Adopting WhatsApp for urgent care escalation

Health Innovation North West Coast supported the testing and implementation in our region of Martha’s rule, a major patient safety initiative. One of the pilot sites was at Alder Hey Children’s NHS Foundation Trust. This case study focuses on Alder Hey and has been produced with the support of Health Innovation North West Coast.

Summary

Alder Hey Children’s NHS Foundation Trust was the first UK paediatric hospital to adopt digital platform WhatsApp for urgent care escalation. The Trust wanted to use a simple and accessible way for families to request an urgent clinical review following the introduction of Martha’s Rule, a patient safety initiative for inpatient hospital care that gives patients and families a means to seek an urgent review if their condition, or their loved one’s condition, deteriorates and they are concerned this is not being responded to.

Background

NHS England announced the implementation of Martha’s Rule at 143 sites in England in May 2024. Built on NHS England’s PIER framework and the Call 4 Concern initiative, this programme enhances early recognition and response to patient deterioration. While escalation pathways were in place at Alder Hey, the Trust acknowledged that families had no direct way to request an urgent review and saw the announcement as an opportunity to refine how families engaged with the escalation process.

Actions

The Trust identified WhatsApp as the tool that could enhance its escalation process. WhatsApp is a familiar, intuitive and accessible app that allows families to raise concerns instantly. Alder Hey worked with communications platform service provider LINK Mobility and consulted families and staff to develop a clear, jargon-free platform. Continued collaboration with LINK Mobility has allowed for further refinements to improve accessibility and reduce inequalities. Other trusts have since engaged with the supplier, evidence that the innovation continues to spread across the system.

Implementation

The Martha’s Rule initiative was developed through extensive collaboration and the Trust engaged with families, clinicians and other staff and patient representatives in its design and implementation.

The Trust spoke to hundreds of children, young people and families to shape each stage of the programme and to improve accessibility and clarity. Families said they were unfamiliar with the term Martha’s Rule, so the Trust tested several iterations of posters and other messages to explain the system. Families asked for an intuitive digital channel which led to the adoption of WhatsApp.

Feedback was built into improvement cycles, clinicians provided insights into triage pathways and nursing teams contributed to training design.

Staff also suggested linking to NHS guidance and exploring anonymous options, both of which were adopted.

A culture of openness was embedded throughout the project. Staff were actively encouraged to raise concerns and suggest improvements, which has strengthened psychological safety.

Outcome

Family-initiated urgent reviews have increased since the implementation. Streamlined communication means urgent reviews now take place within an average of 15 minutes from the first request, a significant improvement on previous rates.

The safer, more structured system has led to a statistically significant reduction in reported incidents of harm, near misses and no harm per 1,000 bed days, from 27 to 20. It has helped prevent deterioration, reduced the need for higher acuity care, and improved patient flow.

Staff report that miscommunication has been reduced while relationships with patients have been strengthened and there is a more collaborative approach to care. The 2024 NHS Staff Survey at Alder Hey showed an improvement from previous years and an 84 per cent positive score on the subject of concerns raised by patients and families.

Use of WhatsApp has led to greater equity by removing digital literacy barriers associated with app-based or web-based platforms, making escalation accessible to all families, regardless of technical ability.

Other Trust departments are exploring the use of WhatsApp for post-discharge support. The model has clear applications in several clinical and operational areas.

Spread

The Trust team is actively trying to spread their innovative use of WhatsApp throughout the NHS. Information governance issues were fully addressed by Alder Hey Digital team. The team worked with Health Innovation North West Coast, the regional representatives of the Patient Safety Collaborative, to explore ways of sharing the work with other NHS organisations. Health Innovation North West Coast worked with Martha’s Rule implementation sites on facilitating its adoption and hosted shared learning events, as well as organising a celebratory event to mark the end of the first phase.

The Trust has also worked with NHS England to identify ways to spread the work and outlined their scheme at regional conferences.

Ward staff at the Trust also benefit from teaching sessions, along with structured training materials, while the Trust’s Chief Nursing Officer and Allied Health Professions/Healthcare Professionals Lead chairs a monthly collaborative meeting where learning is shared with the network of Cheshire and Merseyside’s acute hospitals.

The Trust is exploring how the platform could support its Patient Advice and Liaison Service to improve engagement with children, young people and their families.

Patient and family feedback

Many families were unaware of Martha’s Rule, while others said it was regrettable that there was a need for the system but that it provided a crucial safety net.

Feedback from parents and young people reinforced the view that the process needed to be simple, accessible, and intuitive. Therefore, the opportunity was taken to redefine how families engage with escalation processes.

Quotes:

• ‘A useful tool that ensures we are listened to at the right time.’
• ‘I felt very worried about my son but felt reassured after the Martha’s Rule review that the right things were being done.’

Benefits

The benefits of the WhatsApp system include:

• It’s a familiar, low-barrier channel that allows families to raise concerns instantly
• Its accessibility removes digital literacy barriers
• Its simplicity obviates any additional anxiety for families
• It creates a clear and direct communication channel for staff, and supports documentation and tracking
• The platform’s simplicity also allows it to be scaled very readily.

Key learning

• There are clear benefits in piloting the system in limited areas, using the Plan-Do-Study-Act tool.  
• Streamlining communication leads to earlier and more effective intervention. Staff adopted a common language approach which refined their processes in identifying timely escalation of care.
• Extensive collaboration provides the basis for the successful adoption of a new system. Families, clinicians, digital and other staff and patient representatives were involved in the WhatsApp deployment in a truly multi-disciplinary approach
• The structured, transparent escalation process has reduced miscommunication and strengthened clinician-patient relationships.
• Face-to-face training sessions, alongside structured training materials, are highly effective, leading to a measurable increase in staff confidence in handling escalation requests, ensuring a consistent and timely response across teams.
• Identify key stakeholders and partners who can help in disseminating the system and ensure best practice.
• Promote a culture of openness and encourage families, patients and staff to raise concerns.

Read more about Health Innovation North West Coast’s support for the implementation of Martha’s Rule.

Martha’s Rule is now available in every acute hospital in England. Read more on the Health Innovation Network website.