Monday, 27 February 2017

All About My Vasectomy!

Ok, so I said I was going to write something about my vasectomy experience, and as I had the follow up appointment last Thursday now is probably a good time.

The beginning
My wife and I decided some time ago we didn’t want more children. We have two happy, healthy kids and a modest but comfortable lifestyle, it’s enough for us. Kids are rewarding but maintaining family life whilst both working full time is hard. A vasectomy seemed the long-term solution to contraception. My Dad had one after my younger sister was born, and my brother-in-law had one a couple of years ago, so it wasn’t a ground-breaking decision, even for a practising (Cafeteria) Catholic.
Around the middle of 2015 I discussed it with a GP at my local surgery and he made the referral. I hoped it would be something that could be done quickly, but I struggled to find the right time as I was doing a stressful job I hated. Just over a year ago I took voluntary redundancy and got a less stressful job. I’m now much happier, my career prospects and work life balance are better and crucially it’s easier taking time off.
The run-up
After the referral I received a letter from NHS Choices explaining how to go online and choose a provider. There were two in my area; one was BMI Shirley Oaks, a private hospital in Croydon I’ve used before, the second was a GP surgery in Redhill which does outpatients appointments. Neither is great location wise, but BMI Shirley Oaks is easier. Due to my circumstances it was September 2016 before I actually booked an appointment.
The booking process was straight forward, but there is a lack of information about the medical process that follows; you simply book an available slot. I assumed, in the absence of alternative information, the actual procedure would be carried in that slot. So I booked a couple of days off work in October, Thursday for the appointment itself and Friday to recover (plus the weekend). It was only when the appointment letter arrived I found it was just a consultation. So I cancelled the Friday leave. Annoying.
The appointment came; I was seen quickly and professionally. I spent about ten minutes with the surgeon, the discussion was pretty much as I’d expected from reading the NHS website and covered similar ground to the GP. He asked if I had kids (yes), any medical issues (CKD) and explained the nature of the surgery and associated risks. He did a quick physical exam, jokingly asked if I wanted a circumcision too (no), and told me I would need to shave my scrotum before surgery. Then he pencilled me in for surgery under general anaesthetic on a Friday morning in January 2017. I then went to see a nurse who recorded my height and weight and informed me that if my BMI had been over 40 I would havebeen rejected for NHS funded surgery at that hospital, I inferred it could be done there privately which suggested bizarre healthcare rationing rather than clinical based commissioning.
I thought that would be it until the big day, I was wrong. The next week I received another letter with a date for a previously unmentioned second consultation. I thought it must be a mistake, but I was wrong, I needed pre-surgery tests. Annoying again. Fortunately it was between Christmas and New Year and I already had leave booked.  I went back to the hospital, saw a nurse, she took some swabs, went through the medical history form I’d completed at the first appointment, put me on an ECG machine for five minutes, weighed me again, and took some bloods (giving me matching arms as I’d had my regular CKD bloods taken at the GP surgery that morning). I never saw the results of these tests, but I was told NOT to shave my scrotum ahead of surgery as nicks might cause infection, if necessary it would be done in theatre (in the event I used electric clippers a couple of days before to ‘thin’ things out). 
The day itself: pre-surgery
I was told not to eat or drink anything after midnight the day before but I played safe and consumed nothing after 7 pm. On the day itself I was told to arrive for 7.30 am, so I got up 5.45 am and caught an early bus into Croydon and a bus back out to Shirley leaving myself good time. It was an absolutely freezing January morning and given my actual slot wasn’t till after 11 am I’m far from convinced I needed to be there so early. Mildly annoying.
I was quickly shown to a perfectly pleasant room and told a nurse would with me shortly to do check in. After 9 am the surgeon popped his head in to say hello, then about twenty minutes later the anaesthetist came and ran through some basic health questions. He asked why it was being done as a general rather than local, I told him it was the surgeon’s decision. He offered to switch to a local, which he said carried less risk. I considered this, but to be perfectly honest I preferred a general as I wanted to be asleep whilst they were fiddling around my undercarriage (yes I know they’ve seen it all before, but that wouldn’t make it any less embarrassing or uncomfortable for me).
Sometime after 10 am the ward sister came to see me, she answered a few questions such as how long I was likely to be kept in (basically until after I’d passed urine), offered me something to eat after surgery, and reiterated the advice in the appointment letter about not driving or drinking alcohol after general anaesthetic. She asked who was collecting me and I said depending on time it would be my Mother-in-Law or I’d get a taxi (which was true), and asked if someone would be at home afterwards and I said yes (which was a lie). My wife was taking the kids to my parents for the weekend, partly for a family birthday party and partly to give me a few days peace.
But I still hadn’t had a visit from the nurse to check me in. It was gone 11 am when two nurses rushed in offering apologies. There had been a mix up; they thought I’d been checked in by the night staff when I first arrived. So after spending three hours hanging around doing nothing I was speedily checked in, changed into a gown and ushered down to the operating theatre.
The day itself: post-surgery
I came around after midday in the recovery area. My senses came back pretty quickly and I didn’t feel any pain, I was just a bit hazy with temporary difficulty swallowing. After a short time I was moved back to the room and within ten minutes I was up and out of bed. Moving around was okay, I just felt very tender with a dull ache down below. Going for a wee was a bit awkward, not because of any physical restriction, but because the bandaging got in the way. My scrotum was held in a sort of string net jock strap contraption packed with surgical wadding, it kind of pushed everything upwards making aiming straight a little tricky (although my wife would say that’s not new).
I spent a few more hours in the room. Nurses came in and out to do checks, I was able get dressed, have some water to drink, and the ward sister came back to give some post-op advice such as when I could remove the dressings (next day in the shower). About an hour after surgery some tea and sandwiches arrived, which was much appreciated given I hadn’t eaten since the previous evening. I was eventually discharged around 4 pm (on the understanding that someone was home). It was too late for my Mother-in-Law to collect me, so I got a taxi home where aside from making myself cups of tea (I chose to follow advice about not drinking alcohol) and some dinner I basically spent the rest of the day watching television in bed.
I didn’t feel the need to take any painkillers, there was a constant low level ache, and occasional sharp spasms of pain when I moved too fast, but it was tolerable. My mobility was restricted, I shuffled around being careful not to make sudden movements, and I made sure I slept on my back. Most of all I was immensely grateful my son was away for the weekend given his habit of jumping on me when I’m lying in bed!
The days following surgery
I generally took things very easy for the next couple of days. I let the dressings come off in the shower the next morning. I did have a look at myself in the mirror, my scrotum was very red and hugely swollen which meant everything looked and felt very unfamiliar, especially when going to the toilet. I had two small nicks, one on either side, that had been sutured closed. I was advised to wear snug fitting underpants to provide support, which was not a problem as I usually wear briefs. For the first few days I wore a base layer under my trousers which added extra support, and also kept me warm as it was bloody freezing outside. I also wore a clean pear of briefs each night underneath my pyjama bottoms.
The next day I felt well enough to clean out the rabbit hutch and to meet up with a mate at the pub for a few drinks and something to eat. We bumped into an old acquaintance that used to play rugby league with us, upon learning of my plight he giggled each time I shuffled slowly past his table on the way to the toilet! Sunday I did very little till my wife and kids got back in the afternoon. My step count went through the floor!
Monday I went back to work. It was a little uncomfortable, mainly during the commute to and from the office. Fortunately there was no strike that week so Southern Fail merely offered its standard mediocre service rather than the ‘unfit for transporting cattle’ effort that sometimes (don’t) turn up. As I do a desk job there was nothing to stop me working and I didn’t even tell my colleagues what I’d done, but I doubt I could have done a manual job.  
It is difficult to describe the way I felt for those first few days. I was tender, I was swollen and things felt different, my scrotum was large and heavy like an overinflated water balloon. There was some pain, but it was not acute or chronic. I can best describe it as being in a state of hyper sensitivity, I think boys learn very quickly how sensitive their reproductive organs are and act accordingly, if the same sort of discomfort came from any other part of the body i.e. a stiff shoulder or a mildly sprained ankle, I would have simply carried on regardless. But the locus of the discomfort and infrequent bursts of pain when I inadvertently applied pressure to the area e.g. lying in the wrong position; meant I was constantly aware of it. There was also an annoying tendency for the areas around the two little scars to itch slightly.
It took a couple of weeks for the swelling to go down. But after four weeks it was completely healed, the sutures had disappeared and everything was back to normal. On Thursday, approximately one month after surgery, I went back to see the surgeon for a check-up. The consultation lasted about five minutes and he gave me a letter for my GP to arrange sperm count tests in May. In my case I hardly needed a follow-up; all it did is confirm everything is okay, but I understand it’s a necessary step as there may have been issues.
Was it worth it? I can’t tell yet, I still need to wait a couple of months before I get the all clear to say my sperm has been permanently restricted. I can say that it’s not as onerous as it seems. I think there is a natural and sometimes perfectly sensible tendency for men to be cautious when it comes to their reproductive organs. I certainly found the physical exam to be a little embarrassing, I was very self-conscious about the idea of a room full of people looking at my private parts even though I’m perfectly aware it’s just a job to them, so I’m grateful I was able to sleep through it. I feel no regret about having it done; providing it works the temporary discomfort is a small price to play for a permanent solution to contraception. The people involved were all thoroughly professional and treated me with respect and care, the only thing that could have been better is more clarity from the very beginning about the steps in the process, I had four different appointments not counting the original one with the GP, I also had contradictory advice about shaving my scrotum, and I probably didn’t need to be checked in four hours before surgery. But overall I wouldn’t hesitate recommending the procedure to others looking for a permanent contraception solution.

Friday, 24 February 2017

NHS Reform as Botched Quality Management

I’ve been following reports about the latest top down reorganisation of the NHS with interest, or I should say following those that made it over the wall  as the plans have been well suppressed. The secrecy is not surprising, top down reorganisations of the NHS usually fail to deliver the promised results and its status  as a deeply cherished national treasure constantly being circled by wolves makes it a highly sensitive subject. I don’t believe it does everything right, but it punches well above its weight and is struggling heroically with demographic changes and funding shortages.

Seems to me these proposed changes have some merit, at least in theory. There is evidence that focusing treatment into specialist centres can deliver better results than having more widely dispersed services. There is also evidence that moving certain types of medical care out of hospitals and into community care is beneficial. Let’s face it; as long as the required support is in place, most people would rather be in the peace and privacy their own home than hospital which is usually a busy places full of sick or dying people. Medical advances mean we often don’t need to stay in hospital as long as we once did, in the past minor procedures involved multiple days stay, now many  procedures can be handled as outpatient cases like my recent snip (which I must get around to writing something about).

The big problem is the availability of the necessary support. Most sensible people know that the resources to shift more patients out of hospital and into community healthcare simply don’t exist. As far as these plans go it's the ‘Elephant in the Room’. Both Government and NHS bosses  know full well that the NHS, England and Wales especially, barely has enough GP’s and other community healthcare professionals to cover existing demand. At the same time the related provision of social care services which is delivered by local authorities is on the verge of collapse due to years of Government austerity. Some improvements may be possible with tinkering around the edges, but it's wishful thinking to believe this can work without massive incremental investment in community healthcare and social care.

There is a fundamental lack of trust in the Government to do the right thing, it’s not helped by the fact that the leadership of the Conservative Party sends out ambivalent signals on the NHS. Whether it is ideological dogmatism over privatisation to the whiff of individual venality, trust is low. It’s not something to dwell upon here, but my own anecdotal experience as a former Conservative activist tells me  there is a clear divergence between the grassroots and upper echelons on this one. It is all reinforced by constant disingenuous responses from the Government that it's spending additional billions on the NHS, when a more truthful assessment is that any such money is simply plugging deficits, inflationary pressures and is probably just shuffled from elsewhere in the health budget. Similar claims around allowing local authorities to increase council tax to support social care are also mendacious. The Government's deliberate political decision to weight the pain of austerity away from the central portfolios, combined with raises to the minimum wage and the demands of an ageing population mean local government led social care system is already collapsing. 

This whole mess bears the hallmarks of the classic quality management clusterfuck. Way back in the day when I studied Management I was taught W. Edwards Deming’s mantra that you focus on quality and the rest follows, organisations that invest in quality and get lower failure rates, less rework, higher throughput as consequently long-term cost reduction. Conversely where the focus is primarily on costs any short-term saving tends to be followed lower quality and higher long-term costs. Over the last twenty years I’ve seen this play out in real businesses, I’ve seen incremental investments in quality deliver long-term benefits, and I’ve seen short term focus on cost cutting simply restack the pain for later (I was once partial to a confidential call where a “corporate superstar” exec suggested cutting a quality programme that had successfully demonstrated £8m per year of cost savings in order to save the £2m a year operational costs). 

Now the NHS is a special case, certain things don’t apply, for example fixing someone up now might only lead to more healthcare needs long-term, but that doesn’t mean some principles don’t apply. It’s still better to fix someone up properly today so you don’t have to do same thing again tomorrow, better for both patient and budget. The top down approaches to NHS reorganisation, and the Government’s reluctance to properly fund social care, repeat the same classic costs over quality stupidity. To make long-term beneficial changes there has to be genuine up front incremental investment in quality, not simply using accounting tricks to restack the deck chairs. There will of course be legitimate challenges to this, such as whether incremental investment is just throwing money at a problem, and there will be illegitimate opposition to it such as the brainless political fetishes around deficit reduction.

Perhaps it’s time to start resolving some of the fundamental problems? Such as admitting that healthcare and social care cannot really be separated, that attempting to shunt patient care into places where there simply isn't resources to treat them (or even worse where the Government's own policies has removed those resources) is just stupid? But most of all maybe we just need to be realistic about the fact that we don't really spend enough in this area and we should maybe reprioritise certain expenditure (I'd start with these sacred cows)?  

Thursday, 2 February 2017

More BMI Bonkers!

Another bonkers story about NHS health rationing based on BMI junk science. It appears certain NHS Trusts are rejecting joint replacement operations for obese people who have BMI over 35. They are supposed to go away and lose 10% of their body weight to be reconsidered. Having suffered from gout in the past I know that joint pain is a serious hindrance to leading an active and healthy lifestyle, but gout is sporadic rather than permanant, so God knows how those who need joint reaplcements are supposed to get around this problem.

I'm currently BMI 36 and could probably cheat under 35 by starving for a few days ahead of any medical, but at the start of 2016 I was close to 40. Losing 10% of my body weight (c.13kg) took a year to do and it certainly wasn't trivial, it took lifestyle changes including changes in physical activity. That's where the stupidity of this kind of rationing comes in, to get the treatment they need these people need to lead a healthier and more active lifestyle, but without that treatment they will struggle to lead a healthier and more active lifestyle. Plus if my experiences are anything to go by there will be little in the way of practical support to overcome the lack of acute treatment.