NHS England has today introduced Jess’s Rule, asking doctors to take a ‘three strikes and rethink approach’. The rule is named for Jessica Brady, who died in 2020 aged 27, having had more than 20 appointments with her GP surgery in the six months before her death. Mostly seen virtually – a fact attributed to Covid – she eventually went private. There, her terminal cancer was belatedly diagnosed. She died three weeks later.
Discussions about Jess’s Rule began under the Conservatives and have come to fruition under Labour. Both parties have shown an unshakeable commitment to taking a serious problem, highlighted by a tragic death, and turning it into performative bureaucracy which won’t fix the problem it pretends to honour.
Jess’s Rule isn’t even a rule – it’s guidance. GPs are being asked ‘to think again’ after three appointments, if someone’s ill health is not diagnosed or their condition worsens. Nor does NHS England even make much effort to pretend that anything new – besides a press release – is being introduced. ‘No additional training or materials are required for its implementation,’ it says of the rule.
NHS England notes that 50 per cent of young people need three or more appointments before getting their cancer diagnosis. For the population as a whole, the figure is 20 per cent. The fact they state this in their announcement shows how desperately unserious they are. Those statistics aren’t a reflection of bad doctoring, but the fact that cancer is less common in youth.
Something real, something better, is badly needed. Not because young people are overall badly served (diagnosis is always more difficult where disease is rare) but because in Britain our performance in diagnosing cancer early in all age groups is poor. We already have models of rigorous review in some areas – every perinatal death, for example, is formally investigated. Cancer care could benefit from the same approach.
Three steps would help: first, auditing every cancer in the young to understand diagnostic delays; second, creating standardised systems in general practice for reporting and reviewing near misses, as hospitals already do; and third, using large datasets to study why some diagnoses are made promptly and others catastrophically late. Work in recent years on colorectal cancers missed at colonoscopy shows how powerful this can be. A national programme of surveillance, combining individual case review with population data, would give us genuine insight into where errors lie and how to reduce them.
Doctors aren’t meant to wait until a third appointment before wondering if we’ve got a diagnosis right; we’re meant to wonder that every time. Nudges, though, can sometimes help. Safety checklists have been shown to save lives – prompts to run through the obvious steps in a methodical way. We’re human and we miss things. A conscious rethink after three unsatisfactory attendances isn’t a bad idea, but it’s hard to see it helping a GP surgery that hasn’t done it after 20.
Only five months passed between Jess Brady’s GP appointment and her death. If a diagnosis had been made earlier it may not have meant her cancer was curable, but it would have given her options, and it wouldn’t have left her feeling abandoned by a medical service that should have done so much more.
Politicians and government have responded in a superficial way
I am no lawyer, but I wonder if rules and laws named after people tend to be bad laws. ‘Great cases, like hard cases, make bad law,’ said Justice Oliver Wendell Holmes Jr, of the US Supreme Court. ‘For great cases are called great, not by reason of their importance… but because of some accident of immediate overwhelming interest which appeals to the feelings and distorts the judgment.’
Jess’s Rule prioritises emotional appeal over effective reform. Successive governments have missed the opportunity to do something meaningful, opting instead for a press release which sounds good and offers little. Jess Brady’s poor care has attracted enough notice – and been pursued with such generous energy by her mother, who stands nothing to gain save the sparing others the fate of her daughter – that attention has been paid. But not enough. Politicians and government have responded in a superficial way, while trying to look like they’re taking a problem seriously. Depressingly, I suspect they don’t understand the difference, and don’t want to make the effort to try.
As a parent and a patient and above all as an imperfect doctor who makes mistakes and would appreciate help in making fewer, I think more is needed. Jess Brady deserved better in life and her memory deserves better now. Jess’s Rule falls short of the complex effort required to learn from what she went through. For every complex problem, said H. L. Mencken, there is an answer that is clear, simple, and wrong.
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