Professor Nitin Kapur is a Paediatric Respiratory and Sleep Physician at the Queensland Children’s Hospital in Brisbane, and President of the Paediatric & Child Health Division of the Royal Australasian College of Physicians.
This blog was produced for the .
Towards patient centric care
Health care delivery models globally are shifting, with patients becoming equal partners in their health care journey rather than just recipients of treatment.
These ‘patient centric care’ models prioritise patients’ needs, values and preferences and emphasise active patient involvement in their health. When delivered well, these models not only enhance patient experiences, but also improve health care outcomes.
Patient and family activated escalation systems such as Martha’s Rule in the UK and Ryan’s Rule in Australia encompass many principles of patient centric care such as respecting patient preferences, providing clear information and empowering the patient to raise their concerns in a timely and appropriate manner.
What is Ryan’s Rule?
Ryan's Rule is a three-step process supporting patients, families and carers to escalate concerns if a patient’s condition is getting worse or not improving as well as expected (Figure 1).
It was implemented in hospitals across Queensland, Australia, in 2013 following the tragic death of Ryan Saunders in 2007 from an undiagnosed streptococcal infection causing Toxic Shock Syndrome. Parental concerns about his deterioration were not responded to in a timely manner, and there were no formal mechanisms for the parents to escalate their concerns. The Department of Health subsequently introduced to minimise the possibility of a similar event occurring. It is recognised as a ‘safety net’ to support the recognition and response to acute clinical deterioration.
- Click or tap to see Figure 1: Steps in Queensland’s Ryan’s Rule activation
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Learnings from over 10 years of implementing Ryan’s Rule
Since its launch 11 years ago, there have been 13,977 activations in Queensland - a state seven times the size of the UK but with just one-twelfth of its population - averaging 3–4 calls per day. Ryan’s Rule has seen steadily increasing use, with annual activations quadrupling since 2016.
“Concerns not being heard” and “Disagreement” have been persistently the most common reasons for activations, with other reasons being inadequate pain management and the appropriateness of discharge. Requesting a second opinion from another health care team was an uncommon reason. Most activations (52%) did not result in changes to planned care, though 199 calls (2.7%) did result in urgent escalation of care, potentially evading a poor outcome. Paediatric data identified higher rates of change in management plans as a result of Ryan’s Rule activation in children, though urgent escalation of care remained uncommon. You can see a (PDF) from the 2024 International Forum on Quality on Quality and Safety in Healthcare held in Brisbane
Patient and carer education about the Ryan’s Rule process is crucial. It should be clear it is an escalation mechanism, not a complaint mechanism. Feedback suggested that the process was easy to activate with >90% activators reporting satisfaction with the process and the outcomes, despite no change in management in most cases. While data from the clinician’s perspective on this process is sparse, in a small cohort of responders (n=57), healthcare professionals tended to perceive activation as a "complaint", whilst those activating tended to perceive them as a "concern" ().
Inequality of access was a noted concern during the initial years. The system was seen as less favourable to the patients and families who do not speak English as their first language, as well those who are First Nations (Aboriginal and/or Torres Strait Islander people). This was mitigated by having information tailored to support diversity. There are now brochures in 11 languages besides English, and for adults, paediatrics, maternity and First Nation patients. You can for families and carers of people with a disability on the Queensland Government website.
The strengthening of the first two steps of Ryan’s Rule (see Figure 1), by investing in communication enhancement and training, was found to be pivotal in ensuring concerns are managed without need for the step 3 activation. While there were initial concerns that some patients may ‘weaponise’ this as a bullying or bargaining tactic, resulting in patient-led care instead of the goal of patient-centric care, this was not substantiated in most circumstances.
The teams responding to the activations have gone through some iterations over the years. The need for urgent clinical escalation of care was an uncommon outcome of the activation, and so the involvement of the medical rapid response team (MET or “crash” team) in every activation was considered a poor use of resource. In many centres, this was hence changed to a Ryan’s Rule team, the structure of which varied depending on resources available at each health jurisdiction but usually constituted a safety clinical nurse consultant as well as a relatively ‘senior’ junior medical officer. In smaller centres where such teams were not available, the rapid response team continued to respond to the Ryan’s Rule calls.
How is Martha’s Rule different from Ryan’s Rule?
While the broad tenets of Martha’s Rule – which has been tested in 143 sites in England - are similar to Ryan’s Rule, there are some key differences. NHS staff at these pilot sites are also empowered to activate Martha’s Rule to seek an independent review for the patient from outside their current treating team. Nearly 10% of Martha’s Rule activations over the last 12 months have been staff-led, so this may reflect that NHS staff are not always able to raise concerns through the usual escalation pathways. The data available from the Phase 1 (April 2024 - March 2025) implementation across 143 sites in England suggests that of the 573 activations, nearly 10% led to urgent escalation of care. Again, this is much higher than seen in Australia.
On implementing Martha’s Rule
I do believe that “vision without execution is hallucination”.
I do believe that “vision without execution is hallucination”. Implementing Martha’s Rule across the NHS in England or the UK presents a major change, requiring a significant investment of resources by the NHS; the already stretched rapid response teams should not be expected to bear the brunt of providing a 24/7 safety net.
Here in Australia, alternative pathways of response are already being devised to suit the needs of each service. Our experience suggests that the response needs to be rapid, and nurse- or doctor-led, but not necessarily activating the full rapid response team. There is also a need for organisational cultural change - not just a technical change - for this to succeed.
Success of any new process is fully dependent on the constituents being fully on board with this change. A thorough ongoing consultation and feedback needs to be incorporated as this gets rolled out to additional NHS sites.