No knee jerk implementation of Martha’s Rule

The important issue of a patient’s right to a second medical opinion has recently hit the headlines with Martha’s Rule, which relates to the tragic death of 13-year-old Martha Mills in NHS care and the circumstances surrounding this.

Haroon Siddique writing in The Guardian states the Inquest finding that “Martha Mills would probably not have died of sepsis if King’s College hospital doctors had heeded warnings” and moved her to intensive care.

Merope, Martha’s mother, talked about her family’s experiences in the foreword to a Demos report and calls for the NHS to learn from the tragedy. Her words have caused shockwaves across nation and NHS, with acute NHS patient safety lessons to learn from what she says.

There is a groundswell of support for Martha’s Rule, with Health and Social Care Secretary Steve Barclay committed to introducing the rule in England. This is excellent news, but development and implementation must not be rushed.

Some implementation concerns

There will undoubtedly be concerns in hospitals that Martha’s Rule will result in resourcing difficulties - putting further pressure on scarce NHS resources, if more people start asking for second opinions.

The NHS faces an infinite demand for finite resources and sadly will always be short of money, which seems to be an inescapable fact of our funding model. However, the Demos report states some encouraging research findings on Call 4 Concern (C4C) scheme referrals that take place in some Trusts:

“In 2019, a further evaluation of C4C referrals in Royal Berkshire was carried out. Over a seven-year period, 534 calls to C4C were made. The study found the service was being appropriately activated, with only 5% of referrals deemed not to be a C4C.” (p.10).

It may well be that Martha’s Rule will be used sensibly and will not affect NHS resources too much.

Publicise the Rule properly

Martha’s Rule must be publicised properly. The GMC Code binding doctors already describes a patient’s second opinion right, but Martha’s parents probably didn’t know about this. Martha’s Rule should not be tucked away in some Code or lost in the NHS Constitution, which patients may not be aware of.

How are people supposed to know when a second opinion is needed? Several specialists might be involved in the patient’s care and not everything is consented or discussed with the family - putting the onus on the layperson, who may not be equipped to make such decisions.

What happens if clinicians treating the patient disagree with the independent opinion? Who will arbitrate and, if the family requests a second opinion which later proves to be wrong, who bears responsibility and legal liability? Will fragmented opinions lead to devolved clinical responsibility?

Patients and families often feel ‘red flagged’ and subsequent investigations into failures in care have shown that such families get often labelled by clinicians as ‘difficult’ during handovers. Arguably asking for a second independent opinion is the ultimate way to saying that you don’t trust the clinical team and leads to being treated differently.

The important role of education

Healthcare staff have a key role in discussing Martha’s Rule and the respective power imbalance between the layperson and highly trained medical professionals. Power differentials exist both within and between the health professions; many nurses, for instance, advocate with doctors on behalf of patients and families.

Being a patient almost inevitably makes one vulnerable, in turn inhibiting open, assertive discourse. There is a fine balance to be struck between families in vulnerable situations seeking solace from health professionals and feeling able to, or being encouraged, to express challenge or explore doubt. Clinicians must develop skills which allow patients and families to find their voice, attending as much to what is not said as to what is.

The best clinicians actively listen, emotionally engage, and seek the optimum point between efficient service delivery and individualised care or experience. The challenge for clinicians is how to open debates and discussions that might otherwise be lost or never even occur. A formal patient or family right is only the start of that process.

What is a second opinion?

We must also consider what is meant by external or independent opinion – does it mean another consultant in the same hospital, or in another hospital but the same NHS Trust, or will it have to be sent outside the Trust?

Whilst we welcome Martha’s Rule, it must be underpinned by a well-thought-out, high-quality scheme - properly advertised, easily accessible and binding all Trusts. The Rule must not be viewed as a panacea to cure the NHS of all its patient safety ills. The issues are complex, and a policy choice such as Martha’s Rule is too important to fall foul of knee-jerk implementation.