Marthas Rule Summative Evaluation_NIHR PSRC Network

SafetyNet / Martha’s Rule Summative Evaluation

National Martha’s Rule Summative Evaluation

This study is funded by the National Institute of Health and Care Research (NIHR) and is conducted by the six NIHR Patient Safety Research Collaborations (PSRCs), under the leadership of the NIHR Central London PSRC.

For any queries, please contact: marse@ucl.ac.uk

In April 2024, NHS England began implementing and testing Martha’s Rule in 143 hospital sites across England, as part of a major patient safety initiative aimed at protecting patients during their hospital stay. The initiative ensures that patients’ insights and concerns about their illness and recovery are consistently heard and acted upon. Tragically, some patients die in hospital because their concerns are not acknowledged or addressed. Martha’s Rule requires that patients are asked daily about how they are feeling, and it also enables patients, families, and staff to seek expert help in managing serious illness if a patient’s condition deteriorates and they feel their concerns are not being adequately responded to.

Although Martha’s Rule has been widely implemented, many unanswered questions remain about the most effective ways to implement it and whether it reduces patient deterioration across all groups. In response to an NIHR funding call to evaluate the impact of Martha’s Rule on patient safety improvement, the network of all six NIHR Patient Safety Research Collaborations (PSRCs) has started a large-scale summative evaluation of the initiative.

The study builds upon a formative evaluation conducted by the NIHR Policy Research Unit in Quality, Safety and Outcomes of Health and Social Care, which provided an in-depth exploration of how Martha’s Rule was being introduced using a case study approach across three NHS Acute Hospitals.

The summative evaluation will bring together leading patient safety researchers, clinicians, patients and public contributors to examine how Martha’s Rule is working in practice and its impact on patient outcomes, healthcare inequalities and NHS services.

The three-year research programme is being led by the NIHR Central London PSRC based at UCLH and delivered by SafetyNet – the NIHR PSRC Network. Each PSRC will study how Martha’s Rule is working in its own region and share findings nationally.

Funded by the NIHR, the PSRCs carry out research to improve patient safety across England, with a collective goal to address and reduce inequalities in health and social care. Find out more about the NIHR PSRCs.

Read the announcement

About the study

The study will provide the first comprehensive national evaluation of the initiative, generating evidence to inform the future development of Martha’s Rule across the NHS.

Researchers will analyse data from all acute NHS hospitals implementing Martha’s Rule to understand how different approaches to implementation affect patient safety outcomes, including rates of clinical deterioration, escalation of care, intensive care admissions and mortality.

Alongside this national analysis, researchers will undertake detailed work in 16 NHS trusts across England in a wide range of hospital settings, patient populations and regions. Through observations, interviews and detailed case studies, the team will explore how Martha’s Rule is being delivered on the ground and how it is experienced by patients, families and healthcare professionals, and the factors that help or hinder its success.

One important aspect of the study is to understand how Martha’s rule impacts on detecting and escalating deterioration across different patient groups, including how the initiative works for people who may face barriers to having their concerns heard, including people with communication difficulties, cognitive impairment, language barriers and those from underserved communities.

The programme will also assess the wider impact of Martha’s Rule on NHS services, examining how it affects clinical workloads, specialist review teams and healthcare resources. Health economists will evaluate whether the initiative represents good value for money while also considering its potential contribution to reducing healthcare inequalities.

Importantly, patients and family members with lived experience of serious deterioration and patient harm will play a central role throughout the study. Working alongside researchers as equal partners, they will help shape the research, interpret findings and ensure the evaluation remains focused on what matters most to patients and families.

The findings will be shared with NHS organisations, policymakers and healthcare professionals throughout the life of the project, helping to support the ongoing implementation of Martha’s Rule and improve patient safety across England.

Issues to be explored, using mixed research methods throughout:

Implementation processes and lessons learned
Workload of managing deterioration (structures, processes – activity)
Patient outcomes
Health inequalities and equity of services
Impact on staff and organisations
Macro and micro culture
Costs and benefits
Unintended consequences
How to evaluate complex interventions at scale

Research scope

Scope

Martha’s Rule Phase 1 and Phase 2 sites – NHS acute hospitals across England (n = 221)
16 sites for in-depth qualitative study
Adult & paediatric models sampled to capture institutional differences
Maternity and neonates out of scope

Patient & Public Involvement & Engagement (PPIE) and Equality Impact

Need for diverse patient representation – to ensure evaluation reflects full spectrum of patient experiences and needs
Need to capture patient priorities such as feeling heard as well as traditional outcome measures
Need to consider effects on staff, system burden, risk management
Equality impact assessment

Qualitative workstreams (with crosstalk with Quantitative Team)

Sixteen qualitative sites across six PSRC regions

Documentary Analysis

Review and analysis of key documents: Standard Operating Procedures and communications materials, structured wellness question aids and recording forms, etc.

Two phases of data collection involving:

Research observations
- General ward observations
- Focused observations of clinical meetings and events (e.g., handover, safety huddles, episodes of acute deterioration), and risk meetings, shadowing critical care outreach or similar or equivalent services
- Focused observations of the Patient Wellness Question(naire) (audio recorded in 2 sites*)
Interviews with range of patients (including CYP), family, implementation team, ward managers and medical staff, CCOTs, medical directors, Health Innovation Network leads

Six of the sixteen qualitative sites also quantitative Electronic Health Record sites

Public awareness survey: update (early discussions with YouGov to plan 20 item survey underway

Quantitative workstreams (with crosstalk with Qualitative Team)

Health Economics analyses throughout

Time-series analyses of all sites
Hospital Episode Statistics (HES) & Office for National Statistics (ONS) data
Care Hours Per Patient Day (CHPPD) data
NHS England Martha’s Rule returns*
Analyses of most/all sites’
DESERVE data
- Resourcing / infrastructure/ways of working of rapid response systems x 2

CCOT(s)

Whole weeks’ activity data re. all deteriorating patients (Martha’s Rule cases and all others) x 3
Time-series analyses at six sites (also qualitative sites)
Electronic Health Records

About Martha’s Rule

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 in 2023 a coroner ruled that Martha, aged 13, would probably have survived had she been moved to intensive care earlier.

In response to this, and other cases related to the management of deterioration, the then Secretary of State for Health and Social Care and NHS England committed to implement ‘Martha’s Rule’ – a patient safety initiative as part of a wider NHS strategy to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.

Martha’s Rule is intended to give patients, families, carers and staff, 24 hours access to rapid review from a critical care outreach team (CCOT) or paediatric critical care outreach team, if they are worried about a person’s condition.

Martha’s Rule includes three components:

The NHS must introduce a structured process to gather daily feedback from patients and families about their condition (initially for all in-patients in acute and specialist Trusts).
All staff must have 24/7 access to a CCOT for concerns about patient deterioration;
All patients, families, carers, and advocates must have access to the same 24/7 CCOT review, via well-publicised mechanisms;

In April 2024, NHS England introduced the implementation and testing of Martha’s Rule in 143 hospital sites across England.

DESERVE

National Evaluation of Deteriorating Patients Services: a Martha’s Rule Summative Evaluation sub-study

DESERVE is an NHS-wide evaluation investigating the services available to support unwell and deteriorating adults and children in hospitals across England. This will enable an understanding of the variety and extent of these services available nationally and how they have developed over time.

This national service evaluation is a sub-study of the NIHR-funded Martha’s Rule Summative Evaluation.

DESERVE aims to determine the current provisions across the NHS for unwell and deteriorating patients in acute hospitals:

The teams or individuals that respond to acute illness and deterioration
The warning scores and escalation pathways used.
The changes and improvements that may have occurred through the recent introduction of Martha’s Rule.
How structures and processes may affect patient outcomes.

DESERVE study committee

The sub-study is organised and delivered by the Martha’s Rule Summative Evaluation team:

Principal Investigators: Mr John Welch and Prof Ramani Moonesinghe

The study committee includes: Dr Kate Honeyford, Dr Dave Brealey, Dr Katharina Kohler, and Dr Chris Woodmansey.

How will the DESERVE study work?

Data collection will be via online forms sent after the recruitment invitation is completed (using the REDCap (Research Electronic Data Capture) system). The data collected will focus on health service interventions and workload rather than patient factors. Any patient variables will be de-identified.

When will the DESERVE study happen?

The survey of sites’ structure and processes to be completed by end of August 2026 (e.g., make-up of responding individuals or teams and escalation protocols used,

Details of patients escalated and their outcomes (activity and workload) for a one-week period in either September, October or November 2026. (This will be repeated in a one-week period in 2027, and in 2028).

What would we like you to do?

If you are involved in caring for deteriorating patients, we would like you to complete the recruitment invitation with:

Information about your hospital site(s) deteriorating patient services.
Contact details for site leads who will be able to report on how their service(s) manage deteriorating patients

Data collection details

The site survey – investigating the resource provisions for deteriorating patients across the NHS – will be open from June 2026 with completion date by the end of August 2026.

Data will be collected onto the webforms directly
Each outreach service will be a designated site and will submit a separate site survey

One-week snapshot audit – investigating activity and (anonymised) patient outcomes over a 7-day window – will be in a 7-day period of the local site’s choosing between 01/09/2026 – 30/11/2026.

Local sites will be enter data directly into the webforms, or if preferred paper forms will be available which can be used on-shift and during the data collection period, for local Collaborators to then enter the data into the webforms later on.
All Site Leads & Local Collaborators (as agreed within each site) will be named and listed within the collaborative authorship section

Access DESERVE survey