What Is QOF?

The Quality and Outcomes Framework (QOF) is a voluntary annual reward and incentive programme for all GP surgeries in England, detailing practice achievement results. It is not about performance management but resourcing and then rewarding good practice.

The QOF has undergone several revisions since its introduction in 2004. The 2008/09 QOF contains four main components, known as domains. Each domain consists of a set of measures of achievement, known as indicators, against which practices score points according to their level of achievement.

  • clinical care: the domain consists of 80 indicators across 19 clinical areas (e.g. coronary heart disease, heart failure, hypertension)
  • organisational: the domain consists of 36 indicators across five organisational areas – records and information; information for patients; education and training; practice management and medicines management.
  • patient experience: the domain consists of five indicators that relate to length of consultations and to patient surveys
  • additional services: the domain consists of eight indicators across four service areas which include cervical screening, child health surveillance, maternity services, contraceptive services

The QOF gives an indication of the overall achievement of a surgery through a points system. Practices aim to deliver high quality care across a range of areas for which they score points. Put simply, the higher the score, the higher the financial reward for the practice. The final payment is adjusted to take account of surgery workload and the prevalence of chronic conditions in the practice's local area.

The NICE QOF Indicator Programme

NICE’s role is to manage the process to develop the clinical and health improvement indicators for the QOF. This involves prioritising areas for new indicator development, developing and selecting indicators, and ensuring consultation with individuals and stakeholder groups.

NICE will also recommend whether existing indicators should continue to be part of the QOF. For example, where the activity being measured has become part of standard clinical practice, there would no longer be a need to provide a financial incentive.

What are the Clinical Indicators in QOF?

There are currently 20 clinical indicators in QOF. They are:



Points Available 2009/10



Atrial Fibrillation




Chronic Kidney Disease




Coronary Heart Disease










Heart Failure






Learning Disabilities


Mental Health




Palliative Care







Total points 697


Each QOF point is worth approximately £120 to an average GP practice (5891 patient list size)

Patient Experience Domain 91.5 points
Additional Services Domain 44 points

Therefore, there are potentially a total of 1355 QOF available across the four domains

Full access to details of QOF guidance can be found at http://www.nhsemployers.org/Aboutus/Publications/Documents/QOF_Guidance_2009_final.pdf

What are the changes to the Clinical Indicators for 2009/10 from 2008/9?

Heart Failure (9 new points)

One new indicator (which moves the current HF DES for England into QOF):
HF 4
: The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers. (9 points; thresholds 40-60%) 

Chronic Kidney Disease (11 new points)

Five additional points will be allocated to indicator CKD 5:
CKD 5:
The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded). (5 additional points (so the indicator will be worth 9 points in total); thresholds 40-80%)  While this indicator will not change, the guidance will be changed.

One new indicator:
CKD 6:
The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the previous 15 months (6 points, thresholds 40-80%)
The negotiating parties have confirmed that the majority of pathology laboratories in the UK have the capability and capacity to provide these tests

Contraception (8 new points plus 2 points from 2008/09 CON indicators, CON 1 and 2 which will be removed)

Three new indicators, as recommended in the 2008 expert panel report:
SH 1:
The practice can produce a register of women who have been prescribed any method of contraception at least once in the last year, or other appropriate interval e.g. last 5 years for and IUS (4 points)

SH2: The percentage of women prescribed an oral or patch contraceptive methods who have also received information from the practice about long acting reversible methods of contraception in the previous 15 months. (3 points; thresholds 40-90%)

SH3: The percentage of women prescribed emergency hormonal contraception at least once in the year by the practice who have received information from the practice about long acting reversible methods of contraception at the time of, or within one month of, the prescription (3 points; thresholds 40-90%) 

Depression (20 new points)

One new indicator:

DEP 3: In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 5-12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care.

It was also agreed that the depression section of the QOF guidance should be amended as follows:

2008/09 Guidance - "For the purposes of QOF measurement 'at the outset of treatment' is defined as within one month of initial diagnosis."

2009/10 Guidance - "is defined as within 28 days of initial diagnosis."

Cardiovascular Disease - Primary Prevention (13 points)

Two new indicators:

PP1: In those patients with a new diagnosis of hypertension (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients who have had a face to face cardiovascular risk assessment at the outset of diagnosis (within three months of the initial diagnosis) using an agreed risk assessment tool. (8 points; thresholds 40-70%) For the purposes of QOF measurement, 'at the outset of diagnosis' is defined as within three months of initial diagnosis.

PP 2: The percentage of people diagnosed with hypertension dianosed after 1 April 2009 who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet. (5 points, 40-70%)

Diabetes Mellitus (7 new points plus 28 current points)

There are currently two indicators with HbA1c targets (DM 7 and DM 20) which have been subject to changes. We will also introduce a new indicator. The three indicators are as follows:

DM 23:
Replaces DM 20 (which has a HbA1c target of 7.5 or less and is worth 17 points)
The percentage of patients with diabetes in whom the last HbA1c is 7 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months (17 points; thresholds 40-50%)

DM 24: The percentage of patients with diabetes in whom the last HbA1c is 8 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months (8 points; thresholds 40-70%)

DM 25: replaces DM 7 (which has a HbA1c target of 10 or less and is worth 11 points)
The percentage of patients with Diabetes in whom the HbA1c is 9 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months (10 points; thresholds 40-90%) 

Chronic Obstructive Pulmonary Disease (COPD) (2 new points)

One revised indicator:

COPD 13: 
Replaces COPD 11 
The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the previous 15 months (2 additional points so the indicator would be worth 9 points; thresholds 50-90%)

Reallocation of points

The following points will be removed:


Current Value

New Value

Points removed

PE 2




PE 6












BP 4








AF 3















NICE comment on 2010/11 QOF decision

There will be no changes to QOF for 2010/11

“Following the publication of the NICE menu of indicators for consideration for the 2010/11 QOF on 10 August, NICE has now been informed that the menu will not be taken forward for next year's QOF due to be introduced in April 2010. Whilst disappointed by this decision NICE recognises that this year's negotiations, between the GPC and NHS Employers, have been carried out alongside a set of unique and important circumstances for primary care, principally the ongoing concerns over swine flu and the important role primary care has to play in delivering flu vaccinations.

Where indicators from the NICE menu are not included in the national QOF, they are available for PCTs to adopt for local quality schemes using local contracts, informed by NICE’s advice on clinical and cost effectiveness evidence. This currently applies to the indicators on the NICE menu for 2010/11, given that there will be no changes to QOF for 2010/11.”

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