By Isabel Hanson.
After the tragic death of thirteen-year-old Martha Mills in the UK, Martha’s mother Merope Mills said that she was told to “’Trust the doctors’… It turned out to be the worst advice I will receive in my whole life”.
Martha had developed sepsis from an abdominal injury. Her mother knew that something was wrong, and she expressed her concerns to hospital staff. Martha needed urgent escalation to intensive care, but despite her mother’s concerns, she did not receive life-saving treatment in time.
Sadly, Martha’s death is not an isolated case. The death of two-year-old Ryan Saunders in Australia in 2007 from misdiagnosed toxic shock syndrome is another poignant example. Martha’s family has called for doctors, bioethicists, and health policy advisors to think deeply about how we could prevent these errors from occurring in future.
Martha’s Rule, a Patient Activated Rapid Response (PARR) service proposed by Merope Mills and recently endorsed by the UK government, may be an important step towards reducing errors, and providing an additional pathway for patients and families to voice their concerns in the treatment process, while strengthening trust in healthcare relationships.
PARR services provide a phone number for patients, family and carers to voice their concerns and request an urgent clinical review. PARR has been successfully implemented in other countries, such as Ryan’s Rule in Australia, where it has improved clinical care and reduced some medical errors by identifying cases of early deterioration in patients.
While doctors and nurses are trained to listen and respond to the concerns of patients and their family, in practice, less than optimal healthcare settings can limit this capacity. Whether it be due to insufficient staffing or resources, the competing needs of other unwell patients, breakdowns in communication with patients or between clinical teams, or toxic hierarchical work cultures, in some cases the voices of patients and carers can go unheard. In these circumstances, PARR services can create a protected space for patients and carers to have their voices listened to and valued in the treatment process.
The effectiveness of Martha’s Rule will be determined by its implementation. Martha’s Rule has been framed in the media as the creation of a ‘right’ to a second opinion. In our recent article Getting Rights Right: Implementing ‘Martha’s Rule’, we support the introduction of Martha’s Rule but argue that there are ways to frame Martha’s Rule that could rebuild trust in the healthcare system more effectively than through a ‘right’ to second opinion.
The success of Martha’s Rule for patients and health professionals will be appraised in the years to come. In the Journal of Patient Safety and Risk Management a quadruple aim for successful PARR services has been proposed: improve patient experience, improve staff experience, reduce costs of care, and improve population health. In their review of evidence from PARR services across the world, they conclude that “challenges to effectiveness of PARR might stem from the trust of patients in the system and their ability to activate it during times of acute illness”.
Trust is foundational in every aspect of healthcare. When there is trust between patients and healthcare professionals, patients report less symptoms, improved quality of life, and more satisfaction with their treatment.
When adults or children become unwell, they are vulnerable, and doctors and nurses have the knowledge, skills, and resources to diagnose and treat their illnesses. This creates an unavoidable power imbalance between patients and healthcare professionals. This imbalance can be bridged by communication, listening, and trust.
Patients who seek care need to be able to trust that their doctors and nurses will listen to them and act in their best interests. The perception that patient concerns will not be respected and responded to can lead to a loss of trust and damage the relationship between patients (and their families), and healthcare providers.
There is a risk that if Martha’s Rule is perceived as the ‘right’ to receive a second opinion in every instance, that this could be corrosive to the very thing it seeks to advance: improved clinical care and trust between patients and healthcare professionals.
Introducing Martha’s Rule to the NHS holds the promise of preventing avoidable deaths and improving clinical care. However, the language and values underpinning the Martha’s Rule PARR service will be crucial for effective implementation.
As Martha’s Rule is implemented across the UK, let us focus on building a health service that strengthens trust between patients and healthcare professionals. A system that can move beyond the language of rights and be grounded in the foundational values of the NHS: clinical excellence, compassion, dignity, and patient-centred care.
Paper: Getting rights right: implementing ‘Martha’s Rule’
Authors: Mackenzie Graham [1], Isabel Hanson [2], James Hart [1], Peter Young [1], Sapfo Lignou [1], Michael J Parker [1], Mark Sheehan [1,3]
Affiliations:
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
Competing interests: None declared.