My Lords, I congratulate my noble friend Lord Chan and other speakers. At lunch-time I realised that I could be here for this important debate and I am very pleased to take part in the gap. I shall focus more generally on health inequalities, rather than specifically on the North West situation, which my noble friend and other speakers have already done so admirably. I declare an interest as chair of the advisory board to the English Longitudinal Study on Ageing at University College London, led by Professor Sir Michael Marmot.

The study is funded partly by the American Government through the National Institute on Aging and partly by the British Government through the Department of Health. It follows a large representative group of people of 50 years old and over. It is designed to monitor how inequalities play out across the years and affect morbidity and mortality. The Centre for Health and Society at UCL was heavily involved in the Acheson inquiry in 1997 and has been since in other developments.

I first became interested in health inequalities in the context of the demographic revolution that we are under-going, but it has wider societal implications. Only two weeks ago on 13th October, we debated another aspect of this issue in the excellent short debate on obesity, which should be considered as one manifestation of health inequality.

Noble Lords may be aware of UCL's Whitehall study, which studied civil servant mortality rates in men aged 40 to 64. For the top grade of civil servant, mortality was half the average rate. As a result, we are lucky enough to have some of them here in this House. For executive grades, mortality rates were 20 per cent lower; for clerical grades, it was 35 to 40 per cent higher; and for office support grades, mortality rates were twice the average—a four-fold difference between top and bottom grades.

Those are startling figures, which we have also seen in other areas—for example, on smoking, obesity, and so forth. To a great extent, that justifies the Government's focus on groups at the bottom of the scale. However, the UCL research is finding that the key group to focus on to make the greatest impact on outcomes is not necessarily or exclusively those at the bottom, but often the people just "below the middle". At an International Longevity Centre lecture in June, Sir Michael Marmot said:

"the fact is that there is a social gradient . . . and these inequalities run right through from top to bottom".

However, that is not to say that we should not focus on those at the bottom of the scale at all. Sure Start is a very important initiative—which, in particular, looks at deprived neighbourhoods—that is open to all-comers. Getting the message about a gradient to policy-makers is sometimes difficult because, as we know, governments like to set targets. The target is the most socially excluded—those people right at the bottom—which is right, but these people should not be focused on exclusively.

The issue is very complicated: it is more complicated than just assuming that low income alone causes health inequality. For example, for black males in the USA, the median income is 26,500 dollars per year; in Costa Rica, it is 6,400 dollars per year. But life expectancy in Costa Rica is 75 years, compared to 66 years in the USA among the same group. What perhaps is more important is relative social exclusion—that is, how people feel within their own society about relative deprivation as well as actual deprivation; those things about which people are aware. Today, we are very aware of what is going on around us. It is not about genetic determinants alone; it is about things which we can see make a great difference—just like Seebohm Rowntree sought to do in the 19th century. To the credit of the Government, they are trying to do that.

It is crucial to take a life-course approach. I touched on that in the obesity debate; it is very important. The conclusion is that autonomy and control over one's life is another key factor in reducing inequality. Mortality rates must be reduced. It is very important to do so because not only are health inequalities unjust, but they are also grossly inefficient and something within our power to remedy.