Recruitment.

Recruitment and workshops occurred between July and October of 2021. Local community members were recruited for the consumer workshops through advertisements in local papers, Facebook invitations and emails circulated to people connected to the Local Health District (LHD). Eligible people lived within the new facility’s proposed catchment (49 suburbs) in Sydney, New South Wales, Australia, as defined by the LHD’s planning team on 16^th July 2021. Health providers were recruited via broadcast emails sent by the LHD.

Study advertisements contained a link to an online questionnaire hosted on the REDCap platform [17]. In accordance with the Australian National Statement on Ethical Conduct in Human Research [18], clicking on the link and completing the questionnaire was taken as implied consent for their data to be collected. The questionnaire was used to lodge participants’ expression of interest in the study and asked for demographic data including age, gender, location, ethnicity, and contact information. Health providers were asked to specify their role and specialty, while consumers were asked about their health, including whether they had a chronic condition. All data was securely stored on the university’s servers and was used only to report the demographics of participants collectively. No remuneration was offered for participation in the workshops or supplementary interviews. Everyone who submitted an expression of interest questionnaire and was sent written information about the study. All participants of the workshops gave formally written consent to take part.

Workshops.

The specialist unit model was presented at five consumer and five health provider two-hour workshops. All these workshops were held in English. The workshops (held separately for consumers and health professionals) were held online using the Zoom videoconferencing platform and were offered both within and outside of working hours. Planned face-to-face focus groups were not possible due to COVID lockdowns. Supplementary interviews with interested participants identified in the workshops were conducted online and over the phone.

Workshops were designed to elicit the strengths, barriers and enablers of the specialist care unit model. Two researchers (from a team of six) facilitated the workshops. One researcher introduced the topic and asked the questions while the other took detailed notes. To minimise bias, the researchers chosen for each workshop / model of care were different, but at least one of the pair of researchers for each group was a postdoctoral health service researcher, experienced in qualitative methods. After each workshop the detailed notes were reviewed and discussed by both researchers to agree they represented an accurate record of the proceedings.

Each workshop presented a scenario that illustrated the model of care, featuring a person with a high impact, high prevalence condition (e.g., dementia). After introducing the workshop, facilitators described the specialist unit model, alongside the scenario that presented the model of care in a patient context. Specialist dementia units were understood as being located within a larger public hospital.

Harrold is an 82-year-old man with mild dementia, who develops a urinary tract infection. He has been referred to a specialist dementia unit in a geriatric care ward at the local hospital. Harrold and his family are reassured that he will receive the highest level of evidence-based care for dementia from a specialised team of health professionals.

After presentation of the scenario, the researchers asked questions from the perspective of the patient, then more generally, about the strengths and weaknesses of the model, whether it seemed appropriate and usable, and to identify any safety issues they might envision. Table 1 shows the wording of the questions. Health providers were asked the same questions but from the perspective of delivery of care. Researchers prompted participants to elaborate where necessary. Detailed notes on the discussions were taken by the second researcher. Scenarios and schedule of questions were refined through a pilot focus group with people from outside of the geographic area, who then gave feedback.

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Table 1. Schedule of questions used in the workshops after presentation of the patient scenario.

https://doi.org/10.1371/journal.pone.0293025.t001

Analysis.

Handwritten notes from workshops were de-identified and aggregated into a consumer, and a provider narrative summary (in Microsoft Word) which followed the structure of the question framework. The narrative was then analysed deductively by two senior members of the research team (AC and NR) by collating and synthesising barriers and facilitators, risks, and benefits of the specialist model of care. Verbatim or paraphrased quotes from the handwritten notes were matched to each point. Results were verified by the whole team. Survey responses were analysed using the Microsoft Excel software tool to generate descriptive statistics of the participants’ demographics. These data were compared to the catchment demographics to assess how well they represented the local community.

Consumers.

For consumers’ health conditions, there was a spread across the major physiological systems with the majority having experienced cardiac, lung or bone related conditions. This is representative of the catchment where cardiac, chronic pulmonary disease and musculoskeletal problems are listed in the five most common causes of hospitalisation (see S2 File) [19]. All the consumers were proficient in English with 23% speaking another language at home (e.g., Punjabi, Serbian). Although most of the consumers identified as Australian (82%), there was evidence of ethnic diversity (e.g., Indian, Middle Eastern), which also reflects the demographics of the catchment.

Providers.

Fifty-five percent of the providers worked in the LHD while the remaining 45% worked in areas outside of the LHD, but within the new hospital catchment. The providers worked in a variety of professional roles including management, nursing, allied health, medical, general practice and administration. Allied health professionals included physiotherapists and speech pathologists (Fig 1)

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Fig 1. Distribution of provider roles in focus groups.

https://doi.org/10.1371/journal.pone.0293025.g001

The providers reported having a diverse range of medical specialties with most having an ‘other’ speciality such as obstetrics and psychiatry (33%), then bone (16%), lung (15%), abdominal (12%), heart (10%), psychology (7%), and renal dialysis (8%).

Most of the providers rated their English proficiency as excellent (95%) with 31% speaking another language at home (e.g., Italian, Mandarin). Although most of the providers identified as Australian (83%), there was evidence of ethnic diversity (e.g., South American, Aboriginal and Torres Strait Islander).

Summary of findings.

The specialist care unit model presented was viewed favourably by consumers and providers as being convenient, patient-focused and likely to deliver high quality care. It was also noted as being easy to navigate (in contrast to other models of care) as every service that was needed was there in the unit. Both consumers and providers valued the sense of reassurance that a specialist team brings. Providers were positive about the model, stating evidence of good outcomes from such specialist units and that they “rarely hear negative feedback” about the model. Some consumers were uncertain about what they perceived as a narrow focus of the specialist units and wondered if this would mean co-morbidities might be overlooked or not treated as well, as by a generalist. There was also debate among both consumers and providers as to whether specialist units would match the particular needs of the community. Key issues identified by the participants are shown in Table 3. We have structured the results below under the broad headings of: (i) barriers, challenges and risks (for consumers then providers), and (ii) enablers and opportunities. Extracts from the notes (paraphrased or shorthand quotes) are given to illustrate issues raised in the workshops.

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Table 3. Themes from the workshops for consumer and provider participants.

https://doi.org/10.1371/journal.pone.0293025.t003

Barriers, challenges, and risks.

Consumers and healthcare providers identified barriers and challenges that may be encountered when delivering or receiving care in specialist units. Key themes identified by both consumers and providers included accessibility, a perceived narrow scope of practice, patient wellbeing, coordination with other services, resources and infrastructure, and awareness and expectations of the unit within the hospital and the community.

Consumers. (i) Accessibility. The first issue that consumer participants identified was accessibility to the specialised unit. Specialist units were seen as few and far between and may involve burdensome travel. Issues around infrequent, inconvenient, or unsafe public transport, lack or cost of parking, and problems with wayfaring in an unfamiliar hospital were all mentioned. Travelling to a distant specialist unit when an acute complication arises may not be an option if there is a closer general facility. The distance may also be a barrier to family or friends who wish to support the patient. Specialist ambulatory units may not be available out of hours and may negatively influence the decision to seek care in a timely manner. There were also fears that specialist units may not be publicly funded, resulting in increased costs to patients.

Complications may not be prioritised if they have to travel to the specialist unit. [Consumer 1 interview 2]

(ii) Narrow scope of practice. The second theme was around patient factors that consumers perceived may make the specialist unit a poor fit or even unsafe for some patients. There was discussion around possible mismanagement of “border-line” cases who may not fully meet the criteria for a specialist unit, potential for missed care that the specialist unit may not often manage, and a perception of a narrow, inflexible, specialist focus. Co-morbidities may mean the focus should be on a different condition to that of the specialty (e.g., a patient with stable, well-managed dementia but unstable angina in a dementia unit). Linked to the perceived narrow scope of care was uncertainty that if the patient’s condition changed, would they be able to stay in the unit or would they have to be relocated. Moving to another unit was seen as causing possible disruption to already initiated care and distress to the patient. Broader, generalist services were seen as perhaps more suitable and safer for patients with complex care needs. There was also uncertainty around the appropriateness of care in an inpatient specialist unit rather than other models such as ‘hospital in the home’.

Specialist units have a too narrow focus. [Consumer 1 Workshop 6]

How do the medical staff choose where to admit the patient if they don’t fit the criteria for the special unit but still need that specialized service? [Consumer 3 Workshop 8]

Is it appropriate for this patient to be treated in this environment? Does he really need to be in the hospital for this or can it be treated at home? [Consumer 1 Workshop 8]

(iii) Patient wellbeing. Patient wellbeing was also questioned in a specialist unit, in one case triggered by a prior negative experience of such a unit. In contrast to the hospital in the home model, consumers thought that patients may be anxious or overwhelmed by the unfamiliar setting (especially if they are living with dementia) and the large spectrum of patient conditions in the unit could be detrimental. There was also a perception among some participants that patients would be cut off from home, family or other supports if in a specialist unit. Some consumers called for adjacent family or carer accommodation to facilitate support for the patient.

The patient is not in their own environment—it may be a trigger for anxiety. [Consumer 2 Workshop 8]

(iv) Resource and infrastructure concerns. Consumers identified resource and infrastructure concerns associated with the specialist unit model. Limited funding could lead to understaffing or use of untrained or inexperienced staff which in turn would lead to a poorer quality of care. It could also result in equipment or other resources being suboptimal. Limits to specialist unit capacity was seen as another risk which required general services as a back-up. Investing in specialist units may not be appropriate for the needs of the community and may limit services.

The specialist unit is only good if the general hospital can handle overflow. [Consumer 2 workshop 6]

Providers. Providers identified several barriers, difficulties and risks associated with specialist hospital care, covering many of the same issues as consumers. Providers discussed potential access barriers to specialist unit care including burdensome patient travel over long distances.

(i) Accessibility. Further barriers to access were the limited capacity of the units. Once full, there was a perception that there was nowhere else suitable to transfer patients. Specialist units are often well staffed with allied health professionals. If a patient cannot access a specialist unit bed, they are likely to be placed elsewhere in the hospital with limited allied health support which could be detrimental.

The specialist unit could lack flexibility or flex beds to put overflow patients elsewhere in the hospital. [Provider 2 Workshop 6]

Sometimes these models become so popular they are victims of their own success. [Provider 1 Workshop 4]

(ii) Narrow scope of care. The narrow scope of practice in a specialist unit was a key concern. Providers discussed the “tunnel vision” that can result from a too narrow focus of care and the trend toward more specialisations when what was needed were more mixed specialties. They also speculated that if criteria are too tight, then maybe no one fits, making it a redundant service. Further, inflexible inclusion/exclusion criteria could lead to a lack of choice for patients and their families about where they are best treated.

The Unit [develops] tunnel vision and end up having no access to dealing with other conditions. [Provider 1 Workshop 8]

Need the ability to access all hospital resources when you want to access them. Too much specialisation means you lose the ability to care for simple things. [Provider 5 Workshop 2]

Safety issues were raised by providers. Co-morbidities were frequently mentioned with a perception that a specialist unit may not be able to successfully diagnose and manage other conditions. Concurrent mental illness was cited as an example of where placement in a specialist medical unit may be inappropriate. In addition, there was a perception that the system lacked robust referral protocols that ensured patients could access the care they needed from other health providers.

Depends on the setting facility that the patient needs. For example, if a patient with mental health issues is in a cardiac-specific unit, the patient may decompensate their mental health while in care of cardiac unit. [Provider 4 Workshop 2]

(iii) Resources and infrastructure concerns. Providers identified potential resource barriers and health system factors that may affect specialist hospital care. Limited capacity to take other patients may lead to bed block, or less flexible bed management if there is a regional crisis and a need for extra beds. Design of the wards and the specialisation of the staff may make them a poor fit for other patients. Providers speculated that specialist hospitals and units may not be integrated well with other hospitals and services in the district.

(iv) Coordination with other services or departments. Coordination and quality of care were also identified as barriers. Admission barriers included difficulties in appropriately placing patients, and administration and triage concerns.

We’d face frustration every day in terms of which specialty the patients should fall under. One solution is to use admission matrices that help decision making regarding who [which specialty team] patients get admitted under. [Provider 1 Workshop 2]

There’s a risk of hot potato-ing in terms of what is the underlying condition? [Provider 1 Workshop 2]

Also, in line with consumers, there was speculation around whether a specialist unit would suit the needs of the area as they only serve a subset of patients. Providers noted that smaller hospitals would struggle to adequately staff and resource a specialist unit which were perceived as expensive to establish and operate.

(v) Awareness and expectations. There were conflicting views on patient demand for specialist units. Some thought there would be a lack of patient interest and so low demand, while others believed they could be overwhelmed.

Everyone goes there because they know it is good, then the number of beds becomes an issue. [Provider 1 Workshop 6]

Enablers and opportunities.

Across workshops, consumers and providers identified benefits of the model, and supporting factors or enablers that may assist in delivering high quality, specialist unit care. Key themes identified by both consumers and providers included: systems and processes, accessibility, people, comfort and environment, resources and infrastructure, education and skills.

Consumers. (i) Expert care. The benefits of the model were clearly articulated by the consumers. The high quality of care and the ease of a “one stop facility” were mentioned frequently. Specialist trained staff were seen as more compassionate and knowledgeable about the condition and so more likely to give high quality care. As a result, the patient’s outcomes would be better. The idea of wrapping appropriate, specialised services around the patient was noted several times as particularly valuable to shift the focus onto the patient:

The focus of care is on the patient and not on the provision of services. [Consumer 1 interview 2]

It’s important to have all the services in the one unit that are specialised. [Consumer 1 workshop 2]

(ii) Coordination with other services or departments. Consumers described the importance of systems and processes to support the delivery of specialist hospital care. Participants spoke of needing efficient access to other services, including sharing of medical records, mitigating the perceived hazard of missing care for co-morbidities.

You would need access to records from different facilities, in case the patient needs other special services. [Consumer 4 Workshop 6].

(iii) Accessibility. Physical accessibility was raised as an important enabling factor for specialist hospital care, such as drop off and pick up spots, proximity to public transport, and services for culturally and linguistically diverse patients. Appropriate security to maintain the safety of patients, staff and visitors was also mentioned for high-risk units.

It would be easy for family members to transport the patient to the unit if site is local. [Consumer 3 workshop 6]

(iv) Competent staff and stable funding. Finally, consumers discussed at length the importance of able and competent multidisciplinary staff and stable funding.

Staff need adequate training and education for care and appropriate assessment, and to designate the patient to the correct specialized care. [Consumer 3 Workshop 8].

Providers. (i) Awareness and expectations. Providers identified patient, staff, and community education as key enablers for the success of the proposed specialist unit model. This included ensuring the community and potential referrers (e.g., GPs) are aware of the benefits and limitations of the model, and do not have unrealistic expectations.

If somebody turns up with something even as simple as a urinary tract infection–everybody needs to know the plan in the event of a deterioration. This does not mean just listening to the family. [Provider 3 Workshop 4]

(ii) Coordination with other services or departments. Providers identified key systems and processes as enablers for the specialist unit model including streamlined admission pathways such as rapid assessment protocols for patients that do not need to go through Emergency. A high degree of collaboration across departments was seen as necessary to support these pathways, and to transfer care easily if needed. This relied too on a good and flexible culture among all the hospital’s staff, and some flexibility in the admission criteria.

You can’t know everything, even in a specialised unit [so one needs to collaborate with other health professionals]. [Provider 1 Workshop 4]

Implementing processes and pathways in specialised units means that all the staff know what needs to be done for that patient at different stages in their care and the expectations for discharge. [Provider 1, workshop 4]

Integration with multidisciplinary care is needed. For example, [Hospital X] had a mental health unit connected to the general hospital and flow of patients between units was easy. [Provider 1 Workshop 2]

You need some leeway in the criteria so people get in when they need to, but not too loose that everyone ends up there. [Provider 1 Workshop 6]

As in the consumer workshops, providers emphasised the key role of well-trained appropriate staff including specialist staff, multidisciplinary teams and specialist emergency teams. Providers also commented on the need for complementary models of care, especially integrated care. This would ensure referrals and transfers to other health services outside of the specialist unit were smooth.