Jess’s Rule: Improving the Diagnostic Performance of General Practice Teams in England

 Jessica Brady, a 27-year-old satellite engineer at Airbus in Stevenage, Hertfordshire, previously in good health, consulted her GP practice in June 2020 with abdominal pain. She had a total of twenty consultations with the practice and an emergency hospital admission without a definitive diagnosis being made, although it was suggested at one point that she may have ‘Long COVID.’  Jess then saw a private ENT specialist and was referred back to hospital, only to find out on 26 November 2020 that she had stage 4 adenocarcinoma, a cancer of mucus-secreting glands which had already spread to her liver, lungs, lymph nodes, bones, and spine. The organ in which the cancer first developed could not be identified. Jess sadly lost her life shortly thereafter, following a five-month illness, on 20 December.

 Andrea and Simon Brady, Jessica’s parents, have since set up a charity in her name-the Jessica Brady CEDAR (Cancer Early Diagnosis, Awareness & Research) Trust- to “support earlier cancer diagnosis within Primary Care.” The Bradys have also co-designed a poster, in collaboration with the Department of Health and Social Care (DHSC) and NHS England, to ‘Jess’s Rule’, which was published by NHS England on 23 September 2025. These posters have now been distributed to all 6, 710 GP practices in England, and will be advertised in every surgery from the week commencing 24 January 2026.

 According to Jess’s Rule, GP teams should “Reflect, Review and Rethink”, guided by a “Three Strikes and we Rethink” strategy which prompts GP teams to reconsider their original diagnosis (es), or the lack of one, after a patient consults the GP practice for the third time with the same symptom (s). These symptom (s) may either not be responding to the prescribed treatment plan or may be worsening despite optimum treatment for the diagnosed condition.

 It is considered good practice to review a diagnosis if the diagnosed condition fails to respond, and often progresses, despite appropriate treatment. The diagnosis may be wrong, the treatment plan may need to be reviewed, or there may be coexisting and unrecognised issues with physical and/or mental health. In other words, the patient’s body is trying to tell those who are prepared to listen to consider a different approach. In emergency medical practice, a review by a more senior healthcare professional is recommended when a patient makes an unplanned reattendance, within seven days of initial presentation, for the same condition. In these circumstances, the patient may need to be redirected for more suitable care geared to their needs, which may include referral to a hospital specialist, but not necessarily so. A similar line of action seems entirely appropriate in general practice, when a face-to-face consultation, an informed discussion between team members, and an in-house second opinion might suggest alternative pathways for investigation and treatment. Many delayed diagnoses of, and thereby treatment for, brain tumours, cancer, sepsis, and other life-threatening conditions are a direct result of failure by clinicians to consider the possibility of these illnesses in their list of differential diagnoses. Many cancers, in particular, are only diagnosed when the patient visits an emergency department for a second opinion, often for unrelenting and worsening pain, malaise, weight loss and other “red flag” symptoms. Various stereotypes of illnesses and biased thinking by healthcare professionals contribute to the resulting delays in diagnosis, as well as misdiagnoses.  

 Achieving the correct diagnosis often requires access to specialised blood tests and diagnostic imaging, accompanied or followed by referral to a hospital specialist team, which, however, may not be readily available to GP teams in an NHS where everything seems to be rationed, often rightly so. Diagnostic delay may thus reflect a whole-systems problem in which there is restricted access to and a series of barriers to achieving diagnostic accuracy. While Jess’s Rule is welcome, seamless streamlining of the diagnostic process within the NHS is necessary if its fuller benefits are to be realised.

Ashis Banerjee