NHS Sussex Community NHS Foundation trust: Myalgic Encephalomyelitis (ME) and Chronic Fatigue Service (CFS)

Sly Saint

Sly Saint

Senior Member (Voting Rights)
I've lived in Sussex the whole time I've had ME and I've only just found this.

First of all its the old gripe, IE chronic fatigue used instead of chronic fatigue syndrome.

I'm part way through watching the video and again its entitled living with chronic fatigue.

Interesting that they say it's more than tiredness when this is what the NHS says is the main symptom.
So far, some of the content is OK, but this mixing of chronic fatigue and CFS carries on even though they then say, it's not the same as chronic fatigue. Very confusing.

They also are wrong on the moderate sufferers (doesn't comply with NICE even) saying that people who are moderate might have to reduce their work hours and make adjustments.

Then they start on Boom and Bust.


As I said I'm only about 10 minutes in, its 31 minutes long.
(no mention of ME/CFS so far, they just talk about making a diagnosis of Chronic fatigue syndrome)

Myalgic Encephalomyelitis (ME) and Chronic Fatigue Service (CFS) (sussexcommunity.nhs.uk)

eta:
Transcript



0:01
[Music]


0:08
I used to commute in London into one area and just walking to the tube


0:14
station or walking down to the shops and walking back again actually started to get quite effortful and um before that I


0:21
was I was jogging three times a week I'd done the couch to 5K I did a lot of


0:26
swimming and stuff and I was finding that I just I couldn't do that and but it was


0:32
just the kind of the normal walking that used to be I wouldn't think about that um was becoming problematic I just felt


0:40
like things were much more difficult um it was hard on my heart and lungs I felt it felt more


0:48
of a pressure um I felt out of breath more and of course I was someone that was actually quite active so that


0:55
wouldn't have happened normally for me at all in fact I like doing a ro


1:00
exercise and all that kind of [Music]


1:12
stuff it's a state of being where one feels completely and


1:20
utterly depleted of any energy whatsoever so people do do describe it


1:28
in different ways cuz is different for different people in terms of the severity but some people say it's like


1:35
the plug's been pulled out other people will say well one lady


1:41
described it to me really poignantly and said it's like my blood has been replaced by lead um someone other people say it's


1:49
like you're covered in sandbags or you feel like you're covered by cement it's just that inordinate effort to do even


1:57
the simplest of things often people will just describe it is that really full


2:02
exhaustion physically cognitively so that sort of mental


2:08
processing um emotional exhaustion as well and


2:15
um sometimes people have described it as kind of wading through tweal that real


2:21
kind of being hit by a bus there's lots of different descriptions that people use but I think it's very different to


2:27
tiredness and it is that all encompassing debilitating fatigue that can affect


2:33
getting up having a shower going out for a walk making a meal going to work so it


2:40
can it can have a kind of you know a really full impact on someone's life so


2:46
people that are more affected mildly might still be able to work they might be able to study they might still be


2:52
able to engage in Social family activities if you're more moderately


2:57
affected then you might struggle to work so you might have to reduce your hours


3:03
you might have to um make other adjustments you will definitely have to make adjustments to your social and


3:09
family life and those that are severely affected um can be housebound or even


3:15
bed bound so it really does affect people very very differently so it can


3:20
affect family life it can affect Intimate Relationships


3:25
friendships um and that can have a real impact


3:32
on you know how connected someone is with other people so it can have a real


3:37
kind of impact on a sense of [Music]


3:47
isolation I went to the doctors quite a few times the trouble is um I don't think they knew what was wrong with me


3:53
and I didn't know what was wrong with me so I had to just keep coming back cuz they'd say one thing and it wouldn't


3:58
quite work and so would go back and try something else it was kind of a bit of a accumulation of experiences so it took a


4:06
long time actually it was actually a friend who spoke to me and who had


4:13
chronic fatigue who I didn't see the parallels at all because they were more ill than me um that mentioned to me said


4:22
there's some of the things you you're describing really sounds like me have you talked to the doctor about it and I


4:28
kind of didn't want that to be the case because I've seen other people that have


4:34
um had real limitations in their life and mobility and at the time I was still


4:40
able to work and do things and I kind of didn't really want to think that that might be something that I might have to


4:45
do with but um they were right they were spot on I think a lot of people get


4:50
mistaken with you know chronic fatigue and then assuming that that's chronic fatigue syndrome but there is a real


4:56
difference chronic fatigue can be linked to other conditions so a lot of physical


5:01
health conditions can have fatigue as a symptom um plus some mental health


5:07
conditions such as anxiety and depression also have fatigue as as part of their symptom so um although somebody


5:16
might be chronically fatigued and it's impacting on their life there may be a reason for that due to another physical


5:22
condition or mental health condition and if that is um the cause of their fatigue


5:27
it's really important that that gets checked and that blood um tests are done


5:33
and consultations with GPS and other Specialists may be really really important once any cause or possible


5:42
explanation has been ruled out then we look at making a diagnosis of chronic fatigue syndrome but there is quite a


5:48
strict criteria in terms of making that diagnosis and it can take quite some


5:58
time usually I can definitely see an energy


6:04
crash coming um I'll usually know when I'm booking


6:10
too many things in that I probably will be pushing things but if they're really


6:15
nice I might just decide to go for it so even this week um I'd had a really nice


6:22
weekend I'd done two things which was quite a lot they were lovely


6:30
but um going out and seeing people but I knew that that would be quite a lot and


6:35
then I also did archery on Wednesday and


6:41
um I I had to I knew that it was going to be struggle to then be okay to do


6:47
this on Friday so I had to cancel things for Thursday and I still actually felt


6:53
pretty ill on Thursday well boom and bust you can apply it to lots of different situations so it's used in in


6:59
terms to demonstrate talk about the economy for example but we talk about it in terms of activity when it comes to


7:05
chronic fatigue syndrome so if you imagine in your mind's eye that you have


7:14
a level of activity that you would normally do on a day-to-day basis and


7:19
you can take this back to before you became unwell so before you became unwell you


7:25
had your job your family responsibilities your social life you had all of those things that you did on


7:31
a regular basis that was manageable and was doable and was enjoyable and that is


7:37
what we call your Baseline it's a regular amount of physical social mental


7:43
activity that you can perform on a regular basis and what happens to your Baseline is that it drops considerably


7:52
what doesn't drop is your obligations your commitments your responsibilities


7:58
what happens with boom and bu is that people will strive to do what they want


8:04
and need to be able to do they will either push through their symptoms and say I'll just do this this is my


8:10
responsibility this is what I do this is the person that everyone knows me to be there might be pressure from other


8:16
people often it's pressure from ourselves to strive to do what we've always done


8:24
um because that level of functioning is no longer sustainable because our level


8:29
of function is down here there's a crash we can't sustain it and that crash is


8:35
this enforced period of inactivity and that might


8:40
last days it might last weeks it might last hours it really really does depend


8:46
I think the take-home message about boom and Bast is that it becomes a vicious cycle it


8:52
perpetuates and and people often feel propelled to do more when they feel


8:57
slightly better out of guilt out of expectation from others expectations of


9:02
themselves but it really is not the way forward in terms of managing chronic


9:08
fatigue and chronic fatigue syndrome The Way Forward is to recognize those early


9:14
warning signs recognize when you're going beyond your Baseline and to stop


9:19
then recharge and then go back again to that activity stop and recharge so that your


9:28
Baseline becomes more of a a wavy sort of concept of to what you can


9:34
sustainably manage activity-wise in the long term not just in the short


9:43
[Music] term I know quite a lot of about stress


9:48
theoretically from just my background and my education um and also from


9:54
experience like everyone else in the world who has stress um for me and my fatigue it's


10:01
[Music] um it's like it condenses the fatigue


10:06
and um um amps it up basically so I


10:11
described it to a uh friend and colleague that it's um I


10:17
don't know if you ever seen these old French movies by Francis Trusseau it's the new V where it has this like this big uh


10:27
like View and then it go smaller and smaller and smaller into the small view of the scene it's a bit like that so um


10:35
my abilities and my attention my focus from being kind of at a normal level


10:42
starts to condense down um being able to


10:47
be active starts to decrease and the more discomfort I get so it gets more


10:54
um effortful to move um even in I I think


11:00
particularly breathing as well and um even uh standing upright for example all


11:07
of this gets more and more harder and harder and harder until I literally can't do anything like I can't I need to


11:14
lie down and I can't speak to anyone and I can't I just can't do anything at


11:21
[Music] all
Click to expand...
 
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They do Graded Activity. It's goal oriented, with a timescale.

They call it Building Up Your Baseline.

This Sussex 'ME/CFS/Chronic Fatigue' service is still obsessed with GET

https://www.sussexcommunity.nhs.uk/...s/patient-resources/building-up-your-baseline



'Building up your baseline'

'A diagnosis of mild-moderate ME/CFS does not stop somebody from building up their baseline when they feel ready to do so, be this physically, cognitively, or socially.

The key is to find any activity that is meaningful to you and/or that you enjoy and would like to work on as a goal. Write down your goal and make it specific, measurable, achievable, relevant to your life/situation and with a timescale.

Start at a level that is manageable (this may feel very low level to start with) on top of your normal daily activities. It should be an amount that doesn’t flare up your ME/CFS symptoms – this is your baseline. Stick to it and don’t be tempted to do more on days you feel able to.

When you have become familiar with engaging in your baseline activity ‘little and often’ and feel ready to increase the duration, you take a step up by initially increasing the length of time you engage in the activity.

A maximum of 20% is a good measure e.g., 5 minutes of reading or walking would become 6 minutes; aim to build up gradually the number of days you can maintain this baseline e.g., aiming for 5 days in the long term, but starting from where you are, it is not a race.

Do not build on your baseline every day or week e.g., you must start somewhere, so perhaps try 5 minutes engaging in the activity, testing this out over a two-week period for safety in terms of risk of flare up of symptoms, avoiding post exertional malaise (PEM). If you can manage this safely over consecutive days, you may then decide to increase to 6 minutes and test again over a two-week period again before increasing further if you choose to do so.

You may prefer to increase by less.

Remember you’re in the driving seat. You decide when you’re ready to do a little more. Equally, your baseline is flexible and may be slightly reduced if you have a setback.'

.
 
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2nd part of transcript
I think it's really important to
11:29
look at stress in relation to chronic fatigue syndrome because often it can play a role in sort of many years before
11:36
the illness actually developed so somebody might have had and experienced quite a stressful childhood the the
11:42
actual onset or the actual trigger might have encapsulated an element of stress
11:48
and then what happens on the body is that um it can have an impact on the body system in terms of kind of coping
11:55
with those events um and what we also know about stress is that it's an
12:01
exacerbating sort of factor so it can help to maintain the symptoms of chronic fatigue syndrome so it is important to
12:08
kind of look at stress um we know that stress is a good thing it can help us to kind of perform and enable us to manage
12:16
difficult situations and normally what happens is once that stress situation
12:21
has passed the body will automatically sort of self-regulate and it will go into the opposite state which is that
12:28
more relaxed um balanced state so there's two kind of systems that are working within
12:35
the autonomic nervous system there's the fight ORF flight system that's what we call the kind of sympathetic nervous
12:40
system and then there's the more relaxed which is the opposite the sort of restful state which is the
12:48
parasympathetic nervous system and what research has shown with chronic fatigue
12:53
syndrome is that that stressed fight or flight state is more actively switched
12:59
on and it's more hyperaroused so the smaller little daily
13:05
hassles can trigger a response that's kind of out of proportion with that and it will stay switched on so it won't
13:12
sort of self-regulate itself as optimally as it
13:27
should I had a very small dog that walked at very slow pace and um like to stop and I
13:35
would just be mindful look at the trees look at the you know when she stopped and then we'd walk again and um so kind
13:41
of yeah not push myself with that but fresh air Sunshine's always good um there's loads of stuff so um there's
13:50
loads of stuff I I apply anyway about prioritizing things that I do need
13:56
to do things that I don't need to do managing the energy I have um very much kind of
14:05
also it being okay if I can't do something and coming to the point where I'm not necessarily content with
14:13
it but it I accept that that's the way it is and not stressing out about that
14:18
as well and I think that's been a process that's a mindset but engaging in that if things are stressful that like
14:25
really I've over the years I've got to a point where I know when I'm reaching the point I just know actually that's it for
14:31
the day and that's just the way it's got to be and so rather than getting really more stressed about that it's just
14:37
accepting [Music] it so therapeutic rest is essentially a
14:45
way of re-calibrating your body recharging your battery so it's not
14:51
doing nothing but it's also not scrolling on your phone watching TV
14:59
reading a book that sort of thing I had a a a a lady who's who was able to
15:04
recognize through discussions of of therapeutic rest that actually she wasn't actually resting she was lying on
15:11
the sofa watching TV or she was lying on the sofa with her sodoku book so
15:17
although on one level you know her body was resting her mind was actually still
15:23
busy and what we know about supporting fatigue with chonic syndrome is that we
15:30
also need to kind of really support that mental energy that people are using there's various techniques that you can
15:35
use to therapeutically rest you can practice mindfulness you can use guided
15:41
visualizations you can do autogenic relaxations there's a whole loads of
15:46
different techniques you can use if you Google and into YouTube re relaxation or
15:54
um mindfulness I suppose the main aim of therapeutic rest is to recharge just to
16:01
give your body a break from being switched on and it's it allows those
16:07
Waters to kind of calm and to steal and for your body to be replenished so full
16:14
disclosure I wouldn't say I've mastered therapeutic rest and I've been practicing it for about I don't know
16:19
seven years or so I've had lots of different um attempts at it so I went
16:27
through a phase of using mindfulness uh recordings which was
16:34
really nice um sometimes I'd listen to music that helped me I know for other
16:39
people even listening to something might be difficult so it's been with practice I
16:46
don't do it as regularly as they um it
16:51
can be prescribed but um I think that's
16:57
okay you don't have to let that wave build and build and build and build and then
17:03
have a crash afterwards if you can notice what we call the early warning signs just like you would if you were
17:09
driving a car and you had warning signs to say that you got to do something
17:15
differently you've got to stop you've got to slow down you've got to go round and round about we encourage people
17:21
to knowledge their body's own warning signs whether that's feeling tearful
17:26
whether it's feeling a buildup of exhaustion whether that's feeling sore throat headache nausea it can be a
17:32
whole range of different physical or cognitive mental sort of signs so the
17:39
the bigger the crash the more prolonged and pronounced the crash will be so if you can sort of nip it in the bud so to
17:47
speak you your recovery time will be significantly less it's like brushing your teeth it's not something that you
17:53
can do once and then hope to never get tooth decay over again it does need to to be something that you practice on a
18:00
regular basis because you'll get better at it the more you do it your your body
18:05
will start to notice the effects of it and you may well even start to enjoy
18:17
it sleep is really important and I think what often happens is that sleep can be
18:23
disruptive so sometimes people find that they're they waken in the morning and
18:29
they're not feeling refreshed that's a real Hallmark of kind of chronic fatigue syndrome so even though they may have
18:36
being in bed kind of asleep for a number of hours they're still not waking feeling replenished sometimes people have
18:43
noticed changes in their sleep as well so they may have um maybe waking more frequently in the night and then not
18:50
able to get back to sleep so there may be periods in the night that actually they're lying awake feeling
18:57
irritated um maybe starting to feel a bit more stressed and then it's not conducive to sort of going back to sleep
19:03
so to compensate that they're sleeping more in the day so more prolonged daytime napping and then what can happen
19:10
with that is the sort of body's body clock gets um there's a there's a sort
19:15
of maladjustment that happens with that um so getting a really good routine with
19:22
sleep can be one of the first things to try and kind of look at really um
19:28
regular wake up time regular going to bedtime um trying to have a bit of a
19:33
wind down time half an hour before actually um getting off to sleep just
19:39
trying to calm the body down so that it's conducive for Sleep
19:46
[Music]
19:54
coming so uh one of the nice things um again about the clinic was um we had
20:02
a session about communication of having chronic fatigue um with your nearest and
20:09
dearest and um I had two of my nearest and dearest come to the session and um
20:16
what was lovely is they do uh hold me accountable sometimes so if they if they see me um and they think I'm pushing it
20:24
a little bit or you know I'm having a little bit too many day naps they'll actually say are do you need to sort of
20:30
recalibrate a bit in so having some other people remind me is good as us I
20:38
you know eventually I'll come to the same conclusion myself but it's nice to have a bit of um peer
20:47
support so one of the key things with trying to balance activity um is to balance it with
20:55
periods of rest so trying trying to plan in periods of rest interspersed with
21:03
activity and that what what happens with that is that that will support the body whilst it's engaged in activity um and
21:11
using the energy for the activity um there can be other tools that are really
21:16
useful in terms of Trying to minimize that tendency to sort of do too much in
21:22
a day so often people will find things like planning their day beforehand so
21:28
planning in the rest times but also planning in their sort of to-do list making sure that it's
21:33
realistic um sometimes when people are doing a particular activity they might need to Pace themselves and take short
21:40
breaks so minimizing the amount of time that they're on a screen for example um
21:47
or um make sure that they move their body gently if so they're not sitting for too long um prioritizing what's
21:57
important because of often we can start the day and think I've got 15 jobs to do but actually when we really stand back
22:03
and look at all those jobs which ones are essential and which ones could we delegate to somebody else or which ones
22:10
could we actually not do I think there can be um a bit of almost a sense of
22:16
kind of Liberation to kind of stand back a bit and think actually do you know what I've been doing the washing up
22:22
every day um and actually I can delegate this to members of the family and you
22:28
know share the life skills with that oh no that's the best bit about get chronic fatigue actually is just being like
22:35
right I'm just not going to do as much that's actually been really good um so I
22:40
had to move to um a location that was uh slower pace for various reasons and
22:48
actually it suits me a lot better I've had to say no to something there's
22:53
things like I used to be able to do that I just can't but it so I prioritize
22:58
really important things and that's been really nice um because that's kind of
23:04
better quality of life isn't it actually not doing things just for the sake of it but just doing a few good things um and
23:10
it's actually really nice just doing less I think I like it's
23:16
there's still I still get very frustrated there's still stuff that is a loss or a grief because I would like to
23:22
do it and I can't but I do appreciate things being a bit simpler as well and
23:28
that choice has been made for me so I make the most of [Music]
23:38
it unfortunately there's no real evidence out there to show that one
23:44
particular diet is good for chronic fatigue syndrome there's no exclusion
23:50
diets there's no particular supplements that you should be taking unless you're deficient in something you shouldn't be
23:56
excluding anything from your diet and unless you you've got an intolerance to it so the advice really is the general
24:04
healthy eating so five to seven portions of fruit and vegetables a day protein
24:10
with every meal breakfast lunch and dinner um and water drinking plenty of
24:17
water I think a little bit more specific to chronic fatigue syndrome if you've
24:22
got nausea as one of your main symptoms is to eat regularly but small and small
24:29
and often I suppose one of the problems with diet and chronic fatigue syndrome is
24:35
meal preparation as well is trying to think of what to prepare for a meal
24:42
going out to the shops and buying the stuff to prepare actually doing the preparation and then eating it when you
24:48
feel ill you should definitely keep a stock of frozen fruit frozen vegetables
24:53
some people batch cook or ask other people to batch cook for them them so they've got frozen portions of food for
25:01
for those days where it's just too much to be able to stand or sit and prepare something
25:06
[Music]
25:13
yourself seeing others and talking with others about it really helped having the
25:20
occupational therapists talk about it and just be so kind and
25:26
affirming was wonderful after a long period of being quite I think the word
25:33
disenfranchised where you're not actually acknowledged at all made a massive difference and other things like
25:39
learning how to communicate limitations rather than getting frustrated about it and not knowing how
25:46
to say actually I can't do this or I find this a bit difficult in a way that's uh not
25:53
defensive has made things 100 times easier I would say the strategy is really really really do help a lot of
25:59
people to engage with their families to re-engage with work to just feel I mean
26:05
somebody once said to me thank you because you've enabled me to be a functioning member of my family again
26:11
which was a real Accolade which is a real lovely thing to hear so these strategies need to be interwoven into
26:18
your daily routine it doesn't happen overnight but we've had people that have
26:23
returned to work and then been able to sustain those working hours um we've had
26:29
people that have been able to engage more in social activities and to um
26:36
start going um you know doing more physical activities but yes sticking
26:41
with the strategies can have a real a real benefit and actually over the long term people are able to do to get back
26:49
to doing some of the things that that had been lost or had been stopped
26:56
before how do I I feel about my fatigue um I still find it very annoying
27:03
um [Music] uh I think self-acceptance
27:11
acceptance um of what I have and what I don't have
27:17
helps a lot for me to see the good things as well as the bad things
27:24
so I feel that I manage it as best I can and actually I'm very very fortunate to
27:30
do as much as I can do um and for some people that you know
27:36
everyone has different ranges for that um I do absolutely in some ways think it
27:42
I have benefited from it as I said from just prioritizing quality of life over
27:49
just doing things and whether or like it or not it's that's happened that's made me do that and that's good um
27:58
I wouldn't say I I wouldn't if I could not have it that would be great I suppose you have to not think too much
28:06
about it and and think about all the negative things associated with it and just take each day as it comes remember
28:14
that when you're in your lowest points it's not always going to be like that with chronic fatigue syndrome and Emy it
28:21
does fluctuate so the bad days are never going to be bad days like that all of the time then are moments of sunshine
28:29
there are moments of Joy there are glimmers of Hope and and there is hope you know recovery is is possible
28:37
prognosis it's not a deteriorating Condition it's not a degenerative Condition it's not something that gets
28:43
steadily worse over time so I I think it is possible for people to live a full and rewarding life
28:51
despite having the condition learning to learning to live with it it I used a
28:58
metaphor with somebody once they did find it quite helpful it's like wearing a backpack the backpack is is there the
29:06
backpack is going to be with you but you can still enjoy life wearing that
29:11
backpack you can still have moments of laughter and fun and happiness and love
29:17
even though it's there you don't need to disregard it and and just totally get rid of it in order to have a fulfilling
29:23
life one person said to me and it might sounds really strange to hear this but
29:29
but she actually said that it was it was really beneficial getting unwell because
29:35
it made her stop and look back and reflect on how fastpaced her life was before she became
29:43
unwell and although it was quite a painful experience and a painful
29:48
reflection it made her take on a different approach to the life going forward so she slowed her Pace down she
29:57
took took time for herself more um communicated more with others shared her
30:04
feelings and her sort of um Thoughts with other people but also asked for
30:09
help she was somebody that really struggled to ask for help and actually
30:15
by talking more about her illness experience she she sort of allowed other
30:21
people to kind of come in and support her and she said she wouldn't have done that
30:26
before You're Not Alone um I would I would just say that you've
30:34
probably been braver than a lot of people have ever realized dealing with what you've been dealing
30:40
with be kind to yourself um not in a like Namby pambi um but way but actually
30:46
in a um in just giving yourself a bit of slack um as you learn things be brave as
30:56
well sometimes it doesn't work straight away and that can be really annoying um
31:01
but it's it's okay for it to be hard as well I would say it is hard and um
31:06
and yeah it's okay that it is hard cuz it is
Click to expand...
 
"I think it's really important to
11:29
look at stress in relation to chronic fatigue syndrome because often it can play a role in sort of many years before
11:36
the illness actually developed so somebody might have had and experienced quite a stressful childhood the the
11:42
actual onset or the actual trigger might have encapsulated an element of stress
11:48
and then what happens on the body is that um it can have an impact on the body system in terms of kind of coping
11:55
with those events um and what we also know about stress is that it's an
12:01
exacerbating sort of factor so it can help to maintain the symptoms of chronic fatigue syndrome so it is important to
12:08'



So sounds a lot like the 'childhood trauma causes CFS' ideology.

.
 
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encapsulated an element of stress...

oh really? now where would that be?

I can see them all nodding their heads about their wonderful grasp of neuroscience - yes, see that trauma? it methylated that bit of your DNA and well, we don't really know how it works but we are quite sure something traumatic happened to you and this is why you have CFS. But I don't remember anything bad?...You repressed it. It is now in your subconscious controlling your body and mind. What body system? ummh, we are not sure really but you must learn to relax and sleep better, you are not good at coping with normal life stress. But I was perfectly able to before I got the infection? No, you only thought you were....forget about the trigger, that was coincidental.
 
hibiscuswahine said:
encapsulated an element of stress...

oh really? now where would that be?

I can see them all nodding their heads about their wonderful grasp of neuroscience - yes, see that trauma? it methylated that bit of your DNA and well, we don't really know how it works but we are quite sure something traumatic happened to you and this is why you have CFS. But I don't remember anything bad?...You repressed it. It is now in your subconscious controlling your body and mind. What body system? ummh, we are not sure really but you must learn to relax and sleep better, you are not good at coping with normal life stress. But I was perfectly able to before I got the infection? No, you only thought you were....forget about the trigger, that was coincidental.
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It’s an oldie, but it’s a goodie.

Louise Hay can rest easy in her grave, now that in a land far far away in the damp and earthly realm, the NHS has vibrationally ascended to the wealth creating entrepreneur purple leader level.
 
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