Take your time with Jess’s rule
In light of Jess’s rule, Copperfield urges GPs not to lose sight of the clinical value of time, judgement and doing nothing
I assume you’ve landed here because you read, re-read and re-re-read my original blog about Jess’s rule. Do that three times and, because of the rule, you’re directed for a second opinion. Mine. Again.
So now Jess’s rule is national policy, apparently. Hence the need for further reflection. And I’d say three things.
- I agree with everything I said earlier.
- Jess’s rule simply formalises what any sensible, self-respecting GP would do in a clinical cul-de-sac: stop, review, reflect, reconsider and make a clear plan. Which is also a shout for continuity, so three cheers for three strikes.
- Far from needing encouragement to act quickly to clarify diagnosis or seek further opinions, many clinicians are taking Jess’s rule and running with it: increasingly, the norm is one strike and you’re out.
This latter point is a major issue, and a greater problem than the one that Jess’s rule seeks to solve. Of course, serious delayed diagnosis is tragic, emotive and causes much soul searching. But in the great scheme of things, these cases are thankfully rare – particularly in comparison to the numbers of patients affected by a one-strike approach of unnecessary treatment, indiscriminate investigations and reflex referral.
It’s mad and getting madder. Cough? Antibiotics. Teeny twist to the ankle? Physio. Tired for a week? Tick every box on the path form. Or if you want a recent specific: a nine-year-old child with constipation causing an occasional bleeding fissure referred on the two-week pathway – the only referral bounce-back I have ever cheered.
This isn’t just noctorism (I know some GPs who seriously need to move their action/inaction dial) but, mainly, it is.
The result is raised expectations, tests generating more tests, spiralling admin, iatrogenesis and incidentalomatosis, frazzled GPs and a gridlocked system.
As every experienced GP knows, sometimes the best thing to do is nothing. Wait and see. Let things evolve or resolve. But we seem to have forgotten about the diagnostic or therapeutic value of time. Perhaps because we don’t bloody have any.
So, take on the common sense of Jess’s rule by all means, but don’t let it lower our threshold for yet more unnecessary intervention. Otherwise, the few who genuinely need prompt help will find that the only second opinion they get is the medical examiner’s.
Dr Tony Copperfield is a GP in Essex
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READERS' COMMENTS [6]
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One thing you forgot, Tony : We have all had that one patient (or maybe several, in a larger practice), who either has nothing physically wrong with them, or possibly they do, but it has already been diagnosed; who keeps coming back with a new symptom every week, and sometimes the same symptom by a different name, at a different time of day, in a different body part, or shown off in a different OPD clinic and told to ‘see your GP about it urgently’ (thanks OPD sister). Mainly we see them each time, 3rd, or 33rd, and do nothing harmful. Occasionally we seek a second opinion from a Partner, or, more likely, from the VTS Registrar, but continuity, and lack of endless supply of Registrars, brings them back. Does Jessss’ rule still apply? – It will keep the hospital in business anyway.
The exhaustively busy “GP”, Dr Fuller, is next working on a list of 3 salad ingredients that lazy GPs should tell their patients to eat daily – she’s calling it cole’s law….
All the reporting seems to omit the actual facts as to what constitutes the “Jess’s law” programme so I’ve looked further. The answer is:
1. A poster for consulting rooms
2. An optional online teaching module about cancer in young people.
(https://www.england.nhs.uk/long-read/jesss-rule-three-strikes-and-we-rethink/#how-will-jess-s-rule-be-implemented)
I don’t see that there can be much objection to the optional online learning module. The poster is also pretty reasonable – it just says “3 strikes and we rethink”. So the actual campaign is modest in scope and not unreasonable. The widespread publicity and attendant controversy seems a little disproportionate!
Other than officialdom “changing the rubicon”
As usual Dylan. I expect in 3 or 4 years we’ll be asked to do a 2 day mandatory away day as part of our contractual requirement, but there will be 4 spaces to book onto for the entire patch. (See also: Oliver McGowan training)
I understand this is needed to teach ‘noctors’ as a first aid qualification does not teach you clinical acumen, but it is better to ban all MAP and have properly trained and competent professionals whom are not constantly degraded, especially by bad managers and politicians.
I am offended sensible practice that has existed for over a century is now be re-coined Jess’s Rule. Don’t know who Jess is but the media campaign has clearly caused additional demands on top of normal standard practice (that often already includes what is described).
What happens in reality is that your success rate with 2WW/3WW goes from low numbers to less than 1%, whilst the NHS waiting time bottleneck is not fairly tackled. Unfortunately we give too many appointments, so I have already seen skin tags being referred as breast cancer, 3-day mouth tiny ulcer as head and neck cancer, post-contraceptive bleeding as gynaecological cancer, molluscum/scabies as skin cancer. Thankfully some services are just saying it is not cancer and that they are only a cancer exclusion service but it is yet another additional intolerable strain on the NHS.