Lean on me

Before Janet, 80, from Folkestone met Sally Simkiss, her care coordinator, two years ago, life felt confusing and lonely. Janet, a former government worker, returned to the UK in 2010 after living in Greece for nearly 40 years.

While there, she cared for her husband through Alzheimer’s until he died in 2006. Returning to England alone was a huge change and, over time, her health suffered. Janet was managing sleep apnoea, an underactive thyroid and heart issues, alongside the strain of navigating mountains of paperwork linked to her years abroad.

“I was on my own for the first time in my life,” Janet said. “Everything felt muddled. I stayed indoors. Even simple things like letters, appointments or forms felt overwhelming.” Sally Simkiss, Janet’s care coordinator who works for Total Health Excellence PCN, first became aware of her situation when Janet’s healthcare records came through.

“I could see straight away that if we did not act, she would probably end up in hospital,” Sally explained. “I arranged a visit and it was a privilege to be invited into her home.

"You get to know the real person when you visit. What people need is not always what they can explain on the phone.”

At that time, everyday tasks such as managing appointments, ordering medication or keeping on top of bills felt unmanageable for Janet. After a lifetime of independence, she found it difficult to trust people. Sally took a gradual and reassuring approach, working closely with colleagues across health and care services to reduce risks and support Janet safely at home.

“We started with small steps, building confidence and understanding,” she said. “I began visiting regularly, helping Janet make sense of her medical needs and liaising with her GP and specialists.”

That included close working with KCHFT’s Integrated Pharmacy Team such as Tanya Sweet, who are part of the Integrated Neighbourhood Team that meets regularly to discuss high risk patients and agree the right support.

“During those visits I was able to check her sleep apnoea equipment, which had broken, and refer her to the right team so it could be fixed. I also made sure her medication was properly organised.

“I was there from the word go for everyday things. We still sit together on the phone to organise bills, manage paperwork and keep track of appointments. We meet twice a month, but Janet knows she can also call me during working hours.”

Janet remembers Sally’s first visit clearly.

“She was like sunshine walking through the door,” she said. “The difference with Sally is that she does not come once and disappear. She rings. She pops in. She notices things. She helped without ever making me feel incapable or unwell.”

Sally works closely with a wider neighbourhood team, which brings together senior GPs, community nurses, pharmacists, social services and social prescribers.

The team meets regularly to discuss patients most at risk of hospital admission, making sure medical, social and practical needs are addressed. During this time, Janet experienced several health setbacks, including chest pains that needed blood tests and changes to her medication. The team acted quickly.

“I was able to seek out a GP experienced in caring for older patients who reviewed her treatment and explained everything clearly,” Sally said. “As a team, we also realised her thyroid medication may have contributed to the chest pains, so a full review was put in place with help from the Integrated Pharmacy Team and nursing colleagues.”

“Once things were explained properly and sorted out, I felt clearer,” Janet added. “It lifts a great weight from your shoulders.”

Two years on, Janet’s life looks very different. Through social prescribing, she has quickly immersed herself in volunteering.

She has worked in the past with dementia groups and helps with lunch clubs in the community and is now actively looking for other roles. “She walks or takes the bus independently and has built strong friendships in her community,” Sally said. “Her confidence has grown and she has a real sense of purpose again.”

Today, Janet lives independently and feels safe and supported.

“Having Sally in my life means I tick over clearly,” she said. “When things feel muddled, she helps clarify them. Whether it is health worries, paperwork or just reassurance, she is there.”