Quality and Outcomes Framework, 2020-21

Please note: The outbreak of Coronavirus (COVID-19) in the last quarter of 2019-20 has led to unprecedented changes in the work and behaviour of GP practices and consequently data in this publication may have been impacted.

As such, caution should be taken in drawing any conclusions from the data without due consideration of the circumstances both locally and nationally as of 31 March 2020 and we would recommend that any use of this data is accompanied by an appropriate caveat.

The tables for QOF 2020-21 present data from both the current reporting year and the previous reporting year for prevalence only as the changes to the way practices are paid in 2020-21 mean that the achievement and personalised care adjustment (PCA) data extracted for the 2020-21 reporting year could be misleading and not representative of activity undertaken, and any comparisons with data from previous years are not recommended. Further details are in the Guidance for GMS contract 2020/21 in England published by NHS England and NHS Improvement and The General Medical Services Statement of Financial Entitlements (Amendment) Directions 2021.

The Quality and Outcomes Framework (QOF) covers 20 clinical, 4 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. QOF information is valuable for many secondary uses.

Some aspects of the NHS Digital published QOF information 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 2021, and so include all adjustments up to 30 June 2021.

Following validation, the published QOF dataset includes data for 6,571 practices. In the 2020-21 reporting year 6,796 practices eligible for QOF were open and active at some point; this gives a coverage of 96.7%.

The outbreak of coronavirus (COVID-19) in the last quarter of 2019-20 has led to unprecedented changes in the work and behaviour of GP practices and consequently the data in this publication may have been impacted.

As such, caution should be taken in drawing any conclusions from this data without due consideration of the circumstances both locally and nationally as of 31 March 2020 and we would recommend that any use of this data is accompanied by an appropriate caveat. 

To support the ongoing response to COVID-19 and the need to proactively target and support the most vulnerable patients during this period the following changes have been implemented in 2020-21:

• Some indicators will continue to be paid based on practice performance. These are:
  • The four flu indicators targeted on patients with coronary heart disease, COPD, stroke/TIA and diabetes, will have the number of points attached to them doubled.
  • The two cervical screening indicators will have the number of points attached to them doubled.
  • Register indicators.
• The requirements of the Quality Improvement (QI) domain have been amended to focus upon care delivery and restoration of services using QI tools.
• The remaining 354 points will be subject to income protection based upon historical practice performance and to practices agreeing an approach to QOF population stratification with their commissioner.

The total points available to practices is 567 and all payments will be subject to prevalence and list size adjustments.

Further detail of these indicators and their requirements are detailed in the Guidance for GMS contract 2020/21 in England published by NHS England and NHS Improvement  and The General Medical Services Statement of Financial Entitlements (Amendment) Directions 2021.

These changes mean that the achievement and personalised care adjustment (PCA) data extracted for the 2020-21 reporting year could be misleading and not representative of activity undertaken, and any comparisons with data from previous years are not recommended.

Due to income protection applied to the majority of QOF 2020-21 indicators practices were not awarded points based on their activity recorded against these indicators in the 2020-21 reporting year.  The ACHIEVED_POINTS displayed in the csv file are those the practices achieved in QOF 2020-21. The numerator, denominator and personalised care adjustment (PCAs) do relate to the activity in the year, however the achievement points in the ACHIEVED_POINTS csv file will not necessarily be based on this numerator, denominator and PCA data. Further details on income protection can be found in the Technical Annex.

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 to ensure consistency of approach and outcome.

The validation process for the current year excluded:

183 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.

9 practices which closed before 1 April 2021 and this closure was recorded before 1 July 2021.

17 practices which did not have a status of ‘A’ (Active) on 31 March 2021.

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 2021.

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 2021. This delay after the financial year-end maximises the number of practices whose achievement is signed-off, whilst still allowing publication in September.

QOF publications are available on the NHS Digital 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, CCG, STP, regional 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.

We provide an online database which allows users to view detailed information about practices in a more visual format.

Where NHS Digital data is reused, NHS Digital 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. 

Overview of year on year changes are:

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 time-frame 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, time-frame 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 time-frame 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

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 Digital 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 Digital 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 CCGs) 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 Digital.

QOF publications are subject to risk assessments concerning disclosure. No personal identifiable data has been identified in this year’s QOF. Standard NHS Digital 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: 

https://uksa.statisticsauthority.gov.uk/about-the-authority/uk-statistical-system/types-of-official-statistics/

Please see links below to the relevant NHS Digital 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