Public health communicators should stop telling people to rely on their instincts

The current Streptococcus A outbreak is causing much concern in the UK. The tragic death of 16 children has made the headlines, and health services are struggling to cope with a surge of anxious children and their parents.12 In the meanwhile, the UK Health Security Agency (UKHSA) has disseminated public health advice through outlets, including schools, to raise awareness among parents about the actions to take if a child is symptomatic.

UKHSA’s advice contains much sensible, factual information. But one element sits at odds with this. The guidance says: “Parents know when their child is not themselves, so if you think your child is poorly and getting worse, trust your instincts and contact NHS 111 or your GP.”3

There are two assumptions here. Neither is necessarily correct. Firstly, do parents always know when their child is “not themselves?” We know that appraising your own symptoms is challenging. This partly explains why so many people with covid-19 failed to self-isolate during 2020/21—they did not appreciate that their symptoms were linked to covid-19.4 But this becomes even more difficult when you are trying to understand the symptoms of someone else, particularly when this is a young child.5

Second is the assumption that parents will understand how to “trust their instincts.” What does this phrase mean? Does it imply that parents should seek care if they are worried? It seems to. But how does a parent know when, how much, and why they should be worried about an illness which they have no prior experience of? In a survey of 4184 adults in Great Britain, only 4% reported they were “very confident” that they could even identify the symptoms of Strep A, with a further 28% being “somewhat confident.”6 Parents are not health experts and rightly expect the health services to help them understand whether their child’s symptoms are a cause for concern. Anecdotally, several parents we have spoken to have asked us the same question that many GPs will be familiar with—“should I be worried?”

The current Strep A outbreak may be new, but this advice feels familiar. The 2022 outbreak of childhood hepatitis led to similarly confusing advice to parents to “trust your instincts.”7 During the swine flu outbreak, the public were advised to seek help from health services if, having checked their symptoms online, they were “still concerned.”8 Perhaps predictably, such vague advice often results in a surge of patients seeking care. But when senior health officials advise that concern about symptoms justifies help seeking, it is also often accompanied by further messages that convey at best ambivalence, or even contradict the first message. So, when during the early stages of the swine flu pandemic, England’s chief medical officer reported that “there was now ‘exceptional influenza activity’ across most of the country, he also added that ‘Some of these will have the worried well among them.’”9 This past week, the news for Strep A is much the same, with one report describing the “weekend of the worried well.”10 It is clear that this is seen as an undesirable outcome. Yet while there is little doubt that the increases in attendances are adding to the pressure on over stretched services, describing demand as being driven by the “worried well” is pejorative and unhelpful.11 How can we issue advice to people to seek help if worried, or when their “instincts” tell them to, but then issue messages of concern when this is exactly what people do?

Less obvious, but more troubling, is the opposite problem—when people respond to messages by not seeking care when they should. Many patients and/or parents take a generally conservative approach to seeking care. We should be thankful that most parents are unwilling to consult for every cough, cold, or mild temperature. This is particularly the case where pressure on healthcare resources is widely discussed—not wanting to be seen as “a timewaster” is a well known barrier to help seeking at the best of times.12 In a situation where public health officials need to promote help seeking for serious illness, vague advice to trust your instincts is unlikely to help when the underlying instinct is that one should try not to “bother the doctor.”

So where does this leave us? Our best guidance is that, wherever possible, advice about when to seek help during a suddenly occurring major incident should be based on objective indicators: a temperature of a certain level, presence at a certain place at a certain time, a rash, or whatever indicators suit the incident.13 This is often not easy, we know. But, asking anxious patients to use their own emotional state or instincts as a guide as to whether to seek care, is at best unhelpful and at worst dangerous.