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I’m not normal any more

As soon as the funeral was over, it started – what I call the ‘W’ question. ‘Are you back at work yet?’ anxious friends would quiz me. ‘Have you thought of going back to work yet?’. ‘Have you set a date for going back to work yet?’. At a social event I attended in the spring, two different people asked me the same tiresome thing in as many minutes. If there’d been a third, I think they would have got a slap.

I went back to work two months after my husband died. I would have gone back sooner if my elderly father – ironically, the ‘work-urger-in-chief’ – had not fallen ill in mid-March and needed me to take care of him. I went back not because I really wanted to, or because I felt ready to; I went back to shut everyone up. When your life partner is seriously ill – and then dies – you spend hours of your time trying to keep other people happy. Most of them are far less affected by what’s happened than you are. No one warns you it’s going to be like this.

The Greek Chorus of Everyone, who seemed to be running my life now, told me work would do me good. ‘You’re back at work!’ they’d enthuse. ‘That’s great!’. Then they’d launch the killer follow-up: ‘And is it helping?’. If I told the truth, and said it wasn’t, their reaction would range from disappointment to barely-hidden disapproval. So I lied more often than not, and said yeah, it’s helping – course it is. Eventually I came to believe that the whole are-you-back-at-work thing was just a code for a rather different question, one that social conventions wouldn’t permit, which was: ‘are you back to normal?’ Because it made things so much easier if I was back to normal.

But it was the normality, the banality, of work I couldn’t cope with. Yes, there was the fact that the hospital where I worked – or tried to – was the same one that had failed my husband in his hour of need. Yes, there was the disillusionment with nursing that followed from that, and the disengagement. And yes, there was the day I broke down in ED because the last time I was there was when he was admitted, and we sat in a cubicle for hours, talking to pass the time, all unaware how precious were those words because three weeks and one day later he’d be dead, and words between us would be finished for ever.

But mostly, it was that returning to work was a public proclamation that the tide had rolled back in to cover up the grief, that spring had sprung after a long hard winter and things were…normal – except they weren’t. Not inside my head. They never would be again.

Colleagues were always kind and understanding. Patients, meanwhile, safe in the knowledge that staff are professionally prevented from telling them where to get off, could be stunningly, jaw-droppingly insensitive.

*

‘Are you married, love?’

‘Er…I’m a widow’. (Is it OK to lie to patients when it’s about an aspect of yourself that’s of no consequence to them? Could I just say no, and talk about the weather? Just say yes and talk about the weather? Which is closer to the truth?).

‘Oh I’m sorry. When did your husband die?’

‘A few months ago’.

‘Well, you’ve done the right thing coming back to work. Work’s the best medicine there is’.

(Medicine? Am I ill then? Is that what’s wrong with me? Do you know the cure?).

*

‘Are you married, love?’

‘Er…I’m a widow’.

‘Oh I’m sorry. When did your husband die?’

‘A few months ago’.

‘Well you’ve done right thing coming back to work. What you need to do is lose yourself in work’.

(What? Why? I’ve lost my husband so it doesn’t matter if I lose myself as well? I’m nothing now I don’t have him? Is that what you’re trying to say?).

*

‘Are you married, love?’

‘Er…I’m a widow’.

‘Oh I’m sorry. Not met anyone else yet?’

(You what? He only died in February! And anyway, what makes you think I’m looking for anyone else?).

*

I know – of course – that people just want to help. They want to be constructive. They don’t like to think I’m at at home on my own, and they don’t realise they’re pressurising me. But I’ve given work a good go – eight months – and it’s not working out. From the bits of my old life that still remain, I can’t re-create a ‘normality’ that no longer exists. The hole in the middle is too big, too gaping to ignore; to try to do so is simply to join the pretence. So I am going to put it lovingly aside now in a box marked ‘the past’ – where it can be as it was, for always – and look for a new direction. Because I’m not normal any more.

Now the day will never come

Because you weren’t with them, it only hit me years later that they were your parents – that faintly comical couple who stood right out from the shuffling group of mums and dads and daughters being shown around the grammar school one summer afternoon in 1972. “This is the chemistry lab”: we silently surveyed the rows of polished workbenches and Bunsen burners – then filed out again, most of us none the wiser. But your mother didn’t want to leave. She wanted to stay behind and explore every sacred corner; or else just stand there, imbibing an atmosphere thick with scholarly endeavour.

It was around the time of my eleventh birthday; I knew nothing of adult relationships then, but even I could tell that in this one, your mother was the driving force. I can see her now: tall and willowy, with an expression, as she advanced, of pure ecstasy, as if she already glimpsed the longed-for dreaming spires and Groves of Academe opening up in front of her. Your dad, rotund and short, was dragged along in her wake, red-faced and perspiring in his suit.

They lagged behind the rest of us. Your mother, I smirkingly fantasised, believed that to her had been granted special powers to appreciate the seat of learning; savouring it couldn’t be hurried. I don’t know if her reverence for education was born of thwarted ambitions of her own, but she certainly communicated it to you. You unashamedly loved school. It was one of the things that made you uncool.

So when I think of you, I remember someone who was confident and hard to ignore, but in spite of that, had few close friends. We shouldn’t have done it, but we all put the other girls into boxes: brainy, arty, tarty, ‘troubled’, funny, conventional, weird…you were none of these. Yes, you were conventional – but rather than the desire to meet a nice boy and settle down, yours was an intellectual conventionalism: you equated being clever with being good. And yes, you liked the arts – but only, perhaps, because you thought good girls were all-rounders. And of course you were bright – but others were brighter, and to me, your later success had more to do with hard graft and your vicariously ambitious mother. You were a sub-group of one.

I think it was a disappointment to you that school offered few friends with whom you could pursue pure learning. It was the ’70s, and even the swottiest of us had sidelines in Marc Bolan, platform soles and under-age consumption of gassy beer. Did you long to join in? Did you not dare, because your mother wouldn’t like it?

Your mother. ‘Mummy’. Oh my God, you never shut up about her. ‘Mummy says this’ and ‘Mummy says that’. Did you know we were all laughing at you? Half of you was still back at junior school, the other half was already middle-aged. I was surprised that in adulthood, you re-located so far away from her. Did you finally need to get some distance?

In sixth form, you made friends with M – another refugee from the 1950s – who transferred from a secondary modern so she could do ‘A’ levels. Though not your intellectual equal, she shared your unembarrassed studiousness. A misfit in her previous school, she dreamed The Grammar would be a Promised Land of acceptance and friendship based on love of study. She was pathetically mistaken, of course. With her sensible shoes and Famous Five vocabulary (“Golly! You’re right, I reckon!”), most of us regarded her as mildly ridiculous. You were the only one to offer the companionship she so obviously craved.

At Christmas 1979, the school invited back those of us who had left at the end of the summer term, for a social evening. There you were, in a powder blue blouse complete with pussy bow, straight from the wardrobe of the recently-elected Margaret Thatcher. You said you were enjoying Cambridge, and had joined the Christian Union. The Christian Union? FFS girl, it’s Cambridge! You’re mixing with the finest minds of your generation and you join the Christian Union? I turned away. I never saw you again.

I didn’t forget you though. You had numerous, ever-changing career ambitions. Systems analyst was one. Alone amongst us, you scanned the horizon and saw…computers. Over the years, I often wondered if you fulfilled your early promise. Now I learn you died four years ago.

Looking back, I understand a couple of things. One is that secretly, I always recognised that we were kin: in my heart, I too preferred books to boys; and like you, I too longed to be good. The difference was that I couldn’t accept that side of myself or ever show it because I wanted too badly to be one of the gang. You weren’t like that; you were true to yourself and never courted popularity by trying to be someone you weren’t. I think the reason I remembered you is that you were a kind of shadow self to me; I was curious to see where a route I could have taken, but did not, might have led.

Probably you could never in your life have named a T-Rex Number One. But I’m glad you grew into yourself and embraced a role that was so obviously right for you; and I’m glad too that you found people who understood and valued you. In the pictures I saw, there was something in your face there never used to be: fun. The news of your passing has affected me more than I can say. I sincerely regret that a life as good and useful as yours was cut so short.

Grumbling Appendix: an announcement

Dear Friends,

Grumbling Appendix has decided to take a break from blogging about nursing. I hope to return at some point in the future, but in the meantime, if anyone is interested in my latest thoughts, my sideline in TV reviews will continue – between you and me and the gatepost, Dorret quite liked my take on Great British Bake Off Week 3!

 

Thanks to everyone for reading and I hope I have occasionally managed to make people think, even if only a little.

What else did I do wrong?

By Basket Press

Aside from, as per my last post, being over-educated for nursing in the ’80s, or ever depending who you listen to, I was also the wrong gender, what with being male even in mental health (MH) which traditionally has a higher proportion of nurses who are male (see a couple of GA’s recent posts).

I don’t think this was viewed as such an affront as being educated (this is England, with its at best ambivalent attitude to learning) but I still wasn’t right. Please don’t get me wrong: I am not complaining, rather observing and describing.

OK, I have never responded well to “Oh, you’re a male nurse?” “No, I am a nurse who happens to be male: there isn’t a separate part of the register which says male!” But that tends to be outside nursing.

There were then, and still are, problems in being male and accepted as working in a caring role. Even the children of my general nurse sister struggled with the idea of me as a nurse. Acceptance is easier, it seems to me, if there are either higher educational expectations and perceived power and authority (medicine, for example) or more technical, nuts and bolts aspects to the job (physiotherapy or radiography, for example) than in something less well-defined and generally perceived as lower status (nursing for example) and especially than in a branch of nursing which can be even less tangible and of lower perceived status than others. Clichéd, stereotypical views of how one must think and behave as a man seemed to stop many from seeing an actual person: all the exhortations to see patients as whole people go missing when it comes to colleagues.

Allied to this I have rarely completely conformed to local gender stereotypes: throughout school and university I was seen as being unmanly, not a proper male, as I wasn’t a macho dickhead northern male (1970s, remember); I was thought to be gay before I even knew what that is, something which, with weary inevitability, has followed me since, especially once I entered nursing. Again, an inability to see a person, but rather reduce them to a lazy set of preconceptions. Would it have helped if I was gay? Dunno, I probably wouldn’t have conformed to stereotypes of gayness either…

By the by, I was never really a ‘hetty’ either (as a gay friend insisted on calling heterosexuals, as if I was “straight” that meant he was “bent”, which was not how he saw himself), being married but quietly child free by choice, which some seem to take very personally, my existence apparently undermining their decisions.

And then it starts to get a bit meta, as people would make assumptions about what assumptions I would make (the possibility that I would try not to make any assumptions did not compute). This was often around how I supposedly viewed women: I’m male, from northern England, of a certain age, therefore…Wrong! I was brought up by and around women in responsible, senior, professional positions, who exercised authority and power. This was normal for me. My year at grammar school was the first when the two single sex grammars in the town went co-ed; the 6th form was half female and as many females as males went to university. This was normal for me. At university half of my course was female and I spent much time learning about that 1970s wave of feminism. This was also normal for me.

I know that is not usual, but it happened. That was my reality, where I came from.

It was assumed that I would head rapidly up the greasy pole, a combination of assumptions about education and gender. OK, I quite like being in charge, but this isn’t a gender characteristic, more to do with personality as my sister behaves in very similar ways: if push comes to shove we both prefer being the one making decisions and accepting the consequent responsibility, or as my wife described both of us “You two just go into nurse mode whenever anything serious happens!” Neither of us flaps nor panics, we are both calm and decisive people, who don’t scare easily and want things done as quickly and efficiently as possible. Oh, and we don’t suffer fools. At all.

I did not go up the pole particularly quickly (see other posts for details of my difficulties with management), rather following what interested me from the limited range of options.

Then factor in the “You’re male so you can’t possibly work with…” Oh really? At one point or another I have successfully worked with bairns with eating disorders, male and female, depressed bairns, male and female, self-harming bairns, male and female, bairns with gender identity or sexual identity issues and…and…In my experience it is rare for my gender to be a real problem (I have been chosen by a couple of young ladies to be the one to whom they would disclose sexual abuse). Yes, there are certain aspects of care, especially in in-patient settings, where gender of a nurse can matter, but that one cuts both ways. And outside that it is the quality of the working relationship which matters and how one can make that work: I can persuade some very difficult young people, male and female, to talk to me, which has nothing to do with gender and everything to do with personality, approach, skill and experience.

Patients come in all manner of different forms, reflecting our society, why is it still so hard to accept that nurses might? Why is caring seen as the preserve of a limited part of that society? Why do some persist in stereotyping, to the detriment of us all? Whatever happened to open-minds and acceptance?

How did I get here?

By Basket Press

A couple of recent posts here (thank you Florian and GA) made me try a different tack to my usual, more politicised, management-critical one.

I didn’t take a “usual” path into nursing: attended a state grammar school in the ’60s and ’70s; did as ordered and went to university, emerging with a science degree. My mum swore my first word was “Why?” and that my first phrase was “How does it work?” and it was all downhill from there, taking nothing for granted and questioning pretty much everything.

My background includes pit village Methodism with its underlying ethos of public service, and the significant adults in my life did just that: nurses, physios, teachers. The parents of my school mates were similar: teachers, lecturers, doctors. This is what grown ups do it seemed to Junior Basket Press. I gave up the God bits, but still describe myself as culturally Methodist.

An oddity of my upbringing was that I didn’t meet a child my own age until I started school. It took until my early 20s to feel comfortable with people, and consequently I consider making a living talking to people an achievement.

Unfortunately I graduated in 1979 and became a Founder Member of Maggie’s Millions.

The next few years were a mix of dole, trying to convince myself I was a real scientist, dish washing, more dole, and 2 jobs working for environmental charities with youth and school groups.

Then the light dawned: the groups I most enjoyed working with were from schools for blind bairns, those with emotional and behavioural difficulties and other out-of-mainstream provision. I found these groups both more challenging and rewarding than others.

The last of these jobs finished and I was on the dole again. I should note that a previous bit of societal rejection had brought out my under-lying tendency to depression, which I’ve lived and dealt with the rest of my life.

A colleague suggested considering nursing. Luckily, I had a cousin who was a nurse tutor, whose advice I sought. Her sensible suggestion was to find a Nursing Assistant (NA) post in Mental Health (MH) to check out if it was for me.

I hit lucky. Responding to a generic NA job ad at the local MH hospital, I found the adolescent psychiatric in-patient unit was after NAs, preferably with a background working with young people. I interviewed well, referring to how my own difficulties could give me an appreciation of what others might experience. I got the job.
This went well enough for me to successfully apply for nurse training.
And the problems began.

It was obvious very quickly that graduates were unwelcome: I never referred to my degree unless directly asked, but the tutors knew, people in my group knew, and word got around. I found it hard to disguise my tendency to ask questions and challenge any lack of evidence. Assumptions were made about me by people I hadn’t even met, which were all negative (“Wants to be a nursing officer right off” was as polite as it got) . This meant I had to be better than anyone else at straightforward clinical care in order to be taken remotely seriously.

I wasn’t alone in these experiences: the two other graduates training at the same time as me went through this. Indeed it was one of them who advised me that I needed to volunteer for things which folk didn’t like doing, to play along with ward nights out and be better than excellent at day to day stuff to survive,. So I got a reputation as a bit of a smartarse, but one unafraid of hard, dirty tasks, who wouldn’t shirk and gave as good as they got in the black-humoured hospital repartee. It paid off in uniformly good ward reports.

If only it was just at work…All my immediate family, bar the afore-mentioned cousin, took a dim view of me “wasting” or “throwing away” my degree by not just going for nurse training but, even worse, MH nursing. This included two general nurses and two physios…OK, I was the first in the family to go to university and obtain a degree, but everyone else thought it belonged to them and they had a say in how to use it. Fortunately I had learned not to listen to most of my family, which was just as well as it never got any better; there was never any recognition that I was doing something useful and necessary that I was good at.

Apparently it was impossible for a graduate to carry out basic care, because I lacked common sense, was too airy fairy, too bothered about theory, didn’t live in the real world, came from another planet, didn’t speak English, had three heads…And yet the necessity for medics to be graduates wasn’t queried, because…No-one could explain that.

Yes, I questioned what we were told in nursing school, mostly because, when a paper was forthcoming, we were being fed misinformation and mangled statistics. I questioned things on wards. I asked consultants about their reasoning and how they reached a particular judgement. And I was always polite. I need to know why, and if a particular thing is justified and supported by evidence; I won’t just do as I am told.

What I learned from all this was that most medics do not mind sensible questions; nurse tutors didn’t understand statistics and got uncomfortable when questioned; many nurses in big MH hospitals and on my general placement rapidly get set in their ways and don’t like to be challenged, no matter how politely, no managers like being questioned or challenged and take against those who do so. The latter two phenomena made me question myself and nearly drove me out of nursing years ago, but didn’t.

Read some posts on this very blog by younger nurses: how much has changed? Not much, despite the efforts various of us have made over the years, which is very sad.

Hello and Welcome…

Hello and welcome to the new NHS fun games show ‘How Essential Is Your Job‘?! Leaving aside the obvious caveat that if you’ve got time to play it, your job probably isn’t essential, let’s have a peek at some sample questions!

Question 1: A ward has an outbreak of C Diff. Your role is a) assist and comfort soiled patients; b) ensure sufficient staff are available to assist and comfort etc; c) co-ordinate/investigate/monitor/contain; d) draw ward’s attention to overspend on nursing wipes. Question 2: A patient needs to be specialed. Your role is a) act as special b) ensure extra nurse is available to act as special; c) co-ordinate rapid transfer to environment less likely to cause distress; d) inform the ward (by phone, obvs) that a special is unaffordable and will need to be found from within existing resources, goodbye.

Now tot up your scores! Mostly A’s, B’s or C’s – sorry, your job is not essential. You are advised to contact your nearest Job Centre. Mostly D’s – congratulations! Your job has been rated ‘essential’ and is not at risk. How do I know this? Actually, I don’t – but in the absence of any clearer definition of ‘essential’ in Monitor Chief Exec David Bennett’s recent letter to Foundation Trusts (FTs), I think we’re free to assume that for the next few years, saving money will be more important than saving lives.

To be fair, after publishing his letter, in which he warned that ‘almost unprecedented financial challenges’ meant FTs should consider filling vacancies ‘only where essential’, Bennett did backtrack to the extent of issuing a statement saying that ‘this section of the document related to non-clinical staff’. As the esteemed Basket Press OTP observed in a below the line comment on this story, you could be forgiven for thinking Vicky Pollard is in charge of Monitor these days (‘but yes but no but yes but no but yes…’).

But even after this so-called clarification, questions remain. Bennett’s spokesman added that he would be ‘surprised’ if Trusts interpreted the letter as an instruction to stop hiring clinical staff. ‘Surprised’ eh? As a sanction, it’s not really up there with being barred for life from ever darkening the door of public sector employment, is it? I can’t imagine that Finance Directors up and down the land are quaking in their boots about the prospect of making a spokesman feel mild-to-moderate ‘surprise’ when the s*** from the next Mid-Staffs hits the fan.

More worrying still, Mr Mild Mannered Spokesman also declined to elaborate on another of Monitor’s recommendations: that safe staffing guidance should be ‘adopted in a proportionate and appropriate way’. Sorry mate, but what does that even mean? You’ve got the guidelines – you either stick to them or you don’t: it’s that simple. Like the Highway Code, safe staffing guidelines are there to protect everyone, all the time, and not – repeat not – only when it suits. Forgive the bluntness, but this is how people end up dead.

I suppose (if we were desperate) we could always turn to Jeremy Hunt for some leadership. In a Q&A session after a speech delivered at the Kings Fund in July, he said he was against introducing a different safe guard – mandatory minimum staffing levels – because ‘you could have two trusts – one with higher levels of staff who spent “a lot of time filling out forms” and another with lower numbers but with “vastly safer care because they worked out systems and process which means staff can spend 80% of their time on patient contact”’. It’s a completely spurious answer of course. Such wide variations should not even be tolerated, much less used as an excuse. True leadership is about turning ‘the best’ into ‘the norm’.

As others pointed out after the Bennett letter broke, the workload remains the same however many staff are available to do it. So while some staff may look ‘non-essential’, all that’s achieved by removing them is reassignment of their work to those who remain. And historically, this has usually meant ‘the nurses can do it’ – after all, they’re available 24/7 and although there might be muttering before home time, they rarely make any real trouble.

NHS nursing is facing a perfect storm. With work on safe staffing apparently sidelined, plus the prospect that we will increasingly be asked to shoulder the work of ‘non-essential’ others, Jeremy Hunt is effectively asking the question ‘what is nursing?’. Which of the following then, is most likely to be his answer?: a) a confident, independent therapy, essential for the delivery of collaborative health care; b) the workhorses of the NHS, there to keep their heads down and get on with the job; c) whatever politicians need it to be at the time; d) form-fillers – didn’t we classify that as non- essential?

You keep using that word…

By Basket Press

Ho hum…Another day, another piece of “official advice” in which David Bennett, the chief executive of Monitor, tells foundation trusts to ensure that staff vacancies are filled “only where essential”, but without offering any advice as to what essential actually means…

The excuse is the usual: save money, y’know, the same reason we have all heard for years why posts are frozen, recruitment is suspended until the next financial year, yada, yada, blah, blah. As David Byrne so perspicaciously put it, same as it ever was.

I don’t know about you, but I would expect a man who in 2011 was the highest paid employee of the NHS in England and was described by the Health Service Journal as the 8th most powerful person in the English NHS to be capable of giving some clearer guidance here. A man who spent 20 years dispensing advice to others about how to run organisations when he worked for McKinsey (yes, that McKinsey, the mega firm of management consultants who seem to run the world) and earned a salary well in excess of what any of us mere nurses are ever likely to see for doing so. But apparently he can’t. Which makes me wonder what he’s there for.

Ever since the first Griffiths report back in the ’80s gave us general management and started the cult of managerialism we have been told that managers should be allowed to manage, and yet here we have one of the top, most highly paid NHS managers side-stepping that very responsibility and passing it on to someone else.

Anyway, “essential”: my handy copy of Chambers says things like “necessary to the existence of a thing” or “indispensable or important to the highest degree”. So how does this translate into NHS terms?

I believe it is time to break out The Basket Press Three Phase Model of Organisational Structure (patent pending), which can be applied to most organisations I’ve come across.

Phase One consists of those staff who carry out the core function of the organisation. In the NHS this means clinicians, nurses, doctors, physios, psychologists, OTs and so on and so forth. That’s us, the ones who do the direct health bits. Without Phase One the organisation might as well pack up.

Phase Two is those staff without whom we don’t function, which is secretaries, receptionists, payroll, porters, pharmacists, lab staff various, radiographers (OK you can make an argument that some of these might go into Phase One, but bear with me as it doesn’t change my overall point), catering, technicians various, and apologies to any I have missed. Without Phase Two we can pretty much pack up also.

Phase Three is the staff we can do without for significant periods of time, if they are needed at all. This brings us to pretty much all management and HR, non-exec board members and the like. If we lose some of these do you actually notice? We can certainly carry on for quite some time, unlike the loss of the other 2 phases.

Now before I am accused of being anti-management, which I’m not really, I just think what we have is over-rated , let me tell you a story or two to expand on this.

In my last job there were regular and frequent times when we were down on clinical and/or admin staff and the rest of us and the patients knew about it every single time: not enough staff for clinics; waiting times going up; prescriptions not written; assessments taking longer to complete, if they could be completed at all; longer for diagnoses to be made; longer times between appointments; inability to respond to crises; letters not sent; appointments not arranged; reports not compiled; phones not answered. Mostly posts were kept empty, as mentioned above, for financial rather than functional reasons, for as long as possible, which just compounded the difficulties created.

And yet, on more than one occasion, we went for up to nine months without a service manager: none of the patients noticed; clinical work happened as it should; the service carried on running; a couple of us signed time sheets and expenses forms; the sky didn’t fall in.

The same was true when the trust did not have a permanent chief exec for months, when there were vacancies for senior HR bods, when we were without a couple of non-exec board members: no-one noticed; patients were still seen; everyone else just got on and delivered the services. And when those posts were filled we still didn’t notice, patients were still seen, only a name on the letter head changed…I can’t remember when I last actually met a chief exec and have certainly never met a non-exec board member and this is after over a decade as a senior nurse.

In another job we had one of those interminable trust mergers, which meant that for over 6 months there was a management vacuum while everyone above an H-grade (Band 7 in current money) played hunt the desk and hunt the job, no-one was contactable, we never saw them, and yet clinical services went on, patients were seen and the sky remained resolutely over head.

And it is always, but always, thus: I’ve lived through several lifetimes’ worth of mergers and restructurings and reorganisations and whatever they call it this week and patients are always seen, even when Sherlock Holmes, a team of blood hounds and Hawkeye can’t find a manager or anyone else supposedly in authority or in any way running the organisation.

So, perhaps Mr Bennett in his position of great power and authority, with all the undoubted wisdom accumulated from years of telling other people how to do things, might somehow find his way clear to telling us what it is that he considers “essential” to the running of a health service? Pretty please, I’m asking nicely, with cherries on top. Please?