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Quality and Outcomes Framework, Achievement, prevalence and exceptions data 2018-19 [PAS]Official statistics
- Publication Date:
- 24 Oct 2019
- Geographic Coverage:
- Geographical Granularity:
- GP practices, Dental practices, Pharmacies and clinics, Regions, Clinical Commissioning Groups, Country, Strategic Health Authorities, Primary Care Organisations, Clinical Commissioning Regions, Sustainability and Transformation Partnerships
- Date Range:
- 01 Apr 2018 to 31 Mar 2019
Frequently asked questions
What is QOF?
The national Quality and Outcomes Framework (QOF) was introduced as part of the General Medical Services (GMS) contract on 1 April 2004.
The QOF rewards practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care. QOF points are achieved based on the proportions of patients on defined disease registers who receive defined interventions.
Participation by practices in the QOF is voluntary, though participation rates are very high, with most Personal Medical Services (PMS) practices also taking part. In 2018-19, the QOF dataset includes data from 95.1 per cent of GP practices in England that were open and active at some point in the reporting period.
Where do the data come from / what is CQRS?
Previously, the QMAS was used for the extraction of QOF data. In July 2013, QMAS was replaced by the CQRS, together with the GPES. These are national systems developed and maintained by NHS Digital.
Relevant clinical data are extracted from GP practices’ clinical systems via GPES, and the QOF data are then accessed via CQRS.
What is in QOF? What are 'domains'?
The QOF covers three domains. Each domain consists of a set of measures of achievement, known as indicators, against which practices score points according to their activity as defined by those indicators.
The three domains are:
- Public health
- Public health - additional services
Within the three domains, indicators are organised into groups. The table below provides a summary of the QOF domains in 2018-19.
|Domain||Indicator group code||Indicator group description||Number of indicators||Number of points available||QOF group|
|Clinical||CAN||Cancer||2||11||High dependency and other long-term conditions|
|Clinical||CHD||Secondary prevention of coronary heart disease||4||35||Cardiovascular|
|Clinical||CKD||Chronic kidney disease||1||6||High dependency and other long-term conditions|
|Clinical||COPD||Chronic obstructive pulmonary disease||6||35||Respiratory|
|Clinical||DEM||Dementia||3||50||Mental health and neurology|
|Clinical||DEP||Depression||1||10||Mental health and neurology|
|Clinical||DM||Diabetes mellitus||11||86||High dependency and other long-term conditions|
|Clinical||EP||Epilepsy||1||1||Mental health and neurology|
|Clinical||LD||Learning disabilities||1||4||Mental health and neurology|
|Clinical||MH||Mental health||7||26||Mental health and neurology|
|Clinical||PAD||Peripheral arterial disease||3||6||Cardiovascular|
|Clinical||PC||Palliative care||2||6||High dependency and other long-term conditions|
|Clinical||STIA||Stroke and transient ischaemic attack||5||15||Cardiovascular|
|Clinical - total||65||435|
|Public health||BP||Blood pressure||1||15||Cardiovascular|
|Public health||CVDPP||Cardiovascular disease - primary prevention||1||10||Cardiovascular|
|Public health - total||7||97|
|Public health additional services||CON||Contraception||2||7||Fertility, obstetrics and gynaecology|
|Public health additional services||CS||Cervical screening||3||20||Fertility, obstetrics and gynaecology|
|Public health additional services - total||5||27|
How do CQRS / QOF data relate to GP practice payments?
Through the QOF, general practices are rewarded financially for aspects of the quality of care they provide. CQRS ensures consistency in the calculation of quality achievement and disease prevalence, and is linked to payment systems.
This means that payment rules underpinning the new GMS contract are implemented consistently across all systems and all practices in England.
For 2018-19 the value of a QOF point was £179.26.
Users of data derived from CQRS should recognise that CQRS was established as a mechanism to support the calculation of practice QOF payments. The QOF does not provide a comprehensive source of data on quality of care in general practice, but it is potentially a rich and valuable source of such information, providing the limitations of the data are acknowledged.
What is in the latest QOF publication?
The information published by NHS Digital relates to general practices in England.
The latest available information is for 2018-19 and is based on data for the period 1 April 2018 to 31 March 2019. The data were extracted from the national CQRS system on 2 July 2019 and incorporate any changes made up to 1 July 2018.
This publication covers three types of data for England:
- Disease prevalence
- Exception reporting
The 2018-19 QOF publication is available here and consists of:
- A summary of the main findings
- A data quality annex
- A technical annex
- This FAQ annex
- A set of spreadsheets of QOF data at five levels (available on the publication homepage):
- NHS England region and national
- NHS England sub-region
- STP footprint
- NHS England CCG
- GP practice
- A spreadsheet of all indicator definitions and their associated points availability (available on the publication homepage)
- .csv files of the data, and accompanying data dictionary (available on the publication homepage)
- An online database at https://qof.digital.nhs.uk/ that allows searches for individual practices, and which presents the QOF data graphically
Previous years and future changes
Where can I find QOF data for previous years?
These data are also available through the QOF online search facility at https://qof.digital.nhs.uk/
Can I have QOF indicator information for years prior to 2004-05?
The Quality and Outcomes Framework was introduced in 2004-05. No QOF indicator information is available for previous years.
How is 2018-19 QOF different from previous years?
2004-05 and 2005-06
The QOF was introduced in 2004-05, the same indicator set was used in 2005-06. In 2004-05 and 2005-06 practices were able to achieve a maximum QOF score of 1,050 points.
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 possible maximum score of 1,000 points.
Some changes were made at the start of 2008-09, with the most significant change being the introduction of two new indicators within the Patient Experience domain. The new indicators, PE7 and PE8, were derived from the results of the national GP Patient Survey, and rewarded 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), so that the maximum QOF score remained at 1,000 points.
Further changes to the QOF were made at the start of 2009-10 and remained in force for 2010-11. These 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; and
Various changes to the points values of some QOF indicators.
Overall, the maximum QOF score remained at 1,000 points.
Changes to the QOF at the start of 2011-12 included:
The introduction of new indicators in the epilepsy, learning disability and dementia clinical indicator sets and the introduction of a new set of indicators measuring quality and productivity.
There were 12 indicators across a range of sets retired, 22 indicators were replaced, either due to changes to indicator wording or coding/business logic changes, five indicators had changes to point values or thresholds.
Overall, the maximum QOF score remained at 1,000 points
Changes to the QOF 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. There were nine new NICE recommended clinical indicators introduced, including two new clinical areas (PAD and Osteoporosis) and additional smoking
indicators. There were three new organisational indicators for improving Quality and Productivity which focussed 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.
Overall, the maximum QOF score remained at 1,000 points.
- Changes to the QOF at the start of 2013-14 included a reduction in the maximum number of points available to 900.
- The indicator codes have all been reset and re-ordered, starting with 001 for each set of indicators to reflect the flow of processes.
- The organisational domain was retired, adding to a retirement of a total of 38 indicators
- A new public health domain was introduced (including a subset of additional services indicators), with some existing indicators reallocated to this new domain.
- There was an introduction of a new public health measure: blood pressure, introduction of a new clinical condition: rheumatoid arthritis, and in total, 12 new indicators were introduced
- Thirteen indicators have been replaced along with changes to the wording where necessary; this was predominantly wording changing from '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.
- Changes to the QOF at the start of 2014-15 include a reduction in the maximum number of points available to 559.
- There has been retirement of two domains; the quality and productivity domain and the patient experience domain.
- Three groups of indicators; hypothyroidism, child health surveillance and maternity have been retired. There are 26 other individual indicators that have been retired, from within conditions that are still measured in the QOF.
- No new indicators or indicator groups have been added this year.
- Some 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.
- There has been no change to the maximum number of points available (559). However, the total number of indicators has fallen from 81 to 77; some indicators have been retired or replaced, and the number of points assigned to some indicators has been changed. The number of points available in each domain has remained the same.
- No indicator groups have been added or removed
- Some 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
- There have been no changes to the number of points available, or to the number or definition of any indicators for 2016-17 or 2017-18, as compared with 2015-16.
The clinical codes used to define the learning disabilities register changed significantly for QOF 2018-19, meaning that 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.
What changes are planned for next year's QOF?
Changes to the QOF for the 2019-20 reporting year are detailed in the 2019-20 General Medical Services contract: Quality and Outcomes Framework on the NHS England website. Key changes include the retirement of 28 indicators, and introduction of 15 new indicators, the replacement of exception reporting with personalised care adjustment, and the introduction of a new Quality Improvement domain.
How do I complain about QOF indicators or suggest changes to the QOF?
The National Institute for Health and Care Excellence (NICE) has responsibility for recommending QOF indicators (including changes); this work is undertaken in the context of the development by NICE of Quality Standards. To find out more visit:
What are QOF business rules? Where can I find them?
QOF data are captured from GP practice systems according to coded ‘business rules’, produced by NHS Digital. The business rules are reviewed twice each year to take account of new clinical codes. QOF business rules are published on the NHS Digital website.
The business rules used for QOF 2018-19 were version 41 - available on the NHS Digital website.
Earlier versions of QOF business rules are available on the Primary Care Commissioning website.
What is QOF exception reporting?
Patients on a specific clinical register can be removed from individual QOF indicators if a patient is unsuitable for treatment, is newly registered with the practice, is newly diagnosed with a condition, or in the event of informed dissent.
‘Exception reporting’ refers to the potential removal of these patients from calculations of practice achievement for specific clinical indicators.
Some exception reporting is applied automatically by the IT system, for example in respect of patients who are recently registered with a practice, or who are recently diagnosed with a condition. Other exception reporting is based on information entered into the clinical system by the GP. Practices may ‘exception-report’ (i.e. omit) specific patients from data collected to calculate QOF achievement scores within clinical areas. The GMS contract sets out valid exception reporting criteria.
Further information concerning exception reporting can be found in the technical annex.
Where can I find information on QOF exception reporting?
An explanation of exception reporting and the calculation of exception rates is available in the technical annex.
Exception reporting at national level is covered in the main findings summary.
A breakdown of exceptions and exclusions by reason per indicator group at CCG level is available in the spreadsheet QOF 2018-19: CCG level, Exceptions and exclusions [.xlsx], available on the publication homepage.
Why are exception reporting figures published by NHS Digital different from the figures in CQRS reports?
CQRS presents counts of exception-reported patients, which roughly equates to the number of people on a disease register who are not included in an indicator denominator.
For the NHS Digital QOF publication, there is a distinction between patients who are exception-reported, and those whose non-inclusion in an indicator denominator is for definitional reasons.
Definitional 'exclusions' are treated as exception reporting by CQRS, and the 'excluded' patients are shown in exception reporting counts. CQRS does this because it is primarily a system to support payments, and its function in respect of exception reporting is to ensure the right patients are not included in indicator denominators.
To give an example, CHD004: The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 September to 31 March.
If the CHD register is 100, and only 10 of those patients meet the indicator criteria, and two of those patients are subject to actual exception reporting, then the relevant figures would be:
CHD Register = 100
CHD004 Denominator = 8
CHD Exception Count = 2
CHD Definitional Exclusions = 90
However, CQRS would show this as 92 exception-reported patients because there is no concept of exclusions within CQRS – they are all exceptions.
The NHS Digital QOF publication considers the underlying exception reporting codes within the CQRS tables and assigns the notion of 'definitional exclusions' to some codes. These are not included in our published exception counts and rates.
Published exception reporting figures therefore do not include counts of definitional exclusions, since these cannot make up part of the indicator denominator.
We only applied exception codes to a very small number of patients, but our published exception rate is very high. Why is this?
Exceptions are identified upon extraction of the data from the clinical system; although exception codes may be manually added to patient records with the intention of excepting a patient from a given indicator (e.g. ‘patient unsuitable’), codes that exist in the patient record as a matter of course are read at the point of extraction and identified as grounds for exception (e.g. ‘patient diagnosed within 3 months of end of payment period’).
Therefore, a patient may be excepted from an indicator even where a clinician has not identified that patient’s record and added an exception code, because codes that are part of the patient’s record are defined as exceptions.
The ‘CCG level, exceptions and exclusions’ file released as part of the publication provides a breakdown of exceptions by reason at CCG level, which may be useful in identifying the exceptions that apply to each indicator. It should be noted that a patient can only be excepted once per indicator, and that sequencing (i.e. the order in which systems check for different exception codes or criteria) may differ from one GP clinical information system to another.
How many practices are in the QOF achievement data? Are all practices included?
Participation in the QOF is voluntary, although participation rates are very high; in 2018-19, the QOF dataset includes data from 95.1 per cent of GP practices in England that were open and active at some point in the reporting period. Some practices may choose not to participate, perhaps because they are specialist centres or because they participate in alternative local schemes. Some practices’ data are removed during validation e.g. due to closure during the reporting year.
QOF achievement for 2018-19 was published for 6,873 general practices in England. These practices made an end-of-year submission to CQRS. QOF achievement figures include data automatically extracted from general practice systems by the CQRS system in March 2019, and data adjustments for the year 2018-19 submitted between April and July 2019.
During validation, a small number of practices were removed from the dataset (for example, those practices whose data are not representative due to their closure or merger with other practices). The results of the validation exercise are available as part of the publication in the ‘Practice validation comments’ workbook on the publication homepage.
The sum of the practice list sizes for the practices included in the QOF publication is 59,386,096. This number may contain duplicate patients where a given practice has closed during the financial year, this is detailed in the technical annex.
Are Personal Medical Services (PMS) practices in the QOF dataset?
PMS practices are able to negotiate local contracts with their regional local offices for the provision of all services. PMS practices may also participate in the QOF, and they may either follow the national QOF framework or enter into local QOF arrangements.
PMS practices with local contractual arrangements are included in the published 2018-19 QOF information.
I do not agree with the published QOF information for my practice
The NHS Digital annual QOF publication is based on an extract from CQRS taken on the 2 July 2019 and relates to the period April 2018 to March 2019.
Prior to publication NHS Digital undertook a validation exercise with all regional local offices to confirm that the total QOF points to be published were as held on CQRS as at 2 July. The exercise also allowed regional local offices to notify NHS Digital of issues or circumstances relevant to practice achievement, including adjustments to QOF achievement (for whatever reason).
Relevant comments from regional local offices are presented alongside practice-level QOF achievement data on the 2018-19 online practice results database, https://qof.digital.nhs.uk/, and in the ‘QOF 2018-19: Practice validation comments’ workbook, available on the publication homepage.
Do QOF achievement scores shown for PMS practices incorporate a PMS deduction?
Where PMS practices use the national QOF, their 2018-19 achievement (in terms of the 559 QOF points available) is subject to a deduction of approximately 100 points before QOF points are turned into QOF payments. This is because many PMS practices already have a chronic disease management allowance, a sustained quality allowance and a cervical cytology payment included in their baseline payments. GMS practices do not receive such payments, but receive similar payments through the QOF. To ensure comparability between GMS and PMS practices, the QOF deduction for PMS practices ensures that they do not receive the same payments twice. Because this publication covers QOF achievement and not payments, all QOF achievement shown is based on QOF points prior to PMS deductions. This is to allow comparability in levels of achievement – so that where GMS and PMS practices have maximum QOF achievement, both are regarded as having achieved the maximum 559 points.
What does 100 per cent achievement mean? What is 'underlying achievement (net of exceptions)'?
Reference to 100 per cent achievement often refers to the percentage of available QOF points achieved. If a practice achieves the full 559 QOF points it has achieved 100 per cent of the points available and may be said to have 100 per cent achievement across the whole QOF.
The level of achievement for certain elements of the QOF can be expressed in the same way. A practice achieving all 435 clinical QOF points available can be said to have 100 per cent clinical achievement even though it may not have 100 per cent achievement overall.
Practices achieve the maximum QOF points for most indicators (especially clinical indicators) when they have met or exceeded the maximum threshold to achieve the points available. For many indicators a practice must provide a certain level of clinical care to 90 per cent of patients on a particular clinical register to achieve the maximum points.
A practice can therefore deliver the required care to fewer than 100 per cent of its patients (90 per cent in this case) to achieve the full (100 per cent) points available. There is an important distinction between percentage achievement in terms of QOF points available and the underlying achievement (net of exceptions) for specific indicators, the latter representing the indicator numerator as a percentage of the denominator.
What is 'percentage of patients receiving the intervention'?
Underlying achievement (net of exceptions) does not account for all patients covered by each indicator, as it takes no account of “exceptions” (patients to whom the indicator applies, but who are not included in the indicator denominator according to agreed exception criteria). Percentage of patients receiving the intervention, gives a more accurate indication of the rate of the provision of interventions as the denominator for this measure covers all patients to whom the indicator applies, regardless of exception status (i.e. indicator exceptions and indicator denominator). This measure is calculated as follows:
Percentage of patients receiving the intervention = (Numerator / (Exceptions + Denominator)) x 100
As an example; a practice has 100 patients on the CHD register, and 10 patients are exception reported from CHD003, making a denominator for CHD003 of 90 patients. The practice delivers the CHD003 intervention to 80 patients. The difference in figures for underlying achievement (net of exceptions) and percentage of patients receiving the intervention is seen below:
Underlying achievement (net of exceptions) = (Numerator / Denominator) x 100
= (80 / 90) x 100 = 88.9 per cent
Percentage of patients receiving intervention = (Numerator / (Exceptions + Denominator)) x 100
= (80 / (10 + 90)) x 100 = 80.0 per cent
Are all practices supposed to reach, or try to reach, 100 per cent QOF achievement?
Not necessarily. The achievement of full points may not be possible or desirable for some practices. Participation in the QOF is voluntary, and practices may aspire to achieve all, some, or none of the points available. It is important to note that for some practices it may be impossible to achieve all the points available in the QOF.
For example, some clinical indicators relate to specific subgroups of patients, and if the practice does not have any such patients it cannot score points against the relevant indicators. A practice that exclusively serves a student population, for instance, may not have patients on some of the clinical registers e.g. dementia, that are covered by the QOF, and although its QOF points total would be less than 559 (or 100 per cent), it may be providing all the appropriate care in respect of the clinical registers that it does hold.
In addition, practices with personal medical services contracts may include quality and outcomes as part of their locally negotiated agreements, and may opt to use part or all the new GMS QOF as a measurement tool. This is an extremely important consideration when undertaking any comparative analysis of QOF achievement.
What if a practice does not have any patients on a register?
In recognition of the fact that it is not always possible for practices to achieve all the points in the QOF, NHS Digital has produced a further measure of practice achievement. This measure takes account of instances where practices cannot achieve points because they have no patients pertinent to an indicator.
For example, in 2018-19 there are 559 points available in the QOF and 45 of these points are allocated to asthma indicators. If a practice does not have any patients on their asthma register, (no patients meeting the established criteria), then they would be unable to achieve any of the points allocated to the asthma indicators. Therefore, even if the practice achieved all the other points available they would only be able to reach 91.9 per cent achievement (514 points achieved/ 559 points available)
In these circumstances, the standard ‘points achievement’ measure can be misrepresentative and may result in a practice’s achievement apparently declining from one year to the next where they have patients on a register in one year but none in the next year.
To represent practice points achievement more fairly, NHS Digital calculates adjusted maximum points achievable for each practice, effectively removing points from the calculation denominator where both of the following conditions apply:
- the practice does not have any patients in the indicator denominator
- the practice has reported no exceptions for the indicator denominator
In essence, the indicator denominator plus indicator exceptions must equal zero. This ensures we are not adjusting maximum points achievable where there are patients on the relevant disease register (exceptions are included in the disease register, but not in the relevant denominator), who have not received the interventions.
For the example outlined above, for a practice with no patients on their asthma register the practices maximum points available would be 514 (559 points minus the ‘unachievable’ 45 asthma points). In this case, the difference between the practices ‘points achievement’ and ‘points achieved as a percentage of QOF points available’ would be as follows:
Points achievement = (Points achieved / All QOF points) x 100
= (514 / 559) x 100 = 91.9 per cent
Points achieved as per cent of points available = (Points achieved / QOF points available) x 100
= (514 / 514) x 100 = 100 per cent
Due to the complexities of calculating and presenting the ‘points achieved as a percentage of QOF points available’ figures, we only provide these for total points, not for any domain or group totals. The figures can be found in the ‘QOF 2018-19: Achievement at practice level, all domains’ workbook on the publication homepage.
What disease prevalence information is available from QOF?
Prevalence information for 2018-19 is presented in the publication for the 6,873 practices that were in the QOF achievement dataset. For the 19 indicator groups in the clinical domain, CQRS captures the number of patients on the clinical register for each practice.
The number of patients on the clinical registers can be used to calculate measures of disease prevalence, expressing the number of patients on each register as a percentage of the number of patients on practices' lists.
What prevalence figures are shown and how are they calculated?
The registers used to calculate prevalence are those submitted to CQRS at the same time as achievement submissions (i.e. end of year submissions). Prior to 2009, ‘National Prevalence Day’ was 14 February. From 2009 onwards, ‘National Prevalence Day’ was moved to 31 March, so for the purpose of prevalence adjustments to QOF payments, prevalence is calculated on the same basis as disease registers for indicator denominators.
In the QOF 2018-19, there are 7 indicator groups with registers relating to specific age groups:
- Blood pressure – aged 45 and over
- Chronic kidney disease – aged 18 and over
- Diabetes mellitus – aged 17 and over
- Epilepsy – aged 18 and over
- Obesity – aged 18 and over
- Osteoporosis – aged 50 and over
- Rheumatoid arthritis – aged 16 and over
For 2018-19 NHS Digital has produced prevalence rates for all of these conditions based on appropriate sub-sets of the patient list size. For example, diabetes registers are expressed as a percentage of patients on practices’ lists who are aged 17 and over. These are produced to help researchers or information users who require more precise prevalence rates for these areas.
How do I get a count of the number of patients who smoke?
The register underpinning the QOF smoking indicators is not a register, or count, of people who smoke. The QOF provides no information on numbers of smokers and non-smokers.
Do QOF prevalence figures differ from prevalence figures published elsewhere?
Differences may occur because QOF registers do not necessarily equate to prevalence as may be defined by epidemiologists. For example, recorded prevalence figures based on QOF registers may differ from prevalence figures from other sources because of coding or definitional issues.
Care should be taken to understand definitional differences, for example when comparing QOF prevalence with expected prevalence rates using public health models.
The QOF only provides recorded prevalence; it does not allude to or report on expected prevalence or estimated prevalence. Nor does it forecast future prevalence rates, as definitions for the QOF registers and their associated indicators are always subject to change. For example, to be on the QOF obesity register in 2015-16, patients needed to be aged 18 or over, and have a body mass index greater than or equal to 30 recorded in the previous 12 months, whereas in previous years, the register included all those aged 16 and over with a body mass index greater than or equal to 30 recorded in the previous 12 months.
What practice list sizes are used in calculating prevalence rates?
The 2018-19 QOF information published by NHS Digital includes practice list size. This is sourced from the latest available Exeter National Health Application and Infrastructure Services (NHAIS) extract on or before 1 April 2019. In the context of this publication, these list sizes are used as the basis for the calculation of raw clinical prevalence.
Are there issues with prevalence for specific clinical areas?
Factors in interpreting information on specific registers include the following:
Some clinical areas have 'resolution codes' to reflect the nature of diseases. Others, such as the cancer register, do not.
Some registers require patients to meet certain criteria in addition to having a diagnosis of the relevant condition. For example, to be on the asthma register, patients need a diagnosis of asthma and a prescription for an asthma drug within the year.
Many patients are likely to suffer from co-morbidity, i.e. diagnosed with more than one of the clinical conditions included in the QOF clinical domain. Robust analysis of co-morbidity is not possible using QOF data because QOF information is collected at an aggregate level for each practice and each QOF register is independent of all other QOF registers; there is no patient-specific data within CQRS. For example, CQRS captures aggregated information for each practice on patients with coronary heart disease and on patients with diabetes, but it is not possible to identify or analyse patients with both of these diseases.
Is it possible to obtain QOF prevalence information by age group? I understand that age-specific prevalence information is available.
We do not have age-specific prevalence data from the QOF. QOF registers are not broken down by age.
Reference to ‘age-specific prevalence’ relates to those QOF clinical areas where QOF registers exclude certain ages; prevalence rates based on these registers are calculated using appropriate sub-sets of the patient list size.
For example, diabetes registers are expressed as a percentage of patients on practices’ lists who are aged 17 and over.
A small number of practices have a list size, but no disease register or achievement - this is affecting disease prevalence calculations in aggregations. Why is this the case?
It is likely that these practices closed or merged with other practices during the reporting year. However, during the validation exercise, validators advised that they wanted the available data for these practices to be included in the release. This can have the effect of reducing the calculated QOF recorded disease prevalence at aggregations (such as at CCG level). At national level, this reduction in QOF recorded disease prevalence ranges from <0.01 percentage points to 0.02 percentage points.
Users may wish to re-calculate local aggregations of QOF recorded disease prevalence by using the practice-level data, and omitting practices that do not have any achievement points recorded.
Where can I find information about individual patients? How do I find out about patients with more than one disease?
There are no patient-specific data in CQRS because these are not required to support the QOF. For example, CQRS captures aggregate information for each practice on patients with coronary heart disease and on patients with diabetes, but it is not possible to identify or analyse information on individual patients.
It is not possible, therefore, to identify the number of patients with both of these diseases.
Can I have figures for specific conditions from the Mental Health register, e.g. for schizophrenia, separately?
No. The QOF mental health register is a count, for each GP practice, of the total number of people "with schizophrenia, bipolar disorder and other psychoses". The information is not captured from GP systems at any lower level of aggregation. The data are captured according to this definition to support QOF payments, and the data capture is designed only to meet payment requirements.
How do I know if practices had special circumstances that have affected QOF achievement?
A validation exercise was conducted in July 2019; NHS Digital invited regional local offices to view the total QOF points for each of their practices as held on CQRS at the point of extraction for the 2018-19 QOF publication.
Regional local offices were asked to confirm that the extract contained all their practices. They were also invited to provide commentary on their practices' overall QOF achievement, as contained in the CQRS extract. Such commentary was invited because QOF achievement for some practices had not been approved for payment (i.e. was still subject to local sign-off) at the time of the CQRS extract (2 July 2019).
For some practices in England, comments were provided by regional local offices to support the published QOF achievement information. Such comments generally referred to:
- Adjustments to QOF achievement that were agreed locally after the date of the CQRS extract for publication (i.e. after the 2 July 2019)
- Practices where QOF achievement remained subject to local review or appeal
- Practices providing specialist services, such as practices that served university populations or asylum seeker populations
- Practices signing up to a local enhanced service
- Practices that have closed or been involved in a merger, resulting in unexpected QOF data
All notes on practice achievement provided by regional local offices are presented alongside practice-level QOF achievement data on the 2018-19 online practice results database, https://qof.digital.nhs.uk/, and in the ‘QOF 2018-19: Practice validation comments’ workbook available on the publication homepage.
In addition, all regional local offices wished to emphasise that for PMS practices the published QOF achievement figures refer to QOF points achieved prior to the application of PMS deductions. This is because the published information covers QOF achievement, not QOF payments, and therefore it was decided that where GMS and PMS practices have maximum QOF achievement (for example), both will be shown as having achieved 559 QOF points.
Some regional local office specific notes were also received about practice codes that are not included in the QOF publication, for example about practices that participated in the QOF but did not use CQRS, or practice codes that did not participate in the QOF
Should I make a league table to show which practices provide the best care or the worst?
Levels of QOF achievement will be related to a variety of local circumstances, and should be interpreted in the context of those circumstances. Users of the published QOF data should be particularly careful in undertaking comparative analysis. The following points have been raised by local healthcare organisations in consultation with NHS Digital:
The ranking of practices on the basis of QOF points achieved, either overall or with respect to areas within the QOF, may be inappropriate. QOF points do not reflect practice workload issues, (for example around list sizes and disease prevalence), that is why practices' QOF payments include adjustments for such factors.
Comparative analysis of QOF achievement, or prevalence, may also be inappropriate without taking account of the underlying social and demographic characteristics of the populations concerned. The delivery of services may be related, for example, to population age/sex, ethnicity or deprivation characteristics that are not included in QOF data collection processes.
Information on QOF achievement, as represented by QOF points, should also be interpreted with respect to local circumstances around general practice infrastructure. In undertaking comparative or explanatory analysis, users of the data should be aware of any effect of the numbers of partners (including single handed practices), local recruitment and staffing issues, issues around practice premises, and local IT issues.
Users of the data should be aware that different types of practice may serve different communities. Comparative analysis should therefore take account of local circumstances, such as numbers on practice lists of student populations, drug users, homeless populations and asylum seekers.
Analysis of co-morbidity (patients with more than one disease) is not possible using QOF data. QOF information is collected at an aggregate level for each practice. There is no patient-specific data within CQRS. For example, CQRS captures aggregated information for each practice on patients with coronary heart disease and on patients with asthma, but it is not possible to identify or analyse patients with both of these diseases.
Underlying all this is the fact that the information held within CQRS, and the source for the published tables, is dependent on diagnosis and recording within practices using practices' clinical information systems.
Further data and re-use of data
What are QOF data used for?
The data are collected primarily to support QOF payments to general practices. They are calculated from the achievement scores allocated to each indicator. The QOF rewards practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care.
Although collected primarily to support QOF payments, QOF information is valuable for many secondary uses:
- Department of Health and NHS England - to inform policy
- CCGs - for monitoring and commissioning
- GP practices - to assess performance in context
- Healthcare researchers and by organisations interested in specific care areas (for example diabetes care)
- Public Health England - especially for recorded prevalence analysis
- Care Quality Commission – for use in GP Monitoring http://www.cqc.org.uk/gpmonitoring
- General public – reviewing local GP care information
Can I re-use or publish the QOF data?
This information has been produced by NHS Digital. You may re-use this document (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0.
To view this licence, visit www.nationalarchives.gov.uk/doc/open-government-licence;
or write to the Information Policy Team, The National Archives, Kew, Richmond, Surrey, TW9 4DU;
or email: firstname.lastname@example.org
Where can I find information on QOF for Scotland, Wales and Northern Ireland?
How can I obtain a list of practice names and addresses?
NHS organisation codes are managed by the Organisation Data Service (ODS): https://digital.nhs.uk/organisation-data-service, and a file containing GP practice details (including addresses) can be downloaded from https://digital.nhs.uk/organisation-data-service/data-downloads .
Alternatively, address details for individual GP practices can be found on the QOF online search facility https://qof.digital.nhs.uk/
I have a problem with my practice’s data on CQRS reports
The QOF publication team has no role in the management of CQRS.
Any issues with CQRS or GPES systems should be referred to (for CQRS) and (for GPES).
Where can I find information on QOF payments to practices?
NHS Digital does not publish data on QOF payments. For information on QOF payments it would be necessary to contact the relevant regional local office or practice.
The QOF publication is based on an extract of data from the national CQRS system, taken on the 2 July 2019, but relating to the previous financial year (1 April 2018 to 31 March 2019).
However, many practices/regional local offices continue to review QOF achievement (and therefore payments) after the end of July, and any such amendments to achievement would not be included in our publication database. The reason for not publishing financial information 'as at end of July' is that this would not always be a robust presentation of final payments, where payments are not agreed until after July.