Obesity and prejudice in the NHS

There's an excellent documentary currently available on BBC iPlayer looking at the prejudice obese people face trying to get treatment in the NHS. The mightily impressive Professor Rachel Batterham shines a light on some of the cutting edge medical science of obesity, breezily demolishing lazy tropes about fat people as she goes. Prof Batterham makes compelling arguments supporting increasing treatment of obesity, not just due to the positive medical outcomes but on the cold, hard economic basis that as expensive as intervention can be non-intervention is far more expensive in the long-term.

Along the way she highlights some of the counterproductive and even explicitly harmful approaches to obesity that give me concern. The lack of proper understanding of, let alone sympathy for, obesity from some medical professionals. The rationing of medical treatment on arbitrary BMI thresholds rather than case by case clinical assessment, the decisions that lead to Catch-22 horrors whereby sick people cannot access desperately needed treatments due to obesity, but are unable to meaningfully tackle obesity because they are denied those desperately needed treatments. There were some pretty disturbing examples of serious medical harm being done by NHS professionals deploying half-baked thinking or outright prejudice against fat people.

A key driver of prejudice is always ignorance. When it comes to obesity there will always be stupid twats who say things like 'it's your own fault your fat cos you ate too many chips'. In the programme professional gobshite Amanda Platell of Daily Wail fame pops up to represent said feckwittery. Now I don't deny there is an element of personal responsibility in obesity, but it's far from the simple dichotomy of the ignorant twat. There are fundamental issues around human physiology and sociology at play in the rise of obesity, which is why it is a growing problem globally. Humans evolved over hundreds of thousands of years but the recent shift to sedentary lifestyles and cheap and readily accessible calories took just a few hundred years. It shouldn't be a surprise to anyone who considers the issue seriously (who isn't a stupid twat) that modern life is incongruous with the way humanity evolved as a species (a recent blog post at Coppola Comment neatly addresses some of these themes). 

One of the most interesting parts of the documentary was a discussion with a representative of an NHS Care Commissioning Group (CCG) who attempted to defend healthcare rationing on the basis that it wasn't meant to be punitive (implicitly acknowledging it is), but intended to get people on the right health pathway (without acknowledging this is pure magical thinking). To be fair to the doctor in question he did at least step up to defend an unenviably weak position and it may be that unsympathetic editing made his arguments appear even more unconvincing, but I rather suspect no amount of turd polishing can make healthcare rationing look better than it really is. It appears a lot of the CCG's who use BMI thresholds completely bottled out of talking to the programme.

Towards the end Prof Batterham made a presentation to a group of CCG and GP representatives (including 'celebrity' GP Hillary Jones) on the serious science behind obesity, the hard economic case for medical intervention reinforcing why it is important to treat obese patients with dignity and respect. Again, giving credit where it's due the participants seemed to acknowledge the flaws in their past thinking, be it simple human prejudice or lack of professional awareness. But these are doctors; you'd expect them when faced with cool, rational and overwhelming evidence-based arguments to come round. Unfortunately it will always be harder to convince the proportion of the general public who are mindless, prejudiced twats. This is after all the post-truth era, and for the mindless twat 'you ate too many chips' is a personal truth that will always rank higher than any science. Let's just be thankful there are people like Prof Batterham leading the line against feckwittery! 

Nightime peeing

Interesting story on BBC last week about how needing to pass urine in the night may be linked to excess salt consumption. For many years now I've found that most nights I wake in the early hours and find I need to wee, but it has become a little more noticeable over the last few years. These days I often find I wake again anytime between fifteen and thirty minutes before my alarm goes off, which is annoying as I invariably need to go when I wake, but that has only happened since I started my current job which requires regular early starts for the London commute. 



I don't believe there there is anything unusual about waking in the night per se, the idea that it is natural sleep all the way through the night without waking is probably a modern myth. But I have pondered the issue of nightime peeing more since my GP warned about the risks of pre-diabetes and I subsequently read it can be sign of diabetes (I'm somewhat reassured by the absence of many other signs). I'd love to be able to sleep longer, I usually manage just over seven hours during the week and over eight at the weekend, but as hinted above this is due to daily routine rather than anything sinister. I do sometimes feel tired at work, but then staring at a computer screen for prolonger periods has that effect. 



There are some obvious reasons for wanting to go for a wee in the night, firstly I'm getting older. Secondly, as a compulsive tea drinker I often drink a large cup in the evening not long before bed. Tea contains caffeine which is sometimes claimed as a mild diuretic, but as a regular consumer the effect on me is probably minimal. A third reason is that I always take a bottle of water to bed with me, which I sip from if I feel thirsty in the night, sometimes I hardly touch it, but every now and again I will consume the lot. But maybe a small contributing factor is the sodium bicarbonate tables I have been taking for for the last couple of years. I remember when the Consultant first put me on them, she gave me Furosomide so I would flush the salt out out first thing in the morning even though I laughed at the idea of needing any assistance going for a wee first thing in the morning! The diuretic tablets didn't last long as they only triggered gout attacks, but the sodium bicarbonate tablets have increased since then.

From tragedy comes hope

I came across this tragic story on Sunday night when I unwittingly crossed the Facebook timeline of a relative who is an acquaintance of the victim's mother. I find stories like this uncomfortable, it raises my worst fears for my own children, but this case happened on a road I have trodden probably thousands of times. The only positive is that this poor little girl has probably saved the lives of several other people with organ donation, something that her grieving mother must be commended for. At such an incredibly painful time it would have been understandable had she batted the question of donation away, that she didn't showed incredible bravery and is a fitting tribute to her daughter (the recipients also have a big sacrifice to live up to). With all the talk of presumed consent it's a shame the pond life responsible aren't having all their organs forcibly donated to more worthwhile causes. I'm sure there's a utilitarian argument for that somewhere.

Woe is me (aka another of my boring moans about diet and fitness)

There’s been little movement in my weight since I started my Lent fast, minor fluctuations up and down. This week I shaded just under 111kg, but it wouldn’t surprise me if I’m a little over next week. I’ve stuck to the no chocolate commitment but I suspect I don’t eat enough of the stuff anymore for it to make a significant impact on my calorific intake. The focus probably needs to be on ‘extras’ like the cup of peanuts I have on Friday and/or Saturday, or the odd piece of cake. Lately I’ve found myself plugging the gap between lunch and dinner with a few crackers or a piece of bread when I get home from work, an apple would be better, although the calorie reduction is probably marginal.

The occasional days when I consume more calorific food and (alcoholic) drink may be more relevant, such as Saturday 4^th March when to watch London Skolars versus Toronto Wolfpack. Great day out, but whilst hardly a binge, the presence of a real ale bar and a mixed grill down the pub afterwards involved significantly more calories than typical. Even then the weekly change in my weight was less than half a kilo which reversed itself without significant effort.

It probably hasn’t helped that I’ve had a few minor, sporadic flare ups of gout over the last couple of weeks, not majorly painful, but enough to cause noticeable discomfort on my daily walks. I treated with Colchicine last week and it seemed to do the trick. Unfortunately, the persistent heel pain I’ve suffered over the last few years is also quite bad, it’s been worse, but is definitely on the upward curve again. I’m not sure if it is plantar fasciitis or something else, either way given my age and weight it’s hardly a surprise. I did raise it with the GP nearly two years ago, the same time as my vasectomy referral, but as it’s small beer compared to the gout attacks I chose not to pursue the issue. With the weather (intermittently) getting better and the days getting longer I really want to be pain free so I can try jogging again, the same old problems of finding time remain, but I’ve got about six weeks to lose another two kilos and something needs to give.

But putting aside my narcissistic whinging about foot pain and weight struggles I have made a couple of attempts at doing something constructive that isn’t all about me. I’ve signed up to the Disability Support Network at work and I’ve also pre-registered for Kidney Research UK’s London bridges fund raising walk in July. The former is something I’ve been considering for a while but have been in two minds about because I don’t consider my CKD to be a disability right now, but I recognise it probably will be one day. The latter will be my first foray into actually raising funds to support treatment for CKD. I’ve added both to the growing list of topics I plan to write more about but may never find the time for!

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)?