Impact assessment

Health Bill: abolishing Healthwatch England and local Healthwatch - equality impact assessment

Published 14 May 2026

Applies to England

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

Recommendations and commitments made in the Review of patient safety across the health and care landscape (the Dash review) and the 10 Year Health Plan for England were the first steps to simplify the patient safety landscape. The next steps will improve quality of care, including safety, by:

• making it clear where responsibility and accountability sit at all levels of the system
• making it easier for staff, patients and users to directly influence how the health and care system operates

Local Healthwatch organisations work under contract to local authorities. To provide local Healthwatch services, they must be a social enterprise. Local Healthwatch organisations have a statutory duty to:

• promote and support the involvement of the public in health and social care services
• represent the public’s views to those who commission and provide care

Healthwatch England is the national statutory committee of the Care Quality Commission (CQC). Healthwatch England’s main statutory functions are to:

• provide leadership, guidance, support and advice to local Healthwatch
• escalate the concerns raised by local Healthwatch
• provide advice to the Secretary of State, NHS England and local authorities, especially where it is of the view that the quality of services provided are not adequate

The bill proposes to abolish Healthwatch England (HWE) and Local Healthwatch (LHW) in their current form.

A new patient experience directorate within the Department of Health and Social Care (DHSC) will bring patient voice ‘in house’ and take over the statutory functions of HWE. The directorate will become a central function of the department and ensure integrated care boards (ICBs) and local authorities incorporate the views of patients and users directly into strategic planning of services for health and social care.

ICBs will be responsible for collecting feedback on the services they commission. They will ensure the same responsibilities for collecting feedback are incorporated in provider organisations alongside existing patient engagement work such as Patient Participation Groups.

Local authorities will be responsible for collecting feedback on their social care and public health functions.

Intended aims

The overall objective is to simplify the patient safety landscape and improve quality of care by making it clear where responsibility and accountability sit at all levels of the health and care system. Fewer organisations in the patient safety landscape will mean that patients, staff and users will have a clearer path to sharing their views. Their voices will influence policy, strategic thinking and planning with the aim of improving the quality and safety of care, both in their local areas and nationally.

To achieve these aims and outcomes, the government must first make legislative changes to abolish HWE and LHW in their current form. It is intended that existing legislation will be amended or revoked, with the functions currently held by HWE and LHW moving to the Secretary of State, ICBs and local authorities.

Transitional arrangements and implementation governance will be developed as primary legislation passes through Parliament.

LHW organisations operate as social enterprises and are funded by and accountable to local authorities. Some social enterprises that carry out LHW functions cover a particular local authority and some cover more than one local authority. Each LHW organisation has their own contractual arrangements in place. The length of these contracts varies, ranging from 1 year to 10 years. With the abolition of LHW arrangements, the contracted organisations will be unable to use the ‘Healthwatch’ trademark. Details on transitional arrangements are to be determined.

If the provisions in this bill come into force (subject to Parliamentary process), it is intended that DHSC will provide policy direction, guidance and support to local authorities and ICBs.

ICBs will be expected to report evidence on fulfilling their new duty through their existing annual statement and local authorities will be expected to provide this evidence upon request. This will show how they have taken patients’ and service users’ views into account when commissioning services.

The feedback gathered will be used to better inform local commissioning of services and support the co-design of services which will be driven by the needs of local communities. As set out in the 10 Year Health Plan, a neighbourhood health plan will be developed by local government, the NHS and its partners at single or upper tier local authority level under the leadership of the health and wellbeing board. Neighbourhood health plans will incorporate NHS responsibility for health services with local authorities’ responsibility for public health and social care services. Neighbourhood health plans will also cover the use of pooled funding under the Better Care Fund. These plans will be brought together to form population health improvement plans and used to inform commissioning decisions.

The new national director of patient experience in DHSC will be responsible for overseeing the collection of more informed feedback from both patients and carers and making it publicly available. The creation of the national director of patient experience role was set out in the 10 Year Health Plan. It does not require legislation to create and so does not appear in the bill.

Effect on staff

HWE is a committee in CQC and so any changes that affect HWE staff will be managed through an internal CQC HR process. This process should support staff by:

• identifying transferable skills and expertise through consultation
• providing the opportunity for staff to be considered for suitable alternative employment where vacancies exist and if appropriate

If an alternative role cannot be found, then there is a risk that individuals could face redundancy.

There may be opportunities for staff to move on Transfer of Undertakings (Protection of Employment) (TUPE) or to find roles within the new patient experience directorate in DHSC. However, as the structure of the patient experience directorate will be finalised after any primary legislation is passed, we are unable to confirm if this would be possible or the numbers involved at this early stage. 

With the abolition of LHW arrangements, the contracted organisations will be unable to use the ‘Healthwatch’ trademark. Details on transitional arrangements are to be determined. Contracts may come to a ‘natural end’, depending on the length of the contract or a unilateral end date may be stipulated during the development of policy and regulations. There may be a risk of redundancies within those relevant organisations at this point.

As with any change of this kind, the uncertainty coupled with organisational change may negatively affect staff morale. This could result in increased levels of stress, absenteeism, sick leave and additional pressure on existing resources for all employees.

For both HWE and LHW there is a risk that staff leave during the transitional period. This could mean that the organisations are under resourced creating pressure on the remaining staff. It is uncertain whether this would differentially impact staff groups with certain protected characteristics.

Effect on patients

The overall aim of this intervention is to empower and make it easier for patients to provide feedback on services by reducing the number of organisations operating in the patient safety landscape.

The aim is for patients and service users to be able to provide feedback directly to the providers and commissioners of services with an understanding that their feedback is being heard directly by those responsible for care provision. This in turn should influence policy and strategies resulting in the provision of services that better reflect the needs of local communities.

There is a risk that during the transition there may be gaps as services provided by LHW and HWE are reduced or stopped. This is being mitigated through robust communications and engagement about timelines and funding with ICBs, local authorities, HWE and LHW organisations.

As the changes are implemented, it may take time for some patients to familiarise themselves with new feedback routes. This may be more apparent for those providing feedback on health services through an ICB. This risk will be mitigated by communications and signposting.

There is a potential ongoing impact associated with the loss of LHW organisations as independent organisations. Some patients may trust independent organisations to provide feedback over organisations that are involved in providing their care. Some patients may prefer to provide feedback to familiar organisations, such as LHW, that are able to relay their experience on patients’ behalf. ICBs and local authorities will need to work with local people and patients to ensure that they are comfortable and able to provide direct feedback on services to those who are commissioning and implementing those services.

ICBs will have flexibility in how they meet their statutory duties in getting the views of patients and users. ICBs will be required to demonstrate how they have met their commitments and taken patient experience into account when commissioning services through an annual statement.

Local authorities will need to evidence how they have fulfilled their duties upon request.

We anticipate that as ICBs and local authorities demonstrate how they implement feedback from patients with clarity and transparency, patients will begin to trust that ICBs and local authorities are listening and taking the necessary action.

Effect on service users

The effect on service users will be the same as the effect on patients.

Effect on carers and family

The effect on carers and family will be the same as the effect on patients.

Engagement and involvement

Throughout the review, Dr Dash heard from more than 100 individuals or organisations with an interest in patient safety and worked closely with senior leaders at 6 organisations. A review advisory board was established to take into account a wide range of evidence and views regarding patient safety from across the health and care landscape. A full list of those spoken with and involved in the review can be found in appendix 1 of the Dash review.

Since the review and in preparation for the legislation, the government has engaged with:

• HWE
• LHW organisations and/or their representatives
• CQC
• NHS England
• National Voices
• the Local Government Association
• directors of adult social care
• other government departments

This engagement has helped to not only hear and respond to queries and questions surrounding the changes, informing communications to local authority leaders, but has also helped to inform the design of the new patient experience directorate. This will ensure that the core functions and principles of HWE and LHW are embedded and patient voice is strengthened in those that commission and provide services. This engagement will continue throughout implementation.

Analysis of impacts

Disability

Disabled people are likely to experience a wide range of challenges accessing healthcare and these are likely to vary depending on their specific disability. Evidence demonstrates that on the whole those with a disability are more likely to have poorer experience of healthcare. There is also evidence that disabled people are likely to face barriers to accessing healthcare^{[footnote 1]}.

In the CQC adult inpatient survey 2024 (the 2024 CQC inpatient survey), disabled respondents reported poorer experiences of inpatient care, including feeling less likely to be treated with respect or dignity, low confidence and trust in doctors and nurses, and feeling less able to discuss fears and worries with staff. They also reported not receiving enough support to help them recover or manage their condition. These poorer experiences suggest that disabled people may be more likely to want to give feedback about their care. Therefore, they are likely to be disproportionately affected positively or negatively by any changes which make it easier or more difficult to provide feedback. 

The changes introduced with this policy will mean service providers and commissioners will go directly to patients and service users to seek their feedback. Providing feedback directly to the provider may, in the absence of arrangements to ensure their inclusion, be particularly difficult for those disabled people who struggle with communication in healthcare settings.

A 2022 Healthwatch accessible information survey found that 1 in 5 respondents struggled to understand most of the information given by services. The analysis looked at respondents who report needing help communicating with healthcare staff. Academic research has identified specific barriers to accessing healthcare for some groups, for example those with intellectual disabilities and/or autism experiencing fear and embarrassment or barriers resulting from a lack of knowledge and awareness^{[footnote 2]}.

Disabled people may struggle to communicate their feedback to providers for the same reasons they struggle with communication in healthcare settings in the first place. This includes a lack of accessible information and an absence of tailored communication, feeling uncomfortable and feeling a negative attitude from staff members. These barriers could potentially affect all forms of feedback for example, verbally, in writing and online. It is worth noting that patients can also choose to provide feedback to ICBs as the commissioners of services if they do not wish to communicate with providers directly.

As per the legislation it is intended that the Secretary of State will have a power to provide guidance to ICBs and local authorities on fulfilling their new functions. This power would extend to the feedback mechanisms for people with disabilities, their carers and families.

LHW organisations provide one of the points of contact for both health and social care feedback. Many disabled people are in receipt of social care. For example, according to the Adult social care activity and finance report, England, 2023 to 2024, more than 127,000 working age and 21,000 older adults with learning disabilities received long-term support. At the same time, overall health is poorer for disabled people. The Health Foundation’s Inequalities in good health by disability status indicator reports that compared with 90% of non-disabled people, only 32% of disabled people felt in good health.

This means disabled people are likely to be disproportionately reliant on both health and social care. Following the legislative changes, health and social care providers and commissioners will need to be mindful of the challenges and opportunities for providing feedback for people with multiple needs. This might be particularly relevant for disabled people as they are likely to be cared for by both health and social care providers.

We do not have data on the number of disabled staff at LHW organisations or HWE. Economic data shows that the employment rate is lower for disabled people compared with non-disabled people. Therefore, if the abolition of LHW organisations leads to redundancies, then disabled staff may find it hard to find new employment opportunities compared with non-disabled staff and could be disproportionately affected.

Sex

Research shows that women often feel that their health concerns are minimised or dismissed^{[footnote 3]}. The 2022 Women’s Health Strategy call for evidence found that 84% of respondents experienced instances of women not feeling listened to by healthcare professionals. This manifests for example in symptoms:

• being dismissed (either as a ‘natural part of being a woman’ or ‘not falling within the typical profile’)
• being viewed as ‘exaggerated’

A more direct feedback route to providers or commissioners could improve women’s experience if those feedback routes are designed with that aim in mind. It is worth noting that providing direct feedback routes for women is in accordance with ICBs and local authorities complying with their public sector equality duty.

We do not expect any differential impacts based on sex for staff, service users, patients, their carers or families, as a result of the abolition of HWE and LHW organisations.

Sexual orientation

Evidence from NHS England on LGBT+ health suggests that homosexual and bisexual people have worse access, outcomes and experiences of healthcare when compared with heterosexual people, for example:

• reporting unequal treatment due to their sexual orientation and feeling that their needs are not taken into account - as reported in the LGBT action plan 2018
• reporting that services follow heteronormative assumptions - as reported in a 2018 report on the health and wellbeing of lesbian and bisexual women

Distrust is widespread, leading some to avoid treatment^{[footnote 4]} and care^{[footnote 5]}. This pattern is more prevalent among older homosexual and bisexual people. LHW organisations have made concerted efforts to gather the views of homosexual and bisexual patients - see LGBT+ experiences of health and social care services in York.

The changes made by this proposed legislation would require patients to provide feedback directly to the health and care services that they may already avoid or where they have experienced poor treatment. The lack of trust and avoidance of health and care services may mean that the feedback of homosexual and bisexual people would not be adequately captured by ICBs and local authorities unless they consider proactive engagement with those groups. It is worth noting that such proactive engagement is in accordance with ICBs and local authorities complying with their public sector equality duty.

Sometimes, partners in homosexual relationships face barriers when interacting with health and care services, for example:

• they are not feeling welcome - as reported in the 2019 Women and Equalities Committee report Health and social care and LGBT communities
• their relationship is not taken as seriously as heterosexual relationships^{[footnote 6]}

This may impact their ability to provide feedback directly to health and care services as they would need to, following these legislative changes. It is worth noting that patients can also choose to provide feedback to ICBs as the commissioners of services if they do not wish to communicate with providers directly.

We do not expect any differential impacts on staff due to their sexual orientation following these legislative changes.

Race

Ethnic minorities, although not a homogenous group, are affected by health inequalities. The picture is complex and evidence from The King’s Fund report The health of people from ethnic minority groups in England points towards a mixture of contributing factors such as the environment, behaviours and deprivation.

According to insights from the NHS Race and Health Observatory’s Patient experience and trust in NHS primary care survey, some ethnic minorities (South Asian and Black) report worse healthcare experiences, compared with the White majority when, for example, they are asked whether they felt ‘listened to’ or whether their concerns were ‘adequately acted on’ in primary care settings.

Healthwatch research into Men’s health: how to improve health outcomes, knowledge and behaviours suggests that LHW is an important source of healthcare information, especially for ethnic minority men. Evidence from across Organisation for Economic Co-operation and Development (OECD) countries points to an increased risk of patient safety incidents for ethnic minorities^{[footnote 7]}. These factors suggest that it will be important for organisations to ensure that the arrangements for feedback that succeed LHW are well designed to include ethnic minorities. We have no evidence to suggest that all else being equal, ethnic minorities may be less able to access the new feedback mechanisms.

Not all patients, whether born in England and Wales or not, speak English fluently. Healthwatch research on Vulnerable migrants: experiences of healthcare reports that this also applies to vulnerable migrants and newly arrived asylum seekers. According to proficiency in English data from the latest Office for National Statistics (ONS) census, more than 5 million people across England and Wales have a first language that is not English.

English language analysis from the Migration Observatory shows just under 1 in 5 of those born in Pakistan and ‘other South Asia’ countries say they ‘cannot speak English well or at all’.

In line with the public sector equality duty, arrangements will need to be put in place to ensure that patients in this situation who wish to provide feedback to their ICB or local authority should be able to do so.

Although patients should at present be supported, for example using translators, research shows that clinicians’ awareness of language support for patients is mixed^{[footnote 8]}. The same barriers may apply to carers or family members who wish to provide feedback on behalf of a patient.

We do not know how many staff of LHW organisations are of an ethnic minority and how many may need to find new employment following the abolition of LHW organisations. GOV.UK unemployment data indicates a higher unemployment rate for ethnic minorities when compared with White ethnic groups. This may be indicative of difficulties among this group with finding employment, compared with White ethnicities.

Age

Although the 2024 CQC inpatient survey shows that younger patients reported worse experience of inpatient care across metrics on waiting times, trust, support and involvement in care, we have no evidence that suggests younger people might be disproportionately affected by these changes.

According to the Health Foundation’s 2021 report on our ageing population, many older people live with multiple conditions and are reliant on both health and social care to varying degrees. NHS England data on hospital admitted patient care activity for 2024 to 2025 reported that there were almost 10 million finished consultant episodes for those aged 65 to 90 and over, compared with just over 7 million finished consultant episodes for those aged 35 to 64.

According to ONS data on older people living in care homes in 2021 70.9% of the care home population aged 65 and above was disabled with day-to-day activities limited ‘a lot’. Similarly to disabled people, there may be a disproportionate burden on older people to approach the providers of health and social care services individually.

Both the Statistical Digest of Rural England and the CQC State of health care and adult social care in England 2023 to 2024 report found that older people are more likely to live in rural areas, which may restrict their ability to access health and care services as provision in rural areas is impacted by poor infrastructure and lack of digital access. Additionally, Age UK reports that many older people are not equipped to use online services (which is one method of providing feedback), with:

• 1 in 3 aged 65 and over (4.7 million people) unable to do basic tasks such as turning on devices, connecting to wifi, opening browsers or logging into accounts
• 1 in 6 aged 65 or over (2.3 million) do not use the internet at all

In changing avenues for feedback about health and social care services, it will be important to ensure the inclusion of older people, some of whom struggle with accessing health and social care services. For the same reasons, it will be important to consider the needs of older carers or family members wanting to provide feedback on behalf of a patient.

We do not know the age distribution among staff members of LHW organisations. While a change in employment may be disruptive for older workers, it may also be challenging for younger workers as ONS youth employment data suggests youth unemployment is rising. However, the ONS states that volatility in their Labour Force survey estimates means that trends over time should be treated with caution.

Gender reassignment

According to Stonewall’s LGBT in Britain - health (2018) report, transgender people report poor access, outcomes and experiences of health and social care with high rates of mental health conditions, reported discrimination, unequal treatment and avoidance of health and care services.

The TransActual report, Trans lives survey 2021: enduring the UK’s hostile environment, says the impacts of overlapping protected characteristics (intersectionality) are worth noting, especially regarding, age, disability and ethnicity. The legislative changes to abolish LHW organisations would require patients to provide feedback to the health and care organisations where they have potentially experienced poor care or the commissioners of those services. This will mean that local organisations will need to ensure they consider the needs of a community that already avoids contact with health and care services ^{[footnote 5] [footnote 9] [footnote 10]}. However, at this point we have no evidence on feedback behaviour which is particular to this group.

We do not expect any differential impacts based on gender reassignment for staff, carers or families, as a result of the abolition of HWE and LHW organisations.

Religion or belief

ONS analysis of religion and health in England and Wales (February 2020) reports there is no evidence that religion or belief have a negative impact on individual physical or mental health, or satisfaction with health. The 2024 CQC inpatient survey found that Jewish people have less trust in their doctors and nurses compared with those of other or no religion but this does not seem to be a consistent trend (the 2023 CQC inpatient survey did not show this). Overall, we do not have systematic evidence that would suggest poorer experiences of patients or social care users due to their religion or belief.

On balance, we do not expect any differential impacts based on religion or belief for staff, service users, patients, their carers or families, as a result of the abolition of HWE and LHW organisations.

Pregnancy and maternity

Following the proposed legislative changes, providers or commissioners will need to ensure that people who have received maternity care are enabled to directly provide feedback, rather than using for example an LHW organisation as third party.

Although there is evidence that some aspects of maternity care have improved recently (such as mental health support), the 2024 CQC maternity survey shows worsening trends in other aspects, crucially in communication and information:

• almost 1 in 5 (18%) did not receive help with communication needs such as translators and easy read materials
• a declining number of people felt they were ‘always’ spoken to in a way they could understand (85% versus 90% in 2019)
• 1 in 4 (25%) did not have the opportunity to ask questions about their labour and birth after having the baby, which is a significant decline when compared with 2019 findings

According to MBRRACE-UK perinatal mortality surveillance, the intersection with ethnicity is worth noting as outcomes are worse for Black and Asian ethnic minorities when considering metrics such as the stillbirth and neonatal mortality rates. The CQC ‘State of health care and adult social care in England 2023 to 2024’ report highlights maternity care as an area for concern with almost half of inspected locations rated as ‘requiring improvement’ or ‘inadequate’.

Directly approaching the provider where poor maternity care has been experienced to provide feedback may be emotionally and psychologically difficult for those affected, therefore constituting a barrier to access for some. It is worth noting that patients can also provide feedback to ICBs, who are the commissioners of services, if they do not wish to communicate with providers directly.

We do not expect any differential impacts based on pregnancy or maternity for staff, carers or families, as a result of the abolition of HWE and LHW organisations.

Marriage and civil partnership

We do not expect any differential impacts on those married or in a civil partnership as a result of the abolition of HWE and LHW.

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

The Health Foundation indicator on the relationship between income and healthy life expectancy found that people who live in more deprived areas and/or are from low-income groups experience poorer health outcomes, while local authority areas with higher incomes tend to have higher male and female healthy life expectancy.

ONS data on healthy life expectancy by national area deprivation shows that at birth, males in the most deprived areas of England were expected to spend 70.4% of life in ‘good’ health, compared with 84.5% in the least deprived areas. For females it was 65.1% and 81.5% respectively.

It is possible that people living in areas of higher deprivation or those from a lower socioeconomic background may be more reliant on health and social care services because of poorer healthy life expectancy.

There is a risk that after the changes come into effect, patients and users will not initially know where to turn to when providing feedback. These groups may be disproportionately affected by this as they may struggle to engage with the health and care system, for example:

• ONS data on trends in patient-to-staff numbers at GP practices found that deprived areas have fewer fully qualified GPs per patient
• a CQC survey of older people found that only about 6 in 10 patients aged 65 and over in deprived areas are satisfied with their access to services and face greater risks of their needs or concerns going unheard

This potentially reinforces existing health inequalities.

Digital exclusion is more prevalent among those on a low income. The UK digital strategy (2017) the states that:

unemployed adults, for example, are 5% more likely to lack the basic digital skills than the national average, and 24% more likely to lack these skills than high earners.

According to NHS England’s digital inclusion framework, 30% of people who are offline feel that the NHS is one of the most difficult organisations to interact with. It will be important to ensure the effective implementation of changes set out in this legislation, so that those affected by digital exclusion do not experience greater difficulty - and ideally experience less difficulty - navigating NHS systems and providing feedback than they have previously done using LHW systems.

It is worth noting that digital exclusion and deprivation intersect with other protected characteristics (for example, disability and sex), disproportionately affecting some groups with particular protected characteristics.

Residents living in rural areas face greater distances to essential services such as GP practices, local authority offices, or healthcare providers where feedback can be given in person. A Healthwatch blog on what people living rurally have told them about their healthcare records that only 43% of people living in rural areas have access to a GP within half an hour’s walk, compared with 95% of people living in urban areas. Therefore, people living in rural areas may continue to face existing barriers to accessing services and engaging with feedback mechanisms on those services. The proposed changes do not improve access for this group unless local authorities and ICBs consider proactive engagement with those groups. DHSC will issue guidance to support local authorities and ICBs. It is also worth noting that in-person feedback is usually not the only route to providing feedback.

Social exclusion

Socially excluded individuals are either born into or pushed to the margins of society, which limits their ability to participate in social, cultural, economic and political life. Groups that are considered socially excluded include people experiencing homelessness, sex workers, prison leavers, care leavers, victims of domestic abuse, vulnerable migrants, victims of modern slavery and victims of modern trafficking. Healthwatch has previously carried out targeted outreach and research to understand the needs and experiences of these groups.

In 2021, the Ministry of Housing, Communities and Local Government (MHCLG) estimated in its Changing Futures prospectus that 363,000 adults (less than 1% of the general population) were experiencing multiple disadvantages across England. This includes a combination of homelessness, substance misuse, mental ill health, domestic abuse and contact with the criminal justice system.

Socially excluded groups intersect with protected characteristics. For example,

• women are overrepresented among sex workers, with male and transgender sex workers representing a smaller but significant minority^{[footnote 11]}
• men make up the majority of the prison population and therefore also make up the majority of prison leavers
• those who are homeless are more likely to live with long-term physical or mental health conditions^{[footnote 12] [footnote 13]}, indicating a strong intersection between homelessness and disability. Older adults experiencing homelessness often display accelerated age-related health vulnerabilities^{[footnote 14]}
• care leavers are predominantly young adults navigating the transition out of statutory support^{[footnote 15]}, representing a young cohort of socially excluded people

Socially excluded groups often experience poorer outcomes in health than the general population and have many similar undiagnosed and untreated long-term conditions arising from mental health, substance dependence, tuberculosis and sexually transmitted infections.

Socially excluded groups are more likely to face barriers when accessing healthcare services, leading to negative experiences and a greater risk of avoiding health services in the future. Common barriers include stigma and discrimination, low health literacy, digital exclusion, transport and logistics, a lack of trust in services and language barriers.

These issues may worsen with the abolition of HWE and LHW, reducing opportunities for socially excluded groups to share feedback on their care experiences. As a result of poor access to services, evidence shows that socially excluded groups underuse some services, such as primary and preventative care, and often rely on emergency services such as A&E when their health needs become acute. For example, according to the Homeless Link’s Unhealthy state of homelessness 2025 audit, people experiencing homelessness use on average 4 times more acute hospital services than the general population. They have higher emergency and inpatient admissions, longer inpatient stays, delayed discharge and more frequent re-admittance to care.

The proposed legislative changes should ensure ICBs and local authorities are considering how to build trust and support socially excluded groups in their access to and ability to feedback about services. In addition, existing guidance would be updated to reflect any new requirements.

Mental health

People with mental health conditions may experience disproportionate impacts from the proposed changes to health and care feedback structures.

The 2024 CQC inpatient survey showed that patients with a mental health condition reported poorer than average experiences of:

• staff discussing any further support needs from health or social care services
• getting enough support from those services after they left hospital
• being treated with kindness and compassion

In 2022, the National Institute for Health and Care Research (NIHR) published a national survey of people with a severe mental illness which found that around 4 in 10 (42%) lacked basic digital skills, such as changing passwords or connecting to wifi ^{[footnote 16]}. It also found that 46% of people with a severe mental illness lacked digital foundational skills or ‘skills for life’, which is twice as many as in the general population (22%). These findings indicate that this group may face additional barriers when accessing online health and care services, which include (but are not limited to) digital feedback mechanisms.

However, this represents an existing barrier rather than a new one created by the proposed transfer, and continued efforts (such as monitoring and evaluation plans) will be needed to ensure these accessibility challenges are not worsened.

Summary of analysis

Overall impact

The department has assessed all 3 aims of the public sector equality duty in relation to the proposed policy. This document is a continuation of the assessment done in the 10 Year Health Plan equality impact assessment.

Impacts of the proposed changes towards reducing unlawful discrimination, harassment and victimisation (aim 1), advancing equality between those who share and those who do not share a relevant characteristic (aim 2), and fostering good relations between those who do and those who do not share a relevant characteristic (aim 3), are considered for each protected characteristic and additional ones.

The changes to feedback mechanisms set out in this legislation aim to make it easier for patients to provide feedback and make the patient voice more effective and impactful. However, there is a risk that these changes may have differential impacts on some groups, mainly those who are more likely to rely on both health and social care services to a greater extent and have poorer experiences of health and social care services. We have no evidence that suggests that one of those groups is more affected than another.

Our analysis showed that barriers in accessing or interacting directly with health and care services exist currently. Therefore, ICBs and local authorities will need to design the future feedback mechanisms with this in mind to advance equality, reduce discrimination and foster good relations. This is in accordance with their duties under the public sector equality duty and DHSC will issue guidance to support this.

Addressing the impact on equalities

The Secretary of State and the reformed DHSC will establish a patient experience directorate that, alongside its other roles, will be responsible for functions of HWE. The aim is for patient voice to be embedded in leadership and decision-making structures. Clear routes for patient insight, feedback and lived experience are meant to directly influence senior leaders at the national level. The patient experience directorate will be responsible for ensuring that all voices are heard including those with protected characteristics. The reformed DHSC will provide guidance and support to ICBs and local authorities, along with clear policy direction on the changes. This will support organisations to build collaborative partnerships with all their local communities.

We will ensure appropriate arrangements are in place to oversee this legislative change and ensure robust governance and accountability. These arrangements will be able to address 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 who, due to their protected characteristics, may find it difficult to give feedback. As public bodies, the reformed DHSC, ICBs^{[footnote 17]} and local authorities are bound by the Equality Act 2010 and need to have due regard to the 3 aims of the legislation as set out in the introduction.

Monitoring and evaluation

An overall monitoring and evaluation plan for the bill will be developed throughout its passage through Parliament and will include provisions to evaluate and monitor the abolition of HWE and LHW organisations. Differential impacts on people with protected characteristics will be monitored and evaluated in line with DHSC and Magenta Book guidance.

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4. Payne D. Caring for older LGBT+ people British Journal of Community Nursing 2022. ↩

5. Skeldon L and others. Experiences and attitudes of the LGBTQ+ community on care/nursing homes Journal of Homosexuality 2023: volume 70, pages 3075 to 3107. ↩ ↩²

6. Almack K and others. Exploring the impact of sexual orientation on experiences and concerns about end of life care and on bereavement for lesbian, gay and bisexual older people Sage Journals 2010: volume 44. ↩

7. Chauhan A and others. The safety of health care for ethnic minority patients: a systematic review International Journal for Equity in Health 2020: volume 8. ↩

8. Irimia M and others. Exploring clinicians’ awareness of language line and barriers in accessing NHS interpreting services Future Healthcare Journal 2024: volume 11. ↩

9. Roller CG and others. Navigating the system: how transgender individuals engage in health care services Journal of Nursing Scholarship 2015: volume 47, issue 5 (subscription required). ↩

10. Mikulak M and others. Health professionals’ identified barriers to trans health care: a qualitative interview study British Journal of General Practice 2021: volume 71, issue 713. ↩

11. Home Affairs Committee (2016). Prostitution inquiry ↩

12. Crisis (2025). People with physical ill health and disabilities representing increasing proportion of people facing homelessness ↩

13. Ministry of Housing, Communities and Local Government (2025). Statutory homelessness in England: January to March 2025 ↩

14. Rogans-Watson R and others. Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel Housing, Care and Support 2020: volume 23, issue 34, pages 77 to 91. ↩

15. Department for Education (2025). Children looked after in England including adoptions ↩

16. NIHR (2022). Barriers to care: many people with severe mental illness lack digital skills ↩

17. ICBs also have a duty to reduce inequalities in section 14Z35 of the Health and Care Act 2022. ↩