Diet Update - Lent is here!

I haven’t posted an update on my diet in awhile; mainly because there hasn’t been much to write about. I’m currently tipping the scales at 111.6kg which is pretty much where I have been for the last two months. My activity levels have been pretty good (step counting is good motivation even if step targets are arbitrary), although my diet has slipped slightly, no bingeing or anything that serious, but I’ve slipped in to the habit of having treats like chocolate or cake three or four times a week where previously it was once or twice a week.

My aim is to get down to at least 109kg for my next appointment with the consultant in two months time. Fortunately help is at hand, Lent started yesterday so it's no sweets or chocolate for forty days (I have to admit being extra naughty on Tuesday indulging in an extra large packet of Reece's peanut butter cups). I managed it last year, even after our parish priest shockingly announced that Sunday's don't actually count as fast days in Lent! I was all for writing to the Bishop to find out what was going on!

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 have been 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.

Conclusions

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.

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)?  

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.

Dangerous charlatanry? Why not automate it…

Another interesting recent article on the BBC about thedangers of NHS trusts using referral services to review GP referrals with the intention of delaying or blocking treatment to save money. Although not this specific process, I do have painful first-hand experience of a GP referral being delayed without proper clinical evaluation.

About six years ago, during the events that led to my CKD diagnosis, I suffered a bout of severe back pain. I went to my GPs who prescribed medication, wrote me a referral to the local NHS back clinic and recommended I try their resident (private) osteopath. I took my medication, I saw the osteopath who provided a little relief but couldn’t work miracles, and I waited for the back clinic appointment.

A few weeks later I got a letter back from someone, their job title was something like ‘Senior Physical Therapist’, saying they’d reviewed the referral and decided I wasn’t worth an appointment at this time, but I’d be put on some kind of pre-waiting list for a place on the official waiting list (which I think was some sort of wheeze to game the genuine waiting list target). This ‘senior’ healthcare professional had basically read the referral from the GP and overrode his decision (which was based on clinical evidence) without examining me or even making any attempt to discuss my clinical symptoms.

During this time my back got much worse, Tramadol, Gabapentin and Diclofenac could only take the edge off. I was hunched over like an old man, I couldn’t walk properly, I couldn’t sit properly, I had to sleep on the floor. If it wasn’t for the fact that I was able to work from home I’d have been signed off sick for a prolonged period (I worked sprawled out on the lounge floor). Due to the lack of activity my weight ballooned by 15 kilos, the consequences of which are still with me today.

I went back to the GPs, I saw the other partner, who read the referral by his colleague, read the half-baked response and assessed the consequences to me which were now well past the point of medication or basic physical therapy. He asked me if I had medial insurance, I did, he wrote a referral to a private consultant, a couple of days later I had an appointment (handily he did a satellite clinic nearby), a couple of days after that I had an MRI which showed I had two bulging discs pressing on my sciatic nerve. About a week after the private referral I had a short procedure to inject cortico-steroid into my spine and the improvement was rapid.

A month or so later I did actually make it onto the waiting list for the NHS back clinic, but by this time the worst was over, my private health insurance had dealt with the acute problem. So instead of being an assessment to treat the acute problem I eventually ended up with a course of physical therapy designed to help me recover from it. Don’t get me wrong, I am grateful for that physical therapy, it taught me long-term techniques for strengthening and protecting my back which are very useful whenever I have any twinges. But the issue remains that without private healthcare I would have been left to rot in crippling agony due to a non-evidence based pseudo-scientific approach from a so-claimed health professional. So that’s how I know it’s dangerous to delay or veto referrals from without clinical assessment. It may save some money, if the patient is lucky enough to go private, or if more likely, they are unlucky and they simply die (being dead is a quick way of cutting healthcare costs).

Now I quite clearly believe the NHS shouldn’t be using dodgy processes like this, but if it’s going to use them in the name of efficiency, there are cheaper and more efficient ways. Working in Business Intelligence I know tools and techniques which could automate the assessment of referrals. These processes are not based on the first hand clinical evidence (that’s the GP consultation), they are based on textual analysis of what the GP wrote, which is something quite different.

With just a little up front involvement from the sort of healthcare ‘professionals’ currently reviewing referrals algorithms could be developed to recognise the patterns that delay treatment and the patterns that progress it. Plug those algorithms into a text mining data science tool like RapidMiner and you have a cheap way of assessing thousands of referrals an hour. Sure, from a clinical perspective it’s just as dangerous and pseudo-scientific as the current referral review process but it’s much cheaper, more consistent and also more objective as a computer doesn’t care for such things as ethnicity, religion or personal persuasions.

So my question is if the NHS is going to use dangerous processes to be ‘more efficient’ and to ‘save money’ why not race straight to the bottom and go with outright automation? With my kind of solution the NHS could do away with most of the costs of the healthcare 'professionals' currently rejecting referrals and instead spend that money on productive treatment. It won’t help the people who need treatment who get their referrals rejected on dodgy grounds, but at least the money currently siphoned off to these charlatans could be used so less referrals get rejected overall?

Fitness trackers and DNA testing

I was intrigued by a recent article on the BBC website about the efficacy of fitness trackers. I’ve been wearing a fitness tracker for about six months now and I’m pretty convinced about its benefits, it’s not that I think it’s some sort of a miraculous panacea, but I find it very useful for encouraging me to keep active. I keep track of my step count each day and if I haven’t been active enough I make an effort to put in a bit extra, or if I fall short one day I try to catch up the next. I also use it to log changes in my weight each week and to keep an eye on how much sleep I’m getting.

It is true that the majority of my weight loss in the last twelve months came before I started wearing a fitbit, but it would be wrong to take that as evidence that not wearing one is more effective that wearing one. I lost more weight at the start because at my starting point I was heavier and my overall fitness was lower, by the time I started wearing one I’d already significantly improved my basic fitness (from a very poor base line) and incremental improvements where always going to be more challenging. To go from homeworking most days to commuting was a step change in activity, but I can only walk to the office once in a morning, and back to the station once in the afternoon and I only get one lunchbreak to take a walk. So there are practical, physical restrictions on the scope for exercise, if not the effectiveness. What the fitbit has done is supported my ongoing progress, helping me to avoid slipping backwards.

One thing in the BBC article that did get my attention is the idea of genetic testing to aid weight loss. I’ve long had a suspicion that there are insights into my diet that could unlock more effective weight loss strategies, at least beyond the usual boiler plate of eat more rabbit more and do more exercise (not that such generic prescriptions are worthless, they’re just very limited). I like the idea of customised dieting advice based on scientific evidence; it’s a bugbear of mine that the various NHS practitioners I regularly come into contact with hassle me to lose weight, but without ever offering any practical, customised support. I don’t hold it against them, I understand resources are tight, but the official Government driven approach appears to be all stick i.e. sugar taxes and treatment rationing (including rationing based on pseudoscience like BMI), and no carrot i.e. making customised nutritional advice more readily available to obese people like myself. I can’t help but feel that the official approach to obesity related health could be more cost effective long-term with a bit more investment and focus short-term.

I’m seriously considering paying for a service like the one offered by DNAFit, I just need to find the one that will offer me the most useful benefit for the fee. What I really want is some customised guidance around what food/nutrition I should avoid and what I should favour. I’m not really interested in the “value added” parts of the products (value added being business speak for boosting profit margins by selling lower value bolt-on products at a price that suggests they are actually high value products); I don’t want recipe books, eating plans or exercise plans, I can work things like that out based on my own preferences once I have the underlying nutritional insight. Nor do I want to be flogged ongoing fitness services or be benchmarked against Olympic athletes, or any of the stuff that probably delivers the most profitable customers.

I’m really just looking for a company that will offer basic but comprehensive diet testing. I’m sure all the “value added” stuff might be useful if I was a fitness nut, or even if I was still playing organised sport like I was ten years ago, but these days it’s simply about being healthy and getting my weight down to 100kg.  But most importantly I want anonymity, whatever my test results are they need to be completely confidential. I don’t want them shared without me choosing to do so proactively, nor do I want the risk of being required to disclose them to some third party (such as an insurance company) at a later date simply because they exist. I know there are pretty good data protection laws in the UK, but that doesn’t mean a company cannot be hacked, nor does it prevent a situation where one day I’m legally coerced into sharing them. Ideally, I’d like the process to be completely anonymous, with my sample and the records from it destroyed within a sensible time frame.

I think I have some research to do, but this blog post lookslike a useful start…

Target hit, well sort of…

I had my Consultant appointment on Tuesday, and by some strange fluke I managed to weigh in at 111.2kg, which was a bit of a surprise as I’ve been pretty consistently weighing in between 112kg and 113kg in recent weeks. I’m pretty certain that 112kg to 113kg is my current stable weight range, so I’ve created a bit of a rod for my own back, when I go back in four months I’m going to need to be under 110kg, which means a loss of at least 3kgs, and that’s not helped by me being a bit naughty ever since Tuesday!

On the positive side my Consultant is happy with my progress, she says my stats are strengthening and showing definite improvement with the weight loss and the medication regime. The closer I get to the ultimate target of 100kg the more time I’m giving myself before I end up on dialysis and the transplant list. I’ve also been free of gout attacks for a long time now, which is a very physical sign of improvement.