynamic arrangements that best serve their patients and staff.

The bill is only one part of a wider modernisation agenda. While the bill is a critical part of government reform, several proposals in the 10 Year Health Plan do not need legislation. Work is already underway to support implementation of neighbourhood health, reducing waiting times and improving health outcomes, among other areas. In addition, a Transformation programme will lead the design of a restructured Department of Health and Social Care (DHSC) to take on NHS England functions, with responsibility for policy decisions on the design and size of the new organisation.

Principles of policy development

To support the 2 overarching government aims, policy development followed a set of general principles:

• preserving policy decisions on areas of legislation that are working well
• ensuring policy decisions on areas of legislation that need to be changed are in line with the ambitions set out in the 10 Year Health Plan
• ensuring clarity of roles and a productive dynamic between different organisations in the health and care system
• balancing the need for legislative flexibility to create an agile, restructured DHSC with sufficient oversight of its functions

In relation to abolishing NHS England, DHSC and NHS England officials conducted a comprehensive and thorough review of legislation underpinning NHS England’s duties and responsibilities to inform the development of the bill. This was done to ensure the bill would clarify and streamline legislation in line with the aims of creating a more efficient, agile, restructured DHSC, as set out in the 10 Year Health Plan.

A Transformation programme was established to support the creation of the restructured DHSC. It is tasked with decisions around the organisational design and size, as well as supporting NHS England and DHSC staff in the transition.

Engagement and involvement

The policies included in the bill stem from the 10 Year Health Plan, which was based around engagement with thousands of staff and members of the public and considered the 250,000 contributions made through the Change NHS campaign.

NHS England policy, delivery and legal officials and senior leaders are directly involved in the development of legislative policies as part of the bill. Where such policies concern ICBs, NHS trusts and foundation trusts, NHS England regularly engages with organisational leaders and representative bodies, including NHS Providers.

Throughout the development of the bill, DHSC has engaged with other government departments and devolved governments, as well as with external stakeholders with expertise in the health and care system.

The decisions to abolish HWE and the local Healthwatch network and to transfer HSSIB into CQC stem from recommendations made in the Dash review, which was based around engagement with more than 100 individuals and organisations with an interest in patient safety and involvement of senior leaders across the 6 organisations under review. These 6 organisations are:

• CQC
• HSSIB
• the Patient Safety Commissioner
• NHS Resolution
• HWE
• the National Guardian’s Office

In preparation for the legislation, DHSC has regularly engaged with HWE, local Healthwatch organisations and/or their representatives, CQC, the Local Government Association, directors of adult social care and other government departments.

The approach to creating an SPR was informed by national public engagement on the use of health and care data, which consisted of workshops with about 80 participants and a quantitative survey with about 2,000 participants.

In terms of NHS England and DHSC staff engagement, the Transformation programme works closely with staff and their representatives to ensure inclusive engagement throughout the programme. This includes:

• ongoing dialogue with staff networks to reflect diverse perspectives
• engagement with trade unions to address workforce considerations
• engagement with other relevant bodies to support transparency and equality in decision-making

Scope and approach

Scope of this equality impact assessment

The scope of this assessment is limited to assessing changes in primary legislation as part of the bill and does not extend to wider complementary non-legislative measures as part of the 10 Year Health Plan. These measures have been assessed separately in the 10 Year Health Plan equalities impact assessment.

Where the implementation of primary legislation requires further policy development, the assessment has been done based on policy intent and with acknowledgement of relevant implementation risks. For example, where the bill will abolish the local Healthwatch network and introduce new legal responsibility for patient engagement on ICBs, we have assessed the equality impacts based on the intent for ICBs to develop better, more dynamic ways of patient representation. Future decisions following the enactment of primary legislation, such as about the content of patient engagement guidance issued to ICBs, will be assessed separately as appropriate.

Where the bill is conferring existing NHS England legal functions onto the Secretary of State and ICBs, we assessed equality impacts on the basis that the Secretary of State and ICBs will exercise them in line with their relevant duties, which include:

• the Secretary of State’s duty to promote a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and in the prevention, diagnosis and treatment of physical and mental health illness (section 1 of NHS Act 2006)
• the Secretary of State’s duty 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 (section 1C of NHS Act 2006)
• the Secretary of State’s public sector equality duty under section 149 of the Equality Act 2010
• each ICB’s duty in relation to the provision of healthcare services to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility (section 3 of NHS Act 2006)
• each ICB’s duty to have regard to the need to reduce inequalities between persons with respect to their ability to access health services and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services (section 14Z35 of NHS Act 2006)
• each ICB’s public sector equality duty under section 149 of the Equality Act 2010

Where measures announced as part of the 10 Year Health Plan create interdependencies with the enactment of primary legislation, we have noted the risks that these interdependencies pose to equalities and described how the department is mitigating them. These interdependencies include:

• after abolishing NHS England, the ability of DHSC to transfer NHS England staff with appropriate support and without substantial negative impacts on staff is interdependent with the Transformation programme work
• after abolishing NHS England and conferring of most of its functions on the Secretary of State, the ability of the restructured DHSC to carry out its new functions effectively and without disruption to services is interdependent with the ambition to reduce the combined size of the workforce by 50%
• after abolishing NHS England and conferring of most of its commissioning functions on ICBs, the ability of ICBs to carry out their new functions effectively and without disruption to services is interdependent with ICBs achieving a 50% reduction in running costs and going through mergers and geographical boundary changes

Approach to this equality impact assessment

We approached the assessment of equality impacts by following the 10-step guide for public bodies in England provided by the Equality and Human Rights Commission (EHRC). We screened all policy proposals for the bill against questions suggested by EHRC to inform initial conclusions on any areas that may have disproportionate impacts for people with particular protected characteristics. For all proposals where we did not identify any equality impacts, we recorded the conclusions and the accompanying analysis and evidence use. For those proposals where we identified either direct equality impacts or risks of negative equality impacts related to interdependencies with wider non-legislative measures, we prepared standalone equality impact assessment reports.

The 6 standalone equality impact assessment reports for the bill are:

• single patient record (SPR)
• abolishing NHS England
• ICBs as strategic commissioners
• reforming the foundation trust model
• transferring HSSIB to CQC
• abolishing Healthwatch England and local Healthwatch

Summary of equalities analysis

The following summary is based on the evidence and analysis presented in standalone equality impact assessment reports for the bill. For details of the evidence against protected characteristics that informed the assessment, please refer to each standalone report.

Equality aim 1: giving due regard to eliminating discrimination, harassment and victimisation and other conduct prohibited by the act

In the health and care system, the first equality aim is related to eliminating discrimination, harassment and victimisation from people’s experience of healthcare services.

Our overall assessment of the primary legislation measure related to improving patient safety and experience through a new SPR is that it may positively contribute to this equality aim. This measure may improve the experience of people who rely more on health and care services and use a variety of services (such as disabled people, older people and pregnant women). Those groups that are more likely to experience digital exclusion, such as those with disabilities and the elderly, may not immediately benefit from being able to access information about their health and care as others, but they should benefit from health and care professionals having access to more complete and up-to-date information. The NHS is seeking to address digital exclusion through its digital inclusion framework.

Our overall assessment of primary legislation measures related to putting power and resources in the hands of NHS organisations providing direct patient care by abolishing NHS England and stripping back national bureaucracy is that they are not directly contributing to this equality aim. This is because these measures aim to do one of the following:

• represent structural changes to the health and care system that do not directly affect how patients and service users experience services
• confer existing legal functions of one NHS body on another NHS body without changing those functions

Abolishing NHS England

We note risks related to the implementation of primary legislation to abolish NHS England and highlight areas where equality consideration should be given to ensure the continuity of progress towards improving patient experience. These areas include legal duties related to patient choice and patient involvement where appropriate expertise and resource in the restructured DHSC are important to support progress. They are particularly relevant to women, pregnant women and LGBT+ people who tend to have worse healthcare experiences.

Empowering ICBs as strategic commissioners

We assess that there may be potential improvement in the healthcare experience of some people with particular protected characteristics (mainly women and ethnic minorities) if ICBs are able to exercise their new commissioning functions effectively and tailor services better to local populations. We note risks related to the implementation of primary legislation due to wider ICB transformation.

Abolishing HWE and local Healthwatch

We note that positive contribution to patient experience is dependent on ICBs’ and local authorities’ ability to design more representative patient feedback mechanisms. Such mechanisms will need to sufficiently address existing barriers, particularly for disabled people, women and pregnant women, LGBT+ people and ethnic minorities.

We will establish a patient experience directorate in the restructured DHSC that alongside its other roles will be responsible for functions of HWE. The directorate will be responsible for ensuring all voices are heard including those with protected characteristics. Guidance and support to ICBs and local authorities will be provided by the restructured DHSC, along with clear policy direction on the changes. This will support organisations to build collaborative partnerships with their local communities.

Equality aim 2: giving due regard to the advancement of equality of opportunity

In the health and care system, the second equality aim, advancement of equality of opportunity, is related to the advancement of access to healthcare services for all people.

Our overall assessment of the primary legislation measure related to improving patient safety and experience through a new SPR is that it may positively contribute to this equality aim. This measure may improve access to the right services, particularly for those with complex needs who rely on multiple health and care services (such as disabled people, older people and pregnant women). At the same time, digital exclusion is a significant challenge in several groups with particular protected characteristics (such as the elderly) and other characteristics (such as lower socioeconomic background). Consideration of the digitally excluded is embedded in the SPR development work.

Our overall assessment of primary legislation measures related to putting power and resources in the hands of NHS organisations providing direct patient care by abolishing NHS England and stripping back national bureaucracy is that they are not directly contributing to this equality aim. This is because these measures either represent structural changes to the health and care system that do not affect how patients and service users access services or confer existing legal functions of one NHS body on another NHS body without changing the functions.

Abolishing NHS England

We note risks related to the implementation of primary legislation to abolish NHS England, specifically where the Secretary of State will be responsible for commissioning certain healthcare services and access to these services needs to be preserved during the transition to a restructured DHSC. The Secretary of State must comply with the public sector equality duty when exercising commissioning functions. We note the specific needs of people with protected characteristics that will be considered to ensure equality of access to Secretary of State commissioned services (including disabled people, children, older people, men and ethnic minorities).

Empowering ICBs as strategic commissioners

We assess that there may be potential improvement in the access to some health services for some people with particular protected characteristics, if ICBs are able to exercise their new commissioning functions effectively and tailor services better to local populations. This includes disabled people, older people, pregnant women and ethnic minorities - evidence suggests these groups are more likely to have barriers to access to some health services. We note risks related to the implementation of primary legislation due to wider ICB transformation.

To mitigate the risk of unintended consequences, NHS England and DHSC are implementing multiple changes to how ICBs will operate and be supported. NHS England published a strategic commissioning framework and committed to a strategic development programme in April 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 most efficient use of limited expert resources and capability for commissioning specialised services.

Abolishing HWE and local Healthwatch

We note that ICBs and local authorities will need to design accessible patient feedback mechanisms. Such mechanisms will need to take into consideration existing barriers, particularly for disabled people, women, pregnant women, LGBT+ people and ethnic minorities, where evidence suggests these groups are more likely to face these barriers.

Two implementation boards will be set up to oversee the implementation of this legislative change and ensure robust governance and accountability. These groups will be able to consider any risks to equality as the transition develops. Work will continue to ensure that inclusive and accessible feedback mechanisms are developed and provided to those that due to their protected characteristics may find it difficult to give feedback.

Equality aim 3: fostering good relations

The good relations duty recognises the importance of taking steps when developing and implementing policies that reduce the potential for community conflict.

Our overall assessment notes instances where future decisions around the implementation of primary legislation need to consider taking such steps. These include the legal transfers of:

• NHS England staff to DHSC and other public bodies, such as ICBs if appropriate
• HSSIB staff to CQC

In these cases, it will be important that staff policies are sensitive to the views and opinions expressed on behalf of different staff groups, so that the needs of different protected characteristic groups are properly considered.

The Transformation programme is working and will continue to work closely with staff in both organisations and their representatives to ensure inclusive engagement throughout the programme. This includes engagement and future consultation with trade unions to address workforce considerations. It also includes ongoing dialogue with staff networks to reflect diverse perspectives and engagement with other relevant bodies to support transparency and equality in decision-making.

Empowering ICBs as strategic commissioners

We note that ICBs should consider the relations between children and young people at risk of entering into the criminal justice system and professionals who support them. This is because timely intervention, including physical and mental health intervention, can prevent them from entering into the system.

Abolishing HWE and local Healthwatch

We note that ICBs and local authorities should consider designing patient engagement activity that can promote good relations between service users and healthcare professionals.

Secretary of State’s duty to reduce health inequalities

We considered the Secretary of State’s duty to have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can get from the health service. We noted the importance of continuing to address health inequalities in the exercise of the Secretary of State’s new commissioning functions for health services for:

• members of the armed forces and their families
• certain specialised services for rare diseases
• high security psychiatric services

Our assessment is that the legislative changes will not have any negative impact on health inequalities.

Addressing the impact on equalities

We noted the potential for unintended consequences related to conferring NHS England legal functions on the Secretary of State and ICBs at the same time as delivering headcount reductions in NHS England, DHSC and ICBs and the wider transformation agenda.

The Transformation programme is mitigating risks to service delivery during the transfer of NHS England functions into DHSC through existing, business-as-usual governance and risk-management processes. Responsibility sits with the relevant director generals and executives, who manage risks through their established functional registers.

To mitigate risks related to ICBs, NHS England published a strategic commissioning framework and committed to a strategic development programme in April 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 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 delivery. It will continue as ICBs exercise the new functions conferred on them by the bill.

In addition, the model ICB blueprint introduced a redesign of ICBs, intended to support them with meeting their 50% running cost reduction without disrupting their ability to act as strategic commissioners. For example, the blueprint suggests selectively retaining and adapting the governance and management functions and reviewing for transfer to other parties those functions that are not core to strategic commissioning. 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 a foundation trust holding an integrated health organisation contract and the budget to meet the healthcare needs of the population. ICBs will continue to have robust plans in place for all functions, which will be reviewed as part of ICB oversight and annual performance assessment process.

We also noted the importance of planning the implementation of staff transfer with equality considerations in mind. The Transformation programme is mitigating risks to staff through engagement with staff networks and trade unions, and through a staggered approach to transformation. For example, a Joint Executive Team was established in November 2025 to provide unified leadership across DHSC and NHS England to support staff throughout the transformation to a single organisation.

Monitoring and evaluation framework

We intend to undertake an evaluation of the bill to provide objective and robust evidence for both learning and accountability. The learning element will feed directly into the development of services and creating an evidence base. The accountability element will support further decisions and approaches to implementing services.

Any costs associated with monitoring and evaluation, including new data collections, have not been quantified at this stage. A more detailed monitoring and evaluation plan will be developed as the bill progresses through Parliament.

The monitoring and evaluation of the bill will need to encompass a uniquely large and complex policy landscape, much of which is still subject to policy refinement. The intention is that each individual bill measure will be considered as part of the monitoring and evaluation strategy.

It is anticipated that measures will be grouped where possible, with the groupings directed by shared objectives. For example, one evaluation is likely to encompass the range of structural reform measures including:

• removing the requirement for integrated care partnerships
• changes to ICB membership

There will also be several policy proposals encompassed by standalone evaluations, such as the Dash review measures (HSSIB and Healthwatch) and the SPR measure.

The evaluations will seek to cover similar research questions and would involve similar methodologies. Precise details of how each bill measure will be handled will be developed in more detail should the bill receive Royal Assent. As such, this proposal sets out the intended aims of the programme and the high-level approaches the department may take towards determining the impact of the bill.

The primary success indicator that the department must monitor is the extent to which the bill successfully meets its aim of enabling the department and the wider health and care system to operate more efficiently and effectively. Should the bill receive Royal Assent, it would be important to undertake a mixed-method evaluation. The evaluation should include elements of impact and process evaluations. This would be needed to understand:

• how the bill has been enacted
• whether there have been any unforeseen barriers
• what impact the bill has had on implementing the 10 Year Health Plan ambitions

This evaluation would aim to answer research questions such as these on impact:

• What impact have bill initiatives had on outcomes in each year after implementation?
• To what extent have the bill initiatives enabled the goals of the policy proposals to be met in each year after implementation?
• What unintended consequences has the reform programme had?
• What impact have bill initiatives had on external stakeholders and businesses?

And these questions on process:

• At a national level, how has the bill been implemented? What barriers or issues has the reform programme encountered during its delivery?
• Has the bill been implemented equitably across the country, patient and staff demographic groups?
• At a health and care system level, how has the bill been implemented? What barriers or issues has the bill encountered during its delivery?
• What workforce, contractual, technology or other resources need to be put in place for delivery?

Existing data collections would need to be reviewed to assess to what extent monitoring and evaluation could be accommodated by current data collections and what additional data would need to be collected. Should the bill receive Royal Assent, the government would ensure adequate baseline data is captured to facilitate the evaluations.

One option being considered is commissioning a research partner to undertake a mixed-method evaluation (or multiple, separate evaluations) to explore the questions set out above. For example, DHSC would consider commissioning using the Policy Research Programme (PRP) open-competition method, through the National Institute for Health and Care Research (NIHR). The precise timing schedule for publication of results would be negotiated when a research partner is in place.

An evaluation of this scale is expected to take between 2 to 3 years from commissioning to completion. However, research outputs would be produced and shared where appropriate before completion. This will allow lessons learned and best practice to be shared within the health and care system. In addition, DHSC would expect that full benefit realisation may stretch beyond the timeframe of a commissioned evaluation. As such, the department would also expect an evaluation partner to propose or develop robust collection mechanisms to enable the department to continue to monitor the impact of the proposals.