Jess’s Rule does not give GPs ‘automatic right’ to refer under new A&G rules, says NHSE
Exclusive Even using Jess’s Rule will not give GPs an ‘automatic right’ to refer a patient to a specialist under new A&G contractual requirements, NHS England has clarified to Pulse.
The clarification of the 2026/27 GP contract plans – which are set to mandate the use of A&G where ‘clinically appropriate’ – came in an exclusive op-ed written for Pulse by primary care director Dr Amanda Doyle.
In the opinion piece, Dr Doyle stressed that moving funding into core would recognise increased GP workload related to A&G – however she also confirmed that it will be entirely up to consultants to determine if a patient sees a specialist under the ‘single point of access’ plans set out with the imposed contract changes.
Introduced to the NHS last year, Jess’s Rule encourages GPs to ‘think again’ if after three appointments about the same symptoms they have been unable to offer a ‘substantial diagnosis’, or if a patient’s symptoms have escalated.
In a webinar on the contract held last week, Dr Doyle had said hospital trusts would be given guidance on where Jess’s Rule comes into play with regards to the new A&G system.
However, in her Pulse op-ed, Dr Doyle went even further, stating that while it will play a safety role in the new system, Jess’s Rule will not mean that the patient will be entitled to an ‘automatic’ referral, but that it will remain up to consultants at the hospital end.
Dr Doyle said: ‘Jess’s Rule will play an important patient‑safety role within the new system. It acts as a prompt for GPs to reflect, review and reconsider a patient’s presentation after repeated consultations, and to escalate for further investigation or specialist input where appropriate.
‘It does not remove GP clinical judgement or create an automatic right to referral, but Trusts will be expected to recognise when Jess’s Rule applies when undertaking clinical triage through single points of access.’
Elaborating on the ‘single point of access’ for referrals first revealed in plans for the 2026/27 GP contract, Dr Doyle said: ‘Introducing a single point of access for referrals is a practical change that supports earlier specialist input, clearer decision-making, and safer patient pathways.
‘It also means the onus is not on the GP to decide whether a referral should be for advice and guidance or an out patient appointment, or simply to obtain diagnostics that aren’t accessible in the community, whilst avoiding having to submit a separate claim for each request for advice and guidance, yet still receiving a full share of the funding via global sum.’
She explained that GPs ‘will submit referral requests via the e‑Referral Service to a single point of access’ and that the ‘decision on whether a patient requires an outpatient appointment, advice and guidance, or an alternative outcome, such as going direct for diagnostic tests will be determined through consultant‑led clinical triage’.
Currently, the £80m A&G enhanced service enables GP access to a £20 Item of Service (IoS) fee for ‘pre-referral requests’. GPs receive £20 for each ‘episode of care’, which could include several interactions with consultants.
But from 1 April, this funding will be moved into the core contract, with GPs expected to use A&G where clinically appropriate. The single point of access pathways – that are to be locally determined – are however not expected to be in place until 1 October.
According to Dr Doyle, the new pathways ‘will streamline care for patients and make it easier for GPs to get specialist advice with the minimum bureaucracy’; and she said that the change would ‘importantly ensure that we recognise this means additional work in core general practice and therefore the additional funding to help deliver that work must be included in global sum’.
The BMA has said it is taking legal advice around the new A&G contractual requirements, amid concerns they remove the right for GPs to directly refer patients.
A&G requests have risen significantly in the last year, but the Government’s ambition that this would divert two million requests from elective care looks set to be missed.
Jess’s Rule was instated in memory of 27-year-old Jessica Brady, who sadly died with adenocarcinoma in 2020, having been ill for six month, in a bid to avoid future deaths.
Read Dr Doyle’s full op-ed here.
Read all of our coverage of the 2026/27 contract here.
Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.
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READERS' COMMENTS [9]
Please note, only GPs are permitted to add comments to articles
the worrying thing about this is the lack of context- GPs don’t simply refer patients for a specific diagnosis (though we might do)- its about the patient who keeps coming back, the worried parents, the case where you know there is nothing significant going on but the patient won’t accept that. And on and on. Added to this, where is patient choice in all this? Are we saying that a patient who simply “wants” a referral – will now have to pay privately even though the Government are constantly banging on about patient rights and choice? it all seems a bit topsy turvy to me- patients told one thing and GPs told another with consultants failing to understand the true reasons why we refer a lot of the time (and its not just diagnostic uncertainty and never has been). How sad that the says are gone of speaking to a consultant colleague for advice, writing directly to them etc. The risk is the patient being stuck in a never ending doom loop of A&G back and forth whilst risk and responsibility sits entirely on the shoulders of primary care. Does no one realise this will only increase admissions and attendance at ED, or misuse of the 2WW pathways when we have run out of options and are utterly exasperated with it all. Unintended consequences are predictable here …..
This ought to be resisted manfully.
The transfer of risk has yet another hurdle To negotiate whilst secondary care is protected, NHS England and Department of Health look to performance manage general practice
Another contributor in another column suggests that the data is being scraped for the purposes of the next generation of AI. It’s bolt on as a single point of access.
The patients will be on our side in this. If we want public support against NHSE, this is the direction we need to fight in.
Under the NHS charter and The General Medical Council, state that all doctors must ‘respect the patient’s right to seek a second opinion’.
Where patients request or belive they require a hospital review – how to referral management services which are designed to block referrals, change risk and complaints from patients when referrals declined/blocked, and harm then comes from this?
I agree with all 3 posts above. I’m still unsure though about whether we have the right to directly split infinitives.
If a necessary referral gets bounced by the inflexible hospital system give the patient the telephone number for PALS and encourage them to make an official complaint.
I would agree on one point, Jess’ Rule is not necessary to give GPs automatic right to refer. That right is enshrined in the NHS Legislation where it says that GPs shall make all referrals necessary for the care of the patient!
That aim actually includes those patients in whom we have no diagnostic or managerial uncertainty, but a patient who does not accept GP’s word for it as well.
1. ‘Dr Amanda Doyle: New A&G pathways do not impact a GP’s decision to refer’
2. ‘Jess’s Rule does not give GPs ‘automatic right’ to refer under new A&G rules, says NHSE’
I very much hope to see Dr Doyle held legally culpable for her incoherent policy, damaging both patients’ and GPs’ ability to determine appropriate care pathways.
I think the biggest issue with this is getting patients to be aware of this. I have not seen it in the non-medical media. The only think mentioned was that GPs are going to get thousands of extra money for using A&Gs