Category Archives: medical

current affairs, medical

£50m? That Goes Nowhere!

In a widely reported impending announcement David Cameron is allegedly to pledge £50m to fund 1000 GP surgeries (roughly 1 in 8) to open 0800-2000, 7 days a week. See for instance here.


Yes, these extended GP hours are something we, the patients, are asking for. And there is a need because currently there are people (just how many is really debatable) who can’t (for lots of reasons) go a GP appointment but unnecessarily clog up A&E.
But yet again the UK government has proved it doesn’t have a clue about how to actually run the NHS. Cameron doesn’t stand a hope in hell of achieving what he’s pledging, because $50m by my reckoning will pay for a quarter of that for just one year.
Here’s why …
Opening 8-20, 7 days will mean around an extra 34-40 hours a week to be covered. (It’s 34 hours if the practice is currently open 0800-1800, 5 days a week; and many aren’t.)
This means every GP practice which is going to extend their hours, as demanded will need to employ at least one extra full time equivalent GP.
And to cover the extra hours they will also need at least one full time extra member of reception/office staff.
Leaving aside where they are going to find all the suitable, spare GPs, let’s look at the cost. Here’s a very broad brush, back-of-envelope, estimate:
Assume that a GP costs the NHS £150K pa (that’s salary plus pension contributions, plus employers NI contributions, plus other benefits like holiday etc.).
Assume similarly that a full time trained receptionist costs £30K pa (again salary plus benefits package). (Yes you do need trained receptionists; medical work is not something anyone off the street can do, and certainly not safely.)
And then remember that the extra hours will also incur costs for heat, light, hot water and other services — let’s assume that’s £25 per week per practice.
Which means each practice would need funding of around £181K a year.
Dividing that into £50M would provide enough funding for around 275 practices, or about a quarter of what is proposed. And 275 practices is little more than 1 for each NHS area (CCG) in the country (by my count there are 211 of them in England).
So even if the “reorganisation” also provides 100% efficiency savings (which would be a world first!) that still means we’ll achieve only 50% of Cameron’s pledge.
So not only will Joe/Josette Public not realise that this may mean his/her GP isn’t open (and they have to go several miles across the borough to find the practice which is open — on a Sunday when there are no buses), but it is going to go nowhere near meeting Cameron’s pledge.
And that’s without all the fancy gizmos, like Skype video consultations, which are being promised. They have to be paid for too!
Oh and if you read the articles don’t be deceived by all the twaddle about the over 75s. That’s been in the plan for a long time; it isn’t new. Just as I suspect the £50m isn’t new money either.
How do we get these people to understand that healthcare is expensive, that the available funds are being misallocated and mismanaged, and that GP services are hugely underfunded compared with 10 years ago? Because they really don’t have a clue how to fix things.

current affairs, medical

Transforming the NHS

1 Comment

As regular readers will know, transforming the NHS so that it can provide excellent healthcare to people in the UK at an affordable cost is something which has exercised my mind for a long time (see, for example, here and here). And I am involved, at a local level, in trying to help unlock this.
Now don’t get me wrong. Many parts of the NHS are excellent. In an emergency they generally work brilliantly, at least in the short-term. And many of the doctors and nurses care deeply about looking after the patients.


However whenever I walk into any NHS hospital, clinic or office** there are several things which immediately strike me:

  • the obscene level of waste
  • the absence of appearing professional
  • the number of staff who seem to spend their lives wandering around doing little or nothing
  • the appalling environment
  • the apparent lack of both money and the will to put any of this right.

And that is despite the fact that the NHS should already have shed-loads of money to do everything we would want it to do if it used it wisely.
The other day I had to visit a local private hospital, and the contrast with the NHS was almost as stark as it has always been. No, it wasn’t perfect. For a start it was far too hot, but it was clean and looked professionally welcoming. Yes, there were plenty of staff around, and they all appeared to be doing something with a purpose. You had a degree of confidence that everyone knew what they were doing and why and that they cared about their patients.
This is more what the NHS should be like. But how to get there?
I keep thinking about this and here’s my three step plan for the paradigm shift which the NHS requires, from top to bottom.
Step 1. Get someone at the top who can successfully run a large, quality, profitable corporation and who is able and willing to tell the politicians to butt out and stay out. Someone like Richard Branson, or perhaps Alan Sugar (no, I don’t care that you dislike them; they’re good at what they do). Someone who will have a vision of how the organisation should be and will implement it regardless of push-back from any level — if you aren’t going to do the job, get out.
Step 2. Tackle the appalling level of waste. This includes finding efficiencies — improved ways of doing things — at all levels. And that means everything from reducing bloated layers of managers and administrators, through cupboards full of medical supplies which have to be thrown out because they go out of date while other departments can’t order the very same thing, to turning down the heating.
Yes, really! Turn the heating down! NHS hospitals, clinics and offices are always far too hot; when people who are usually cold tell me it’s too hot then you really are wasting money! Just this one thing could save the NHS millions.
And while you’re saving money, fix the buildings: even if you can’t build new hospitals (because of time, money or space) you can at least make the ones you have into a habitable environment. Fix the leaks etc. Stop the draughts. Buy some paint. Because they will save you even more money in the long run.
Do those two things and you will start to see a culture change. But to complete the paradigm shift you need to do something just as fundamental the the outlook and attitude of all the staff — from the most world renowned consultant surgeon to the lowest lavatory cleaner. So that means …
Step 3. Everyone needs to take on board four basic beliefs and habits:

  1. Cherish the patients. They are why you are doing what you do. They’re not just important they are your whole raison d’être. They deserve the best.
  2. Put yourself in the other person’s shoes, whether they’re a consultant, GP, patient, nurse, administrator or ancillary worker. Think what effect things will have on them. And then treat them as you would like to be treated.
  3. Work as a single team. Everyone is equal but everyone has different skills. It doesn’t matter if you’re a patient, the most renowned surgeon or the ward cleaner, everyone has an important role which has to be valued as important to the patient’s recovery. (And part of that means valuing people and paying them decently.)
  4. Be empowered. If it is right and needs doing, do it. This has to come from the top by giving everyone freedom (not bullying), and it has to come from the bottom with people grasping that freedom. Unless there is an over-riding reason not to do something, just do it.

No, I don’t pretend it will be easy. That’s why you need the right person, with the right attitude, at the top. Without that one person it will never work because the politicians will keep meddling and the all the vested interests will see the top as weak and keep playing their own games. And then the patient (remember him/her?) is forgotten.
Yes, initially there will be a lot of scepticism and probably a morale hit. But as time goes on, as it begins to work and people start to buy-in, morale will increase and you’ll win lots of crusaders.
But it will take time. I went through this in a multi-national corporation in the 1990s and it took the best part of a decade, lots of head-banging, a lot of people being retrained and several rounds of redundancies for those who couldn’t or wouldn’t adjust. So I’ve seen it done; I was looking up from the bottom wondering WTF was happening; after a couple of years the penny dropped and I too changed. I know it can be done.
So David Cameron and Jeremy Hunt, do you have the balls to do this?
I’m not holding my breath.
____________________
** This also applies to some GP surgeries although most are better as they are small stand-alone businesses which have to keep afloat.

books, medical, science

Book Review: The Secret World of Sleep

Penelope A Lewis
The Secret World of Sleep: The Surprising Science of the Mind at Rest
Palgrave Macmillan, 2013
This is another of those books which I wanted to read and which appeared for either Christmas or my birthday (I forget now which as they are quite close together). This is what the cover blurb says:

A highly regarded neuroscientist explains the little-known role of sleep in processing our waking life and making sense of difficult emotions and experiences.
In recent years neuroscientists have uncovered the countless ways our brain trips us up in day-to-day life, from its propensity toward irrational thought to how our intuitions deceive us. The latest research on sleep, however, points in the opposite direction. Where old wives’ tales have long advised to “sleep on a problem,” today scientists are discovering the truth behind these folk sayings and how the busy brain radically improves our minds through sleep and dreams. In The Secret World of Sleep, neuroscientist Penny Lewis explores the latest research into the nighttime brain to understand the real benefits of sleep. She shows how, while our body rests, our brain practices tasks it learned during the day, replays traumatic events to mollify them, and forges connections between distant concepts. By understanding the roles that the nocturnal brain plays in our waking life, we can improve the relationship between the two and even boost creativity and memory. This is a fascinating exploration of one of the most surprising corners of neuroscience that shows how science may be able to harness the power of sleep to improve learning, health, and more.

Yes, OK, I guess it does do all of that and at a level which is likely OK for the intelligent layman. But as a scientist I found it somewhat lacking, or maybe more correctly it felt loose, in the details. I don’t profess to be very knowledgeable about the neurology of sleep, but I had the feeling that there was more there which is known and which would tie everything together. I may be wrong, and in fairness to Lewis she does say at a number of points “we don’t know how this works”.
Did it tell me anything I didn’t know? Well nothing which I found helpful and which has stuck sufficiently that I could recite it now. As always, yes, OK, I’m probably way above the audience this was written for. I found it an easy but not compelling, or gripping, read — sufficiently so that I whizzed through it far faster than I had expected.
All of this is a shame because I wanted to get that “Wow!” inspirational insight and it didn’t happen. I still feel it should.
As with many modern books it is a slim volume (about 190 pages) and it could have been much slimmer: as always there is too much white space on the page. Even if you don’t want to reduce the font size the leading could certainly be reduced, as could the margins slightly. That would make it a more compact volume, both in looks and physically.
I was also not struck on the cartoon-style illustrations. I didn’t find them illuminating (indeed at times downright confusing) and felt that maybe a few more, better, diagrams were needed for the target audience.
One thing which Lewis does however do well is to write a summary paragraph or two at the end of each chapter. Other authors please copy.
Is this a bad book? No, certainly not. It would likely work very well for an intelligent layman. It is merely that it didn’t work for me; but then it probably wasn’t intended to.
Overall Rating: ★★★☆☆

medical, uncategorized

Be Pushy, Get Drugs

So according to all yesterday’s media — see for example the Guardian and the BBC — we patients need to be much more pushy with our GPs to get the best drugs.

prescription

Prof. David Haslam, chairman of the National Institute of Health and Care Excellence (NICE) and himself a former GP, said that patients need to see themselves as “equal partners” with doctors to get the treatment they need.
He went on to say that patients should demand the drugs they need and only be refused NICE-approved drugs if they are actually unsuitable. He says, inter alia:

When products have been approved for use by the NHS by Nice, patients have a legal right to those drugs — as long as they are clinically appropriate. The take-up should be much higher than it currently is.
Patients have a right under the NHS constitution to these therapies, so I really hope we can improve this.
The fundamental point is, it’s your body.
And the more you understand about the drugs you are taking, or what you might be able to have, the better you are able to work with your doctor.

Several things strike me about this.
Firstly, I cannot disagree with Prof. Haslam’s sentiments. There are drugs which people aren’t getting, for all sorts of reasons including the so-called “postcode lottery” of care provision.
And I applaud his stance that we take responsibility for our bodies, understand them and how they work. This has to be good — as regular readers will know I am a vocal advocate of being comfortable with, and talking about your body, as a route to improved medical care.
But there are several things which worry me here.
We have to be realistic and accept that, sadly, many people are not able to understand even the rudiments of how human physiology works and how drugs work. Unfortunately these are mostly the very people who are going to latch onto some drug/treatment they think they should have and be abusive with their GP when they aren’t given it. Doctors are already under enough pressure, and get enough abuse from patients, that they don’t need more.
And then there are the people who really don’t want to think about these things and want to just trust their doctor to give them the best treatment. Not everyone, regardless of intellectual capability, wants to be engaged in the way Prof. Haslam would like. Yes there is still too much of the doctor as demigod who knows best, but there will always be those who treat any professional this way.
Finally I worry about who will pay for all this. I wouldn’t mind betting that many of the drugs we should be demanding are more expensive than the ones we are being prescribed now. So Prof. Haslam’s approach is going to see the NHS drugs bill increase, perhaps dramatically. You watch in a year or so the NHS will be squealing because the drugs budget is out of control.
But perhaps the biggest problem is how we patients actually find out about which drugs are best for us. I reckon I’m pretty good at ferreting out information and have research skills, but even I find it hard to sort the wheat from the chaff when it comes to drugs — especially when so much drug trial data has never been published.

medical

Oddity of the Week: Faecal Transplant

Faecal transplants (the transfer of beneficial bacteria from the colon of one person into the colon of another) are not an entirely new idea. Their first use in Western medicine dates to 1958, but they have been a part of Chinese medicine since the 4th century. Is there anything the Chinese didn’t invent?
Read more here >>>>

books, medical

Book Review

Dr Tony Bleetman
Confessions of an Air Ambulance Doctor
(Ebury Press, 2012)
I was given a paperback of this book as a Christmas present, which was good as it was one I wanted to read. And who wouldn’t when the blurb on the back cover says:

Drug addicts, lorry crashes, open heart surgery, stab wounds, headless chickens, mating llamas and strip routines — it’s all in a day’s work for emergency doctor Tony Bleetman and his team …
Confessions of an Air Ambulance Doctor is a dramatic behind-the-scenes account of life onboard an air ambulance. Whether they are landing in the middle of the M1 or at a maximum security jail, Tony and his crew Helimed 999 are first on the scene in the most critical of emergencies.
This gripping read will make you laugh, cry and marvel at the wonders of life (and death) in equal measure.

The book certainly lives up to its billing.
Bleetman starts off with stories of the initial days for setting up the first UK Helimed service outside London — that’s no ordinary Air Ambulance but one which carries a trauma doctor plus paramedic rather than two paramedics. Experience has shown that having a trauma doctor on-board does save lives, because they are able to do so much more to help really seriously ill patients than even paramedics can.
And that is hardly surprising when one reads of some of the major surgical interventions that were done on-site by the side of roads and in fields — and yes that does include things like open heart surgery! Which is really scary when one considers that one would not normally want to have this done even in the controlled environment of a hospital operating theatre with three or more surgeons and a full theatre team present. Whereas here this is all done by one trauma surgeon and a paramedic (albeit a super-trained one) in the field with no sterile environment.
Yes I was surprised, amazed and really impressed by some of the things they were doing out in the wild. But when Bleetman tells you about saving severely injured casualties, who would not otherwise have survived to be put in a land ambulance, let alone got to hospital, you have to be impressed and immensely grateful …
… And even more immensely grateful because all of this (with the exception of the paramedics who are paid by the local Ambulance Service) is funded by charity and by doctors giving up their free time for no reward except the satisfaction of helping people. Yes, that’s right, none of this, except the paramedics and, I assume, the drugs, is funded by the NHS! The helicopter, its fuel, the buildings required — ie. all the running costs and capital spend — is all down to big companies and people like us being generous. Which when you consider they would often fly up to six jobs a shift with fuel at £1000 a flying-hour; a helicopter costing millions; and that this is replicated across around two dozen services in the UK means a lot of cash has to be found.
But what about the book? As you might expect it is full of tales of derring-do — real Biggles flying ace stories with a lot of serious (and often bloody) medical stuff added on top. Medical teams are put in positions we have no right to expect them to go (upside down in filthy ditches full of petrol), and they’re almost constantly hampered by officious firemen, police and on-lookers whose objective is to get people out and get things moving and unable to see that doing so will kill the casualty. No wonder these people regularly get called “Muppets” (and that’s the polite version) to their faces.
If you can stomach the medical bit then this is a light but engaging read which I found it hard to put down.
Overall Rating: ★★★★☆

medical, personal

Thoughts on Depression

2 Comments

I’ve done quite a bit of thinking recently about depression. Partly my depression but also more generally. This all came about because a couple of weeks ago I had a fairly major down, which dropped me into both depression and panic and caused me to have to cancel a couple of important things I was supposed to be doing.
One of the things I came to realise is that there seem to be two types of depression. Or perhaps more accurately there are two types of depressive, which may reflect two types of depression as I think they may be able to co-exist. There are also essentially, it seems to me, to be two triggers for depression.
Let’s deal with the triggers first. I’ll call them “Despair” and “Overload”.
Despair
This is the classic “I feel useless and inadequate” scenario; “nobody loves me”, “I’m a mess”,” I’m useless”, “what’s the point of anything?”, “let’s end it all now”. We all get this sometimes and I’m not immune, but it generally isn’t the cause of my depression — more usually a result of me having royally cocked up something.
Overload
The alternative trigger, which is also fairly well accepted as a cause of depression, is excessive (for you) change and excessive load. Too many commitments; way far too much to do; bosses buggering everything around, etc. It’s the classic “I can’t cope with any more” scenario.


OK, so what are these types of depression/depressive?
I’ll call them “Do” and “Sit”.
Do
The standard self-help advice for depression seems to go along the lines of “get up, have a cold shower, put on some good brass band music and get on with life”. Which is fine if (a) you’re not too far in and (b) it works for you. It doesn’t work for me and never has. It broadly seems to fit with the Despair model.
Sit
To understand this let me give some background. Some years ago (like maybe 20 years) I read an article by a couple of medics in (I think) Glasgow who noticed that most people who were hospitalised with depression just wanted to sit in a corner and do nothing. This was contrary to the accepted treatment of giving them occupational therapy or psychotherapy (ie. a treatment of the Do type), which, guess what, for these people not only didn’t work but made them worse. The medics hypothesised that this was because the problem was that these people were reacting to an unreasonable (for them) level of change in their lives and that what they needed was stability. So forcing them to do things was just imposing more change, hence making them worse.
So they tested it by allowing a small number (six from memory) of people to sit in the corner as long as they wanted. And they found that they got better. As long as the occupational therapy was there, and the patient could see it was there, they would eventually come out and start joining in — but only after they’d sat in the corner stabilising for some while. Unfortunately I can’t now find the reference to this work and I don’t know if anyone has followed it up with a properly controlled study.
I realised quite a while ago that my depression was almost always of the Overload type and that making me do things didn’t work. The more I have to do, and the more things change under my feet, the more likely I am to drop into depression. So if I’m feeling fraught, I need less to do. I don’t need more to do. I am always loaded up as much as I can take (and more) so woe betide you if you insist I do more. Which is why people insisting I count calories, go to the gym, cut the grass, whatever, don’t get very far and don’t help me. This is why when I first started having hypnotherapy I told my hypnotherapist (a) I don’t count things, and (b) my obesity and my depression are inextricably linked. Nonetheless he had to learn both the hard way.
One of the other things I’ve noticed over the years is that sometimes, if I have a lot on and I’m feeling anxious, I’ll have a five minute panic. For instance, if I’m going out to yet another meeting I don’t want to, I’ll sit on the bed while getting dressed and panic; not cope; quietly go into meltdown. But after a few minutes I can come out (I usually have to as the clock is ticking on), put my shoes on and cope.
If I don’t come out I go into a proper panic attack and depression and then have to start bailing out of doing things, which is what happened a couple of weeks ago. It’s real “I can’t cope with this and this and this and that. What can I bin so I can recover?”.
Now I’m not pretending that Despair and Overload are black and white. Nor that Do and Sit are. Clearly there is a spectrum of greys here; a continuum. But I suspect that most depressives will be predominantly one way or the other. But it does seem to me that Do will tend to align with Despair, Sit with Overload. That looks logical.
I’m also not pretending any of this is necessarily new but it was an interesting voyage of discovery. I’d be very interested if any of this has actually ever been properly tested, in controlled studies.
And there remains too a necessity for appropriate drug treatment as this often provides some initial respite and a gateway to allow recovery to start.

medical, personal, ramblings

On Flu Jabs and Sleep

I love curiosities!
Early on Friday afternoon I had my annual flu jab. By the evening I was beginning to feel meh. Yesterday I was fit for nothing; not full flu but everything except the severe body aches and high temperature. So I spent the day curled up under the duvet, mostly asleep. Not nice, but better this than having full-blown flu.
I understand why this can be a side-effect of the flu jab: basically it is an immune reaction to the (dead) bits of virus in the inoculation which stimulate the immune system to produce antibodies that protect against the real virus. So it is working as designed.


But what I don’t understand is why this only happens to some people and why it doesn’t happen consistently every year. When I first started having the flu jab it would make me feel mucky for half a day or so — maybe less. But three years ago the vaccine contained bird flu (or was it swine flu?) and that knocked me out for well over a week! (Unless I did actually catch flu at the same time I had the jab — unlikely, methinks.) Last year the inoculation flattened me a for a couple of days. This year it has done much the same.
Yes, OK, it is my immune system working as designed. But is this “excessive” reaction a sign that I have a good strong immune system that gets to work quickly and well? Or is it a sign that I have a weakened immune system which is struggling to catch up? Dunno.
I find this whole reaction (side-effect) curious.
Anyway, as I said, I spent yesterday curled up under the duvet. The curiosity here is “curled up”.
Now I normally sleep flat out. Either on my back or (more usually) on my front; and I always have done ever since I can remember. And Noreen will tell you I’m normally spread-eagled across the bed.
But yesterday I was curled up in a foetal position on my left side. I only ever do this when I’m ill. (Occasionally if very depressed I will curl in a foetal position on my right side; but never on my left side.) I’m guessing this is an ancient animal instinct to protect ones soft parts when most vulnerable (asleep). I’d also guess that being on my left side is because I am right-handed — this position leaves my stronger right hand free to smack any predator in the jaw. Maybe?
So just another curiosity.
I love curiosities!

current affairs, medical

In which I Wonder about Local Politicians

North-West London NHS last year consulted on proposals to rationalise the delivery of A&E services in the hospitals in its area. One element of this is the closure of A&E at Ealing Hospital, close to where I live. This is unlikely to happen for at least three and probably five years.


Needless to say the majority of the local community are up in arms, assisted by some very cynical sound-bites from local politicians and campaigners who see this as a threat to the very existence of the hospital (which according to the consultation it isn’t). Indeed the local council have taken the whole matter to the courts and failed to get a judicial review of the consultation process. Currently a final decision is awaited from the Secretary of State for Health, Jeremy Hunt; this is expected within days.
Following the refusal of the judicial review there was, last weekend, a rally to continue the voicing of protest. According to the reports this attracted a paltry 100 people — clearly the local rent-a-mob don’t like going out in the rain! At the rally Ealing Council Leader, Julian Bell, vowed to fight on and “chain ourselves to the gates before they roll the bulldozers in”.
Whether you agree with the proposals or not, this is just so pathetic. Not only does this portray Cllr Bell as a bad loser, has he actually thought this thing through?
By the time any bulldozers move in (and they should as the current hospital building is hardly fit for purpose) the proposals to which objections are being raised will have been implemented and the hospital will still be operational. According to, and as I understand, the plans the bulldozers would be clearing only a part of the present Ealing Hospital site to enable the building of a new, modern healthcare facility alongside the existing hospital. Only once the new facility takes over could the present building be closed.
So all Cllr Bell seems to be doing is delaying the implementation of improved healthcare for his constituents.
Is Cllr Bell really this stupid? Or is it me that’s missing something?

medical, personal

Aren't You Dead Yet?

Yes, that is a serious question!
Average life expectancy has roughly doubled in the last 150 years. Whereas life expectancy at birth 150 years ago was around 35-40 years it is now around 80 years. (See Why are you not dead yet? which is an interesting read.) Well OK they’re figures for the US, but the UK and rest of the developed world isn’t much different. According to Wikipedia medieval life expectancy in the UK was 30 years, and was still only 31 years in the early 20th century. Indeed (according to World Bank data, via Google Public Data) UK life expectancy has risen 10 years in the last 50!


Forget airplanes, cars, nuclear weapons and the internet. This increase in life expectancy is probably the most important difference between our modern world and life 150 years ago.
Before the advent of modern medicine — and a lot of that has happened since World War 2 — infant and child mortality was incredibly high. And many of those who survived into adulthood were killed by accidents or disease which would be easily vanquished today. Just as an example, one of Noreen’s relatives about 100 years ago died in his mid-30s of erysipelas (St Anthony’s Fire), a bacterial skin infection which today would be quickly cured by antibiotics.
Remember that just because your direct ancestors lived into their 50s, 60s or even 80s, there were many children who died before puberty and hence are no-one’s direct ancestors. In the 19th century families of 10 or 12 children, with only one or two reaching adulthood, are not uncommon. And it was a lucky family which didn’t lose a single child even well into the 20th century.
In fact there is a good chance that you — yes, you reading this! — are already on your second or third life. And that is almost certainly down to either modern medicine or modern safety (think things like seat belts and air-bags).
In my late 20s I had appendicitis. It grumbled for a year or more until the medics decided what it was and removed the offending organ before it blew up. Without that medical intervention I would likely have died of peritonitis within a year or two. Noreen has similar stories — blood poisoning from an infected toe injury; a shattered left elbow (which would have been at least disabling). And we have both been extremely lucky with our health!
We all forget how common such diseases and injuries are and how much we have come to take for granted that they can be fixed. We also forget all those illnesses (smallpox, polio, whooping cough (aka. pertussis), measles) which we never or seldom see because of vaccination.
So tell me, please, why are you not dead yet? Without modern medicine what would have killed you? I’m curious to know.