Jess’s Rule: When “three strikes” means rethink, not repeat
Jess’s Rule is a new primary care initiative, led by the Department of Health and Social Care (DHSC) and NHS England, with the support of the Royal College of General Practitioners (RCGP). Its aim is simple but powerful: to encourage GP teams to reflect, review, and rethink a diagnosis when a patient presents with the same symptoms or concerns three times — especially when those symptoms persist, escalate, or remain unexplained.
Why Jess’s Rule matters
Repeated visits for the same problem are often a sign that something important has been missed. Jess’s Rule reframes a pattern that many clinicians observe: the patient who keeps returning. Instead of assuming the earlier explanations remain correct, the guidance advises practices to treat a third presentation as a trigger for deeper consideration — to check whether tests need to be repeated, whether referral is warranted, whether safety-netting advice was clear, or whether a different differential diagnosis should be explored.
Jess’s story
Jessica (Jess) Brady was 27 when she died of cancer in December 2020. In the five months before her death, she had 20 consultations with her GP practice, yet her cancer was not diagnosed until she was admitted to hospital with stage 4 adenocarcinoma. Her tragic case galvanised her family to campaign for a simple change in how primary care responds to repeated presentations. The result is Jess’s Rule: a humane, patient-focused prompt to ensure that persistent concerns are escalated and reviewed before it’s too late.
How the Rule works in practice
– Trigger at three consultations: When a patient has attended three times about the same symptom or concern, the practice is prompted to undertake a structured review.
– Reflect: Review past consultations and consider whether earlier assessments, safety-netting or investigations remain adequate.
– Review: Re-examine the history, examination findings and any test results; consider whether further investigation, referral or follow-up is needed.
– Rethink: Consider alternative diagnoses, comorbidities, social factors or atypical presentations that might have been overlooked.
Benefits for patients and clinicians
– Earlier detection: Prompt reappraisal increases the chance of timely diagnosis for severe but initially subtle conditions.
– Safer care: Systematic review reduces the risk of diagnostic delay and its consequences.
– Shared decision-making: A clear, repeat-presentation policy supports conversations with patients about next steps and expected timelines.
– Clinician support: The Rule provides an evidence-informed prompt that can reduce cognitive bias and help clinicians justify further action.
Practical steps for GP practices
– Implement a simple flag or workflow in the patient record system to identify third presentations.
– Train staff (reception, triage, clinicians) to recognise and record repeat presentations and to follow local review procedures.
– Strengthen safety-netting: give clear advice on when patients should return and what changes should prompt urgent review.
– Audit and learn: monitor cases where the Rule was triggered to identify system improvements and training needs.
Limitations and considerations
Jess’s Rule is not a rigid protocol. Clinical judgement remains essential: not every repeat contact will indicate a missed serious diagnosis. The Rule is a prompt to consider escalation and review, not an automatic requirement for invasive testing or immediate referral. It should be used in conjunction with effective communication, shared decision-making, and tailored clinical assessment.
If one can’t get an appointment with their NHS GP, it is always better to book a private GP appointment or arrange for some basic blood tests to be done privately.
Conclusion
Jess’s Rule is a compassionate, pragmatic nudge to primary care: take repeated concern seriously. By prompting clinicians to reflect, review, and rethink their approach on a third presentation, the initiative aims to reduce diagnostic delays and improve outcomes — honouring Jess Brady’s legacy by helping others receive timely, attentive care.
