Patient Safety Commissioner for England: Recommendations on Martha’s Rule implementation go to government (1 November 2023)

Summary

The Patient Safety Commissioner for England was asked by the UK Government to run a series of policy sprint meetings to set out what would make Martha’s Rule a success in England. Martha’s Rule would mean that if a patient, family member or carer suspected deterioration or a serious concern, they would have the right to easily call for a rapid review or second opinion from an doctor within the same hospital. In this letter to the Secretary of State for Health and Social Care, Steve Barclay MP, the Patient Safety Commissioner outlines the process and outcome of these meetings and a set of recommendations for the implementation of Martha’s Rule.

Content

The Patient Safety Commissioner states that as part of this process, they held four sprint policy sessions lasting three hours which looked at four separate themes:

• Defining the problem to be solved
• Learning from the feedback regarding NHS England pilots
• Understanding what already exists and how Martha’s Rule fits within the landscape
• Developing the solutions for successful implementation

These sprint sessions were attended by 39 people across four days. Beyond this, the Patient Safety Commissioner also held more than 20 meetings outside of the sprints to hear from patients, parents, patient representatives, regulators, clinicians, professional bodies and trade unions.

The key recommendations from this process are:

• We must implement a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least on a daily basis. In the first instance this will cover all in-patients in acute and specialist trusts.
• All staff in those trusts must have 24/7 access to a rapid review from a critical care outreach team who they can contact should they have concerns about a patient.
• All patients and their families, carers and advocates must also have access to the same 24/7 rapid review from a critical care outreach team which they can contact via mechanisms advertised around the hospital and more widely if they are worried about the patient’s condition. This is Martha’s Rule.

Related reading

Martha's Rule: A new policy to amplify patient voice and improve safety in hospitals (September 2023)