NHS England » Jess’s Rule: Three strikes and we rethink

Jess’s Rule is a primary care initiative to encourage GPs teams to rethink a diagnosis if a patient presents three times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate, or remain unexplained. It is led by the Department of Health and Social Care (DHSC) and NHS England and is supported by the Royal College of General Practitioners (RCGP).

Jess’s story

Jessica Brady passed away due to cancer in December 2020 at the age of 27. In the 5 months leading up to her death, Jess had 20 consultations with her GP practice, and her cancer had not been diagnosed. Jess was then admitted to hospital with stage 4 adenocarcinoma and passed shortly afterwards. Since then, Jess’s family have campaigned for primary care staff to elevate a patient’s case for review after their third appointment with their practice about a condition or symptom.

What is Jess’s Rule?

Jess’s Rule asks GP teams to ‘reflect, review and rethink’ if a patient presents three times with the same or escalating symptoms.

Reflect: Think back on what the patient has said and consider what has changed or been missed. Offer ongoing episodic continuity of care for future direct patient care. If previous consultations have been remote, see the patient face-to-face and conduct a physical examination.

Review: Where underlying uncertainty exists, consider seeking a view from a peer and review any red flags that may suggest another diagnosis, regardless of the patient’s age or demographic.

Rethink: If appropriate, refer onwards for further tests or for specialist input.

How Jess’s Rule will benefit patients

Under Jess’s Rule, listening carefully to the patient’s concerns and taking note of each symptom remain crucial, recognising that patients are experts about what feels normal for their body. Joint decision-making between the clinician and patient remains key in this process.

It is asking for GP teams to rethink the accuracy of their diagnosis, really listening to the patient and taking note of each symptom or concern. This may mean seeing a patient face-to-face and conducting a physical examination if previous consultations have been remote.

After consulting again with the patient, Jess’s Rule encourages GP teams to re-evaluate why the patient’s condition remains unresolved by an existing treatment plan and/or consider why their symptoms are escalating.

Jess’s Rule encourages consistency of care but prompts GP teams to consult with one another to jointly reconsider any red flags that have been missed that could point to another diagnosis, and to challenge any assumptions that may have been made based on a patient’s age or demographic.

What is the significance of Jess’s Rule?

Implementing Jess’s Rule will support GP teams to manage patients with unclear symptoms, helping to improve quality of care and potentially saving lives by avoiding late or missed diagnoses of potentially serious conditions such as cancer or sepsis.

This is important as diagnosing cancer and other serious conditions earlier increases a person’s chance of survival and recovery.

How will Jess’s Rule be implemented?

Many GP teams already apply a version of “three strikes and rethink” in their routine practice. Jess’s Rule formalises this instinctive approach, providing a consistent structure to support reflection and timely action.

No additional training or materials are required for its implementation. Jess’s Rule is designed to align with existing good practice and professional judgement, offering a consistent prompt that should be readily integrated into everyday clinical decision-making.

The Rule builds on the principles set out in the GMC’s Good Medical Practice, particularly the duty to adequately assess a patient’s condition, take account of their history and symptoms, and arrange timely investigation or treatment based on clinical judgement and patient need. It reinforces the importance of working in partnership with patients and acting promptly when concerns persist or escalate.

Resources available to support adoption of Jess’s Rule

A poster for displaying in GP consultation rooms, available for NHS and DHSC staff who can access the Campaign Resource Centre: Campaign assets | Jess’s Rule: Three strikes and we rethink | Campaign Resource Centre.
An RCGP and Jessica Brady CEDAR Trust learning module to support earlier cancer diagnosis in young adults.
GatewayC is a digital early cancer diagnosis resource, designed by the NHS for the NHS, to help GPs and other primary care clinicians detect cancer at the earliest possible stage.