Developing Recovery Oriented Systems of Care through Service Redesign
Driver Diagram
Introduction
The Road to Recovery and Changing Scotland’s Relationship With Alcohol stress the importance of recovery being at the heart of
any service or system of care that works with people who have a drug or alcohol problem. This has been emphasised further in
more recent Scottish Government publications, including HEAT A11: Guidance on Referral Pathways (2009) and the Quality
Alcohol Treatment and Support (QATS) report (2011).
In early 2011, a suite of core outcomes for Alcohol and Drug Partnerships (ADPs) were published
(www.scotland.gov.uk/Resource/Doc/924/0122646.pdf ) of which outcome 7 states that, ‘Alcohol and drugs services are high
quality, continually improving, efficient, evidence-based and responsive, ensuring people move through treatment into sustained
recovery’. ADPs can evidence progress against this outcome through several core indicators, agreed in 2012.
As there is no right or wrong route through recovery, and it can mean different things to different people at different times, for
individuals with a drug or alcohol problem, it means they need access to a range of interventions that will address their needs. This
will include interventions provided by the NHS, local authority and voluntary sector and also involve engagement with other people
in recovery, which may be through mutual aid groups or other forms of peer support.
Ensuring individuals have access to the right interventions at the right time, enabling them to move through treatment into sustained
recovery, will require a seamless interface between local services.
Core indicators have also been developed to evidence ADPs progress against this outcome and include the number of screenings
for alcohol use disorders, the number of alcohol brief interventions, number of people waiting over 3 weeks for treatment and
number of treatments received by individuals at 3 and 12 month follow-up.
Alcohol and Drug Services Driver Diagram
1
Over the past 3 years, the Scottish Government has recognised that in parts of Scotland, work has been undertaken to develop
local recovery oriented systems of care. In some cases, this has involved a realignment of local services, in others, it has involved a
system redesign.
This Driver Diagram aims to support ADPs and services that are considering, and those that have already embarked on, a process
of system redesign. It builds on learning from ADPs that have undergone a system redesign process and also QuEST which has
significant expertise in applying continuous quality improvement approaches within a range of different care settings. It focuses on
the system and the interface between services to ensure that they are responsive, ensuring people move through treatment into
sustained recovery. This document should be considered alongside the Healthcare Quality Strategy, Quality Alcohol Treatment and
Support (QATS), Essential Care, the Orange Guidelines and the National Quality Standards for Substance Misuse (which are
currently being refreshed), all of which provide evidence for high quality services. Links to each of these documents are available
within this toolkit.
What is a Driver Diagram?
A driver diagram is a method for identifying the key parts (Primary Drivers) of a system that need to be improved to deliver the
overall aim and then, for each part of the system, identifying the specific changes (Secondary Drivers) that can be made to improve
that aspect of the system. They are cause and effect diagrams which show how actual changes at a service level and above feed
into the delivery of a wider organisational or partnership aim.
This diagram provides drivers for change at service and ADP level. The practical use of the driver diagram approach is to:


Identify the actions that need to be taken to improve your system of care or service and
Provide, where possible, a link to a set of support resources that can be used to assist with those actions. Resources might
be in the form of tools and techniques or they might be in the form of case studies.
In summary, the driver diagram suggests steps to take that will deliver improvements in line with an overall aim and it provides links
to materials that will help to carry out those steps. The emphasis is on taking action.
Alcohol and Drug Services Driver Diagram
2
Links to materials
As much work around developing recovery oriented systems of care through service redesign is emerging in Scotland, links to
materials take learning from a range of redesign processes with different client groups. While the subject matter may be different,
the principles and processes will still apply.
Aim of the Drug and Alcohol Driver Diagram
This driver diagram focuses on supporting ADPs and services with achieving core outcome 7, as referenced above, and specifically
aims to ensure that:
Alcohol and Drug Services are responsive and are designed to enable people to move through treatment into sustained
recovery.
ADPs will benefit from considering all four primary drivers in developing, or improving, their recovery oriented system of care.
Where alcohol and drug services wish to improve the way their service operates, they should focus more on primary drivers three
and four.
What do I need to consider before using this Driver Diagram?
ADPs should consider:
 Are ADP partners signed up to reviewing the way local services operate and work together?
 Are ADP partners prepared to provide the necessary leadership to manage change, where required?
 What information or data does the ADP have access to that will help? This may include data from the Drug and Alcohol
Waiting Times Database, Scottish Drug Misuse Database or local databases.
 What is the timescale for implementing the system redesign? Does the ADP have the dedicated time and resource to drive it
forward? A Project Initiation Document and Project Plan can help with this.
 What additional support or expertise may the ADP require?
Alcohol and Drug Services Driver Diagram
3
Alcohol and Drug services should consider:
 Is the ADP commissioning our service leading a system redesign? If so, what is our role within this?
 Is senior management signed up to reviewing the way the service operates and prepared to provide the necessary
leadership to manage change, where required?
 What information or data does your service have that will help? This may include data from the Drug and Alcohol Waiting
Times Database, Scottish Drug Misuse Database or local databases
 What additional support or expertise does the service require?
Where should I go to for further help with using this Driver Diagram?
ADPs:
If you would like support with reviewing or improving your local recovery oriented system of care or using this driver diagram, then
please contact the Alcohol and Drug Delivery Teams at [email protected]
Alcohol and Drugs Services:
Alcohol and Drugs Services should contact their local ADP who will be able to provide information of any work being undertaken
locally. Local ADP contacts can be found via: http://www.drugmisuse.isdscotland.org/dat/dat.htm
Your help
If you are aware of any tools, resources or links that other ADPs or services would benefit having access to as part of this Driver
Diagram, please contact the Alcohol and Drug Delivery Teams at [email protected]
Alcohol and Drug Services Driver Diagram
4
Primary Drivers
Secondary Drivers
Roles and responsibilities of each service are developed, agreed and fulfilled
Services interface
seamlessly with
each other within
the recovery
oriented system of
care (ROSC)
Pathways through the ROSC are clear for services and clients
Services are delivered in an integrated and coordinated way
The information required by each service is accessible when needed
A range of interventions are available within the ROSC which support sustained
recovery
A system of care
exists which
enables sustained
recovery
The ROSC is accessible
Appropriate links exist between specialist and mainstream services that support
recovery
Use data to manage demand
Each service
effectively
manages its
demand
Minimise Created and Failure Demand
Systematically review Service User progress and quality of service provision
Each service
effectively
manages its
capacity
Alcohol and Drug Services Driver Diagram
Each service has the right skill mix to fulfil its role in the ROSC
Time available to spend directly with service users is maximised
5
PRIMARY DRIVER
SERVICES INTERFACE SEAMLESSLY WITH EACH OTHER WITHIN THE SPECIALIST SYSTEM OF CARE
Secondary Driver
Actual Change Actions
Roles and responsibilities of
each service are developed,
agreed and fulfilled
Pathways through the ROSC are
clear for services and clients
Alcohol and Drug Services Driver Diagram
Links to actual support
resources/ case studies/
examples
Currently a gap – we are keen to
gather examples of where this is
working well

In partnership with all stakeholders, develop and
agree clearly defined roles and responsibilities
for each service and its staff.

Share roles and responsibilities explicitly across
ROSC, with referrers and with service users

Agree mechanisms for identifying when a
service user is ready for each intervention –
linked to roles and responsibilities of each
service

Develop clear pathways within each service to
cover the client’s time with service, referral to
discharge, transfer or partial transfer
Quality Improvement Hub Process
Mapping:
http://www.qihub.scot.nhs.uk/SearchResults.aspx?tab=basic&q=(string(%
22process+mapping%22%2c+mode
%3d%22and%22))&pm=fql&searchT
erm1=process+mapping&target=eip

Consider how to put in place signals which will
flag when pathway is not being adhered to. This
can be picked up from a variety of sources such
as through regular structured case supervision,
Example 1: service user’s recovery
care plan agreed within two weeks of
assessment commencement. (this is
available from the WT database)
6
Secondary Driver
Actual Change Actions
or ongoing Continuous Professional
Development reviews



1
Map out the present pathways that service users
follow when moving through your service. This
should illustrate how you currently operate.
Develop a map of the ROSC with all services
involved in system – this should illustrate how
you aim to operate
Put a clear timetabled plan in place, outlining all
actions required to implement the ROSC
Links to actual support
resources/ case studies/
examples
DCAQ booklet – Goal Setting and
Case Review 1 :
http://www.qihub.scot.nhs.uk/media/1
69341/goal-setting&case-reviewbooklet.pdf
Quality Improvement Hub Process
Mapping:
http://www.qihub.scot.nhs.uk/SearchResults.aspx?tab=basic&q=(string(%
22process+mapping%22%2c+mode
%3d%22and%22))&pm=fql&searchT
erm1=process+mapping&target=eip
QATS report chapter 2:
http://www.scotland.gov.uk/Publicatio
ns/2011/03/21111515/6
Quality Improvement Hub Project
Initiation Document template:
http://www.qihub.scot.nhs.uk/media/1
69323/pid-template.doc
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
7
Secondary Driver
Actual Change Actions
Services are delivered in an
integrated and coordinated way
Alcohol and Drug Services Driver Diagram

Agree process for how support for individuals
requiring input from more than one service will
be coordinated, incorporating integrated
assessment of risk and support needs

If implementing specific role around care
coordination, develop guidance which identifies
the following; who will undertake this role, under
what circumstances, for whom, and which parts
of the system it will cover
Links to actual support
resources/ case studies/
examples
Quality Improvement Hub: Project
Plan and risk register template:
http://www.qihub.scot.nhs.uk/media/1
62558/template-project-plan.xls
http://www.kingsfund.org.uk/publicatio
ns/case_management.html
particularly pages 15 - 18
http://www.kingsfund.org.uk/publicatio
ns/case_management.html
particularly pages 15 - 18
8
Secondary Driver
Actual Change Actions
The information required by
each service is accessible when
needed
Alcohol and Drug Services Driver Diagram

Clear agreements in place across services on
who receives what information (e.g. named data,
numbers of new referrals per week) under what
circumstances (e.g. to minimise duplication of
collating data.

Implement
standardised
communication
templates at key transition points between
services within and outside ROSC.

Implement process which allows client case
notes and relevant information to be available
across services when required.
Links to actual support
resources/ case studies/
examples
Currently a gap – we are keen to
gather examples of where this is
working well
9
PRIMARY DRIVER
A SYSTEM OF CARE EXISTS WHICH ENABLES SUSTAINED RECOVERY
Secondary Driver
A range of interventions are
available within the ROSC which
support sustained recovery
Actual Change Actions

Carry out regular assessment of local need.

Review the evidence base to determine how
best to meet that need.
Links to actual support resources/
case studies/ examples
Effective Interventions Unit – Needs
Assessment Guidance:
www.scotland.gov.uk/Resource/Doc/26
487/0013530.pdf
QATS chapter 4:
http://www.scotland.gov.uk/Publication
s/2011/03/21111515/8
Essential Care Report 2008:
http://www.scotland.gov.uk/Publications/
2008/03/20144059/0


2
Gather data that will determine volume of need
for each part of the ROSC.
Quality Improvement Hub: DCAQ Data
Requirements 2 .
http://www.qihub.scot.nhs.uk/media/169
Review and align service commissioning 326/dcaq-data-requirements.xls
process based on outcomes required and levels
Lanarkshire ADP Recovery Strategy:
of demand.
http://www.lanarkshireadp.org/Aboutthe
ADP/Documents/LanADP%20Recovery
%20Strategy%202010-2014.pdf
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
10
Secondary Driver
Actual Change Actions
Links to actual support resources/
case studies/ examples

Desired outcomes for services are agreed,
established, reported and monitored
Currently a gap – we are keen to gather
examples of where this is working well

Gather feedback from service users and people
in recovery who are current and former users of
the service to contribute to service planning and
delivery
Alcohol Focus Scotland resources:
http://www.alcohol-focusscotland.org.uk/service-userinvolvement
Scottish Drugs Forum – Online Quality
Survey Tool:
http://www.sdf.resurv.co.uk/index.php
Scottish Drugs Forum - Quality
Improvement Programme:
www.sdf.org.uk/...quality/nationalquality-development-programme/

Incorporate support needs in relation to housing
meaningful activity and employability skills at
each step of recovery
SMR25 contains some information on
housing status:
http://www.drugmisuse.isdscotland.org/
publications/abstracts/ISDbull.htm
ISD Contact:
[email protected]
Alcohol and Drug Services Driver Diagram
11
Secondary Driver
Actual Change Actions
The ROSC is accessible
Appropriate links exist between
specialist and mainstream
services that support recovery

Ensure there are clear routes back into services
when and where required

Work with colleagues in Primary Care to develop Currently a gap – we are keen to gather
examples of where this is working well
a pathway at both commencement of care and
at key points when service user is ready to
address further recovery needs which specialist
services can support. This could be in relation
to:
o Relapse prevention
o Support with access to services that
support recovery
Work with housing providers to identify a
pathway for people within the specialist system
enabling housing needs to be met for those who
require it
Currently a gap – we are keen to gather
examples of where this is working well
Work with housing providers to identify a
process which enables the support needs of
those housed from the specialist system to be
reviewed



Alcohol and Drug Services Driver Diagram
Links to actual support resources/
case studies/ examples
Work with mainstream employability and
meaningful activity services to assess how
support requirements of people recovering from
their drug or alcohol problem can best be met
A Wait Off Our Shoulders, Camden
section:
http://www.scotland.gov.uk/Publications/
2010/06/02115503/4
Scottish Drugs Forum – Online Quality
Survey Tool:
http://www.sdf.resurv.co.uk/index.php
12
Secondary Driver
Actual Change Actions
Links to actual support resources/
case studies/ examples
Scottish Drugs Forum - Quality
Improvement Programme:
www.sdf.org.uk/...quality/nationalquality-development-programme/
Alcohol and Drug Services Driver Diagram
13
PRIMARY DRIVER
EACH SERVICE MANAGES ITS DEMAND EFFECTIVELY
Secondary Driver
Use data to manage demand
Actual Change Actions

Identify variation not in response to client need –
e.g. between clients, care workers.

Gather demand data – number of referrals,
referral source, number taken onto caseload,
number of contacts, DNA rate, range of
interventions offered/ delivered, modality of
delivery eg proportion of group work to individual
Links to actual support
resources/ case studies/
examples
Emerging National Quality Standards
work will help to address this change
action.
Quality Improvement Hub: DCAQ
Data Requirements 1 .
http://www.qihub.scot.nhs.uk/media/1
69326/dcaq-data-requirements.xls
Latest published
information
1
Waiting
Times

Consider whether groupings of demand exist in
terms of clients requiring support. For example;
pregnant clients, offenders, those with Mental
Health needs. Consider how much time these
client groups will require.
QI Hub Psychological Therapies
DCAQ guides3:
http://www.qihub.scot.nhs.uk/media/1
69329/improving-access-booklet.pdf

Implement a drop-in, based on demand and
capacity data. Ensure this does not compromise
planned care provision time
http://www.qihub.scot.nhs.uk/media/1
69332/capacity-booklet.pdf
http://www.qihub.scot.nhs.uk/media/1
69335/demand-booklet.pdf
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
14
http://www.qihub.scot.nhs.uk/media/1
69338/clinical-admin-booklet.pdf
http://www.qihub.scot.nhs.uk/media/1
69341/goal-setting&case-reviewbooklet.pdf
Latest published Prevalence data
Minimise Created and Failure
Demand

Identify and eliminate different types of waste
within the ROSC
Wastespotter’s Guide for Mental
Health 1 :
http://www.qihub.scot.nhs.uk/media/1
62494/mhc_waste_spotter_guide_se
ptember_2010.pdf

Implement client focussed booking processes
Choice and Partnership Approach:
http://www.capa.co.uk/

Develop, agree and implement a DNA policy
appropriate for the context. Implementation must
include information for clients on the policy
Develop, agree and implement a CNA policy
appropriate for the context. Implementation must
include information for clients on the policy


1
Implement a process that allows for unused
appointments to be filled at short notice
DCAQ booklet – clinical
administration 2 :
http://www.qihub.scot.nhs.uk/media/1
69338/clinical-admin-booklet.pdf
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
2
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
15
Systematically review Service
User progress and quality of
service provision

Implement process that enables regular review
of progress in line with recovery plan
DCAQ booklet – Goal Setting and
Case Review 1 :
http://www.qihub.scot.nhs.uk/media/1
69341/goal-setting&case-reviewbooklet.pdf
Scottish Drugs Forum – Online
Quality Survey Tool:
http://www.sdf.resurv.co.uk/index.php
Scottish Drugs Forum - Quality
Improvement Programme:
www.sdf.org.uk/...quality/nationalquality-development-programme/

Implement caseload management system
DCAQ booklet – Goal Setting and
Case Review6:
http://www.qihub.scot.nhs.uk/media/1
69341/goal-setting&case-reviewbooklet.pdf
Wiseman Workload Measure6
http://www.qihub.scot.nhs.uk/media/2
23260/wwm_guidance%20notes_oct
_2011.pdf
1
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
16


Implement case review
supervision sessions
in
professional
Use recovery care plans routinely
DCAQ booklet – Goal Setting and
Case Review6:
http://www.qihub.scot.nhs.uk/media/1
69341/goal-setting&case-reviewbooklet.pdf
Lanarkshire MyRAP tool:
http://www.lanarkshireadp.org/Profes
sionals/SupportforProfessionals/Docu
ments/MyRap.pdf
Scottish Drugs Forum – Online
Quality Survey Tool:
http://www.sdf.resurv.co.uk/index.php
Scottish Drugs Forum - Quality
Improvement Programme:
www.sdf.org.uk/...quality/nationalquality-development-programme/

Alcohol and Drug Services Driver Diagram
Quality is evidenced in service provision
QATS chapter 4:
http://www.scotland.gov.uk/Publicatio
ns/2011/03/21111515/8
National Quality Standards:
http://www.scotland.gov.uk/Resource/
Doc/149486/0039796.pdf
Orange Guidelines:
http://www.nta.nhs.uk/uploads/clinical
_guidelines_2007.pdf
17
PRIMARY DRIVER
EACH SERVICE MANAGES ITS CAPACITY EFFECTIVELY
Secondary Driver
Actual Change Actions
Each service has the right skill
mix to fulfil its role in the ROSC

Conduct assessment of current skill mix within
service

Map skills required to meet type of demand
presenting and consider if service is best placed
within the ROSC to meet that demand

Provide appropriate development opportunities
for staff in order to bridge the gap between
existing and required skills

Alcohol and Drug Services Driver Diagram
Redesign roles in line with skills needed
Links to actual support
resources
Health Scotland Training Needs
Analysis Guide:
http://www.healthscotland.com/docu
ments/5034.aspx
STRADA Training Suite:
https://www.projectstrada.org/v1/inde
x.php?option=com_eventlist&view=ca
tegories&Itemid=132
Currently a gap – we are keen to
gather examples of where this is
working well
18
Secondary Driver
Time available to spend directly
with service users is maximised
1
Actual Change Actions
Links to actual support
resources

Conduct audit of how staff time is split across
different activities that are undertaken by service
Mental Health Activity Tracker 1 :
http://www.qihub.scot.nhs.uk/media/2
23269/diary%20tracker%20template
%20v8%20for%20service.xls

Analyse results of audit and look for
opportunities to increase direct client contact
time
Mental Health Activity Tracker
example analysis7:
http://www.qihub.scot.nhs.uk/media/2
23272/mental%20health%20tracker%
20analysis%20sample%20analysis%
20website%20feb%2012.xls 
Test new ways of organising how time is spent
Quality Improvement Hub7:
http://www.qihub.scot.nhs.uk/SearchResults.aspx?tab=basic&q=(string(%
22pdsa%22%2c+mode%3d%22and
%22))&pm=fql&searchTerm1=pdsa&t
arget=eip
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
19
Secondary Driver
1
Actual Change Actions
Links to actual support
resources
PIN Guidelines:
http://www.scotland.gov.uk/Publicatio
ns/2003/02/16388/18343
Please also refer to your own policies
for managing sickness absence

Look at sickness rates and policies for managing

Look at travel time and routes if applicable
Releasing Time to Care guidance
(available through your NHS Board
Improvement Teams)

Explore effectiveness of meetings
Productive
Leader
guidance
(available through your NHS Board
Improvement Teams)

Ensure effective use of email
Productive Leader guidance
(available through your NHS Board
Improvement Teams)

Explore potential to increase use of groups in
line with the evidence base
DCAQ guides – Demand Booklet 1 :
http://www.qihub.scot.nhs.uk/media/1
69335/demand-booklet.pdf

Look at volume and nature of administrative
DCAQ guides – Capacity Booklet8:
http://www.qihub.scot.nhs.uk/media/1
Please note this tool was developed for use in Mental Health, and may require some modification when applying to Drug and Alcohol systems improvement.
However the principles remain the same and can be applied in the context of drug and alcohol service provision with minor adaptation. If you require
assistance, contact your local Improvement team.
Alcohol and Drug Services Driver Diagram
20
Secondary Driver
Actual Change Actions
duties performed by non-administrative staff
Alcohol and Drug Services Driver Diagram
Links to actual support
resources
69332/capacity-booklet.pdf
21