Quality and outcomes framework FAQs


This section includes FAQs for the following areas:

General questions 

Clinical domain 

Heart failure (HF)

Asthma (AST)

Mental health (MH)

Public health domain 

Smoking (SMOK)

Public health additional services sub domain 

Cervical screening (CS)

Financial and technical 

General answers 

Q: What is the process for making changes to the QOF?

A: NICE became responsible for managing the QOF clinical indicators from April 2009. As part of this process, NICE prioritise areas for indicator development, develops and selects indicators for inclusion on the NICE menu, makes recommendations for the retirement of indicators and consults with individuals and stakeholder groups.

The NICE menu of indicators is published in August each year and the recommendations are used to inform national contract negotiations between NHS Employers and the GPC on changes to the QOF.


Q: When does a new patient first qualify for inclusion in the QOF?

A: Patients are eligible for the care outlined in the QOF indicators as soon as they are fully registered with the practice and treatment commences. However, any patient registered during the last three months of the year will be automatically excepted from all qualifying indicators.

General questions


Q: Is there an age limit for patients in the QOF? 

A: No. Some individual indicators have age ranges associated with them, for example due to the age ranges of the risk assessment tools recommended or the suitability to perform certain tests on particularly young or old patients. Some QOF disease registers have age ranges associated with them which exclude younger patients whose care is mainly managed by specialists. In addition some of the individual indicators have age ranges in line with the care expected to be delivered.

There are times when a patient may qualify for the care outlined in the indicator, however a GP should always treat a patient appropriately using clinical judgement relevant to that individual. QOF includes exception rules which allow practices to except a patient for clinical reasons, for example where there are contraindications, intolerance of medicine or extreme frailty.

General questions


Q: Historically an offer of appointment has been in writing to the patient. Taking in to account the changes in methods of communication and technology, is it acceptable for the invitation to be sent via email or text? 

A: Practices may make use of methods other than written letters to offer patient appointments. However, this must be with the explicit consent of the patient concerned and their acceptance to be contacted via another media. The invitation must also be specific to individual patient.

For example: 'appointment for patient x, at 00.00, on DD/MM/YYYY, at practice Y' 

General questions


Q: What happens if a practice has no patients eligible for a disease area or for specific indicators?

A: QOF rewards practices for providing the care to eligible patients, as outlined in the indicator wording or 'criteria' for the relevant disease area(s). If a practice has no patients that fall in the 'denominator' of a particular indicator or indicator set, then unfortunately they have no patients who require the care described by the indicator and therefore no means to achieve the points associated with that indicator(s). QOF works on a positive payment mechanism basis, which means that a practice starts at zero and works upwards to the maximum number of points available (for 2016/17 this is 559 points).

General questions


Q: Where an indicator requires an intervention to be carried out within a certain time of the diagnosis, will an exception code need to be entered for each year? 

A: Yes. The exception code entered will only except that patient for the year in which the diagnosis was recorded. Given the cross-year nature of some indicators, if the success criteria has not been met in the first year i.e. the test has not be done or the patient has not yet been referred, that patient is still eligible the following year and therefore the exception code would need to be re-entered.  

General questions


Q: What is the purpose of QOF disease registers?

A: The purpose of a register in QOF is to define a cohort of patients with a particular condition or risk factor.  In some cases, this register then informs other indicators in that disease area.  

QOF registers must not be used as the sole input for the purposes of individual patient care and clinical audit i.e. call and recall of patients for check-ups, treatments etc.  There are patients for whom a particular treatment or activity is clinically appropriate but they may not meet the criteria as defined by the QOF register and therefore would not be picked up by a search based solely on the QOF register.  As such, although QOF registers can be used to supplement clinical audit, they should be supported by appropriate clinical judgement to define which patients should be reviewed, invited for consultation etc. to ensure patients do not miss out on appropriate and sometimes critical care.The purpose of a register in QOF is to define a cohort of patients with a particular condition or risk factor.  In some cases, this register then informs other indicators in that disease area.

General questions


Heart failure (HF)

Q: Why was the code for ‘left ventricular cardiac dysfunction’ (Read v2 G5yyD/CTV3 Xaacj) been removed from the ‘heart failure due to left ventricular systolic dysfunction (LVSD)’ component of the heart failure register in October 2015?

A: The HF003 and HF004 indicators are aimed at patients with a diagnosis of heart failure due to left ventricular systolic dysfunction (LVSD). As the Read code for left ventricular cardiac dysfunction does not solely relate to LVSD and following advice from NICE, it was agreed that it would not be appropriate for patients with heart failure due to cardiac dysfunction to be included in these indicators. As such, from 1 October 2015 this code was no longer in the register cluster and patients with just this code will therefore no longer be included.

Practices may wish to review the records of these patients and (if clinically appropriate i.e. if their left ventricular dysfunction is systolic) update this code to G5yy9 ‘Left ventricular systolic dysfunction’ (for EMIS, Vision or Microtest) or XaIIq ‘Left ventricular systolic dysfunction’ (for SystmOne).

For details of these changes see the updated Business Rules.

HF questions


Asthma (AST)

Q: Some of the asthma-related prescribing Read codes were removed from the asthma register in October 2015, why?

A: Part of the register criteria for asthma is based on appropriate prescribing of therapies. The Business Rules included some drug therapies only licensed for patients with a diagnosis of COPD and they are not licensed as a treatment for asthma. As such, the following Read v2 and CTV3 codes were removed from the asthma treatment component of the asthma register:

c1e..% hierarchy containing:

  • c1e1.  ULTIBRO BREEZHALER 85mcg/43mcg inh powder capsules+inhaler
  • c1e2.  INDACATEROL+GLYCOPYRRONIUM 85mcg/43mcg inh powder caps+inh
c1b..% hierarchy containing:
  • c1b..  INDACATEROL
  • c1b1. ONBREZ BREEZHALER 150micrograms inhalation capsules+inhaler
  • c1b2. INDACATEROL 150micrograms inhalation capsules+inhaler
  • c1b3. ONBREZ BREEZHALER 300micrograms inhalation capsules+inhaler
  • c1b4. INDACATEROL 300micrograms inhalation capsules+inhaler
c1d..% hierarchy containing:
  • c1d.. OLODATEROL
  • c1d1. STRIVERDI RESPIMAT 2.5micrograms inhaler
  • c1d2. OLODATEROL 2.5micrograms inhaler

If you have patients with asthma whose sole asthma medication is one of the inhalers listed above then they will no longer appear on your QOF asthma register.

Patients receiving additional, appropriate asthma treatment such as short-acting bronchodilators or steroid inhalers will remain on the register. Practices may wish to review the records of any patients affected by this change to review their asthma treatment however, a change in prescribing should only be done where clinically appropriate.

For details of these changes see the updated Business Rules 

AST questions


Mental health (MH)

Q: Is there a code available which would enable a practice to remove a patient from the mental health register following a resolved episode? 

A: Historically, patients who have been added to the QOF mental health register for schizophrenia, bipolar affective disorder and other psychoses have not been able to be removed via a resolved code. This is due to the lack of professional consensus as to what mental health resolved means. However, over time it has become apparent that it may be appropriate to exclude some patients from the care in the associated indicators because their illness is in remission (or they had a single episode of psychosis some time ago).

From 1 April 2011 practices have been able to record patients as being in remission. Where a patient is recorded as being ‘in remission’ they remain on the register (in case their condition relapses at a later date) but they are excluded from the activity described by the indicators MH002, MH003, MH007 and MH008.

Public health domain 

Smoking (SMOK)

Q: The criteria for SMOK004 and SMOK005 states an offer of support and treatment must be given. Does this mean that the patient must be offered both support and treatment in order to achieve the indicator?

A: The Business Rules for indicators SMOK004 and SMOK005 will look for a record of support or treatment i.e. a suitable code from either the REFERSSSA_COD or the PHARM_COD clusters. The intent of the indicator is for patients to be offered ‘support and treatment’ whether this means a referral to a smoking cessation service, drug treatment or follow-up appointments with the practice (GP/nurse etc) and not for a patient to accept ‘support and treatment’. If a patient declines support and/or treatment, then suitable codes have been included in the relevant clusters to accommodate this.

SMOK questions


Public health additional services sub domain 

Cervical screening (CS)

Q: If a practice has a patient that fails to attend for a cervical smear following three invitations by letter and the patient has not signed a disclaimer, how should that patient be exception reported?

A: In reference to the question, the codes 9NiT and the 9O8S codes were removed. As such, in circumstances as described in this question, the most appropriate code to use is '6853. CA cervix screen - not wanted'.

Financial and technical 

Q: What is the value of a QOF point for 16/17?

A: The value of a QOF point for 16/17 is £165.18.

Q: Are payments adjusted by practice list size?

A: Yes. All QOF payments are weighted by list size (the Contractor Population Index (CPI) and in the clinical domain by disease prevalence.

Q: What is the national average practice figure used for the CPI calculation?

A: The figure on 1 January 2016 was 7460.

Q: How is achievement calculated for the clinical domain?


Q: Does this adjustment formula apply to any other domains in the QOF?

A: No. The target population factor adjustment only applies to those indicators within the additional services domain entitled to under the SFE.

Q: If a practice delivers the care outlined in an indicator but then the patient moves practice, will that patient still count towards the practices achievement?

A: No. A practice is only rewarded for the care delivered to patients registered within the practice at the 31 March each year (REF_DAT or ACH_DAT in the Business Rules). However, when a patient moves to a new practice after having care outlined in QOF delivered in their previous practice, the new practice would be rewarded for this as long as the electronic patient record is up-to-date and accurate.

Q: What happens if a patient’s old practice only delivered part of the care as outlined in the indicator and then the patient moved to a new practice? Will this patient count towards the achievement in the new practice?

A: In such circumstances, the new practice will need to ensure that the care outlined in the indicator is delivered accordingly in order for the patient to be included in the numerator. However, should the indicator require that certain activity is done within a particular timeframe and the old practice has not done this, then the patient may not be included in the numerator.

See the technical business rules and exception reporting section for further information relevant to this question.

Q: If a practice exception reports all eligible patients within a disease area i.e. where a secondary care service is not available, can the practice still claim the points?

A: If all patients are exception reported then this will result in non-achievement of the indicator(s) and no payment will be due.

Q: Will practice achievement information be made public?

A: Yes. QOF achievement for all practices in England is published by the HSCIC each year.

Q: When does the QOF achievement period end?

A: QOF achievement is calculated from midnight on 1 April to midnight 31 March each year, the extraction takes place at midnight on 31 March. See SFE.

Q: Is exception reporting done on an indicator by indicator basis?

A: Exception reporting criteria and guidance are set out in the QOF guidance. Codes for criteria A (patient refused to attend), B (patient unsuitable), G (informed dissent) except the patient from all the indicators in the indicator set. Other exception criteria must be applied on an indicator by indicator basis such as those indicators which have disease specific codes to record contraindications and intolerances (D, E and F) or where a patient has a supervening condition (H) or where a secondary care service is unavailable (I).

However, achievement always overrules exceptions and therefore even if a patient has been exception reported from an indicator and the practice then delivers the activity described (i.e. not with the particular indicator in mind but by default) then this would count towards achievement.

For example, if a patient is exception reported from the diabetes indicator set in July, but the practice checks the patient’s blood pressure in December for an unrelated reason and it is 140/80 or less, then that patient would count towards the achievement for DM003. Achievement will always overrule an exception.

Q: Do exception codes apply to registers?

A: Patients can only be 'excepted' from indicators and not registers within QOF.

Q: Can patients newly registered with a practice who have not had assessments undertaken within the required time from initial diagnosis be exception reported?

A: Patients who are not seen within the allotted time cannot be exception reported. The reason is that if this was allowed then practices could simply exception report any patient who had not met the target, thereby meeting the requirement whether reviews were taking place or not. However, if a patient newly registers or is newly diagnosed in the last three months of the year (1 January – 31 March) they are automatically excepted from measurement indicators. Similarly, for target indicators they are automatically excepted for the last nine months of the year (1 July – 31 March). These patients will however, go in to the denominator for relevant indicators in subsequent years therefore practices should make every effort to deliver the care required in line with good clinical practice.

Q: If an indicator requires that a patient is invited for a review but is exception reported i.e. patient unsuitable or patient did not attend, should they be invited to attend for a review the following QOF year?

A: If the indicator requires that the 'activity' is delivered every X months, then the 'exception' would only be valid for the same timeframe as specified in the indicator wording.  Therefore, the three invites would need to be sent out each year and only when the patients has refused to attend all three appointments can the practice exception report that patient.

For further information on exception reporting, please see the exception reporting section of the QOF guidance.

Q: How long is an exception code valid?
A: Where an exception code is entered for an indicator where the achievement is linked to an activity, care and/or treatment being delivered within a specific timeframe from the date of diagnosis, if that window crosses into the following QOF year the practice would need to re-enter the exception code in the next year to ensure the patient is again excepted. 

For example DM014 requires that a patient has been referred to a structured education programme within nine months of them being added to the diabetes register. If a patient is diagnosed within the last nine months of the 2015/16 year (from 1 July 2015) and a valid exception code is recorded by 31 March 2016, then that patient is excepted for the 2015/16 QOF year. If the nine months from diagnosis window extends in to the 2016/17 QOF year, then the practice would need to re-enter that exception code for 2016/17.

This does not apply to BP002 and CS004 as the exception is valid for the full period as defined in the indicator wording. 

Q: How long are practices required to retain evidence regarding work completed which is related/attributed to QOF achievement? 
A: Practices are required to retain evidence of work completed which is attributed or related to payment, for up to six years. This evidence could reasonably be requested by any local commissioner or NHS England. Some of this evidence would be available from practices clinical systems but hard copies would need to be filed or digitised and held electronically. 

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