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. I will be honest, I was lonely.”
Sally Simkiss, Janet’s care coordinator, first became aware of her situation when Janet’s records came through.
“When I reviewed her records, 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, you pick it up.”
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 early on.
“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 multi-disciplinary team through the Integrated Neighbourhood Team, which brings together senior GPs, community nurses, KCHFT’s Integrated Pharmacy Team, 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 in a coordinated way.
During this time, Janet experienced several health setbacks, including chest pains that required 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. “When things start to make sense again, it lifts a great weight from your shoulders.”
Two years on, Janet’s life looks very different. Through social prescribing, she was referred to Age UK and quickly immersed herself in volunteering. She now supports dementia groups and helps with lunch clubs, reflecting her lifelong belief in giving back.
“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.”
“It has changed my life,” smiled Janet. “One of my favourite memories is when I helped a woman at the centre who looked so distressed. I said, ‘You look like you need a cuddle,’ and she told me she had not had one for years, so I gave her one. That moment still gives me goosebumps.”
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. She makes my life worthwhile”
‘We are the link that keeps patients connected’
By Sally Simkiss
“I am a care coordinator for the Primary Care Network in East Kent. My role is about making sure patients get the right support in their own homes through joined up, personalised care.
“I work closely with senior GPs, KCHFT teams such as community nursing and the Integrated Pharmacy Team, social services and social prescribers as part of the Integrated Neighbourhood Team. Together, we meet to discuss patients most at risk and plan care that keeps them safe and supported at home.
“My visits often go beyond medical care. I notice things forms do not always capture, whether someone has had falls, struggles with mobility or needs help with everyday tasks. Every visit ends with a clear care plan, so patients know what we have discussed and what will happen next.
“The role involves a lot of problem solving and advocacy. Sometimes it is checking medication or going through utility bills. Other times it is liaising with councils, arranging housing, coordinating volunteers or making sure patients know exactly who to contact for help.
“The most rewarding part is seeing people regain confidence and independence. Sometimes the biggest difference is not a major intervention but knowing someone is listening and acting. We are the link that keeps patients connected so they can live well in their own communities. It is a privilege to be part of that.”