Review of ‘A Radical Practice in Liverpool: the rise, fall and rise of the Princes Park Health centre’ Katy Gardner and Susanna Graham-Jones.

NHS Public Health

‘A Radical Practice in Liverpool: the rise, fall and rise of the Princes Park Health centre’ Katy Gardner and Susanna Graham-Jones.

Published by Writing on the Wall. 2021. 268 pages. ISBN 13:9781910580561.

This book covers 40 years in the life of Princes Park Health Centre (PPHC), a progressive practice serving a diverse and deprived inner city community in Liverpool 8. This area in South Liverpool hit the headlines in 1981 with the so called Toxteth riots which were the result of long term deprivation and racism and were sparked off by incidents of police ‘stop and search’. Such tensions still resonate today in our disadvantaged ethnically diverse inner city communities. The authors are two practice partners during the period up to 2005, both of whom played important medical leadership roles in the practice and further afield. Katy Gardner for example has been a regular contributor to the Morning Star, is a longstanding SHA member and remains active in Doctors in Unite.

They have drawn on a wide range of other contributors to tell their stories and provide illustrations from patients, staff and people from the local community in Merseyside. Having been an inner city GP in the 1980s and visited Cyril Taylor as a GP trainee, I feel that this account captures the vision, advocacy and commitment required. The national policy and professional influence of PPHC’s work is reflected in the Foreword by Iona Heath, President of the Royal College of GPs between 2009-2012, who worked for 35 years in the Caversham Group practice in London NW5, a health centre also opened in the 1970s under the leadership of a Socialist Medical Association (SMA) member Hugh Faulkner.

The book provides a wonderful insight into the demands, stresses and strains of idealistic multi professional health workers grappling with the ill health created by socio-economic conditions, problems experienced by homeless people, refugees and asylum seekers and those subject to sexism and racism in all its manifestations. Some of the innovative services offered to their patients were the extended primary care team including social workers, counsellors as well as the more usual teams of district nurses, health visitors and other visiting professionals. The practice projects responded to the local needs in the population such as the Family Health Project for homeless people, the Somali Mental Health project and needs of asylum seekers more generally. A holistic perspective on health and wellbeing, is illustrated by extensive community engagement, patient participation groups and special events such as the 1992 ‘Health thru Arts’ festival. It is a story about a pioneering group practice, embedded in the local community staffed by health and social care workers, volunteers and activists all committed to creating an inclusive health and social service responsive to local needs.

The PPHC was the brainchild of Dr Cyril Taylor who had been a local GP in the area since 1950. He had served as a local Labour councillor, was Chair of the Liverpool Social Services Committee and President of the Socialist Health Association (SHA). He was politically active locally in Liverpool but also nationally being for example a member of the Royal Commission on the NHS. This Commission was established by the Labour Government in 1975 and reported in 1979 to the new Thatcher Tory Government! It is worth noting the risk of these government reports taking too long given our short electoral cycle. The Black Report on Health Inequalities also established by that Labour Government missed the boat too by being published in 1980.

There are golden threads that run through the book and provide the political and moral compass to their work. Cyril Taylor would have been aware of the pioneering Peckham Health Centre developed in the 1920s/30s in SE London where a swimming pool, gym and childcare facilities represented their interest in prevention and family health. As an SMA member he would have known about the policy support for health centres and a salaried service. A more contemporary influence manifest in the book is of his comrade Julian Tudor Hart (JTH), another past President of the SHA. The PPHC was attempting to provide a local and practical response to the Inverse Care Law first published by JTH in the Lancet in 1971.

There is reference in the book to the potential benefit of primary care and public health working more closely together. Another SHA Chair, Alex Scott-Samuel was involved in the early days as a local public health academic in Liverpool University as was John Ashton who worked in public health academia in Liverpool and subsequently within the NHS as a Public Health Director. However the book outlines the serious obstacles that were confronted in making the case for building the Health Centre, staffing it and the ‘powers that be’ resisting the desire of the GPs to be salaried employees.

The SHA and its predecessor organisation the SMA has promoted policies from before the launch of the NHS in 1948 that GPs and other health professionals such as dentists should be salaried employees and working together from purpose built health centres. The group of ‘independent contractors’ include dentists, pharmacists and optometrists and these professionals were one part of the 1948 tripartite NHS – separated organisationally from the hospitals and local authority services such as environmental health, public health, midwifery and health visiting. The SMA since the inception of the NHS had argued for health centres and salaried GPs. A policy document on health centres published in 1975 identifies the need to build modern purpose built health centres so that they could provide a base for extended primary care teams some 27 years after the NHS was born and a decade after the 1966 GP Charter. Since then we have seen what has happened to this vision with the corporate takeovers of community pharmacy, the extensive privatisation of general dental practice and the corporate takeover of the optometry and audiology services. We are also seeing the historic GP corner shops, merged into group practices and then taken over by unaccountable businesses. The original vision of health centres accommodating multidisciplinary teams located in accessible sites for the population served is vanishing. The story of PPHC takes us through a period of change, highlights the obstacles in bringing the vision into action and the damaging changes in NHS management and policy.

The authors document the hurdles that they confronted in developing new services and wanting to move away from the independent contractor status of GPs. The frequent NHS disorganisations proved to be deeply frustrating and demoralising and there is a real sense that idealistic health workers were getting stressed and burnt out by trying to serve their patients in great need on a 24/7 seven day per week basis. The PPHC participated in the short-lived Association of GPs in Urban Deprived Areas (AGUDA), which articulated the higher needs and demands for NHS staff in inner city areas and how the pay and conditions did not compensate for the extra work involved. Encouraging primary care based maternity services with home deliveries and end of life care requires a huge personal commitment the timing of events being outside one’s control. The story of author Katy Gardner falling asleep in the early hours of the morning in a patient’s home while waiting to support the home delivery illustrates the willingness, commitment and consequential tiredness. It is good therefore to note the contemporary success of the Deep End project led by Graham Watt, a former Tudor-Hart MRC Registrar, which while based in Glasgow and across Scotland is also seeding a global network. 50 years on from the publication of the Inverse Care Law the structural determinants of ill health remain and it is good that the aspiration for greater equity in primary care is still alive.

An opportunity for the GPs to become salaried arose in 1998 as part of a Primary Care Act pilot and the PPHC GPs became employees of the North Mersey Community (Mental Health) Trust. From then on however multiple changes were introduced including the creation of PCGs, PCTs, Alternative Provider of Medical Services (APMS) contracts and in 2011 PPHC was put out to tender by Liverpool PCT and awarded to SSP Health Ltd, a GP owned business. This was a very unhappy period and staff had left (Katy herself in 2005) and a poor Care Quality Commission report in 2015 followed. Services remained unsatisfactory and the SSP contract was not renewed. The Liverpool CCG asked the Brownlow Health group to step in and they were more aware of the history of PPHC, with one of Brownlow’s GPs having been a trainee there. This has proved a success with a five year contract awarded to them in 2018. However there remain huge risks as we enter a second decade of Tory government with continuing under investment in primary care with challenges in the recruitment and retention of GPs. Organisationally there are risks of privatisation as the new Integrated Care Systems develop with little in the way of local democratic accountability and assurance about safeguarding NHS provision from national and international ‘for profit’ organisations.

I recommend this book which provides a history of the PPHC from 1977-2017, explores the vision which drove the pioneer practitioners, includes a realistic description of the work involved and the value that a socialist and culturally radical practice delivered to the people they served. The golden thread is like an Olympic torch handed over from socialists in the pre NHS period and through each decade of its 70year history. Organisations like the SHA and Doctors in Unite need to keep the flame alight to safeguard what we have and enthuse the next generation of radical practitioners.

Dr. Tony Jewell was President of the UK Association of Directors of Public Health and was the Chief Medical Officer in Wales. He has been a member of the Socialist Health Association for over 40 years.