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This page provides guidance on the Quality and Outcomes Framework (QoF) indicators for 2023/24 in England. It is effective from 1 April 2023 and replaces versions issued in previous years.
A summary of the changes in the QoF guidance and business rules can be found by expanding the ‘Summary of Changes’ node just below; these changes will be described in more detail further in this guide.
Click here to be directed to the Quality and Outcomes Framework (QoF) 2023/24 document
Summary of Changes
Information in:
Green: Likely to lead to less work or more income.
Amber: Impact likely to be mixed.
Red: Likely to lead to more work or less income.
Black: Likely to make very little difference.
| Indicator ID | Indicator | Information |
| AST011 (AST006) | Appropriate investigations for new asthma diagnosis | Denominator for the indicator is limited to those newly diagnosed since 1/4/23. Small numbers of unachieved patients may lead to underperformance |
| AF008 (AF007) | Anticoagulation for high risk AF | Much more demanding threshold. Assumed that DOACs should be used for almost all. |
| CHOL001 | Lipid lowering for secondary prevention or CKD 3-5 | May require additional coding for people on non-statin lipid lowering. |
| CHOL002 | Non-HDL cholesterol target <2.5 for secondary prevention | Many issues with this indicator (see Cholesterol below). Will need to be prioritised early. |
| COPD001 | Register | Additional COPD patients from the previous QoF years may now appear in your QoF register (people without a record of FEV1/FVC ratio). |
| COPD014 (COPD009) | Appropriate investigations for new COPD diagnosis | Denominator for this indicator is limited to those newly diagnosed since 01/04/2023. Small numbers of unachieved patients may lead to underperformance. |
| CHD015 (CHD008) | CHD <80y with BP <=140/90 | Harder to achieve as if the BP reading is a home BP it must be <=135/85. |
| CHD016 (CHD009) | CHD >=80y with BP <=150/90 | Harder to achieve as if the BP reading is a home BP it must be <=145/85. |
| DEM004 | Dementia review | Number of points available reduced. |
| DEP004 (DEP003) | Review within 10-56 days of diagnosis | Minor change to ensure patients diagnosed with depression in the last 3 months of the previous year have an appropriate review. |
| DM033 (DM019) | BP <=140/90 | Should be much easier to achieve. Indicator updated to reflect change to NICE guidance which indicates that BP target for most diabetic patients is <140/90. NB if the last BP is a home BP it must be <=135/85. |
| HF008 (HF005) | Echocardiogram to confirm diagnosis | Denominator for the indicator is limited to those newly diagnosed since 01/04/2023. Small numbers of unachieved patients may lead to underperformance. The echocardiogram must now be in the last 6 months leading up to the diagnosis. |
| HYP008 (HYP003) | Hypertension <80y with BP <=140/90 | Harder to achieve as if the BP reading is a home BP it must be <=135/85 |
| HYP009 (HYP007) | Hypertension >=80y with BP <=150/90 | Harder to achieve as if the BP reading is a home BP it must be <=145/85 |
| MH021 | New composite indicator requiring recording of 6 different health check components | Difficult exception reporting criteria. |
| NDH002 | Register | Subtle change to the register which will only affect some patients who have resolved diabetes. This should be very rare. |
| OB001 | Register | Adjustments made for ethnicity. Impact will depend on the local ethnicity mix. |
| SMOK002 | Recording smoking status | Harder to achieve by making it clear that 3 consecutive years of ex-smoker status cannot be interrupted by smoker status. |
| STIA014 (STIA010) | Stroke <=80y with BP <=140/90 | Harder to achieve as if the BP is a home BP it must be <=135/85 |
| STIA015 (STIA011) | Stroke >80y with BP <=150/90 | Harder to achieve as if the BP is a home BP it must be <=145/85 |
| VI001 | 3x DTP vaccines for infants | Payment threshold broader with upper threshold 89-96% (vs 90-95%). New exclusion criteria for patients who registered too late to be vaccinated. |
| VI002 | MMR 12 – 18 months | Payment threshold broader with upper threshold 89-96% (vs 90-95%). New exclusion criteria for patients who registered too late to be vaccinated. |
| VI003 | 2nd MMR and DTAP/IPV booster for preschoolers | Payment threshold broader with upper threshold 81-96% (vs 87-95%). New exclusion criteria for patients who registered too late to be vaccinated. |
Quality and Outcomes Framework Reports
The QoF Reports are located in the CDRC Contracting > QoF folder.
If you are not a member of the DCS group on SystmOne and would like access to these resources, information on how to join the DCS group can be found here.
Quality and Outcomes Framework 2023/24 Indicator Information
Expand each node below for further interpretation and guidance on the QoF indicators.
Asthma
AST006 has been changed to AST011.
This is the indicator checking to see if patients with new asthma have had appropriate investigations. New diagnoses will now start from 01/04/23. This means a small number of people without the appropriate investigations might have a larger effect.
Atrial Fibrillation
AF007 has been changed to AF008 – Anticoagulation for higher risk AF. This indicator is now much more difficult to achieve.
This has been billed as a replacement with the IIF AF indicator. However there are some subtle differences. Differences between previous QoF and IIF indicators are noted below.
| AF007 2022/23 | AF008 2023/24 | |
| Threshold | 40-70% | 70-95% |
| Any anticoagulation counted as appropriate. | For the majority of patients, assumes that DOAC should be used and reason has to be given if not. |
| IIF CVD005 2022/23 | AF008 2023/24 | |
| Risk Scores | Did not reference historic CHADS scores. Included moderate risk patients i.e., men with a CHADSVASc score of 1. | Still references historic CHADS scores. Does not include moderate risk patients. |
NB. The business rules seem to imply there are some patients who should be given DOACS whom NICE would recommend warfarin. These are mainly patients who do not have a licensed indication for a DOAC. An example would be a female patient aged 67 with no other risk factors for stroke. Her CHADSVASc score is 2 and anticoagulation is indicated but none of the DOACs would be recommended by the relevant NICE technology appraisals.
Cholesterol
This is a completely new domain with two new indicators.
CHOL001 – The proportion of patients with cardiovascular disease or adults with CKD3-5 who are taking lipid lowering therapy. There are a few potential anomalies in the business rules:
- CVD is defined as anyone on the CHD, PAD, stroke/TIA registers. This might lead to some patients who do not need lipid lowering being included in the denominator e.g. haemorrhagic stroke, septic embolic stroke, type 2 myocardial infarction.
- If patients are on a non-statin lipid lowering therapy such as ezetimibe, a reason for this must be coded. For ‘expiring’ exceptions must be recorded every 12 months.
- Diabetic patients are excluded from the register (presumably because of the concern about double funding in the diabetes domain).
CHOL002 – The proportion of patients with cardiovascular disease (i.e. secondary prevention) whose non-HDL cholesterol is <2.5 (or LDL cholesterol <1.8 if there is no non-HDL cholesterol recorded in the year). This is a very strange indicator for a number of reasons:
- This is the only QoF indicator which seems to deviate from NICE guidance. The guidance references the 2014 JBS3 guidance which predates the NICE Lipid guidance (2023) and the widely promoted Accelerated Access Collaborative Lipid Guidance (2022).
- The thresholds are set very low (20-35%) which reflects the fact that many people in the denominator will not / should not require aggressive lipid lowering (see below).
- The is no exception reporting
The NICE/AAC pathway for secondary prevention can be summarised as:
- Use very high potency statins as default for people with atherosclerotic CVD (e.g. atorvastatin 80mg)
- Consider more intensive treatment if the non-HDL cholesterol does not fall by at least 40% OR the fasting LDL-cholesterol is >=2.6
There will be some people in the denominator where aggressive lipid lowering is not needed/appropriate e.g. haemorrhagic stroke, septic embolic stroke, terminally ill patients, patients with significant frailty. These patients cannot be excepted.
There may also be a risk of undertreatment by following this indicator. Consider the example of a patient with a relatively low pre-treatment non-HDL cholesterol on moderate lipid lowering therapy who achieves a non-HDL-cholesterol <2.5 but does not achieve the recommend 40% reduction.
It is important to address this indicator early because non-achieving patients will need to be contacted, have medication changes and cholesterol reassessment. This will take at least 4-6 months.
COPD
The COPD register business rules have been updated so that all patients coded with COPD before 01/04/23 will now appear on the register. Previously patients with COPD diagnosed after 01/04/21 did not count if they did not also have a record of FEV1/FVC ratio <0.7 (or unable to undertake spirometry). Patients diagnosed with COPD after 01/04/23 will not be included on the register unless they have that ratio <0.7 recorded (or unable to undertake spirometry).
COPD009 has been changed to COPD014 – Referral offered for pulmonary rehabilitation
This indicator has been made more difficult to achieve by reducing the number of exception criteria. Patients declining pulmonary rehabilitation will no longer count as an exception. Exceptions can be made by recording: rehabilitation not suitable; rehabilitation not available; the overarching COPD exception codes; by inviting the patient twice for a COPD review in the year.
Coronary Heart Disease (CHD)
CHD008 has been changed to CHD015 – BP control <=140/90, <80y
CHD009 has been changed to CHD016 – BP control <=150/90, 80y+
These indicators are now harder to achieve because the home blood pressure thresholds have been changed to <=135/85, <=145/85 respectively. Strangely, only the ‘Home blood pressure’ codes have been changed in the business rules. ‘Ambulatory’ and ’24 hour’ blood pressure values are still counted using the older thresholds.
Dementia
DEM004 – The number of points available for the dementia reviews has been reduced meaning there will be less income from this indicator
Depression
DEP003 has been changed to DEP004.
This is now very slightly more difficult to achieve. There have been some minor changes in way the business rules for the depression review indicator have been constructed. This removes an anomaly which meant that a patient with depression in the last 3 months of the previous year was excluded from the indicator if they had had a depression review at any time in the previous QoF year, even if this wasn’t in the required 10-56d time window.
Diabetes
DM019 has been changed to DM033.
The diabetes blood pressure indicator has been changed from <=140/80 to <=140/90 to align with the NICE hypertension guidance. It has also been updated to have a lower threshold for home BP readings (<=135/85) (see CHD for more detail). This indicator should now be significantly easier to achieve.
NB there will be many patients to whom NICE would ascribe a different target e.g.
- patients over 80 years where the target is usually <150/90
- patients with an ACR>70 where the target is usually <130/80
Heart Failure
HF005 has been changed to HF008.
This indicator assesses presence of echocardiogram for diagnosis. The denominator now only includes diagnoses of heart failure after 01/04/23. Echocardiography is now required in the 6 months leading up to diagnosis (not 3 months before or 6 months after as previously).
As the denominator is now considerably smaller, there is greater potential to fail the indicator due to a small number of patients.
Hypertension
HYP003 has been changed to HYP008
HYP007 has been changed to HYP009
These indicators have been updated to include a lower threshold for home BP (see CHD for more detail).
Mental Health
MH021 – New indicator which requires recording (or (limited) exception recording) of 6 issues:
- Smoking status AND
- BMI AND
- Alcohol consumption AND
- Hba1c/glucose AND
- Lipid levels (within 1 or 2 years depending on comorbidity) AND
- Blood pressure AND
There are no general exceptions for this indicator. For a patient who declined to attend for a review, individual exceptions would need to be recorded e.g. BMI declined, declined blood pressure reading, declined to give alcohol consumption … etc.
Non-Diabetic Hyperglycaemia
NDH002
There has been a subtle change to the business rules to make sure that people with NDH and resolved diabetes are included. This should have very little impact as resolution of diabetes (as opposed to remission) is very rare.
Obesity
OB002 has been changed to OB003
An adjustment for most Black, Asian and Middle Eastern patients is made so obesity is defined as BMI >=27.5 in the last 12 months. This will lead to a higher obesity prevalence (and payments) in areas with greater numbers of ethnic minority patients (provided they are being weighed).
Rheumatoid Arthritis
RA002 – The indicator requiring an annual review for patients with rheumatoid arthritis has been removed
Smoking
SMOK002 has been updated to make it clearer that if patients have ex smoking codes for 3 consecutive years, this only counts towards the indicator if it is not interrupted by a smoking code.
E.g.:
- Exsmoker 2019, Smoker 2020, Exsmoker 2020, Exsmoker 2021 – does not count
- Exsmoker 2019, Smoker 2020, Exsmoker 2020, Exsmoker 2021, Exsmoker 2022 – does count
This is not really a change in the business rules but the system suppliers have previously interpreted the rules in a more lenient way (e.g. counting the first example above). This change is likely to lead to a change in the system supplier searches and make this indicator harder to achieve.
Stroke & TIA
STIA010 has been changed to STIA014
STIA011 has been changed to STIA015
These indicators have been updated to include a lower threshold for home BP (see CHD for more detail).
Vaccination and Immunisation
VI001, VI002 and VI003 have all updated (Infant DTP, MMR 12-18m and Preschool MMR 2 doses and DTAP/IPV boost).
These indicators all now have quite complex exceptions for patients who have registered after the time when it would be reasonable to be able to vaccinate them within the required time frames. This is particularly relevant to practices with large numbers of asylum seekers/refugees.
There is still no ability to exception report a child because their parents/carers have declined the vaccine(s).
The payment ranges have been broadened so payment starts earlier BUT the maximum payment threshold has been raised making it harder to achieve this. As a rough estimate, to achieve maximum payment, the maximum number of people who are not vaccinated will be ~1 in 2500 to 3000 registered patients – e.g. 3-4 patients for a 10000 practice.
