GPs encouraged to take ‘three strikes and rethink approach’ as part of Jess’s rule
GPs across England are being asked to ‘think again’ if after three appointments they have been unable to offer a ‘substantial diagnosis’ or if a patient’s symptoms have escalated, under a new Government initiative.
The Department of Health and Social Care said that Jess’s rule, designed in collaboration with the RCGP and NHS England, will ‘help to catch serious conditions earlier’ and ‘support GPs with guidelines that bolster their clinical judgment’.
The initiative encourages GPs to take a ‘three strikes and rethink approach’ after three appointments, as well as reviewing patient records ‘comprehensively’, seeking second opinions from colleagues and considering specialist referrals ‘when appropriate’.
It acknowledged that many GP practices already use similar approaches ‘in complex cases’, but Jess’s Rule aims to make this standard practice across the country, to reduce health inequalities.
The rule is named after Jessica Brady, who was 27 when she died from metastatic adenocarcinoma in 2020, having been ill for six months.
She suffered from symptoms – including a nasal drip and persistent cough – but had been unable to have physical consultations because this was in 2020, and doctors had said she was likely suffering from Long Covid.
In the five months leading up to her death, Jessica had more than twenty appointments with her GP practice but eventually had to seek private healthcare. She was later diagnosed with stage four adenocarcinoma and was admitted into hospital where she died three weeks later. Her parents have since been petitioning for Jess’s rule to be implemented.
The RCGP has developed an eLearning resource with the Jessica Brady CEDAR Trust which was published at the beginning of the year, although it will now be updated to reflect Jess’s Rule is now national policy.
DHSC has clarified that the initiative is a ‘rule’ and not ‘law’, so it will not be followed by legislation.
RCGP chair Professor Kamila Hawthorne said that if a patient repeatedly presents with the same or similar symptoms, but the treatment plan does not seem to be making them better – or their condition is deteriorating – it is ‘best practice’ to review the diagnosis and consider alternative approaches.
She said: ‘We hope that by formalising this with Jess’s Rule, it will remind GPs to keep this at the forefront of their minds.
‘The college has also worked with Jess Brady’s family and the Jessica Brady CEDAR Trust to develop an educational resource for GPs on the early diagnosis of cancer in young adults, based around the principles of Jess’s Rule.’
Jess’s mum Andrea Brady said: ‘Jess lived for just three short weeks following her terminal cancer diagnosis. Despite her shock and devastation, she showed unfailing courage, positivity, dignity, and love.
‘Jess was determined that people should understand how desperately she had tried to advocate for herself and seek a resolution for her declining health.
‘In the bleak weeks following the loss of Jess, I realised it was my duty to continue what she had started. It has taken nearly five years to bring about Jess’s Rule. I would like to dedicate this initiative to all the young people who have been diagnosed too late.
‘It has only been made possible because of the people who have listened — politicians, medics, and the nearly half a million who supported the campaign.’
Earlier this year, NHS England had spoken out in support of the rule.
NHS England national medical director Dr Claire Fuller said: ‘I am very humbled by the efforts of Andrea and Simon Brady, who have campaigned for this important initiative which will undoubtedly save lives by avoiding missed or delayed diagnoses and ensuring patients receive the right treatment at the right time.
‘Many clinicians already apply a version of “three strikes and rethink” in their routine practice, but Jess’s Rule formalises this instinctive approach, providing a consistent structure to support reflection and timely action for patients.’
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READERS' COMMENTS [14]
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This is a truly tragic case, however only this week a study was released stating high profile cancer cases create more worried well who create an even bigger demand on services. A coroner blamed this on a fatal delayed diagnosis aswell this week.
Most of modern medicine is based around ruling out common diseases. This guideline will only create greater demand on primary and secondary care, increase investigations. It will likely, unfortunately pander to the worried well, worsen the symptoms of the health anxious, make the diagnosis of somatic and functional diseases harder, and ultimately further hinder and lengthen the time to diagnosis for the unfortunate rare cases and worsen the care of the stoic patients.
The wonderful outcome of unintended consequences…..
This is certainly nothing new has been my philosophy for the past 40 years in practice
I was taught the same thing as a GP trainee over 40 years ago. If you are seeing the same patient for the 3rd time with similar/worsening symptoms and no definite diagnosis then start again from the beginning and seek a second opinion.
Yep. Standard training in 1982 !
lets modify it- 3 strikes with ANP/PA/Paramedic- then pass on to GP who will pass on to A&E 🙂 , useless
I have been teaching this for 30 years
With MB. I love being told how to do my job, that I have been actively engaged with for 40 years, better. Looking forward to my worried well patients quoting Jess’s rule to me …
I was trained 30 yrs ago and the 3 strikes rule was part of my training , traditional primary care is what gp’s want but also what patients want. F2F consultations , no hiding behind digital options , traditional primary care works for all. Nothing will beat that F2F assessment .
Agree with Matt
Either this is an empty platitude (“don’t forget sometimes patients can have cancer” – you don’t say!) or it is a direction to rely less on clinical intuition and more on tests / referrals etc.
If the latter it needs a full risk / benefit assessment. Lowering the bar for EG referral for low-risk patients will worsen access for high-risk patients.
Sad case – but it was cancer of unknown origin.
If you referred after 3 consults, on vague symptoms around here she would sit on a 12month waiting list!
This case has nothing to do with vague symptoms and lack of curiosity. BBC reporting states “She had unintentionally lost quite a lot of weight, had night sweats, chronic fatigue, a persistent cough and very enlarged lymph nodes.” I don’t want to lay into the treating clinicians too much because we don’t have their version of events nor does the reporting state the timescales of when these symptoms develop.
This was a young woman who had multiple red flag symptoms and it is pretty clear had underlying cancer from the symptoms described. I’d much rather the focus was around allowing flexibility in referral pathways so these patients can get seen, rather than adding yet another token eponymous rule (which most GPs have been practicing anyways for years)
I remember years ago my then senior partner telling me about a worried well patient who had presented multiple times to him and other doctors with multiple vague symptoms and had tests done and second opinions from consultants with nil serious found. Eventually they did have a malignancy.
His advice was to always remember that even hypochondriacs can get really ill
Thirty five years ago in 1990 when I started my GP Training this was called “Referral at second contact”. This was changed to “Referral at third contact” 20 years ago and most GPs have been doing this anyway for over 20 years. This is a common sense approach for dealing with unexplained symptoms.
Specialist referral is suggested, so unless referred on a fast track cancer pathway in most areas the lead time to a specialist appointment is several months, so secondary care need to be geared up to receive more patients on fast track pathway if this rule is going to be applied. It will also be interesting to see what the detection rate of cancer in youngish population is following referral.