Self-care--has DIY gone too far?

Self-care, ‘the care taken by individuals towards their own health and wellbeing’, has always been commonplace. People have always made decisions about whether to attempt to manage their own symptoms, seek advice from lay networks, or go to a professional, be that a ‘bloodletter’, apothecary or herbalist. And self-care has continued to be a usual first step since the emergence of modern health care: for example, parents use thermometers to decide if their child needs a day off school, women use home tests for pregnancy, and Porteous et al report in this issue that members of the public prefer self-care to manage symptoms of minor illness. All these activities seem appropriate: patients and clinicians would probably agree that it is not desirable for waiting rooms to be filled with people requiring paracetamol or a sticking plaster. More recently, healthcare providers have actively aimed to promote greater reliance on self-care by providing information and support for health problems. In the UK, this has been through NHS Direct, an increased emphasis on supporting self-care during professional training, and the development of the Expert Patient Programme. There are many drivers for this: an increase in the number of demanding patients has been reported; communication, partnership and health promotion are preferred by members of the public; and advances in technology have enabled the development of quicker, more portable devices and tests that are suitable for home use. Furthermore, increased public engagement, improved life expectancy and technological advances are all likely to impact on the costs of providing comprehensive health services, leading to a need to explore innovative methods of care that could lead to cost savings. Activities that come under the heading of self-care have expanded to encompass a wide range of preventive, diagnostic and treatment activities, from smoking cessation, through pharmacists checking blood pressure, to self-monitoring and selfmanagement programmes. Alongside this, the role of primary care professionals in helping people to know when and how to look after their own health has grown, for example educating and assisting people to self-monitor chronic diseases, such as self-monitoring of peak expiratory flow rate or symptoms by people with asthma. A more recent development is that many, potentially sophisticated, self-care activities can now be initiated by the individual without input or assistance from a health professional. A consequence, or perhaps the cause, of this is that many diagnostic self-tests are being marketed to members of the public. Self-tests for more than 20 different conditions can be bought in pharmacies or over the internet, including tests related to cancers (for example, tests for faecal occult blood and prostate specific antigen), chronic conditions (for example, tests related to diabetes and cardiovascular disease), and infections (for example, tests for urinary and sexually transmitted infections). Some self-tests provide almost immediate results, or the sample is sent to a laboratory and results are returned within days. People who buy self-tests do not need to discuss when they have the test, why they have decided to have the test, or the results of the test with anyone. There are likely to be many benefits in the public becoming more involved in their own care. Self-management programmes for diabetes and hypertension appear to lead to clinically important improvements, and convenience and anonymity is guaranteed for diagnostic tests carried out at home. Self-care has also been described as having the potential to reduce demand on primary and secondary care, with associated resource savings. Nevertheless, self-care encompasses a group of very diverse activities and postulated or proven benefits for one activity, disease area or group of people, may not be generalisable to another activity, disease area or population. Inevitably, most evaluations concentrate on self-care activities that take place with professional knowledge, input and supervision. There is a paucity of evidence relating to the level of use, or the perceived and actual harms and benefits, of activities initiated and used by the public without professional input, such as the use of diagnostic self-tests. Before national screening programmes are introduced, potential harms (for example, false-positive results and consequent false anxiety) are weighed against potential benefits (for example, reduction in morbidity). For individuals using self-tests, there will have been no independent assessment of the whole clinical picture and whether a test is appropriate, and it is possible that the harms may outweigh the benefits. For example, there is an increased likelihood of false-positive results among people at low risk of the condition being tested. People with the greatest healthcare needs, most obviously the elderly or deprived, are less likely to have access to the internet, but the widespread internet advertising of self-tests may mean that people who need the test least are most likely to purchase it, for example young men purchasing prostate specific antigen tests. It is not only false-positive and falsenegative results that may have adverse outcomes: people who get a true positive self-test result could think that they have a disease inappropriately because the whole clinical picture has not been considered, or those with a true negative self-test result may delay consulting when their symptoms are actually due to another condition. Such potential harms highlight the need for clear and adequate information accompanying self-tests. When testing is done in a conventional medical setting, the health professional assists the individual to consider how potential harms and benefits of a test apply to them, to decide whether a test is relevant and appropriate, to interpret the result in the context of the whole clinical picture, and to then decide upon the next steps. People who perform diagnostic