Afew years ago, I was in my early 30s, trying to get pregnant for the first time. Every morning I’d take the bus to work and sit, waiting, at the stop just outside my flat, next to a glowing ad for at-home fertility testing.
I started seeing these ads everywhere: ads that weren’t just for women or about making babies. From genetic cancer screening advertised on trains, to an array of tests available to buy from your local Boots, it seemed suddenly possible to identify allergies and intolerances, assess the health of your bowel or pinpoint vitamin deficiencies from the safety and comfort of your own home. The taglines for these tests ranged from “Your hormones, your way” to “Blood testing made easy” and “Knowledge is power”.
I was precisely their target audience – and I was tempted. Trying for a baby is stepping into a great unknown and once you tick past 30 the public health and popular noise around conception changes from trying your best to avoid pregnancy to worrying you won’t be able to conceive at all. I also have a history of mild to moderate health anxiety, hovering on the edge of hypochondriasis. But I was sceptical that these tests might just cast the illusion of greater control, bodily autonomy and perfect accuracy; all while they flood in to fill the gaps left by the NHS, particularly in the pandemic’s uncertain aftermath.
For Dr Annette Plüddemann, a senior researcher in the Centre for Evidence-Based Medicine at the University of Oxford, this recent boom in easily accessible and personalised medical care was driven by the pandemic. As people slowly stopped stockpiling Covid-19 tests, companies that once produced or distributed lateral flows had to diversify. In 2021, the company Newfoundland was set up. Partnering Acon, it become the UK distributor of the Flowflex rapid antigen test for Covid-19. It now also produces over-the-counter tests for bowel health, male fertility, vitamin D and influenza. If you can test for Covid, why not cholesterol?
Back in 2021, Niki Woods was experiencing extreme fatigue. She’d been to her GP repeatedly seeking an explanation and a solution. From her own research, she thought that perhaps her exhaustion was down to low testosterone levels, but her doctors were sluggish, sceptical and reluctant to do the tests she wanted. And so she took matters into her own hands, buying a test that she could administer herself at home. The process was efficient and professional and the results were clear. As she had expected, her testosterone levels were exceedingly low. She returned to her GP, armed this time with evidence. The doctor referred her to the necessary specialist, who repeated the test and prescribed the required drugs.
Ever since having her Mirena coil removed four years ago, Rita Conry has had spotting in between her periods. She’s spoken to endless doctors and nurses about it and had a few scans to check nothing sinister was going on. They managed to rule out anything serious, but still no one could offer an explanation. She thought maybe the coil had upset her hormones in some way and she at least wanted it investigated. After much frustration, a sympathetic friend bought her an at-home hormone test to measure her levels of oestrogen and progesterone.
Using a pin prick, Conry had to collect a small vial of blood and send it off to the company for testing. The results came back showing there was nothing wrong with her oestrogen or progesterone. While the spotting remains a mystery, the test had still served a useful purpose. Conry has a chronic illness and a long history of having her experiences disregarded by medical professionals. “As somebody who’s had lots of issues that have been dismissed, it feels like these tests are things that can bring you a lot of comfort.” She found the experience reassuring in a way her GP had never been.
Both women had slipped through the cracks of the NHS, deepened by decades of underfunding and cleaved by a system ridden with inequalities and power imbalances. At-home tests seemed to offer them an alternative. For Woods, a diagnosis and effective treatment; for Conry, something else ruled out and, more importantly, a service that took her seriously.
Conry’s “whole experience” was, she said, “amazing. You know, it’s all very techie, a really slick interface, all your results are clear to see.” This side of at-home tests is really appealing: well-designed packaging, bold graphics, well-designed software. But Plüddemann’s key concern about these tests is the science behind the scenes, their accuracy and regulation. “We should ask ourselves whether they are fit for purpose.” While the manufacturers have to ensure the tests work in the controlled environment of the laboratory, “regulators don’t require them to do a study in real-world settings”. In other words, when people actually use these tests on their own bodies, with all their various idiosyncrasies, unpredictable home environments and other illnesses, we don’t know how well they work.
Tech companies have already extended their tendrils into all aspects of our private, intimate lives and more and more people use technology to assess and analyse their own bodies. With watches and rings we track our heart rates, measure our steps and count our hours of sleep. Sociologists call this cultural phenomenon the emergence of the “quantified self”, a way of using technology and data to improve physical, mental, and emotional health. But while things like Apple watches and Fitbits have been around for more than a decade, this “explosion of tests”, as Plüddemann puts it, is “unprecedented”. We are now sick until proven healthy, our bodies under constant, fretful watch. More and more technology of self-surveillance is now at our disposal, but at what cost?
Unlike at-home tests, new drugs need to be trialled both in controlled, laboratory environments and out in the wild. This is because, according to Plüddemann, we are accustomed to thinking about clinical interventions – like medication – in terms of benefits and harms. But the idea that tests themselves might be risky is less widely discussed: “There’s no harm in taking a test, people think.” But while potential harms might not be as catastrophic as those from an untested pill, Plüddemann cautions that inaccurate results can do their own damage. False negatives might lull people into a false sense of security, false positives elevate health anxiety unnecessarily. “Test results have psychological impacts, too,” she says.
Even if you put aside any worries about accuracy, if you are anxious about your own health, with good reason or for no reason at all, these tests can only ever offer a brief snapshot of good news – you didn’t have that one thing, at that one time. There are always more tests to do, more things to rule out, and while modern medicine offers the illusion of certainty, even at its best it must accommodate shades of grey: results that sit on the margins, lumps and bumps that might turn malignant.
The proliferation of at-home tests is frequently touted as a solution to some of the health service’s ills. Newfoundland suggests that its products could reduce the pressure on the NHS “at a critical time” and cites a 2023 poll that showed almost a quarter of patients went to A&E because they were unable to get a GP appointment.
But for Professor Julia Newton, an NHS consultant and medical director for Health Innovation North East and North Cumbria, the companies who sell these at-home tests in pharmacies and supermarkets overpromise: “They’re not the future. Buying over the counter is not going to solve the massive problems that we have in this country.” This is partly because, as Plüddemann points out, the availability of these tests can in fact increase the number of people seeking their doctor’s help. They follow the packets’ instructions, making appointments to help them handle troubling or unsatisfying results.
“I think they serve the worried well, rather than the disadvantaged,” Newton says. “The cost of some of these tests would put off people from disadvantaged communities.” To be able to make use of these tests you also need to have a certain degree of knowledge about what might be causing the symptoms you’re experiencing. “People don’t understand why they need a test, so there’s a huge gap of knowledge and awareness that needs to be filled if people are going to be motivated to buy a test.” This was certainly the case for Woods, a menopause and wellbeing expert, coach and author, who due to her line of work was able to make a well-informed guess about what exactly might be the matter.
But there is a place for at-home tests. The opportunities they offer – to democratise healthcare, make it more accessible and affordable – are tantalising. And the NHS already makes use of at-home tests, but ones they provide, administer and analyse. The UK bowel cancer screening programme sends out home test kits to everyone over 50. Between 2021 and 2022, 68.9% of people returned their tests. The programme diagnosed 6,500 people with cancer and placed a further 12,034 people under surveillance. The NHS has also just started offering “do-it-yourself” HPV tests which allow people to participate in cervical screening from the comfort of their own homes and could boost the numbers screened in England by about 400,000 each year.
Some of the at-home tests the NHS delivers are made by private companies. PocDoc was co-founded by Steve Roest, Dr Vladimir Gubala and Dr Kiran Roest, after Steve’s father experienced a catastrophic stroke when Steve was just a teen. Among other things, PocDoc provides “healthy heart checks”, which allow people to test their own cholesterol and receive the results within minutes. The process and technology was co-designed with the NHS and the service is integrated into primary care. Without these tests, the process of identifying and treating high cholesterol requires multiple in-person appointments and referrals. With an at-home “healthy heart check”, you take your own blood and get the results within seven minutes.
While this is easy and convenient, it also allows people in what Newton calls “historically harder-to-reach communities” to access potentially life-saving tests and treatment; people who the NHS have struggled to engage via conventional methods. We know the NHS is alienating for some people and we know that access isn’t equal, even though it’s free. Life expectancy varies by almost a decade across England, with people in more deprived areas twice as likely to wait a year for treatment than those in more affluent places, and as of 2020, two-thirds of black Britons believe the NHS gives white people better care. At-home tests offer one way to bridge these deep chasms in our welfare state.
As Steve Roest points out, cardiovascular health is a major and under-addressed public health problem. Anyone who has ever had a heart attack or stroke is supposed to be on a register and have an annual appointment to check their blood pressure and cholesterol levels. But on average, and according to Newton, only about 40% of people end up having that appointment. This leaves out a huge number of people who are at risk of future heart attacks and strokes. At-home tests, such as those provided by companies like PocDoc, allow the healthcare system to meet people where they are, whether that’s at home, in mobile clinics, at their mosque, church or community centre. Over the past year, PocDoc and the NHS have distributed over 6,000 tests and while the digital interface might be inaccessible to some, it’s easy and relatively cheap to train someone to guide people through the app or input data on their behalf.
These collaborations between the NHS and for-profit companies like PocDoc are not unproblematic. Over the last 40 years, the health service has increasingly outsourced healthcare provision to the private sector. Various UK governments have justified this expansion by saying it will improve care. However, there is as yet no good evidence to prove that the general trend of increased privatisation equates to better-quality services or a healthier population.
Whatever you think of privatisation, it is almost impossible to disentangle the boom in at-home testing – whether integrated into the health service or sold at supermarkets or pharmacies – from NHS scarcity. In a world of vast and expanding referral waiting times and overstretched GPs, is it any wonder people are looking elsewhere for their healthcare or that companies have occupied abandoned NHS territory? Criticise privatisation all you want, but in the current landscape, if these companies don’t deliver these services, they may sometimes not be delivered at all – and some of these at-home tests at least seem to be doing genuine good for society’s most marginalised people.
There is something else at stake. The rise of the at-home test suggests the border between what we do for ourselves and what medicine does for us is shifting. For some people – such as the worried, wealthy well – the renegotiation of that boundary and the expansion of over-the-counter tests could leave them healthier, happier, more empowered, able to circumvent the delays of the public sector, and take matters of their body and mind into their own hands. But for others, the future looks a little more troubled. Baked into this boom, and even into the state’s own use of at-home tests, is the tacit admission that the NHS as it stands does not serve some people. For those alienated by the health service – those harmed by its inequalities – the solution these tests offer does not improve the dignity, quality, or accessibility of primary care itself. It does not make GP practices and their staff more welcoming places – it outsources the issue. Medicine has its problems, so here, do it yourself.
