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The challenge of implementing ‘Martha’s rule’

By Dr Muiris Houston - 17th Mar 2024

‘Martha’s rule’

A recent NHS initiative is a step forward for patient safety, but has major resource implications

Have you heard about ‘Martha’s rule’? I’ve just come across this new proposal in the NHS. The rule will allow hospital patients and their families the right to demand an urgent second opinion if their condition is deteriorating. It sounds like a good patient safety initiative, but, gosh, how do you staff a major initiative like this when it’s already incredibly difficult to fill many NHS posts?

Some 25 years ago, Cyril Chantler observed: “Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous.”

In 1999, the US Institute of Medicine report To Err is Human noted how between 44,000 and 98,000 deaths occurred each year as a result of medical error in the US. It must be said that healthcare professionals globally have accepted the challenge to make patient care safer; for example, Atul Gawande’s surgery checklists and our own Deteriorating Patient Improvement Programme.

Complex systems, such as healthcare, require complex solutions. Systemic risks to inpatient safety include overcrowded hospitals, lack of inpatient and critical care beds, delayed clinical assessments, and poor nurse/patient ratios. These factors cause harm to patients and will continue to do so until they are tackled.

The genesis of Martha’s rule was described recently in the British Medical Journal (BMJ). It is led by the parents of Martha Mills, who died of sepsis in 2021 at King’s College Hospital in London just before her 14th birthday. The coroner in the case stated that “the serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists”.

Her parents expressed concern about Martha’s condition. They also asked about getting a second option. However, they said that they were not listened to.

They campaigned on the issue and received support from the cross-party think tank, Demos.

According to the BMJ, this has seen widespread backing for a system that allows patients or their families to insigate an urgent clinical review.

This would be carried out by another team in the hospital if the patient’s condition was rapidly worsening and there was concern the patient wasn’t getting the care they needed.

Following the campaign, NHS England said Martha’s rule is to be rolled out to at least 100 acute care Trusts this year. The escalation process will be available 24/7 to patients, families, and NHS staff. It will be advertised throughout hospitals and is intended to be easily accessible.

Her parents said they were pleased with the new process.

“We believe Martha’s rule will save lives. In cases of deterioration, families and carers by the bedside can be aware of changes busy clinicians can’t; their knowledge should be recognised as a resource.”

They said they hope that the rule will help change medical culture. By change they mean giving patients greater power and encouraging medical professionals to listen more. It might also serve to normalise the idea that doctors should welcome being challenged.

The rule’s introduction has been welcomed by the Royal College of Physicians and the British Medical Association. Dr Vishal Sharma, Chair of the BMA’s consultants committee, said the Association welcomed Martha’s rule, in principle, to help ensure similar tragedies are avoided in future.

Dr Sharma didn’t shy away from what I see as the biggest challenge for such a major initiative. He argued that significant resource implications arose from the implementation of the rule, given existing staff shortages.

“For this to result in improvements for patients, it is essential that the current workforce crisis is addressed so that critical care outreach teams have the necessary staff they need to deliver this initiative. More must also be done to embed a supportive culture across the NHS where staff know they can speak up about problems and have time to listen to families and others when issues arise.”

And there, in a nutshell, is what I fear will be a likely failing in the introduction of Martha’s rule. The initiative requires protected time for freshly staffed reviewing teams to listen to patient and family voices. But time has never been valued as a currency in our health systems.

I sincerely hope I’m wrong and that we see a successful version of Martha’s rule being implemented in Ireland.

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