1. Overview

A letter from NHS England’s Director of Patient Safety, Dr Aidan Fowler, was sent on 21 February 2024 advising of the upcoming implementation of Martha’s Rule.

NHS provider organisations are now invited to submit an expression of interest to be amongst at least 100 sites taking part in the first phase of Martha’s Rule from Spring 2024. This document provides information to support organisations considering expressing an interest, including the criteria for inclusion and an overview of the support and resource NHS England will offer to participating sites.

Section 1 provides background information.

Section 2 explains how organisations can express an interest in taking part in the national programme to implement Martha’s Rule, including the link to the expression of interest (EoI) form in section 2.0 on page 3.

1.1 Background and context

Acute physical deterioration can occur in any health and care setting and is a dynamic process in which a patient becomes suddenly more ill, potentially leading to death. It can be identified by changes in standard physiological indicators, such as respiratory rate and blood pressure, and mental state and behaviour (for example, lack of eating, not engaging in usual activity), although the signs can be subtle early on.

The underlying causes of deterioration are varied, and not always easy to determine early in the episode. They are most commonly due to infection but can include vascular, trauma, metabolic and other exacerbations of chronic illnesses. Deterioration is a widespread precursor to death and is sometimes not reversible. However, in many cases, improved management of deterioration could lead to recovery and other improved outcomes.

Martha Mills died in 2021 after developing sepsis in hospital where she had been admitted with a pancreatic injury after falling off her bike. Martha’s family’s concerns about her deteriorating condition were not responded to, and a coroner ruled in 2023 that Martha would probably have survived had she been moved to intensive care earlier.

In response to this and other cases related to the management of acute deterioration, the Secretary of State for Health and Social Care and NHS England committed to implement ‘Martha’s Rule’; to ensure the concerns of the patient and those who know the patient best are listened to and acted upon.

Martha’s Rule will give patients, families, carers and staff, round-the-clock access to a rapid review from a critical care outreach team (CCOT) or paediatric critical care outreach team if they are worried about a person’s condition. Evidence indicates that this review is an additional and beneficial safety net in the identification, escalation and response to deterioration.

Martha’s Rule will build on the insights, lessons learned and evaluation of NHS England’s Worry and Concern Improvement Collaborative which involves 7 regional pilots and began in 2023. This programme of work has implemented and evaluated methods for patients, families and carers to escalate their concerns about deterioration and to input their views about their illness into the health record.

To ensure that Martha’s Rule is effective, it will be implemented alongside an integrated programme to improve the management of deterioration using the ‘PIER’ framework, which helps systems to prevent, identify, escalate and respond to physical deterioration. This work will improve how the NHS supports staff to manage deterioration and encourage greater involvement from patients, families, and carers.

The Martha’s Rule and Managing Deterioration Programme will be led by Senior Responsible Officer Dr Aidan Fowler in his role as NHS National Director of Patient Safety. Working in partnership with the National Nursing Directorate, the National Patient Safety team will lead implementation, collaborating with colleagues from the NHS England Children and Young People and Critical Care (adult, children and young people, and neonatal) teams.

The Care Quality Commission, professional regulators and the Royal Colleges will continue their involvement during implementation.

1.2 What is Martha’s Rule?

There are 3 components to Martha’s Rule:

1. All staff in NHS trusts must have 24/7 access to a rapid review from a CCOT who they can contact should they have concerns about a patient.
2. All patients, their families, carers, and advocates must also have access to the same 24/7 rapid review from a CCOT, which they can contact via mechanisms advertised around the hospital, and more widely if they are worried about the patient’s condition.
3. The NHS must implement a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least daily. In the first instance, this will cover all inpatients in acute and specialist trusts.

2. Submitting an expression of interest

Before registering your site’s interest, please first review the supporting information in this document.

Once read, registration can be completed using the Phase 1 of Martha’s Rule expression of interest form.

The closing date for registration is 9am on Wednesday 10 April 2024.

If you have any further questions, please email england.psimprovement@nhs.net with the subject heading ‘EoI query’. Please remember to include contact details for you and/or another member of your team.

2.1 Phase 1 of implementation

Martha’s Rule will begin with a phased approach involving at least 100 sites that provide adult acute inpatient services and/or paediatric acute inpatient services and who have an existing onsite 24/7 critical care outreach team (CCOT) or paediatric critical care outreach team (PCCOT).

“The main role of a CCOT is to identify and institute treatment in patients who are deteriorating within the hospital but outside of the intensive care unit (ICU) and either help to prevent admission to ICU or ensure that admission to a critical care bed happens in a timely manner to ensure best outcome”. (NICE guideline 94, 2018)

For the purposes of this expression of interest, 24/7 CCOT/PCCOT capability is defined as a mechanism which is available 24/7, by which patients who are identified as deteriorating (according to the national early warning score version 2, paediatric early warning score, or similar routine assessment) can be independently evaluated and treated outside the critical care unit by practitioners who have been deemed competent according to national or local frameworks.

The first phase of the programme will focus on supporting sites who have onsite 24/7 CCOT/PCCOT to test, implement and evaluate all 3 components of Martha’s Rule for children and adult acute inpatients. This will add to our established intelligence from the Worry and Concern Improvement Collaborative and will prepare for scale up to the remaining health and care settings in England by 2027.

This focused approach at the initial phase 1 provider sites will inform the development of wider national policy proposals for Martha’s Rule that can be expanded in a phased way across the NHS from 2025/26 in sites that do not currently have onsite 24/7 CCOT/PCCOT.

We will also identify ways to roll out adapted Martha’s Rule models across other settings including community and mental health hospitals where the processes may not apply in the same way.

2.2 The support offer from NHS England

NHS England will provide professional leadership, advice, guidance and support to the implementation sites and will work collaboratively with a range of organisations as part of the support infrastructure. While not an exhaustive list, this is the type of support that sites can expect within the first year:

• Around £40,000 given to each site in 2024/25. This is expected to be paid in full to successful sites in quarter 1 of 2024/25 via existing Specialised Commissioning routes. This money can be used for appropriate activities that test, develop and implement Martha’s Rule. For example, production of project resources, clinical backfill, and quality improvement/project management/data coordination support.
• National policy will be outlined and disseminated.
• Learning provided by the Worry and Concern Improvement Collaboratives to form the development of models to be adopted, adapted, scaled-up and spread.
• Implementation guide to steer sites with planning and implementing Martha’s Rule across their site.
• The Specialised Commissioning team will ensure that there is the following support from the adult critical care and paediatric operational delivery networks:
  • to support development of standards, guidance and resource that reduce unwarranted variation in service design and delivery of CCOT/PCCOT
  • support communication between different parts of the system to ensure a system-based approach to implementation
  • communicate consistently and effectively with units.
• Expertise and support provided by the patient safety collaboratives through the Health Innovation Network (formerly academic health science networks). Using their quality improvement knowledge and experience of implementing national programmes with provider organisations, they will:
  • support teams to translate policy into practice and local implementation
  • convene peers across organisations to support learning and accelerate implementation using a breakthrough series collaborative approach
  • connect different parts of the system to ensure a system-based approach to implementation.

2.3 Criteria for inclusion

To be considered for inclusion in the first phase of Martha’s Rule implementation, sites must:

1. Be a hospital site providing acute inpatient services for all ages, with an established onsite 24/7 adult CCOT.

or

2. Be a hospital site providing paediatric acute inpatient services which has an established onsite 24/7 PCCOT.

or

3. Be a hospital site providing acute inpatients services for all ages, with an established onsite 24/7 adult CCOT and an onsite 24/7 PCCOT.

4. It is not necessary for a site to have a PCCOT to participate in year one provided they have an adult CCOT.

5. If a trust has more than one hospital site that wishes to take part, separate expressions of interest must be submitted for each site that meets the inclusion criteria.

6. Confirm their 24/7 CCOT and/or PCCOT fits the following criteria as it is acknowledged that different sites have different names for their outreach services. For this programme, the outreach service must have the following:

• 24/7 CCOT/PCCOT is defined as a mechanism which is available 24/7, by which patients who are identified as deteriorating (according to the national early warning score version 2, paediatric early warning system, or similar routine assessment) can be independently evaluated and treated outside the critical care unit by practitioners who have been deemed competent according to national or local frameworks.

7. Commit to actively work with patients, families, carers and staff during the implementation phase. This could include patient safety partners, patient public voice representatives, those with lived experience and staff focus groups.

8. Have executive sponsorship and an identified leadership and governance structure for Martha’s Rule implementation at trust and/or site level.

9. Commit to work with the appointed external evaluation partner and national analytical support throughout the programme to ensure appropriate measurement and data collection methods are in place and routinely provided.

10. Identify a nominated implementation lead for each site who has the capability and resource to coordinate and communicate throughout this phase 1 implementation year.

11. Identify a member from the organisation’s quality improvement team (or equivalent) to support with implementation and alignment to broader quality and safety improvement work.

12. Undertake an equality impact assessment for the proposed work on Martha’s Rule and ensure this is used to inform implementation across the site. Careful and purposeful consideration must be given to reducing inequalities and ensuring that Martha’s Rule accommodates those in communities of global majority populations.

13. Have a clear governance approach outlined for the management and operationalisation of this implementation phase. This will include board oversight, accountability, governance and reporting within the trust/site. Where appropriate, this will also provide reports and updates to all relevant partners, groups and boards to the system, region and national programme team. For example, quality and safety boards; acute deterioration groups; patient safety specialists, etc.

2.4 Working with sites and populations that sit outside of the inclusion criteria

If you are a mental health, community or other service implementing or planning to implement Martha’s Rule, we would like to learn from your experience. However, given the level of resource allocated at this point, if you are not eligible for this expression of interest process, we will not be able to allocate additional financial resources to you.

However, we will ask you to identify yourself via the expression of interest response form so that we can explore working with you outside of the expression of interest process.

2.5 Sites with paediatric inpatient services but no onsite paediatric critical care outreach team

It is, of course, vital that we learn how to implement Martha’s Rule in paediatric acute inpatient services that do not have onsite PCCOT at present and establish a sustainable model and pathway.

We are conscious of the complexities involved in adult CCOT responding to requests to review deterioration in children; therefore, in addition to working with sites to explore adult CCOT responding to escalation from onsite paediatric settings, and those with a dedicated PCCOT, we are also going to work with groups of sites within an operational delivery network footprint to test in more detail how to implement Martha’s Rule as part of a wider paediatric critical care network approach. A separate process will begin shortly to explore this in detail.

2.6 Timeline

This work plays a vital role in improving the management of deterioration across our patient populations. Phase 1 of Martha’s Rule will form strong foundations for the remainder of the programme and will steer our future work in this area.

Please submit an expression of interest to be a part of this innovative programme by using the expression of interest form.

The closing date for registration is 9am on Wednesday 10 April 2024.

If you have any further questions, please email england.psimprovement@nhs.net with the subject heading ‘EOI query’. Please remember to include contact details for you and/or another member of your team.

Publication reference: PRN01239_ii