John Goldie is a retired GP and medical educator
When I began my career in General Practice, I quickly noticed the “Three strikes and you’re out,” metaphor cropping up in registrar teaching sessions and coffee break conversations. Despite its prevalence, it seemed curiously absent from the medical literature. Then came a case that brought it to life: a young man with unexplained fatigue. My first assessment was thorough, with tests arranged. When these came back normal, I offered reassurance. Yet the patient returned, still tired. What next? Admitting I could find no cause, we agreed I would refer them for further investigation.
When a problem persists across multiple consultations, the skill lies in recognising when to stop repeating the same steps and consider a new approach.
This highlights a fundamental tension in general practice—the balance between continuity, timely escalation, and our gatekeeper role. When a problem persists across multiple consultations, the skill lies in recognising when to stop repeating the same steps and consider a new approach. The third visit becomes a signal to pause, broaden the differential, and escalate if needed.
Jess’s Rule
What had once been an informal heuristic is now formalised in “Jess’s Rule.” This was recently introduced by the Department of Health and Social Care and NHS England.1 Its message is: Reflect, Review, Rethink. However, as Emilie Couchman recently noted, achieving continuity in today’s pressured general practice is harder than ever.2 Recent qualitative work shows both patients and clinicians struggling to maintain relational continuity amidst workforce shortages and rising demand.3 Structured prompts like Jess’s Rule therefore play a vital role in safeguarding patient safety.
Clinical rationale for escalation
Repeated presentations with unclear or persistent symptoms suggest our first explanation may be wrong. We must guard against cognitive biases—anchoring on early impressions, “normal” results, or reassurance bias closing our thinking. The third visit should function as a reset: step back, reconsider, and perhaps involve the wider team. Structured review tools or differential diagnosis checklists could help (e.g., NICE red flag checklists).
Escalation depends on factors such as age, comorbidities, red flag symptoms, and symptom progression. The “three strikes” heuristic offers a practical reminder to balance caution with pragmatism, especially for hard to diagnose conditions.4 Lower referral thresholds can reduce short and medium term mortality,5 but risks include overwhelming secondary care, fuelling patient anxiety, or over medicalisation. GP referral thresholds need balance between patient safety and efficient healthcare use. Crucially, escalation need not mean losing continuity—the GP remains central, holding the patient’s story together while specialists add expertise.
Professional identity and referral thresholds.
Escalation is not just clinical; it shapes how GPs see themselves. General practice relies on both codified rules and individual judgement. “Three strikes and we rethink” provides structure, but nuanced assessment decides when escalation is truly needed.
Symptoms may evolve, for example “tiredness” becoming “mild joint aches.” Does this count as the same problem for the purpose of the three-strike rule? Such questions require a nuanced approach. Nuance requires expertise. Expertise means knowing when to trust instinct and when to question it. Reflection, feedback, and humility are its essential companions.
Referral thresholds vary,5 shaped by training, resources, and risk tolerance. Negativity towards GP referrals from secondary care staff, often reflecting overstretched systems, is a rarely discussed negative influence. A reflective professional—one who recognises limits, remains open, and admits uncertainty while seeking help—is best placed to support patients.
Ethical reflection
Escalation is not just clinical; it shapes how GPs see themselves. General practice relies on both codified rules and individual judgement.
The third presentation is more than a procedural milestone—it is a moral signal. Non maleficence demands we avoid harm from delay. Involving patients in escalation respects autonomy. Justice requires fair access to diagnostics and referrals. Finally, honesty about the limits of primary care is itself an act of care—naming those limits openly builds trust more than repeated but empty reassurance.
Developing the knowledge
Like many GPs, I learned the “three strikes” heuristic through the hidden curriculum. Jess’s Rule brings it into the formal curriculum, but experience and reflexive practice shapes how it is applied. Reflexivity interrogates assumptions, clarifies roles, and adapts practice in uncertainty. In modern general practice, team reflexivity is increasingly vital. Role modelling is also important. When senior colleagues and the wider practice team openly model honesty and humility, it encourages everyone to do the same. As Bandura’s research shows,6 people tend to adopt behaviours they see working well for others.
Three strikes is not a dismissal, but an invitation: to reflect, review, and rethink—together, with humility guarding against harm.
References
1. NHS England. Jess’s Rule: Three strikes and we rethink. NHS England guidance letter. 2025.
2. Couchman E. Jess’s Rule: advocating for continuity, ownership, and generalism in general practice. BJGP. 2025: 75 (760): 500-501.
3. Manley Burch PB, Iles S, Poppleton A, Checkland K, Skyrme S. What do patients and clinicians think about continuity in general practice in England? BJGP. 2025; 0323.
4. Mendonca, S.C., Abel, G.A. and Lyratzopoulos, G. ‘Pre-referral GP consultations in patients subsequently diagnosed with rarer cancers: patient survey data and analysis,’ British Journal of General Practice, 2016: 66(646), pp. e171–e178.
5. Lewis, J. and Burton, C. ‘Understanding the consequences of GP referral thresholds: taking the instrumental approach,’ BMJ Quality & Safety, 2023: 32(11), pp. 689–691.
6. Bandura, A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J: Prentice-Hall. 1986.
