Quality and Outcomes Framework, 2023-24

The Quality and Outcomes Framework (QOF) covers 21 clinical, 5 public health and 2 quality improvement aspects of GP practice activity and represents one of the richest sources of information from primary care.

QOF data is collected primarily to support payments to GP practices and is a valuable source of information for many secondary uses.

Some aspects of QOF published by NHS England are also presented by the Care Quality Commission, NHS.UK, and other information dissemination routes.

The accuracy of QOF information depends on:

• Clinical case finding by GPs: for example, information from QOF diabetes registers or about QOF diabetes indicators depends on people with diabetes being diagnosed
• Clinical coding: for example, when patients are diagnosed with diabetes, the quality of QOF data about people with diabetes depends on the GP practice maintaining accurate and coded clinical records.

QOF data for this release was downloaded on 1 July 2024, and so include all adjustments up to 30 June 2024.

Following validation, the published QOF dataset includes data for 6,267 practices. In the 2023-24 reporting year 6,444 practices eligible for QOF were open and active at some point; this gives a coverage of 97.3%.

The following changes have been implemented in 2023-24:

• The total points available to practices (635) remains the same as last year. The ‘Indicator definitions’ file (available on the publication homepage) shows the points allocation for 2023-24.
• A number of indicators have been added/retired for the 2023/24 reporting year. All  the Quality Improvement domain indicators are changed annually. A new Cholesterol indicator group, comprised of two indicators, has been added.
• For the 2023-24 reporting year, the depression disease register has been changed; it only captures patients who have been newly diagnosed with depression (i.e. diagnosed within the reporting year, or in the last 3 months of the previous reporting year but did not receive a review in that reporting year). The 2023-24 depression register can therefore be considered a representation of incidence, and the figures cannot be compared with depression disease register figures for previous years.
• For the 2023-24 reporting year, the obesity disease register criteria has changed. BMI thresholds have been appropriately adjusted for ethnicity in line with NICE guidelines – either with a BMI ≥30 in the preceding 12 months, or a BMI greater than or equal to 27.5 kg/m2 recorded in the preceding 12 months for patients with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background. 

The total points available to practices is 635 and all payments will be subject to prevalence and list size adjustments.

Additional information can be found in https://www.england.nhs.uk/gp/investment/gp-contract/

QOF is extracted from CQRS and in years prior to 2019-20 was processed and then passed to external regional local office representatives for validation.

In 2019-20 following the abolition of regional local offices and after consultation with NHS England this validation process was integrated into an automated process carried out by NHS Digital, now part of NHS England, to ensure consistency of approach and outcome.

The validation process for the current year excluded:

109 practices where the total number of points achieved was less than or equal to the total number of QOF points that can be achieved for indicators which require a manual response only.

0 practices which closed before 1 April 2024 and this closure was recorded before 1 July 2024.

3 practices which did not have a status of ‘A’ (Active) on 31 March 2024.

0 practices where the count of registered patients was not recorded in the 'Patients registered at a GP practice' publication in any of the 3 months prior to 31 March 2024.

The first validation rule that excludes a GP practice is counted as the reason for exclusion from the publication, although a GP practice may fail more than one validation rule. Details of GP practices excluded for these reasons can be found in the PRACTICE_VALIDATION_OUTCOMES.csv which is part of the publication.

QOF information relates to achievement over a financial year. QOF achievement can take some months after financial year-end to be agreed between practices and NHS England.

The extract of QOF data for this publication was made from CQRS on 1 July 2024. This delay after the financial year-end maximises the number of practices whose achievement is signed-off, whilst still allowing publication in August.

QOF publications are available on the NHS England website at Quality and Outcomes Framework

Included is a summary of the 'main findings', 'technical annex', 'FAQ annex' and 'data quality annex'. Information at GP practice, Sub ICB Location, ICB, Region and National levels are presented in Excel workbooks, and the underlying (‘raw’) data is available in .csv files which can be found on the publication homepage.

An online database is provided which allows users to view detailed information about practices in a more visual format.

Where NHS England data is reused, NHS England should be clearly acknowledged as the data source. Please see Terms and conditions for more information.

QOF information is collected primarily to support QOF payment calculations under GMS contracts, and this data collection is (for clinical information) based on detailed coded business rules. QOF clinical registers may not match disease definitions used by epidemiologists and may not cover all ages. As a result, QOF indicators may not be defined in the same way as similar measures from other sources.

It is important to take account of QOF definitions (including coding contained in QOF business rules) before comparing QOF information with other data sources, for example comparing QOF disease prevalence with expected prevalence rates based on public health models.

Individual QOF indicators and/or the business rules associated with them can change from year to year. Levels of achievement and personalised care adjustments (formerly exceptions) rates therefore may not be directly comparable each year. 

Achievement

Payment protection has been applied to the QOF service for 2020-21, 2021-22 and 2023-24, though was not implemented  2022-23. This may affect QOF activity and/or its recording for these years.

When comparing QOF data with and between years in which payment protection has been applied, users should be aware that published achievement data for payment protected indicators may not be indicative of activity in that year.

NHS England have published information about the implementation of QOF payment protection:

• 2020-21: Guidance for General Medical Services Contract 
• 2021-22 : Letter to practices
• 2022-23 The ending of income protection can be found in a letter to practices.
• 2023-24: QOF guidance for 2023-24

Changes to NHS geographies

On 1 July 2022 Integrated Care Boards (ICBs) were established as statutory bodies. With Sub ICB Location replacing CCG level data and ICBs replacing STP level data. For further information on these changes please see the following links:

• NHS England - ICBs in England
• Organisation Data Service (ODS) - ICBs

GP practices have been mapped to their respective PCNs, Sub ICB Locations, ICBs and Regions using reference data current on 1 April in the year of publication. This mapping has been applied to data for both the current and previous reporting year; this should be borne in mind when making comparisons between years (please see the section ‘Comparing QOF data over time’ in the 'Technical annex').

Overview of year-on-year changes

2004-05 and 2005-06

QOF was introduced in 2004-05, the same indicator set was used in 2005-06. In 2004-05 and 2005-06 GP practices were able to achieve a maximum QOF score of 1,050 points.

2006-07 and 2007-08

From April 2006 a revised QOF was introduced, including new clinical areas, and revising some clinical indicators. The revised QOF continued to measure achievement against a set of evidence-based indicators but allowed a maximum possible QOF score of 1,000 points.

2008-09

Changes were made at the start of 2008-09.

• The introduction of two new indicators in the Patient Experience domain. The new indicators, PE7 and PE8, were derived from the results of the national GP Patient Survey, and rewarded GP practices for providing 48-hour appointments (PE7) and advanced booking (PE8). These two new indicators were worth a total of 58.5 QOF points, and their introduction coincided with the removal of some indicators (or points associated with indicators)

Maximum possible QOF score remained at 1,000 points.

2009-10 and 2010-11

Changes made at the start of 2009-10 and remained in force for 2010-11 included:

• The introduction of new indicators in the existing heart failure, chronic kidney disease, depression, and diabetes clinical indicator sets
• The introduction of two new indicators under a new cardiovascular disease (primary prevention) clinical indicator set
• The removal of some patient experience indicators; changes to contraception indicators within the Additional Services domain of the QOF
• Various changes to the points values of some QOF indicators

Maximum possible QOF score remained at 1,000 points.

2011-12

Changes at the start of 2011-12 included:

• The introduction of new indicators in the epilepsy, learning disability and dementia clinical indicator sets
• The introduction of a new set of indicators measuring quality and productivity.
• Twelve indicators were retired across a range of sets
• Twenty-two indicators were replaced, either due to changes to indicator wording or coding/business logic changes
• Five indicators had changes to point values or thresholds.

Maximum possible QOF score remained at 1,000 points

2012-13

Changes at the start of 2012-13 included:

• The retirement of seven indicators (including five from the Quality and Productivity area), releasing 45 points to fund new and replacement indicators.
• Nine new NICE recommended clinical indicators introduced, including two new clinical areas (Peripheral arterial disease and Osteoporosis) and additional smoking indicators.
• Three new organisational indicators for improving Quality and Productivity which focused on accident and emergency attendances.
• Sixteen other indicators were replaced, either due to changes to indicator wording or coding/business logic changes or to changes to point values or thresholds.

Maximum possible QOF score remained at 1,000 points.

2013-14

Changes at the start of 2013-14 included:

• The indicator codes have all been reset and re-ordered, starting with 001 for each set of indicators to reflect the flow of processes. 
• Thirty-eight indicators were retired which included the organisational domain
• A new public health domain was introduced (including a subset of additional services indicators), with some existing indicators reallocated to this new domain.
• Twelve new indicators were introduced which included a new public health measure: blood pressure and a new clinical condition: rheumatoid arthritis.
• Thirteen indicators have been replaced along with changes to the wording where necessary, which was mainly changing 'GP practice' to 'contractor'.
• There was of the end-of-year overlap for most indicators by changing the indicator timeframe from 15 to 12 months or 27 to 24 months.

Maximum possible QOF score available changed to 900.

2014-15

Changes at the start of 2014-15 included:

• Two domains retired: the quality and productivity domain and the patient experience domain.
• Three indicator group retired: hypothyroidism, child health surveillance and maternity.
• Twenty-six individual indicators retired from within conditions that are still measured in QOF.
• No new indicators or indicator groups have been added this year.
• Minor changes to indicators have resulted in new indicator numbering. Epilepsy now has only one indicator (the presence of a register). Learning disability has had the age restriction removed and is no longer for those aged 18 or over. Blood Pressure has also changed its age restriction from age 40 or over to age 45 or over.

Maximum possible QOF score available remained at 900.

2015-16

Changes at the start of 2015-16 included:

• Total number of indicators fell from 81 to 77 with some indicators being retired or replaced.
• The number of points assigned to some indicators has been changed but the number of points available in each domain has remained the same.
• No changes to the number of indicator groups
• Minor changes to indicators’ wording, timeframe or maximum available points have resulted in new indicator numbering. This affects the dementia; chronic kidney disease and obesity indicator groups as follows:
  • DEM002 and DEM003 are now numbered DEM004 and DEM005 respectively, due to changes in the wording and points for DEM002, and changes in the timeframe for DEM003.
  • CKD001 is now numbered CKD005 following a change in wording
  • OB001 is now numbered OB002 following a change in the age group to which the indicator applies

Maximum possible QOF score available changed to 559 points

2016-17-18

• No changes to the number of points available, or the number or definition of indicators for 2016-17 or 2017-18, as compared to 2015-16.

Maximum possible QOF score available remained at 559 points

2018-19

Changes at the start of 2018-19 included:

• Clinical codes used to define the learning disabilities register changed meaning the register (and associated recorded disease prevalence) is not comparable with previous years. The indicator ID has changed from LD003 to LD004 as a result, although the description remains the same.

Maximum possible QOF score available remained at 559 points

2019-20

Changes at the start of 2019-20 included:

• A new quality improvement domain (worth 74 points) was introduced, broken down to indicator groups prescribing safety and end of life care
• Nineteen new indicators were introduced 15 within existing conditions (worth 101 points) and 4 in new domain
• One indicator group retired: contraception.
• Twenty-eight individual indicators retired (worth 175 points), from within conditions that are still measured in QOF.
• Personalised care adjustments (PCAs) replaced exceptions more information can be found in the technical annex.

Maximum possible QOF score available remained at 559 points

2020-21

Changes at the start of 2020-21 included:

• A new non-diabetic hyperglycaemia indicator group in the Clinical domain (worth 0 points) was introduced.
• Fourteen new indicators were introduced 13 within existing conditions (worth 70 points) and 1 in the new indicator group.
• One indicator group retired: cardiovascular disease - primary prevention containing 1 indicator worth 10 points.
• Thirteen individual indicators retired (worth 151 points), from within conditions that are still measured in QOF.
• A new age qualifier 6 years and over applied to the asthma register.

Maximum possible QOF score available has increased to 567 points

2021-22

Change at the start of 2021-22 included:

• One new domain, Public health – vaccination and immunisation containing one new indicator group (Vaccination and immunisation) comprising of four new indicators worth a total of 64 points.
• Five new indicators were introduced within existing conditions (worth 0 points).
• Five individual indicators were retired (worth 42 points), from within conditions that are still measured in QOF.
• Eleven existing indicators had their points allocation changed from last year.

Maximum possible QOF score available increased to 635 points.

2022-23

Change at the start of 2022-23 included:

• The total points available to practices (635) remains the same as last year, although 14 indicators have had their points allocation changed. The ‘Indicator definitions’ file (available on the publication homepage) shows the points allocation for 2022-23.
• Indicators remain the same as last year (2021-22) except for the Quality Improvement domain indicators which are subject to change annually.
• Last year’s Learning Disabilities and Supporting Early Cancer Diagnosis Quality Improvement modules have been replaced by Prescription Drug Dependency and Optimising Access.
• In addition to replacing these modules 4 new Prescription Drug Dependency management information indicators have been added, although no QOF points have been attributed to them.

Total points available to practices remained 635.

2023-24

Changes for 2023-24 include:

• Total points available remains at 635, though points allocations by indicator have changed. The ‘Indicator definitions’ file (available on the publication homepage) shows the points allocation for 2023-24.
• AST006 replaced by AST011
• AF007 removed
• AF008 added
• CHD008 replaced by CHD015 – introduced different BP control targets for readings taken by home blood pressure monitoring
• CHD009 replaced by CHD016 - introduced different BP control targets for readings taken by home blood pressure monitoring
• New Cholesterol indicator group, comprised of two new indicators
• COPD register updated and COPD009 replaced with COPD015 - spirometry requirement baseline start date changed from 1 April 2021 to 1 April 2023 to reflect difficulties undertaking spirometry during Covid-19 pandemic
• COPD008 replaced with COPD014 – indicator now requires referral (not an offer of referral), and a new PCA for ‘declined offers of referral’ introduced
• COPD009MI1, COPD009MI2, COPD009MI3 - dates re-baselined from 1 April 2021 to 1 April 2023 to reflect difficulties undertaking spirometry during Covid-19 pandemic
• Depression register - updated to capture patients newly diagnosed with depression only (i.e. diagnosed within the reporting year, or in the last 3 months of the previous reporting year but did not receive a review in that reporting year)
• DM019 replaced by DM033 – introduced different BP control targets for readings taken by home blood pressure monitoring
• HF005 replaced by HF008 - patients now only considered to be on the register where diagnosis has been confirmed by ECG (re-baselined to 1 April 2023).
• HYP003 replaced by HYP008 – introduced different BP control targets for readings taken by home blood pressure monitoring
• HYP007 replaced by HYP009 – introduced different BP control targets for readings taken by home blood pressure monitoring
• MH021 - new indicator added (% patients with schizophrenia, bipolar affective disorder and other psychoses who received all six elements of the Physical Health Check for people with Severe Mental Illness)
• NDH001 replaced by NDH002 - new exclusion criteria introduced (patients now excluded where they are currently on the diabetes register and have not received an IFCC-HbA1c reading or fasting plasma glucose test since the quality service start date and up to and including the earliest of (a) quality service end date or (b) earliest unresolved diabetes diagnosis)
• OB002 replaced by OB003 - BMI thresholds have been appropriately adjusted for ethnicity in line with NICE guidelines.. 
• RA002 - indicator removed
• SMOK002 - indicator logic updated
• STIA010 replaced by STIA014 – introduced different BP control targets for readings taken by home blood pressure monitoring
• STIA011 replaced by STIA015 – introduced different BP control targets for readings taken by home blood pressure monitoring
• VI001, VI002 and VI003 all had a new PCA added for newly registered children.
• Last year’s Prescription Drug Dependency and Optimising Access Quality Improvement modules have been replaced by Workforce Wellbeing and Optimising Demand and Capacity in General Practice modules.

Specific issues and caveats concerning the interpretation of QOF data are covered in the Technical annex.

During each publication cycle, data quality is assessed by the NHS England collection and publication teams, and where queries arise, data suppliers are contacted to validate and confirm data submissions.

Customer feedback is regularly solicited through QOF publication feedback  or comments can be sent via:

Email: [email protected]

Telephone: 0300 303 5678

QOF data downloaded from CQRS by NHS England is a secondary use of the data.

The primary use of the QOF data is to support QOF payments to GP practices.

No increased respondent burden.

Published QOF information is derived from the data available via CQRS. Users of CQRS (appropriate individuals from practices and Sub ICB Locations) can monitor their own QOF information on a continuous basis throughout the year. In addition, they have access to reports which provide the same level of information as that which is published by NHS England.

QOF publications are subject to risk assessments concerning disclosure. No personal identifiable data has been identified in this year’s QOF. Standard NHS England protocols around information governance are followed in the production of QOF publications.

The data contained in this publication are Official Statistics. The code of practice is adhered to from extraction of the data to publication.

Please see links below to the relevant NHS England policies:

Statistical Governance Policy:

https://digital.nhs.uk/data-and-information/find-data-and-publications/publications-supporting-user-documents

Freedom of Information:

https://digital.nhs.uk/article/253/Freedom-of-Information