The formative evaluation of the implementation of Martha’s Rule: Interim Report (NIHR Policy Research Unit, March 2026)

Summary

In June 2024, Martha’s Rule was introduced into 143 NHS Trusts. This rule allows patients, families and staff to quickly request an urgent review from an independent medical team if they’re worried a patient is worsening and feel their concerns aren’t being heard. It also requires hospitals to regularly check in with patients and families about how the patient is doing. 

This interim report presents findings from an independent evaluation of Martha's Rule carried out between November 2024 and February 2026. This was undertaken by the patient safety arm of the National Institute for Health and Care Research (NIHR) Policy Research Unit in Quality, Safety and Outcomes for Health and Social Care to understand how the first rollout of Martha’s Rule is working for patients, families and healthcare staff. It draws on a prospective in depth case study across three hospital trust pilot sites, involving observations, interviews and documentary analysis, accompanied by a systematic review of literature and a public awareness survey, which was conducted in collaboration with Picker.

Content

Key learning points highlighted by this report include:

• To date, one in three people (public, patient and family) are aware of Martha's Rule, and some minoritised groups face additional barriers to understanding.
• Patients, families, and staff value Martha's Rule for its ability to amplify their voices, facilitate open communication, promote collaborative care and improve escalation pathway between ward and critical care outreach teams.
• Patients and families lack clear information about the purpose of the structured wellness question and its role in their care.
• There is variation in the way in which the wellness question is being operationalised, with a shift to informal ways of asking and inconsistencies in recording patient and family voice.
• Awareness appears limited amongst some staff groups, particularly medical and specialist teams and transient staff.
• Callers to the helpline are seeking clearer information about ongoing care and support after escalating concerns.
• There may be barriers for some groups - those most in need may be least able to access Martha's Rule; these are not limited to those with protected characteristics.
• Not all trusts/wards/teams are 'equal' - differences in responding team (critical care outreach) and ward cultures (and priorities), as well as staff attitudes and delivery models, can influence the adoption of Martha's Rule and ultimately, patient, family and staff involvement in the identification of deterioration.
• Implementation has placed additional demands on critical care outreach staff, who are routinely tasked with managing escalations of deteriorating patients. This has raised concerns about responding to general concerns via the helpline leading to emotional burden, delayed responses and potential compromises in care for other critically ill patients.

Related reading

• Embedding Martha's Rule into practice—Lessons from the national pilot
• Martha's Rule - Merope Mills (Martha’s mother) explains Martha’s story (31 March 2026)
• Martha's Rule: Jo and Anna share their patient experience of Martha’s Rule (NHS England, 31 March 2026)