Neighbourhood health: A bridge over troubled waters
Kae Skinner, 68, from Maidstone, faced a spiral in her mental health after years of struggling. Here's how a multidisciplinary team, led by her GP, stepped in.
For Kae Skinner, life changed forever in 2020. During the Covid-19 pandemic, her daughter died from cancer aged just 32.
She reflected: “Nothing prepares you for the loss of your child and you never, ever get over it.”
In the years that followed, Kae's own health took a turn for the worse when she developed double pneumonia and was put into a coma. Kae had also lived through domestic abuse in the past, something that left her with PTSD. For a long time, she coped by staying busy.
“I've always been strong at work,” she said. “No matter what's been happening in my life, I could focus there.”
But towards the end of last year, a stressful situation changed everything. Her coping mechanisms failed.
“I stopped sleeping,” Kae explained. “The exhaustion made everything worse. I was crying all the time. Meetings made me physically sick. I couldn't function.”
Eventually, Kae contacted her GP surgery and, instead of a single appointment followed by a long wait, things moved quickly. She was referred into a neighbourhood-based approach that brought together her GP, a care coordinator and other professionals.
“It wasn't just one appointment and then being sent away,” Kae said. “They stayed in touch. They checked in. They noticed when things weren't improving.”
One of the biggest changes for Kae was feeling known. Her GP understood her history, but she was also supported by Care Coordinator Claire Edwards, who acted as a consistent point of contact.
“Claire was the missing link,” Kae said. “Someone who could see the whole picture.”
Adjustments were made early. Kae was encouraged to spend time outdoors, reconnect with the world around her and allow herself space to recover rather than push through. Talking therapies followed alongside medication to stabilise her anxiety and help her sleep. Crucially, these were coordinated rather than isolated.
“Everything worked together,” Kae said. “I wasn't left to figure it out on my own.”
Slowly, things began to change.One day, Kae noticed the constant feeling of anxiety had eased.
“I suddenly realised I didn't feel on edge anymore,” she said. “That was huge.”
While the challenges at work have not disappeared completely, Kae feels able to face them now.
“I feel capable again,” she said. “I've got my confidence back.”
On a recent trip away, Kae found herself chatting easily with strangers, something she would never have done months earlier.
“Before, I would have retreated. Now I can engage again. It feels like me coming back.”
Looking back, Kae believes the timing of support made all the difference.
“If this had happened years ago, I think I would have hit breaking point,” she said. “Instead, people noticed, stepped in early and stayed with me through it.
“My mental health didn't exist on its own. It was tied to grief, trauma, physical illness and what was happening in my life right then. The care I received recognised that."
Coordinated care saves lives
Claire Edwards is the Mental Health Care Coordinator at ABC Primary Care Network in west Kent who helped Kae.
She said: "I bring together GPs, specialists and community services through regular meetings. We take time to understand each patient's full story and coordinate the support.
"This moves away from fragmented, reactive care. It improves communication, reduces gaps in support and helps prevent people from falling through the net.
"Outcomes like Kae's demonstrate how coordinated care can transform lives."
