A Tale of Life, Death and Healthcare in the Information Age

A crunch of bicycle tyres on gravel announced the arrival of Dr Lawrence Ho, health counsellor. He held up his NHS smartcard at the automatic security barrier, smiled inanely in the guessed direction of a concealed camera and the gate opened immediately.

That could be a good sign ­ the security system had matched up the data scanned from his card with his photograph stored digitally in the register of NHS practitioners, and had approved him as an authorised visitor.

Or it could mean that someone had hacked the system to allow anyone in, which would mean some very unauthorised visitors could be in the vicinity. That was more likely, in this part of town. He walked into the courtyard cautiously, wheeling his bike before him, one hand on the saddle, as an obstacle to potential attackers.

But the gate closed promptly behind him, another good sign, and the courtyard of the 1990s Telecare development looked free of graffiti and excrement. It was even dotted with expensive-looking potted shrubs. An excellent sign.

From force of habit, however, Dr Ho selected a stout handrail on which to chain up his bike and, after removing his bulky practice bag from the carrier, carefully activated an electric-shock protector.

He fished an old-fashioned palmtop computer from his bag and scrolled through to find the right case notes.

­ Barbara Henderson, born 1924, living alone in a Telecare apartment. She had been a widow since 1944. The case-notes referred to a son, George, born in 1945, but identified a grand-daughter, Bonneville, as next of kin.

­ Wonder if that's the famous Bonnie Henderson?

The notes confirmed that Dr Ho's patient was ambulatory, able to feed, wash and clothe herself, but with deteriorating eyesight. Mrs Henderson's regular health counsellor, a district nurse, had recommended referral for cataract removal.

Dr Ho had volunteered to sort out the formalities with a housecall. While his liking for housecalls marked him out as a serious eccentric among some of his colleagues, he like to think of himself as a little old-fashioned. And getting out and about gave him a breathing space from the seemingly endless conveyor belt of patients suffering predominantly from poverty and old age.

As a qualified physician, Dr Ho was unusual in a profession largely made up from nurses, physiotherapists and even "complementary practitioners". And although he sometimes disparaged his qualification in front of patients ­ "I was the last of the sawbones"­ his non-MD colleagues were in little doubt that he considered himself a cut above anyone who had escaped the full rigours of medical school and life as a houseman in the old NHS.

Anyone complaining about long working hours at Elephant Health Farm, an optimistically named primary care development on the site of an old traffic roundabout in south London, got very short shrift when reminded of life in the 1990s.

Of course Dr Ho could earn a much higher salary practising as a consultant with the National Hospital Service, especially in a tele-practice, than doing the rounds of community healthcare. But he would miss the contact with real people. Deep down, however, Dr Ho knew that, thanks to electronic decision-support, a patient would get much the same treatment whatever the formal qualifications of the health counsellor. The difference, Dr Ho maintained, was that he could cope when the decision-support machine went wrong.

He pushed the doorbell of flat four and waited. Moira, the district nurse, should have warned her client that he was on his way, but old ladies sometimes forgot...

The door flew open.

­ You're late. The nurse said you'd be here at three.

Sometimes, Dr Ho yearned for the old days, when patients were glad to get any sort of service at all. Nowadays, they were getting used to precise appointment times.

The flat was in good shape inside as well as out; it felt warm (too warm for a man who had just got off a bicycle, but he approved of that. In 2010 people still died from circulatory disease brought on by insufficient heating, and even from outright hypothermia) and with only the slightest smell of incontinence.

Around the walls, his practiced eye detected electronic sensors disguised as plaster ornaments. Flying ducks weren't exactly to his taste, but they seemed to be working fine.

The idea of Telecare was to monitor the lifestyles of vulnerable people without making it too obvious. This was a fairly basic set-up, by modern standards. Simple sensors monitored room temperature, the use of domestic appliances and the toilet, together with comings and goings around the flat. Somewhere, a computer assembled from them a profile of normal life. Any significant deviation ­ if the resident failed to get out of bed, for example ­ automatically alerted staff at the primary care centre, who could either check up by video or make a personal call.

Under the flying ducks, photographs lined up on Barbara's mantlepiece told a life story: a faded black and white portrait of a grinning young man, sailor's hat at a jaunty angle on his head. Next, in colour, a 1970s wedding party, with baggy trousers, long hair and cigarettes. A stylish young ­ or perhaps not so young ­ woman with two small children, very twenty-first century style. That, of course, was Bonnie.

To read Barbara's clinical record, more securely protected than her administrative details, Dr Ho inserted his smart-card into his computer and typed in two passwords, one his own, the other a PIN number issued that day by the National Register of Health Counsellors which proved his registration was still live. He fumbled for the right scrap of paper. In theory, he could be struck off for writing down the PIN, but it was humanly impossible to remember a new one each day.

Last year, the health centre had announced plans to issue counsellors and other employees with up-to-date information devices which would recognise their users by palm-print.

Like many other capital projects, however, the contract was caught in the budget crisis caused by the big freeze of '07 and the procurement suspended. A false economy, Dr Ho suspected. If the old information system were to fail, it could end up costing the health centre a lot more money in the long run.

Dr Ho skipped impatiently through screens of cartoon graphics designed to help less qualified helpers in emergencies. While he waited for the right information to come up, he launched automatically into his bedside manner.

­ And how are we today?

­ It's a long time since anyone asked me that. All the attention I get nowadays is from that woman on the video screen. Despite half a century in the south, there was still a touch of Geordie in Barbara's voice.

­ Well I'm glad you can see the screen. I hear your eyes aren't quite what they used to be.

­ If you want to talk about cataracts, say so. We had proper schooling, in my day, and I'm not afraid of long words.

She leaned forward and peered quizzically at his face.

­ Thought you'd be an Indian, but you don't look like one. Japanese, are you?

­ Quite close. Hong Kong, actually. Now, you can see me through your right eye, but what about the left?

The doorbell rang.

­ Get it, will you? It's probably the security man.

But it was a familiar-looking woman wearing a raincoat and an annoyed expression.

­ Who the hell are you?

­ It's OK, I'm the doctor, Lawrence Ho. Mrs Henderson asked me to let you in. You must be Bonnie.

­ Never you mind. Barbara, are you in there?

­ It's all right dearie, he says he's not a Jap.

Bonnie caught Lawrence's eye and they both grinned, for an instant. Then her expression changed.

­ It's a good job you're here. I?ve got some awful news to tell her. Could you wait in the kitchen?

An hour later, over a pot of tea, they talked.

­ She's away on her nap, but there's not much else I can do. Will she take it badly?

­ Course she will. She's had more than her fair share of tragedy. Maybe this one'll finish her.

­ Her husband ­ your grandad ­ has he been dead long?

­ Even my dad never knew him. Merchant navy in the war, torpedoed in the Atlantic while Nan was expecting. He was a stoker, working below the waterline. They told Nan he died instantly, but I don't think she ever believed them. He was a wild one, apparently, just like my dad.

­ I should've talked to her about it. My old man's dad was in the Navy in that war, but he came through without a scratch, if you don't count addiction to treacle duff.

­ Can't have been that many Chinese sailors, or did they just get left out of the history books?

­ Probably they were. But my grandad was a pretty lowly type. He was the ship's laundryman.

­ You're kidding.

­ Never heard of Chinese laundry? That's how it started. British warships used to pick up a laundryman in Hong Kong and take him everywhere as a sort of subcontractor to do the officers? mess-jackets and the like. It went on for generations, quite a good job really. I'd have been one myself if my old man hadn't married into business and made a pile back in the eighties.

­ And here you are pedalling around South London trying to keep senile old biddies in this world for a few more days.

­ What else do you want from a doctor? Any time someone like you feels off-colour, you can check your symptoms on a computer, look it up in the colour video encyclopaedia, and order all the drugs you need ­ or don't need.
The only thing left for people like me is either to be a hospital consultant, in front of a video screen all day, or to get on my bike and sort out people who can't afford TopHealth subscriptions and help them out with a bit of bedside manner. My mum thinks I should be in a disease palace. Me, I suppose I like getting out and about. Hell, that's my phone; I'm only allowed to divert calls for an hour a time. You'll be keeping an eye on your gran, will you?

­ Of course. I'll kip down here overnight if I can find a way to turn down the heating.

­ Not my department, I'm afraid. Sorry, got to run. See you again, Ms Henderson.

­ Thanks, Dr Ho.