Tuesday, 13 June 2017

Hair today

Purple flowers and wooden bridge
Krakow Botanical Gardens, July 2016
It's been a long time since I sat down to write, and I was wondering why. I'm pretty sure it's because of an HBO television series called 'The Newsroom', which I started renting from LoveFilm because it is written by Aaron Sorkin, who also wrote the best TV I have ever watched ('The West Wing'). The Newsroom is not as good as The West Wing, but it is a very close second, and I bought the DVDs and have been rewatching the first series before even going on to series 2. Each episode is about 45 minutes, which I would otherwise spend noodling on the laptop, hence the lack of blogging. I could be watching an episode now, that's the sacrifice I'm making.

Recent activity: weeks ago I visited Lola II and Mr M for a weekend, my colleague left work and we had a night out to celebrate and commiserate, I had a large percentage of my hair cut off, I had a long meeting with the builder who's going to manage my kitchen renovation, there was an election, and I went to work and badminton and meditation in the usual way. We also did some meditation in the park as our contribution to Buddhist Action Month. BAM! "Don't just do something, sit there!"

Group getting ready to meditate in the park

While I was visiting Lola II and Mr M we went to a performance of 'Roller Diner' in London's Soho, and it was rather good, although it took a while for me to get comfortable with the style of it. I haven't been to the theatre for quite a long time, and our seats were right at the front so not much distance between me and the actors. Despite my assertion that being called 'Roller Diner' meant that there was bound to be roller skating in it, there wasn't. I didn't mind being wrong on this occasion, because there was plenty to keep me interested. Based on this experience I wouldn't mind going to the theatre again.

We also went to a Street Food event at Alexandra Palace and then a lovely long walk on Sunday, and it was the Bank Holiday weekend so I even had Monday to get more done at home. There's still so much to do, although I'm gradually moving the old downstairs office upstairs, and emptying the kitchen into the old downstairs office and getting rid of whatever I don't use through Freegle, Nextdoor.com, Facebook Marketplace, eBay and the 'Household Waste Recycling Centre' (aka the local tip). Talking of eBay, the big philatelic project is nearing its conclusion with a total net profit of more than £250 as of today. I've finished selling the main postal mechanisation literature, and the very last bit is stamp booklets which is something new to me.

Then there was that general election as well. International politics at the moment feels like a particularly violent roller coaster ride with no option to get off. Just keep riding, and endure what's in store over the next political horizon - will it be a gentle bend or a vertical drop? I don't think there is the same sense of imminent catastrophe as there was at the height of the Cold War, just a sick feeling that our society is becoming ever more divisive and those holding political power have very little in common with either my way of thinking or of those who would disagree with me. Political thinking has never felt more like a gambling habit. I do often wonder how it will end.

Long hair in the hairdresser's chair

Wednesday, 7 June 2017

What I've been reading

Image of the book cover

by Charlotte Perkins Gilman

narrated by B. J. Harrison
"An all-female society is discovered somewhere in the distant reaches of the earth by three male explorers, who are forced to re-examine their assumptions about women's roles in society."
An interesting situation made more interesting by the values of the time - early 20th century - when women were assumed to be less than men by nature rather than societal norms, wives were chattels, and rape within marriage was not only legal but thought quite reasonable, at least by the men. The author paints an attractive picture of a society run by women who are intrigued by the three men who intrude upon their world. One of the three is completely won over by their society, one is expelled ultimately because he is unwilling to change his view that women wish to be 'mastered', and the third (the narrator) falls somewhere between the two. The book ends quite suddenly with the narrator and his new wife, a native Herlander, leaving for his home. There is a sequel 'With Her in Ourland', but reading the synopsis and reviews it sounds a bit too much like a feminist lecture.

Image of the book cover

Alex's Adventures in Numberland
by Alex Bellos
"Mathematical ideas underpin just about everything in our lives: from the surprising geometry of the 50p piece to how probability can help you win in any casino."
I used to read this sort of book all the time, but I still have a shelf full of other books waiting to be read, getting in the way. Very readable, a good mix of things I already know and new ways of looking at maths, nothing that leaps out in my memory, but I'd be glad to read it again one day.

Image of the book cover

The Short Stories of Saki: 65 of Saki's Most Popular Tales
by Saki (Hector Hugh Munro)

narrated by Cathy Dobson
"Sly, observant, unpredictable, and irreverent stories - Saki was a great observer of the English classes and their distinctions and foibles. He had a way of turning an ordinary situation into something clever and surprising."
All with a certain style and many with satirical cruelty, these are my ideal examples of the short story. Beginning, middle and end, sometimes straightforward but often leaving a good deal to the imagination. Masterful use of language - not quite Wodehouse but nearly as good. Only the odd vocal tics of the narrator brought it down a little.

Wednesday, 24 May 2017

Matters arising

Cornflower bud
April 2017
After the parking episode described recently, I think I have not written about my other parking issue, because parking is one of the least interesting and most discussed issues of modern times. Outside my garage there is a white line to indicate that parking is not permitted across the entrance. As we have seen when it was removed by the re-surfacing works this line served a useful purpose, but it was only just long enough, and cars parked legally would slightly obstruct the garage entrance, but not enough to stop me getting in and out. I wrote about this briefly in a previous post, and eventually did contact the council's white line department to ask if it could be lengthened, to which they said 'No'. However, after the re-surfacing work the line was re-painted at the longer length that I had been asking for. So that's interesting. Or, more accurately, it isn't. Enough with the parking already.

I went to a local meeting. Some money has been allocated to be spent on improvements to the park at the end of my road, and the council thought they'd ask the locals what they would like. There was already a prototype group to ask, because the Friends of the Park had been convened when the park was threatened with being taken over by cars, caravans and motor homes during the National Bowling championships in the summer. It was a good meeting, and surprisingly good humoured and constructive. The main problem seemed to be the newly installed skate park, which is very popular and attracting swarms of local 'yoof', but is also attracting their litter despite the many litter bins in the vicinity.

The yoof in attendance were polite and well-spoken and made good points. There were also representatives from the bowling club, the tennis club, local dog-walkers, parents and runners who are the main constituency of park users, as well as all the candidates for the local election taking place a couple of days later. It looks as though the most likely purchases may be outdoor gym equipment (but there is a separate pot of money that may fund this anyway) or a refurbishment of the under-used tennis/cricket pavilion to make it more usable for e.g. a cafe. My previous local councillor who I can no longer vote for was there, and I took the opportunity to thank him and express my regret that he would no longer be representing me.

Work news: I delivered the 'short carb counting course' pilot. Prizes are available for anyone who can come up with a better name - my best shot at the moment is Candi, which stands for Carbs and Insulin. This comprised four hours about carb counting extracted from our usual four days about Type 1 Diabetes, to deliver to people who can't spare four days and maybe don't have Type 1 Diabetes. We had five attendees and I think it went well. I have yet to look at the feedback sheets.

We also had a small meeting attended by our business manager, two doctors, three nurses and me. It was supposed to discuss the future of the insulin pump service, which is set to expand by about 10% every year. As usual the meeting was utterly pointless and did not result in any useful discussion or conclusions, but it was quite a nice social event within the department. We are having a follow-up meeting with just three of us, which may be more constructive. All I actually want from the meetings is to understand how our service is funded and managed. It doesn't seem much to ask, but so far I have failed to achieve even this small advance.

Two CPD courses for me last week as well - the first about Clinical Audit presented by one enthusiastic and knowledgeable man and one girl whose presentation style was simply to read out loud the text written on each Powerpoint slide. I tried to be constructive in my feedback, but she was terrible. I discovered quite a lot about Clinical Audit, including the fact that what I planned for evaluation of the short carb counting course isn't Clinical Audit at all, it's Service Evaluation. The other course was a compulsory three-year update on DESMOND, the Type 2 patient education product. Also very interesting, and delivered in the same rooms of the same hotel as the first big Techshare conference that I helped to launch and run in the 1990's.

Much leisure activity to report - the music group continues, with the prospect of me being the sole baritone saxophonist at the July concert because my fellow saxophonist has a previous engagement. There are significant exposed baritone solos in the pieces we are playing, and I am not at all confident of successful delivery, seeing as how I'm really not very good at playing the beast even though it is enormous fun.

I also spent a whole day with the Buddhists at our usual venue - a nearby village hall - and the weather was lovely and we did some meditation, some chanting, some discussion and another 'puja' ritual. I still don't think I'll be joining in with the rituals any time soon, but for the first time I really felt that I had made progress with the meditation. It's been so gradual that it's hard to detect, but it feels easier to do and in my everyday life I am employing some of the positive behaviours that it's supposed to promote, and and feeling better for it.

The LTRP took a step forward with the rebuild of the airing cupboard, which looks lovely and needs only to be painted. While they were here the carpenter and his mate were kind enough to carry my filing cabinet upstairs to the new office, about which I am disproportionately excited. I also went back for a second meeting with the woman from the alternative kitchen supplier who has very strong views on her products and doesn't mind sharing them, and who speaks very loudly. I am trying not to be too influenced by these factors and to focus on the content rather than the style of delivery.

Tuesday, 16 May 2017

Shopping, touring and parking

Chestnut mushrooms
Borough Market, May 2016
Sometimes I don't have much to say, but at the moment I'm almost driven to the keyboard to let off a bit of steam. Actually, the pressure has dissipated a bit because I've told most of the hairiest stuff to Lola II and Mr M on the phone already, but writing it down can help too.

While you've been enjoying the niceties of diabetes technologies, activities at Lola Towers continue unabated. I think I am actually unable to lessen the quantity of stuff going on because I'd rather have too much than too little to do. Accepting that this is true may help me to stop moaning about how busy I am.

I have had a bit of a shopping spree - online, of course. With some actual camping coming up, and also with the prospect of being without a kitchen for a while over the summer, I decided to get a move on and decide on what sort of camping stove to get, followed by actually buying it. So that's one thing crossed off the enormous 'To Do' list.

The building where I work is fairly relaxed but the hospital as a whole is trying very hard to make sure that quality standards of all sorts are maintained, and the latest standard to be addressed has been the one about uniform: bare below the elbow and hair above the collar. The Dietetic Manager sent an email round to highlight this, and I have had to accept that if I am caught transgressing now it will be rather more of an issue than before we were specifically told to abide by the rules.

Keeping hair tied back is fairly easy and I can manage fine without a wristwatch, but I do find that the wristband Fitbit pedometer has helped me to carry out a bit more activity and a few more steps every day, and I was reluctant to give that up. So I also rode the wave of rare shopping motivation to try and use up all the remaining TV-watching points on a Fitbit device that clips to clothing so I wouldn't have to wear it on my wrist. Unfortunately after I'd ordered the TV-watching vouchers it turned out I couldn't use them to buy this gadget, but I bought it anyway with real money. Within a week I had gone and put it in the washing machine. [It has a surprisingly effective rubbery jacket, so it survived unscathed!]

Local elections came and went - constituency boundary changes meant I had to choose a new candidate to vote for, and I am glad that the incumbent Green Party candidate was elected - small patches of Green and Lib Dem yellow appear among the sea of blue in this county. I am dreading the General Election. Each time there are more hateful personalities and policies among the distorted propaganda, political bickering and biased media, and less integrity, honesty, generosity and truthfulness. It has become a choice between wasting a protest vote, or tactical voting for the least detestable party that stands a chance of ousting the most detestable. Sometimes democracy is a burden.

Lola II and I went to Shrewsbury for her 'birthday' weekend this year. It is rather a nice city, with river, hills, interesting independent shops and many many coffee shops and churches. I bought a rug! It was a bit of a surprise but maybe this shopping thing I seem to have acquired is seasonal. There was a rug shop in the market, and we had a bit of a think about how to manage a rug purchase when we were spending the day wandering about and staying in a B&B, but the vendor agreed to deliver it to the B&B. The rug is red and black and very striking. I like it.

Other things we did in Shrewsbury - a rather interesting guided walk looking at buildings all round town from medieval to modern times. Particularly interesting was the half-timbered building faced with brick to fit in with the style of the newer Regency buildings around it. We were also shown a modern frieze on a building, including a small plaque containing two faces, and asked who they were. Lola II guessed one as the Queen, and rather flippantly I said the other looked like Michael Heseltine. My guess turned out to be right, and the other face was Margaret Thatcher - the frieze was a reference to the introduction of the Poll Tax. We ended Saturday with a local theatre company performing 'Anything Goes' which was a delight.

On Sunday Lola II and I did a lot of walking and talking and had a Japanese lunch, which made me happy. And during the weekend my ebay sales record was broken by a postcode promotion leaflet much like all the others, except that it featured Sherlock Holmes on the front. It was clearly Sherlock fans rather than the more sober philatelic collectors who bumped the successful bid up to a frankly ridiculous £16. I was even more delighted because I happened to have two of the same leaflet, but the person whose offer of £15 was outbid must have come to his or her senses, because they failed to take up my Second Chance offer at that price.

The only other recent event of note was on a Friday when, most unusually, all my clinic slots were full and I was expecting seven people in the morning. Out of the front door as usual in the morning I was confronted with a car parked right in front of the garage, completely preventing me from getting the car out.

The road was resurfaced a few days ago so all the road markings were missing, and this might have contributed to the situation. No matter why, the question was, what do I do? A few neighbours were out and about but none knew whose car it was, so I phoned the police non-emergency number for advice. A friendly woman took the details and asked if I had knocked on any neighbours' doors. I caught the hint and asked if it would be worth my while - could she perhaps give me the address that the car was registered to? No, she couldn't tell me the address, but yes, it would be worth my while to try a few doors. Meanwhile, she would pass my case to 'Despatching' who would send someone over when they had the chance.

I really didn't fancy knocking on doors at 8 o'clock in the morning, so I waited. At work, my colleagues had started to contact the patients who were booked in - unfortunately a couple turned up anyway because they hadn't checked their phones. An hour later I phoned the police again to see if I should just cancel the whole morning's clinic, and got the distinct impression that nothing was going to happen very quickly. Another hour later I did get a phone call, and this time the policeman told me which house the car owner lived in, but there was nobody at home, so I put a note through the door. At this point I tried contacting the council parking enforcement department, who also said they would send someone round although we agreed that there was very little that could be done.

After a further hour (now it was after 11 o'clock) the police controller called me back to see if anything had changed. I didn't see how any policeman could help me unless they could track down a mobile number for one of the occupants of the house, and it didn't seem like that was something they were going to do. She said she'd send someone round anyway because they might be able to move the car, which would have been really interesting to watch.

At 12.15 p.m. there was a ring at the door - the neighbour had returned from a very unimportant trip into town and was distraught at the trouble she'd caused. She hadn't noticed the garage, she was busy telling the kids off when she'd parked - it was hard to be angry at a genuine mistake and she acknowledged how it had really messed up my day. We did agree that it was unlikely that she'd do it again.

Tuesday, 9 May 2017

Bolus advisor masterclass part 2: Post-prandial correction

Owl at the entrance to his burrow
Cotswold Falconry Centre, April 2017
The first instalment of feedback from the recent course I attended was mostly about adjusting insulin dosage to account for fat and protein content of meals. The second half of the course left several delegates behind...

Post-prandial correction doses

This was by far the nerdiest section of the course, and took quite a bit of concentration and asking the presenters to 'just say that again more slowly.' It was all about how the bolus advisor technology built into blood glucose meters and insulin pump handsets works out correction doses of insulin when blood glucose is high following a meal.

Unless you have a fully functional pancreas, you cannot avoid your blood glucose rising after a meal, even if you have injected the 'right' amount of rapid-acting insulin. Trials have shown that for the rapid insulins currently on the market, the ideal time to inject is 15-20 minutes before a meal. This is usually impractical, because you don't know how much insulin you will need until the food is in front of you, and then you don't want to wait 15-20 minutes before eating it. So the period when the injected insulin is reaching the peak of its action ('offset time') lags behind peak glucose entering the bloodstream, and this is one reason why post-prandial blood glucose tends to rise more than for a person without diabetes ('meal rise'). But if you've worked out the right amount of insulin, your blood glucose should return to 'normal' levels within four hours, which is the 'acting time' for rapid insulin.

So if you monitor your blood glucose less than four hours after your last bolus or injection, the blood glucose level that you see may actually decrease further without any action from you, due to 'insulin on board' - active insulin still in your system. So how do you know whether to correct it or not? At any time within four hours of your last injection, how high is 'too high'?

Imagine a scenario where your blood glucose level is within the ideal range before a meal, you have counted 60g carb in your meal and your insulin to carb ratio is 1 unit for every 10g - this means you will need 6 units of insulin. Roche told us that other manufacturers' algorithms assume that all insulin injected is 'active' insulin. So if your correction ratio is 1 unit of insulin to reduce your blood glucose by 3 mmol/L, then immediately after the meal your blood glucose could be up to 18 mmol/L higher than its pre-meal level and you would not be advised to take a correction dose because of the 6 units of active insulin. Roche also told us that other manufacturers assume a linear reduction in blood glucose, so after 2 hours your blood glucose could still be up to 9 mmol/L higher than the pre-meal level and no correction would be advised.

Fig 1. Correction is not advised if blood glucose falls below the line
This is not good. Even in the worst case scenario, blood glucose should not rise this high after a meal. There's no perfect number to aim for, but (assuming the meal wasn't Frosties) I would be happier with a meal rise of no more than 4 mmol/L, and 3 mmol/L would be even better.

Roche's algorithm makes quite a different set of assumptions, the main one being that only pre-prandial correction doses (insulin injected because pre-prandial blood glucose is too high) count as active insulin after the meal. Insulin injected for carbs is accounted for, and is not available to act on a high post-prandial blood glucose level. They say they have evidence to support this assertion.

So for Roche, a correction is required if the blood glucose rises higher than the 'meal rise' setting during the 'offset time'. After that a linear decrease to the pre-prandial level by the end of the 'acting time' is assumed. If meal rise is set to 4 mmol/L, offset time is 1 hour and acting time is 4 hours, then a blood glucose rise of 9 mmol/L at 2 hours would definitely suggest a correction. The shorter the offset time and the smaller the meal rise settings in the handset, the more aggressive the correction regime. For someone frail and elderly or prone to hypos it makes sense to have a higher meal rise and a longer offset time, to minimise risk of over-correction and hypoglycaemia.

Fig 2. Correction is indicated for the same post-prandial blood glucose level as Fig 1

Blood glucose correction after snacks

This was the hardest part of the course to understand, and therefore to explain. It would be so much simpler if people with Type 1 diabetes didn't eat between meals! But given that they do, they need advice on whether to correct blood glucose after a snack. The aim of the 'snack size' setting is to determine whether to apply a 'meal rise' and 'offset time' or not.

The 'meal rise' setting doesn't change depending on the size of the meal; it is the same whether the meal is small or large. So the 'snack size' setting is the carb threshold between applying a meal rise or not. If 'snack size' is set to 20g of carb, then for snacks up to this amount correction will be indicated afterwards if blood glucose is above the line in the previous graph. If a 'snack' 2 hours after a meal contains 30g of carb then the meal rise is applied at that point and a new graph is drawn, with corrections only advised for blood glucose levels above the new line.

Fig 3. Presence of the meal rise allows post-prandial blood glucose to be higher without advising correction

This is pretty sophisticated stuff, and I'm pretty sure that none of our patients understand how these settings are used. I'm only just working it out as I write this. What it boils down to is that most people using a basic type of meter have to take a stab in the dark when correcting post-prandial blood glucose levels, but people who are using this technology should get a good indication of whether to correct and how much insulin to give, as long as the settings have been adjusted to meet their particular requirements.

I always try hard to make sure that the main insulin to carb ratio and correction factors are right, but I have been less attentive in the past about the meal rise and snack size, because up to now I didn't understand what they were for.

The last point to mention is what we can do for people using pumps and meters that use the linear algorithm in Figure 1, which don't give useful advice about post-prandial correction. The team delivering the training suggested shortening the acting time setting to 3 hours instead of 4, because then at least a few more high blood glucose levels will fall above the line. This is not ideal, but the best they could come up with.

Wednesday, 3 May 2017

Bolus advisor masterclass part 1: Counting fat and protein

Market stall 'CARNES' with hanging sausages
Seville, November 2016
It's been a few weeks since I attended this course, and it's time to assemble my thoughts and learning points. It was a terrific day and I certainly learned quite a lot, most of it very relevant to my work with people with Type 1 diabetes. In fact, two days after the course I was passing on some of the information to the group I was teaching at the time.

It is important to note that the day was hosted by one particular pump manufacturer, Roche, so there is a likelihood of bias. Having said that, I think the majority of information supplied was correct - it would be fairly straightforward to check, although I haven't done so. The first topic covered in the day was a comparison between the specifications and capabilities of the different insulin pumps on the market. Then we focussed on the algorithm that each manufacturer uses to guide the user in the amount of insulin to give in various circumstances: for exercise, for high fat and protein meals, and to correct high blood glucose levels after a meal or snack.


The guidance around exercise wasn't very different from what we already advise - if you're exercising within 90-120 minutes after a meal you could give less insulin for the meal; if not then you'll probably have to eat or drink some carbohydrate to prevent blood glucose dropping, and if you're using an insulin pump you've also got the option of reducing background (basal) insulin. I've written extensively and comprehensively on the knotty topic of exercise and Type 1 diabetes. It's a challenging area, and management.is very individual. All the pumps work in a similar way, although the Roche handset has some features that help with the mathematics of percentage reductions.

High fat and protein meals

OK, this is going to start getting technical (although nowhere near as nerdy as the section on post-prandial correction doses in part 2).

For people with Type 1 diabetes, the evidence suggests that best management of blood glucose levels, and therefore long-term health and freedom from diabetes-related complications, comes from matching insulin injected and carbohydrates consumed. (Just for contrast, the approach for people with Type 2 diabetes in the first instance is weight loss).

The first point that hit home during the course was that although we focus on counting the carbohydrate in a meal, there is a contribution to blood glucose that comes from the protein and the fat in a meal. When we focus on carb counting, there is an unspoken (and for me until now, unrecognised) assumption that the meal is constituted of a 'normal' proportion of carbs, fat and protein. I actually know this to be true, because we have found when someone with Type 1 goes on a very low carb diet they need more rapid insulin with meals than the carbohydrate content would suggest.

Fat and protein have another effect alongside their contribution to blood glucose levels - they also slow down the digestion of carbohydrates. The action profile of insulin can't be adjusted to suit the meal composition - rapid insulin has a fixed onset, peak and acting time that doesn't change, so giving insulin in the standard way before a meal when it's a high fat/protein meal doesn't work very well, and post-prandial blood glucose often ends up way higher than one would like.

Up to now, conventional wisdom suggested that for a high fat meal carbs should be counted as usual, but the matching insulin dose should be delayed and/or split (if on injections) or spread over a longer time period (if on a pump), to account for the delay in digestion and later peak in post-prandial blood glucose. This course not only suggested that more insulin is needed because of the greater contribution of fat and protein to blood glucose, but gave some useful guidelines on how much more is needed, and how it should be delivered.

Six different high fat/protein meals were listed: fish and chips, Indian and Chinese takeaway, pizza, pasta with creamy sauce and fast food (McDonalds, KFC etc).  The following procedure was recommended separately for each.

As a first attempt, you should give 25% more insulin than you need for the carbs and deliver 50% at the start of the meal, and 50% an hour later (if on injections) or over 2.5 hours (if on a pump). Then, to see if these percentages are right, you should monitor blood glucose at 2.5 hours and 6 hours without having any more food or insulin. This will work best if your blood glucose level is within the normal range before the meal.

The 2.5 hour test is to find out whether the 50/50 percentage split is right. If blood glucose at this stage is more than 4 mmol/L higher than it was before the meal, then more insulin is needed up front - they suggest increasing by 20% at a time (i.e. switching to a 70/30 split next time). Conversely, if blood glucose is lower at this point than before the meal, the split should be changed to 30/70.

The 6 hour test is to find out whether the 25% extra insulin is right. If blood glucose at this stage is between 2 and 6 mmol/L higher than before the meal, next time add on another 10% - instead of 25% extra, add 35%. If at 6 hours blood glucose is more than 6 mmol/L higher than before the meal, next time add on 20% (to 45% extra). Conversely, if blood glucose is lower at this point, then next time knock the percentage down by 10% to 15% extra.

Multiple experiments may be needed to get the best results! Apparently parents are often taken aback when their Type 1 children come home from a carb counting course and assert that they've been given homework that requires them to eat fish and chips, takeaways and fast food.

Coming soon: Part 2 will contain even more technical stuff about how to manage post-prandial correction of high blood glucose levels.

Thursday, 27 April 2017

What I've been reading

Image of the book cover

Pride and Prejudice
by Jane Austen

narrated by B. J. Harrison
"When Elizabeth Bennet first meets eligible bachelor Fitzwilliam Darcy, she thinks him arrogant and conceited; he is indifferent to her good looks and lively mind. When she later discovers that Darcy has involved himself in the troubled relationship between his friend Bingley and her beloved sister Jane, she is determined to dislike him more than ever."
A delight. Obviously. Even with an American narrator.

Image of the book cover

A God in Ruins
by Kate Atkinson
"This book relates the life of Teddy Todd – would-be poet, heroic World War II bomber pilot, husband, father, and grandfather – as he navigates the perils and progress of the 20th century. For all Teddy endures in battle, his greatest challenge will be to face living in a future he never expected to have."
An interesting book, and a modern one to punctuate the ceaseless stream of 'classics'. It jumps about in time so is a little difficult to follow, and there's a twist at the end that I'm not sure I'm supposed to take seriously - if I did, it would alter the whole narrative. I have a shelf for books that I intend to keep and another for giving away, and after some consideration this one will get given away. It's not terrible, I just don't think I'd read it again.

Image of the book cover

Heart of Darkness
by Joseph Conrad

narrated by David Rintoul
"The story of Marlow's search for Mr Kurtz, the company agent whose "unlawful soul" has been "beguiled beyond the bounds of permitted aspirations" in his dealings with the natives of the Belgian Congo."
Not a great choice for the audiobook format, since the narrative is more atmosphere than plot. It's been a long time since I saw the film but I remember not liking that very much either, so I was hoping the book would live up to its 'classic' status. Most of it wafted past me in the car while I was thinking about something else, and I couldn't be bothered to play it again to hear what I'd missed.

Sunday, 23 April 2017

More progress

A one-storey stone coach house or garage and three storey half-timbered building
Tusmore Estate, April 2017
Nothing special to report for the last few weeks, although I've been having a good time. We had a family gathering on mum+dad's 60th wedding anniversary, which in true family style was celebrated by nothing special at all other than all of us being there. I have done a few of the jobs on my list that have been waiting for quite a long time, including meeting the new landlord of the Pub Next Door, buying house insurance, and putting up the last curtain in the new office/spare bedroom space which can be drawn across to separate the two 'rooms'.

The upstairs space is now structurally finished, but furniture needs to be brought upstairs which will need the help of some burly individuals who can help me move a filing cabinet, desks (one from downstairs to upstairs and the other in the opposite direction) and a bookcase. That will, I think, complete the office move, except for deciding what to do about the noticeboard.

More on the LTRP front - I now have working drawings to give the kitchen suppliers and builders, and I have sought alternative quotes. The alternative builder has so far not responded at all, and the alternative kitchen supplier was very scathing about my washing up preferences! She did however come up with the useful suggestion that my next step might be to settle on the appearance of the floor. I am going to have a vinyl option called Karndean, and I drove to the main Karndean showroom in Evesham, which was well worth the trip. I came away with three different samples large enough to make a choice at home, and the confidence that any one of them would do nicely.

Three shades of Karndean wood effect

Oh yes, I have been to see H+B in the North West along with Lola II, Mr M and Sister D, and we all made ourselves thoroughly at home over lunch. We were hoping to do a bit of walking in the afternoon, but the weather put a stop to that. I took the opportunity of visiting our Postal Mechanisation guru on the way home, since he also lives in the North West. He was very kind and welcoming even though it was Good Friday, which is just as well because we spent nearly five hours (FIVE HOURS) going through another three boxes of material that mum had unearthed. I got home at 2 a.m.

However, I had to agree with Lola II, Mr M and Sister D that I was spending too much time on this stupid ebay project. Although I find it mildly enjoyable, the time spent for meagre financial return is simply not worth it, and I have plenty of other more enjoyable occupations that I have no time for. So the plan was that I would go through the new stuff with the PM guru but would ask him to dispose of anything of value, and throw away everything else. This is what I did, so now I am only going to finish auctioning the material I already had. There is one box remaining, so it will still take a month or two.

I spent a day at the Birmingham Buddhist Centre doing meditation, listening to lectures, talking to all sorts of people and then watching a kind of ritual that is the closest buddhists seem to get to formal 'worship'. The thought most prominent in my mind was 'I can't imagine ever joining in with that', but who knows? They are a thoughtful and sincere group of people and I have a lot more in common with them than with any of my work colleagues and many of my friends.

Over the Easter break, as well as the northern excursion I did another ten mile walk with the Meetup group I joined for the New Year walk. The walk leader this time set a rather fast pace, and by the end my legs were aching and I'd also managed to acquire an impressive blister on my little toe. If I sign up for another long walk I'll have to watch out for who's leading, but in fact I'll probably stick to the five mile options in future. The picture at the head of the blog was taken on the route, but the estate is privately owned so we didn't go in and I don't exactly know what the buildings are.

Lastly, badminton news: Club #2 held an end-of-season tournament (they don't play over the summer) and I won the top lady prize. While you may think this indicates my advanced badminton skillz, you should consider the alternative explanation, which is that I have chosen to play in a club containing players who are significantly older and significantly less fit than I am. But I was runner up for the past two years, so it's still rather nice to win something.

Lone tree, green field, grey skies
North Oxfordshire, April 2017

Monday, 17 April 2017

One Census entry, 1861

Chinese pagoda sculpture and part of skyscraper on a sunny day
Birmingham, April 2017

A guest post today, written by Hugh. This is the story of an investigation sparked off by a previous blog post in which I described some of the history of Lola Towers.
It started innocently enough some years ago, tracing my wife’s family on a genealogy website (Genes Reunited). Then mine. Then the family trees of friends. None of them properly, you understand. No physically visiting out-of the way Registries or parish registers, like you see on “Heir Hunters”.

Then I found Family Search, the Mormon website which generated the standard programme for formatting and processing information. I don’t use Free BMD, or other sources, much. But it’s fascinating how much you can find out with minimal tools, and with time on your hands.

It begins

Then Lola I put some information on her blog about the history of her house in Leamington. Out of interest, I looked up the residents starting with Joshua Fardon, stated to be the licensee of the house (it used to be a beerhouse) in 1861. I should say that by now I had a Platinum membership, giving me unlimited online access to original Census returns, not just the transcribed version that gets into Web searches including Family Search.

This turned out to be just as well, because the transcribed 1861 Census entry for the Cricketers Arms pub, Archery Road, says, [with calculated birth year in square brackets]

Samuel Boid Head M 40 Knowle, Warks, Inn Keeper [1820/1]

Ann Fardon Dau M 25 Milverton [1835/6]

Marie Boid Dau Un 19 Leamington, Milliner [1841/2]

Ellen Boid Dau Un 17 Leamington [1843/4]

William Beesley nephew Un 16 Leamington gardener (apprentice) [1844/5]

Elizabeth Boid Dau 7 Leamington [1853/4]

Frederick Fardon Grandson 4 Leamington [1856/7]

William Fardon Grandson 1 Leamington [1859/60]

This is odd, because the licensee I was looking for was Joshua Fardon (from 1854), and I had already failed to find him in Leamington Censuses. I was unable to identify Samuel Boid and his daughters in either the 1851 or 1871 Censuses.

Tracking down Joshua Fardon

There is a Joshua Fardon Pork Butcher b 1811 Gloucester, in Coleshill Street, Birmingham in 1861. He has several children, one a son, Alfred, born in Leamington in 1850/1, so Joshua’s wife was there at that time. Another son, Albert, was born in 1851/2 in Stafford, so it looks as if they moved about a bit, or maybe one or both “sons” were adopted or stepsons. Maybe a family name, might conceivably be the 1854 Leamington licensee?

So I looked at the scan of the original Census form, and it suggests that Samuel and his daughter are actually named Bird, and they are (some of them) in the earlier and later censuses. It is also rather unlikely that Ann Fardon, married, is the daughter of Samuel Bird given their ages, though I guess she could be a step-daughter. So let’s find out who her husband, Mr Fardon, was.

Family Search rapidly comes up with a marriage of Ann Beasley to Emmanuel Fardon.

Ann Beasley, christened 15 May 1835, m Emanuel Fardon 19 June 1855 at All Saints, Leamington Priors. Her father Richard Beasley Dairyman, his father James Fardon Blacksmith.  (PS James Fardon, b 1793 Temple Guiting was in Leamington in 1851 as a shoeing smith.)

This may be a light-bulb moment, as one of the residents in 1861 was William Beesley, aged 16, born Leamington.  According to the 1851 Census, we have the right Richard Beasley and Ann Beasley, from their occupation and birthplace:

1851 Census Living 8 Brook Street, Leamington

Richard Beasley Head  Mar 46  Warwicks Burton Dassett, Milk Mann (sic) [1804/5]

Maria do Wife Mar 39 Warwickshire Borsell [1811/2]

Ann Do Dau 15 Milverton [1835/6]

James Do Son 13  Leamington [1837/8]

Maria Do Dau 10 Do [1840/1]

Ellen Do Dau 8 Do [1842/3]

William Do Son 6 Do [1844/5]

Elizabeth Do Dau 2 Do [1848/9]

Charlotte Do Dau 2 Do [1848/9]

Servant Thomas Spittal 18

Notes: guessing slightly, Borsell is Balsall Common near Knowle, Warwickshire; and Burton Dassett is a vanished village 11 miles South of Leamington.

Elizabeth and Charlotte were both christened on 14 Feb 1849.

So is William, born Leamington 1844/5, the same William as in the 1861 Census? If so, why is Ann Fardon described as “Daughter” and William as “nephew”?

Unravelling the mystery

One hypothesis for the 1861 Census is that Samuel Bird married the widow Beasley, if Richard Beasley had died. She would have been Maria Beasley b 1811/12 Borsell, according to the 1851 Census (by which we established that Ann Beasley 1835/6 Milverton and William Beasley 1844/5 Leamington might be sister and brother). Alternatively, maybe Maria Beasley 1811/2 Borsell was a relative of Samuel Bird, 1820/1 Knowle, near Borsell.

I have tried and tried, and cannot resolve these alternatives by any confirmatory evidence, indeed Richard Beasley had NOT died (see below). The most likely hypothesis is that the Census taker, either at the house or when transcribing his field notes, has confused two separate people, or left a line out in the transcription, so that the Bird children are indeed Samuel Bird’s children, but Ann Fardon is NOT his daughter, but the wife of absentee Emanuel Fardon and relative-in-law of absentee landlord Joshua Fardon, and the Fardon children listed as grandchildren are in fact the grandchildren of Ann or Emanuel’s father. There’s a thought: is the missing person Ann’s father Richard Beasley?

The family listed for Richard Beasley in 1851 are widely scattered by 1861 – son James in the army, Elizabeth in service in London, Maria, Charlotte and Richard not to be found on Genealogy websites. The only William Beesley 1844/5 Leamington is the one we have already as “nephew”. In 1871, the only candidate for William Beasley 1844/5 is in Leamington, married, a painter and glazier.  So maybe “nephew” is another error by the Census taker in 1861. Also, in 1871, Richard (widower) and daughters Elizabeth and Maria, and a son Thomas, but not William 1844/5, are living in Leamington at “cottage back” Archery Road, round the corner from the Cricketers Arms.

The next step

We were going to find out more about the Fardons.

On Googling “Fardon”, we find on Geni an immense labour of family love which suggests that the Fardons came originally from Temple Guiting, Gloucestershire, had Joshua and Emanuel as family names, were given to calling themselves by other Christian names than their own, and had a number of publicans in the family. I have to add that the family site on Geni is not wholly consistent with other sources.

It is possible, but not certain, that Joshua (1811) and Emanuel (1822) are cousins, the sons of brothers James and Richard Fardon. Another Fardon, Henry Fardon, lived in Leamington in 1861. He was born 1803 in Temple Guiting and died Milverton 1875. Emmanuel 1822, though, was away from Leamington in 1851, in service in Reigate, not to be found in 1861, and in 1871 in Harrow with his wife Annie and three children, including Frederick and William all identified by their ages and birthplaces.

And this is just one entry in the 1861 Census!

Monday, 10 April 2017

Commissioning Structured Education

Outside view of the tent pitched in my garden
April 2017
I bought a tent! It arrived on Tuesday but I was working all five days last week, and had commitments on all five evenings so I didn't even open the box until Saturday. I had to mow the lawn before I could try it out, but it's looking good so far. The first test will come in July with a camping trip to Devon.

The extra day's work last week was a course all about advanced features of the Roche Bolus Advisor. This is the algorithm that is used in one particular blood glucose meter and insulin pump handset to try and suggest the right amount of insulin in any situation. It was a brilliant course but I don't have my notes with me at the moment, so that blog post will have to wait. In the meantime, I shall complain about a different meeting I went to on Wednesday.

The Clinical Commissioning Group (CCG) for the area where I work is a baffling organisation. Maybe all CCGs are baffling, but I couldn't say. Its role is to decide which health services should be provided to the local population and, as the name suggests, commission those services. Obviously I am affected by the commissioning of services relating to diabetes, but I couldn't tell you the mechanism by which commissioning is done, or how we are paid as a result. I think I know the names of one or two people in the whole chain of management that administers this process but I have no understanding of the process at all. No idea whatsoever. Not at all.

Recently there has been a national campaign to promote the provision and take-up of Structured Education for people with Type 1 or Type 2 Diabetes. Structured Education isn't just any old course, it has a definition within the national guidelines. It has to be evidence-based, have specific aims and learning objectives, have a curriculum that is written down with supporting materials, be delivered by trained educators, be quality assured by trained, competent, independent assessors who measure criteria that ensure consistency, and be audited.

Recently a pot of money was announced for Structured Education and bids encouraged from CCGs. The email from the CCG asking what we deliver in our area ended up with me, so I responded describing our courses as well as asking more about the bid in case I could provide some insight, given that I am actually delivering Structured Education to actual patients. "No thanks, we're fine" was the reply.

I heard no more, and then a colleague forwarded a message to me describing a workshop that the CCG were proposing to hold to discuss Structured Education. All sorts of people had been invited, but not me. They were happy to add my name to the list, though, and then a few days before the meeting was due to be held we received the documents that were going to form the basis of a discussion about what is delivered in our area, where the gaps might be, and how we could improve things.

That's all very admirable, but when we came to read the figures in the documents for the programmes that we were actually delivering, it became clear that they had spoken to nobody who was actually doing the job. The figures suggested that no courses at all for Type 1's were being run in one area, and that courses that were being run in the other area were completely inaccessible.

I try not to get annoyed about how the NHS is run, but this was very provoking. The CCG was convening a workshop to discuss a service that I personally deliver along with just four other people. Not only had they not spoken to any of us, but they hadn't bothered to even invite those who deliver the service that was to be discussed, and had circulated completely inaccurate data. My colleagues tend to assume conspiracy, but I generally believe it's either laziness, ignorance, or lack of time. The seeming inability to pick up the phone is particularly annoying though.

Anyway, we wrote a short rebuttal of the data and asked for this information to be circulated (it wasn't), and turned up at the meeting anyway. The person who presented the data did express doubt about its accuracy, but we weren't given an opportunity to clarify. We will be getting together with CCG representatives as a result of the meeting, but my confidence in their competence is pretty low. As for outcomes - there was a lot of the usual talk about how things could be better, but my experience is that nothing changes as a result of a meeting, especially if there is no new money. The CCG doesn't yet know the outcome of their bid.

By chance this has all coincided with a change in the administration of our course. I had long been dissatisfied with how patients were identified and notified about courses. We would set dates for courses a few months in advance, but when people were referred they were simply stuck on a waiting list. About a month before a course was to start (which might be a very long time since the referral was made) about twenty people on the waiting list were contacted in the expectation that we'd get about eight to turn up.

So the waiting list was full of people who, despite having presumably agreed to the referral, had no intention of attending. Many of those who had intended to come had forgotten what it was all about by the time they received an invitation. Although we wrote back to some referrers, most never found out whether their patient had attended or not. And we couldn't tell how long anyone might have to wait.

I got together with one of the other educators and our administrator and suggested how things might work better. I was taken aback by their resistance to any change at all, and it became clear that if I wanted improvements I was going to have to take over the admin myself, at least temporarily. So I fired up Excel and made a start, and so I had a good idea of how things stood in time for the CCG's meeting.

Last year we were struggling for staff with only two of us available to deliver the course. Now we are getting up to full strength with four (and soon five) of us, but at the same time referrals have increased dramatically. The waiting list stands at about ninety people, and there are virtually no referrals from GPs, so if this starts to happen (as it should) we will be properly overwhelmed.

So the next thing to do is to get in touch with everyone on the waiting list to weed out those who can't or won't attend - that should reduce numbers significantly. Then I'll be offering actual course dates to fill up all the courses to the end of the year, and we'll see how many people are left over and if extra capacity is needed. We can't just put more people on a course, because (due to an error of the previous administrator) we had 12 attending the last course, and it didn't work very well at all.

The full course takes four days over three weeks - so what about those who can't spare the time for this? I am putting together a much shorter version which will be piloted in May over just four hours, and if successful we can at least offer something to people who can't commit to four days. But that won't be Structured Education.

When I started this job I was determined to keep my head down and have no bright ideas that would result in extra work. Nobody thanks you for extra hours, and I don't work with the sort of people who inspire any sort of innovation - as evidenced by their reluctance to consider admin change, even though they now see how much better it will be. I have started to hope that this job will be my last, if I can get an early retirement date. But I can't seem to help wanting to change things and making extra work for myself.

Inside view of the tent with porch and 'bedroom'

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