Prime 75+

Di Whaller | Practice Manager | Arden Medical Centre, Stratford-upon-Avon


Following concern across the practice about social isolation amongst our older patients and its impact, we took the decision to partner with healthcare organisation Prime GP to implement an initiative which was both personal and proactive, and which promised to tackle head-on the issues related to loneliness through:

  • Delivering a service within primary care to patients aged 75+
  • Offering health, social, and voluntary care interventions
  • Reducing loneliness and social isolation
  • Decreasing dependency on health services

Prime75+. Its Conception

Following identification by South Warwickshire CCG that the ageing population was one of its biggest concerns, it recognised the need to commission services that were not only flexible and diverse, but responsive to the changing needs of the population, while also being cost-effective in an increasingly challenging financial environment.  The CCG’s main aim was to tackle the issues impacting the ageing population and help improve the quality of life for those living with long term conditions – primarily by changing the way the CCG provided care for those patients, and enhancing their experience of local services, as well as ensuring consistency across the area. 

With the population of 75s and over at just under 26,000 in March 2014, SWCCG allocated £1.3 million for 2014/2015, and it was agreed the CCG would:

  • Produce an information booklet initially known as the ‘Silver Book’
  • Provide an online resource to support clinicians
  • Commission a generic service – a ‘Proactive Care Team.’

Practices then fed back to advise they would prefer the CCG to allow them to commission services that they felt were appropriate for their local population, in essence opting out of the generic service. This was agreed on the basis that a clear distinction was drawn between any new service and the services/funding already in place.


  • Early September 2014 the CCG issued a template for GP practices to complete either individually or collectively to bid for funding, and this was supported by Q&A sessions at Members’ Councils. The template covered an overview of the service, its delivery model, outcomes, patient engagement, equality and diversity, financial model, health inequalities, how this differed from existing schemes, activity monitoring, implementation plan, risks and mitigation plans
  • Early October marked the closing date for applications
  • End of October applications were assessed and scored by representatives from the CCG (officers not clinicians) WCC, Public Health and the LMC, with Lay Members of Public and Patient Involvement
  • Early January 2015 Prime GP was selected as a chosen service provider and scheme commenced.

The project was commissioned by NHS South Warwickshire CCG in December 2014, with Arden Medical Centre one of four GP practices across the county involved in the initial pilot. 

How does it work?

We have a dedicated Project Manager who attends the surgery for one full day every week.  The Project Manager works closely with our clinical and practice staff to identify all and any individuals aged over-75 who are (or at risk of being) lonely, socially isolated and, in some cases, frail. Whether they are widowed, living alone, or simply struggling to get out and about, patients under her remit are able to access a new holistic service which empowers them to take control of their own health and wellbeing – both physical and mental.

prime-75Once patients are identified, the Project Manager finds shared interests and looks at what activities are on offer within the community. Views about the type of support and level of engagement required are sought from our patients themselves and, where there are gaps, we work together to organise and coordinate activities that are appropriate to patients’ needs and desires – anything from first aid courses and gardening projects to mosaic classes and tea parties (including a 20,000 Year Tea Party which saw the collaboration of the biggest over 75 patient group in the history of the NHS).  This not only promotes the development of friendships and self-confidence, but reduces the reliance of the individual on the one person they previously saw as their sole trusted confidante – their GP.

The positive impact of this patient engagement has been showcased in a number of ways, with one being the production of a dedicated information guide designed to help individuals remain happy and healthy in their senior years.  Developed ‘by’ older people ‘for’ older people, the Prime75+ project brought over 50 elderly patients together through bespoke sessions where ideas, thoughts and feedback were obtained on ways in which older people could be encouraged to live independently and with dignity.  The result of this collaboration was the ‘Stay in the Prime of Life’ booklet, which the patients were involved in from initial conception right the way through to final design and production.

From our own GPs’ perspective and as a practice, the model is really simple yet highly effective, and is clearly having a positive impact on our isolated and lonely older patients. Not only that, but it is reducing their dependence on the health care system and freeing up valuable GP time (and subsequent workforce pressures).

All of our medical staff have been fully briefed on the project and are encouraged to signpost all and any patients who they consider could potentially benefit from her support.

What were the challenges?

Implementing the project has been a seamless process, thanks to the support and guidance received from the whole Prime GP team.  All those involved in the project had to naturally sign a confidentiality agreement in line with data protection procedures, but we have not been faced with any ‘challenges’ since we launched Prime75+. 

What has the impact been?

As a practice, we have seen the number of GP appointments amongst patients seen by our dedicated Prime75+ Project Manager reduce by a phenomenal <33.3%>.  Appointments that are now booked by this cohort are necessary in terms of medical needs, providing confidence to our GPs, and ensuring patients that do need medical attention are prioritised.  Not only is Prime75+ significantly reducing GP appointments amongst those in receipt of the service, but we are also seeing a monthly trend in the reduction of hospital admissions.  More importantly, the project has had a significant impact on patient satisfaction, it has raised the profile of the practice in the community, and everyone involved has benefitted from a huge feel-good factor.

As a practice, we acknowledge that patient engagement has been key to the initial successes of this project and that change is also not something that happens with one appointment – indeed, the most powerful impact begins to happen when a genuine, trusting relationship is built which replicates that which the patient has with their doctor.  And this is the type of relationship our participating patients have developed with the Prime75+ Project Manager. 

Arden Medical Centre values the real importance of building relationships with the community, and recognises the impact Prime75+ can continue to have on the health and wellbeing of our patients. Ultimately, Prime75+ is a simple yet hugely effective model which is having such a significant impact on patient satisfaction, access to GPs (and subsequent workforce pressures), and occurrences of avoidable hospital admissions.  With vast improvements to health, well-being and morale across our practice alone, we believe that this initiative has the very real potential to bring about major change across the NHS as a whole and to successfully tackle the loneliness and isolation agenda.

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Steve Sharples

my PPG does this through a monthly tea party in which 50+ people come.

It has changed a lot of lives by improving health and well being

cost to patients - nil the PPG Fund raise - so far about £4k

for a view see

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