Tuesday, 24 October 2017

No defence for healthcare tourism

Not entirely convinced by opposition to measures designed to stop health tourism. To be clear nobody is going to be denied immediate critical care; you're not going to get thrown out of A&E bleeding to death if you cannot prove who you are. Seems to me the people who will largely be inconvenienced are those not entitled to 'free' treatment, which is pretty much the point, and almost certainly the source of the disgruntlement.

I know people wail about the bureaucracy of it all, but you do actually need some sort of administration to get most things done. Collecting basic identity information about patients is the necessary first step in all medical treatment. Every time I go to my GP or the hospital I'm asked to confirm my details. The first time I visit a new facility I'm asked to verify who I am. This is good practice, not because it prevents health tourists, but because it gives medical professionals access to information they need to treat you properly.

It's really not too much trouble for most people to verify who they are if they want ongoing healthcare. Admittedly, there may be some challenging circumstances, some patients have special needs, but binning off faux-moralistic preaching there are processes in place to deal with them. We may not have a utopian system, but it deals with millions of vulnerable people every year without bodies piling up in the streets (bodies blocking beds is far more common).

The real problem seems to be the myth of 'free' NHS treatment, which is precisely what attracts health tourists. Those who moan about denying 'free' treatment to ineligible patients too easily forget it's not really 'free'; someone always has to pay! People up and down the country have to work hard to fund the system, a system that is always, and always will be, financially challenged.

Monday, 23 October 2017

Not quite Priapus

I picked up the results of my third andrology test last week, the one I did in late September. The result was pretty much the same as the other two; I’m still showing traces of immotile sperm. This basically means I have low fertility, low enough to make conception very unlikely, but not completely impossible. With that in mind the GP is reluctant to sign off on the vasectomy, instead he’s written to the consultant for comment, and has given me a form for a fourth test.
Whilst it’s nice to indulge the notion that I’m just so damn fertile a vasectomy couldn’t stop me, it’s getting annoying now. I’m going to delay the next test till I hear back from the consultant. I was aware it didn’t always work, but I seem to be in the zone where it has pretty much worked but a small risk remains, the key is to quantify it and decide what comes next.
The real reason the GP wanted me to see me was to talk about the Nephrologist’s recommendation that we review my blood pressure medication and also get a Hep B screen and vaccination tied in with my January bloods. The Hep B screen is a pre-emptive measure is to protect me from risk of further kidney damage, but would probably need to be done in advance of dialysis anyway. Unfortunately, I haven’t taken any blood pressure readings since before my last nephrology appointment, so I need to do some and send them into the surgery so he can decide if action is needed.
Whilst I was there I also got my annual flu jab. As a member of an ‘at risk’ group I get a reminder every year, but last year I was able to get one at work from the occupational health team. This year work decided to cancel blanket (optional) inoculation of staff on the grounds that it’s unnecessary (basically a cost cutting measure with an epidemiological backstop behind it), although ‘at risk’ groups were encouraged to see their GP. The GP himself was most bemused to hear this, apparently this year’s strain is particularly virulent and my employer may come to regret the decision. So, there we go, I have been warned, but then I’ve been inoculated too!

Thursday, 19 October 2017

Recruitment ineptitude and IKM test claptrap

Going off topic again, but hell it’s my blog, and this deserves remarking upon even if just for sake of catharsis. I believe sometimes in life you come across stuff that is so shit it actually took a special effort to be that shit; this is such an occasion.

I recently applied for a different role with my employer, a small step up the hierarchy, in a different department, but at a level I’ve operated at before. It was in the area of data visualisation, a currently trendy niche of Business Intelligence (BI). I’ve worked in BI for years, and data visualisation has been a significant part of that. I’m actually pretty happy in my current role, and there are significant dis-benefits to moving, but unfortunately it is about the only way someone like me can progress upwards so I had to try.

The spec asked for experience of one or more of a bunch of BI tools, there are lots of these out there, they’re much of a muchness and if you can use one you can normally pick up others quickly. I’d used some, but not all of them; and as none were listed as essential that was a tick. The spec also asked for experience and knowledge of a range of areas that are tangential or peripheral to data visualisation and BI. I have such experience, they are specialist areas in their own right and I’m not a specialist in them, but I’ve worked alongside side such specialists for a long time so know the ropes, just not to their level of expertise.

All this I made clear in my CV and covering letter, and that got me through to the next stage, an IKM technical assessment. This is where things took a turn for the bizarre. The test was supposed to be focused on data visualisation, but it only very briefly touched on the subject. Instead there were highly detailed questions on three of the software packages, two of which I’m not particularly familiar with, and none of which are regarded as leaders in the data visualisation space (curiously the job spec does pick out the leaders and I do have experience of them). The rest of the test was highly detailed questions relating to specialist areas tangential or peripheral to data visualisation.

I strongly suspect this IKM test was never designed to be about data visualisation, I’d estimate that less than 10% of the questions were specific to that subject. Instead it looks like someone, not really knowing much about data visualisation, bodged together parts of tests intended to assess certain other specialist subjects and called it a ‘data visualisation test’. It could be that IKM doesn’t have a genuine data visualisation test, it is quite niche, or it could be that the recruiting department asked IKM to bodge together some sort of weird multi-specialism test (the questions were too detailed to be general knowledge, but covered too many specialist niches to be on any one specialism). Whatever the truth it took some effort to put together something this shit.

I’ve made my feelings known to both IKM and to HR, but don’t expect any response. I’m just pissed off I wasted my time. Either the job title and spec should have been changed to reflect the essential skills required (I am sceptical about the number of specialisms required, as they’d typically be spread over four or five specialist roles in  a data and analytics team) or the test should have been focused on data visualisation with less detail on tangential and peripheral roles. My annoyance is tempered by the fact that success in gaining the role would have involved moving to a less convenient location, in a department that has a bad internal reputation for being inflexible, bureaucratic and generally behind the curve. The grass was never going to be greener on the other side, but it was at least a stepping stone. 

Thursday, 5 October 2017

Sliding towards the inevitable

So, my appointment came and went three weeks ago now. After all my fussing about weight gain I ended up weighing in at 113kg, which was 2kg above my previous appointment, but pretty much where I’ve been for the last year.
As it was the Consultant didn’t give me a hard time, mainly because my eGFR has shown its first significant decline in a couple of years. She did warn me not to read too much into it, as individual readings can fluctuate significantly, but it does appear I’m starting to shuffle off the plateau. Her best guess is that I will need a transplant in somewhere between six and ten years to avoid dialysis.
It’s hard to predict this with any great accuracy, as the majority of my readings are stable and the amount of protein in my urine is relatively low versus my eGFR which apparently means I’ve got a chance of edging towards the furthest end of that timeline. The big danger is that I suffer some form of serious illness, which would accelerate the decline. Touch wood, no such thing happens, but it is something I need to be wary of.
I’ve known for several years that failure was inevitable, but I had hoped to delay it for as long as possible. Now I’m at the point where I know the clock is ticking and the challenges ahead are starting to crystallise. In an ideal world a close blood relative would offer me a kidney, as that would provide the best chance of compatibility, but as my Mum and my brother only have one kidney each; that just leaves my sister who has never been tested for kidney disorders or my Dad. I’d be worried about my sister being a donor if only because the odds of her having some form of disorder have got to be high, as for my Dad, I’m not sure about him either as he has suffered from heart arrhythmia in the past.
I suspect that my best hope will be from an anonymous donor; likely involving time on a waiting list, fortunately as I’m relatively young, strong and healthy this perhaps isn’t as risky as if I were older and more fragile. The target weight of 100kg will become of greater importance, the 13kg or so to that destination are proving stubborn, but five years ago I was over 130kg, so I know it is possible. I know medical science is moving apace when it comes to artificial and cloned organs, but I suspect that any breakthroughs will come too late this time round (but given my age it is not inconceivable I will benefit in the future). I may also need to re-evaluate my feelings on presumed consent for organ donation, now my life may depend on it!

Thursday, 31 August 2017

Hawking, Hunt and the NHS

A bit of a long post. On holiday the other week I was diverted by the hullaballoo over Stephen Hawking laying into Health Secretary Jeremy Hunt's plans for a seven-day NHS and creeping privatisation. The intellectual no contest between the world-renowned physicist and the political hatchet man is a noisy propaganda event; more interesting is the underlying clash of ideological* spectrum positions on the role of markets and privatisation.
The Conservative Party is always vulnerable to attack over the NHS, firstly it exposes core differences between rank and file. Secondly, it's a subject many blundering front line Conservatives lack sensitivity for, and thirdly, the spotlight often crosses the sleazier edges of the party. My opinion based on years spent as an activist, is that the bulk of Conservative members support the NHS as a state funded, state run and primarily state provided institution. However, this often coincides with an ideological antipathy towards big government, and tacit support for commerce and entrepreneurship. There are also legitimate concerns about getting value for money and a sustainable financial settlement for the NHS.
This means Conservatives are more open minded about the potential efficiencies from private sector involvement, things others see as taboo. They're not blind to potential dis-benefits, nor risks from rent seeking crony capitalism, but they're pragmatic about cost benefits. The upper echelons and therefore policy direction tends to be disproportionately influenced by the free market wing. They genuinely believe markets deliver benefits to the public (a.k.a. consumer) and offer arguments (of admittedly variable quality) in support. Finally, there is the tiny grubby fringe who associate with free markets, but are better understood as 'freebooters' whose espousal of public interest tends to be mere gloss for crony capitalism.
Nobody is against the idea the NHS should be properly resourced seven days a week, but the concept of a seven-day NHS is more than about having enough staff. At brief glance it’s clear current policies on NHS funding, local government/social care funding, Brexit/ immigration, and healthcare training are incredibly not consistent with sustainable resourcing. The idea of a seven-day NHS seems tied to the free market concept of healthcare as consumer service, and it’s hardly a great leap to see this as swaying towards private provision. However, the much-loathed Mr Hunt has been at great pains to claim the NHS should not be viewed as a typical consumer service (at least not for the consumer). Is this just more evidence of confused policy? The undertones of the freebooters and their clients are hard to ignore.
All this sets up the conflict with those, often on the left, with more statist ideological positions, who see the NHS as something that should be state owned, run and provided. As with Conservatives there are many positions, some strong arguments, some very weak arguments, and there are sectional interests (trade unions and professional associations may pitch themselves as ‘guardians’ of public interest but their members come first). They may be uncomfortable with cost benefit analysis when it comes to rationing emotive treatments. There is also the category error of mistaking virtuous intentions of healthcare workers with achieving the best use resources for patients.
Some opposition is based on misunderstanding of economic forces, be it confusion over the difference between markets and capitalism, or viewing inefficiency through the prism of the broken window fallacy i.e. defending unproductive practices because 'it's someone's job', or perhaps failing to understand healthcare wages are more constrained by monopsony than by competition. Emotive pleading is used to obscure the the tragedy of the commons style problem caused by breaking the link between consuming resources and paying for them. It's too easy to push responsibility for paying to abstract 'taxpayers', especially the conveniently nebulous 'rich', but ultimately shunning potential benefits on ideological grounds means someone else has to put in an extra shift.
I can see legitimate concerns in opposition to private sector involvement, I just happen to think they can be mitigated without throwing away potential benefits. I am aware efficiency destroys low productivity jobs (it's not clinical professionals who are really threatened), and I am aware those workers may face greater risks. But, there are better ways of mitigating this than wasting finite resources. The private sector is not guaranteed to be better, cheaper or more efficient than the public sector, but restricting provision to a monopoly ends any chance of reaping potential benefits and locks in the dis-benefits of public monopolies. Concerns about private providers cutting corners are moot, if commissioning bodies cannot manage contractual service levels there's no reason to believe they can manage internal ones. Conflicts over how commissioning bodies decide to spend their funds exist regardless of the profit motive.  
Public monopoly also enables political meddling, this may welcome for favoured specific political objectives. But enabling meddling is risky, it leaves the door open to populists and pork barrel deals. Such objectives are better managed through legislation or other governance. Some simply object on principle, they despise the idea of private organisations profiting from public funds, but this is naïve sentimentalism, there is no guarantee resources are distributed more justly under public provision, taxpayers still pay and in the absence of totalitarian revolution the fundamental basis of our economy and society remains unchallenged.
I subscribe to the view that organisations should stick to their core competencies, things they are good at, and let others handle the other stuff. From personal experience the NHS is good at providing essential clinical care, that's where its comparative advantage lies. If other organisations have comparative advantage in peripheral services that can benefit us all. We don’t expect the NHS to maintain its own private postal service because we recognise greater benefit comes from letting specialist postal services do it, so why not allow certain types of non-core medical services be handled by private specialists?
Strangely enough this whole conflict tends to overlook that privatisation and marketisation have always been a feature of the NHS. The bulk of GP services and dentists are provided by privately owned practices that contract to the NHS. Many hospital consultants combine public and private work. There doesn't appear to be a groundswell against these examples of privatisation, nor demand for clinicians to become indentured to the NHS. The nomenclature of provision seems to matter as much as the taxonomy; profits for Healthcare.PLC equals bad, profits for Dr X and Dr Y LLP goes unremarked.
Personally, I support the idea of an NHS funded by taxation, where clinical services are generally free at point of consumption to those who eligible (I don't support free treatment for illegal immigrants or health tourists beyond emergency medicine, because there is no such thing as free treatment and they bear no responsibility for costs). I don't believe private insurance is better or more efficient, the state is able to provide comprehensive society wide risk pooling in a way the private sector cannot. But healthcare will always be a finite resource and sustainability is a moral as well as practical necessity. That’s why private provision should be judged pragmatically on the objective cost benefits, not on subjective principles.
* I find the term 'ideological' uncomfortable as it's commonly deployed as a vacuous and unintentionally ironic pejorative to label those who hold opposite or contrary ideologies.

Tuesday, 8 August 2017

Every silver lining has its raincloud...

Haven't blogged in a while. Things are ticking over okay; my weight is stuck around 113kg after a few weeks of minor fluctuations. I have just under a month to try and get as close to 110kg as I can for my next nephrology appointment. My activity levels are pretty good and I've got some holiday over the next couple of weeks that should get me out and about.
I had my second hypothyroidism test ten days ago, whilst I was at the surgery I asked about the results of my second semen test in early July, the receptionist said the most recent test result (which was the one I wanted) had been tagged 'no action'. I said 'I'm not sure what that means', and she said 'neither do I, you'll need to ask a GP'. So last week I got a phone consultation. The doc called me back and says he's very sorry, but he couldn't understand what the results meant. To his credit he called the andrology lab which confirmed it had detected traces of what are known as non-motile spermatozoa. The lab also advised it had just upgraded its equipment (is there a vasectomy pun in there?) and it would be advisable for me to have another test. As it's better to be safe than sorry that's what I am going to do.
After the consultation I did a bit of googling and it turns out non motile sperm is detected after about a third of vasectomies. Pregnancy is highly unlikely from non-motile sperm, but not impossible, hence why doctors are nervous about giving the all clear when they are present. So, I’ve made a third andrology appointment, but I’ve done it for just before my nephrology appointment so I only need to attend the hospital once.
On the positive side I tested negative for hypothyroidism, although that means I lose an excuse for being a fatty and I also need to renew my annual NHS prescription certificate. Every silver lining has its raincloud...

Sunday, 16 July 2017

Getting jizzy with it!

It's been a couple of weeks since my last post. On Sunday 2nd I completed the Kidney Research London Bridges Walk, it was a good event and I really enjoyed it. I covered the seven miles in my target time of two and a half hours, a reasonable pace given it was a hot day and the route went through some of London's most congested pedestrian areas. Parts of the Southbank and Westminster Bridge took far longer than their physical distance suggests due to throngs of tourists and numpties blocking the pavements trying to take selfies against the backdrop of the Palace of Westminster. Also, on the narrow stretches of the northern Thames Path it was easy to get stuck behind gaggles of Sunday shufflers out for a lazy stroll.
I spent most of the walk listening to the Black Tapes Podcast, which I've become addicted to of late. Although I was nominally walking alone, and it was by no means a race, the other walkers helped me maintain a decent pace and I never risked losing motivation, which might have been the case had it been a random walk along the river. Factoring in my travel to the City Hall start, the walk itself, and the trip to Byron afterwards I clocked up a personal best 25.8k steps. I'm now looking for other similar activities, I know there are walking groups in my area, but my preferred modus operendi is a bit too anti-social for that, I might try and map out some local 5k routes I can walk/jog when I have time.
Last week was my 40th birthday, so my wife, knowing I'd taken a day’s leave, booked me an extra special treat... a trip to the dentist! It's not that I'm afraid of dentists, although I did have a couple of horrible experiences as a child, I just got out of the habit five or six years ago. The practice I was registered with wasn't convenient and as it's not always easy to register with a good NHS dentist I never got around to moving. So, after years of nagging, my wife took matters in her own hands and registered me with her dentist. It was about time; I'd been starting to worry about occasional pain twinges from a twenty-year old filling.
It started with the Hygenist giving my pegs a good scale and polish, they weren't too heavily scaled but what was there was stubborn. Afterwards the Dentist did a check-up and x-rays. Fortunately, nothing of real concern came up, the twinges appear to be the old filling pressing on a nerve, but the filling itself is sound. There was the option to drill it out, line it and refill it, but given it's a negligible issue I decided to leave alone for now.
On the 7th I gave my second semen sample to Andrology at East Surrey Hospital, so I should know this week if my vasectomy has the all clear. If I don’t get the all clear I’ve no idea what happens next. It will be a complete bugger if I have to have another procedure. Also, if my tubes haven’t been properly sealed up what the hell has happened? This week I need to arrange the second blood test for an underactive thyroid, I’ve held off renewing my NHS annual prescription certificate as if I do have hypothyroidism then my prescriptions should become free.
I’m hoping any treatment for potential hypothyroidism will help with my weight loss, but I’m not holding out great hope. The reading that triggered the whole inquiry showed only mild hypothyroidism and my brief reading around on the condition suggested weight loss is only likely with more serious hypothyroidism. I’m still kicking around 113kg, I briefly went up to 114kg after my birthday celebrations, despite high activity levels, but that was due to overindulgence. It just seems I’m in that zone where it takes a lot of activity to shift the dial down even slightly.