23 September 2025

Dear colleagues,

Today, we have announced the implementation of Jess’s Rule: Three Strikes and we rethink. This initiative is led by the Department of Health and Social Care (DHSC) and NHS England and is supported by the Royal College of General Practitioners.

Under this rule, GPs and other clinical primary care healthcare staff will be encouraged to critically re-evaluate symptoms, diagnoses, and patient concerns if a patient presents on a third occasion with the same symptom or concerns. Re-evaluation may be appropriate if the patient’s condition remains unexpectedly unresolved, their symptoms are escalating, or they have no substantiated diagnosis.

Listening carefully to the patient’s symptoms and concerns remains crucial, recognising they are an expert in their own body. Joint decision-making between the clinician and patient remains key in this process.

Jess’s Rule is in memory of Jessica Brady, who died of cancer in December 2020 at the age of 27. In the five months leading up to her death, she had 20 appointments with her GP practice, and her cancer had not been diagnosed. Following a private, self-funded referral, she was admitted to hospital with stage 4 adenocarcinoma and passed away three weeks after her diagnosis. Since then, Jess’s family have campaigned for GPs to elevate a patient’s case for review after their third contact with their GP team about a condition or symptom.

We know that the practice of ‘three strikes and we rethink’ is commonplace in many settings, and GP teams use their clinical discretion every day to get to the bottom of unclear cases. Jess’s Rule reinforces this principle by explicitly encouraging clinicians to revisit patient records, challenge initial assumptions and remain alert to subtle warning signs. Jess’s Rule seeks to reduce diagnostic delays, support clinical intuition, and encourage proactive intervention.

Jess’s Rule means that we reflect, review and rethink.

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.

Implementing Jess’s Rule will support clinicians to manage patients with unclear symptoms, helping to improve quality of care and, potentially, save lives.

Many thanks for your support in implementing this important initiative for our patients and their families. Please visit our Jess’s Rule webpage for more information and helpful resources to support implementation.

Publication reference: PRN02071_i