Quality and Outcomes Framework, 2021-22

The information published by NHS Digital relates to GP practices in England.

The latest available information is for 2021-22 and is based on data for the period 1 April 2021 to 31 March 2022. The data was extracted from the national CQRS system on 1 July 2022 and incorporate any changes made up to 30 June 2022. 

This publication covers three types of data for England:

1. Disease prevalence
2. Achievement
3. Personalised Care Adjustment (PCA) reporting

The latest QOF publication consists of:

• Summary of the main findings
• Data quality annex
• Technical annex
• FAQ annex
• A set of spreadsheets of QOF prevalence, achievement and PCA data at four levels:
  • NHS England region and national
  • Integrated Care Board (ICB) 
  • Sub Integrated Care Board Location (Sub ICB Loc)
  • GP practice
• A spreadsheet of all indicator definitions and their associated points availability.
• CSV files of the data, and accompanying data dictionary.
• An online database that allows searches for individual GP practices, and presents QOF data graphically.

When Integrated Care Boards (ICBs) were established as statutory bodies on 1st July 2022, CCGs and STPs ceased to exist. Therefore, from July 2022 onwards, data will be aggregated to Sub ICB Location, and ICB level. For further information on these changes please see the following links:

• NHS England - ICBs in England
• Organisation Data Service (ODS) - ICBs

Achievement and Personalised Care Adjustment (PCA) data have been re-introduced to the Excel summary tables for the 2021-22 reporting year.

Payment protection has been applied to the QOF service and may affect QOF activity and/or its recording for these years:

• 2021-22 QOF service – practices were advised in December 2021 that payment protection would be applied.
• 2020-21 QOF service - practices were advised at the beginning of the reporting year that payment protection would be applied.

When comparing QOF data between these years, users should be aware that practices were advised that payment protection would be applied at different times during the year.

In years prior to this payment protection was not implemented. NHS England and Improvement published information about the implementation of QOF payment protection; for the 2020-21 reporting year this can be found in the Guidance for General Medical Services Contract document, and for the 2021-22 reporting year this can be found in a letter to practice.

Suppression has been applied to the PRACTICE_PCA_EXCL.csv. Where a GP practice’s disease register for an indicator is comprised of between 1 and 4 patients, all PCA and exclusion counts for the indicators in that indicator group have been suppressed. Where an indicator group is not based on a disease register, this suppression has been applied where the relevant practice list size is comprised of between 1 and 4 patients. All suppressed values have been replaced by '*'.

For this suppression to be effective, all instances of PCA or exclusion counts of 0 are now included in this file.

Comparisons between these two reporting years are not recommended because payment protection has been applied to the QOF service and may affect QOF activity and/or its recording for these years as practices were advised that payment protection would be applied at different times during the year:

• 2021-22 QOF service – practices were advised in December 2021 that payment protection would be applied.
• 2020-21 QOF service - practices were advised at the beginning of the reporting year that payment protection would be applied.

The Quality and Outcomes Framework (QOF) is a national data collection which was introduced as part of the General Medical Services (GMS) contract on 1 April 2004.

QOF rewards GP 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.

GP practice participation is voluntary, though participation rates are very high, with most Personal Medical Services (PMS) practices also taking part. Data on GP practice participation can be found in the Data quality annex.

Previously, the Quality Management and Analysis System (QMAS) was used to extract QOF data. In July 2013, QMAS was replaced by the Calculating Quality Reporting Service (CQRS), together with the General Practice Extraction Service (GPES). These are national systems developed and maintained by NHS Digital.

Relevant clinical data is extracted from GP practices’ clinical systems via GPES, and QOF data are then accessed via CQRS.

QOF covers five domains. Each domain consists of a set of measures of achievement, known as indicators, against which GP practices score points according to their activity as defined by those indicators.

The domains are:

• Clinical
• Public health
• Public health - additional services
• Public health - vaccination and immunisation
• Quality improvement

In the domains, indicators are organised into groups. Details of these can be found in the published Indicator Definitions csv.

GP practices are financially rewarded through QOF 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 GP practices in England.

For 2021-22 the value of a QOF point was £201.16.

Users of data derived from CQRS should recognise that CQRS was established as a mechanism to support the calculation of GP practice QOF payments. QOF does not provide a comprehensive source of data on quality of care in GP practice, but is potentially a rich and valuable source of such information, providing the limitations of the data are acknowledged.

On the NHS Digital website you can find QOF information for years from 2004-05 at https://digital.nhs.uk/data-and-information/publications/statistical/quality-and-outcomes-framework-achievement-prevalence-and-exceptions-data

This data is also available through the QOF online search facility at https://qof.digital.nhs.uk/

The Quality and Outcomes Framework was introduced in 2004-05. No QOF indicator information is available for previous years.

Details of changes prior to 2021-22 can be found in the Data quality annex.

Changes include:

• One new domain, Public health – vaccination and immunisation containing one new indicator group (Vaccination and immunisation) comprising of four new indicators worth a total of 64 points.
• Five new indicators were introduced within existing conditions (worth 0 points).
• Five indicators were retired (worth 42 points), from within conditions that are still measured in QOF.
• Eleven existing indicators had their points allocation changed from last year.

Maximum possible QOF score available increased to 635 points.

Changes to QOF for 2022-23 are detailed in the Quality and Outcomes Framework guidance for 2022/23 on the NHS England website.

The only changes are the introduction of two new Quality Improvement modules

• Prescription drug dependency
• Optimising access to general practice

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: https://www.nice.org.uk/standards-and-indicators 

QOF data is captured from GP practice systems according to coded ‘business rules’, produced by NHS Digital. QOF business rules are published on the NHS Digital website.

If you try to open the PCA files in Microsoft Excel, you may find that the data are truncated; this is because the dataset exceeds the number of rows or columns available in Excel. We recommend importing these files into a database to ensure all data is available, or importing the file into Excel using the Get Data function and performing analysis using PivotTables.

An explanation of PCA reporting and the calculation of PCA rates is available in the Technical annex.

PCA reporting at national level is covered in the main finding's summary.

A breakdown of PCAs and exclusions by reason per indicator group at GP practice level is available as a csv - PRACTICE_PCA_EXCL - available as part of the publication.

CQRS presents counts of PCA-reported patients, which roughly equates to the number of people on a disease register who are not included in an indicator denominator.

In the NHS Digital QOF publication, there is a distinction between patients who are PCA-reported, and those whose non-inclusion in an indicator denominator is for definitional reasons (‘exclusions’).

Definitional 'exclusions' are treated as PCA reporting by CQRS, and the 'excluded' patients are shown in PCA reporting counts. CQRS does this because it is primarily a system to support payments, and its function in respect of PCA reporting is to ensure the right patients are not included in indicator denominators.

For example:

CHD005: The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken

NHS Digital QOF publication would show:

CHD Register = 100

CHD005 Denominator = 8

CHD PCA Count = 2

CHD Definitional Exclusions = 90

PCA-reported patients = CHD PCA Count + CHD Definitional Exclusions (2 + 90)

CQRS would show this as 92 PCA-reported patients because there is no concept of exclusions within CQRS – they are all PCAs.

The NHS Digital QOF publication considers the underlying PCA reporting codes within the CQRS tables and assigns the notion of 'definitional exclusions' to some codes. These are not included in published PCA counts and rates.

Published PCA reporting figures therefore do not include counts of definitional exclusions, since these cannot make up part of the indicator denominator.

PCAs are identified upon extraction of the data from the clinical system; although PCA codes may be manually added to patient records with the intention of omitting a patient from a given indicator, codes that exist in the patient record as a matter of course are read at the point of extraction and identified as a PCA (e.g. ‘patient diagnosed within 3 months of end of payment period’).

Therefore, a patient may be omitted from an indicator even where a clinician has not identified that patient’s record and added an PCA code, because codes or certain dates that are part of the patient’s record are defined as PCAs.

The GP practice level, PCAs and exclusions csv (PRACTICE_PCA_EXCL) released as part of the publication provides a breakdown of PCAs by reason at GP practice level, which may be useful in identifying the PCAs applied to each indicator. It should be noted that a patient can only have a PCA applicable once per indicator.

A full list of PCAs and exclusions (with descriptions) that can be applied to each indicator can be found in the MAPPING_PCAS_EXCL_INDICATOR csv included in the publication.

Participation in QOF is voluntary, although participation rates are very high; The latest QOF dataset included data from 97.5% of GP practices in England that were open and active at some point in the reporting period. Some GP practices may choose not to participate, perhaps because they are specialist centres or because they participate in alternative local schemes. Some GP practices’ data are removed during validation.

QOF latest published achievement data was for 6,470 GP practices in England. These GP practices made an end-of-year submission to CQRS. QOF achievement figures include data automatically extracted from GP practice systems by the CQRS system at the end of the reporting year (31 March). Data adjustments for the year were submitted in the 3 months after the end of the reporting year (April, May and June).

During validation, a small number of GP practices were removed from the dataset (e.g. GP practices whose data is not representative due to their closure). The results of the validation exercise are available as part of the publication in the PRACTICE_VALIDATION_OUTCOMES csv included in the publication.

The sum of the GP practice list sizes for the GP practices included in the QOF publication is 61,604,213. This number may contain duplicate patients where patients have moved GP practice during the financial year, this is detailed in the publication’s Technical annex.

PMS practices can negotiate local contracts with their commissioner for the provision of all services. PMS practices may also participate in 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 latest published QOF information.

The NHS Digital annual QOF publication is based on an extract from CQRS taken on the 1 July 2022 and relates to the period April 2021 to March 2022. It therefore does not reflect any changes that have been made after this date or ‘off-system’ (i.e. not on CQRS).

If you try to open the achievement files in Microsoft Excel, you may find that the data are truncated; this is because the dataset exceeds the number of rows or columns available in Excel. We recommend importing these files into a database in order to ensure all data is available, or importing the file into Excel using the Get Data function and performing analysis using PivotTables.

Where PMS practices use the national QOF, their latest achievement (in terms of the maximum 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 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. As 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 QOF points available.

Reference to 100% achievement often refers to the percentage of available QOF points achieved. If a GP practice achieves the maximum QOF points available, it has achieved 100% of the points available and may be said to have 100% achievement across the whole QOF.

The level of achievement for certain elements of QOF can be expressed in the same way. A GP practice achieving all 401 Clinical QOF points available can be said to have 100% Clinical achievement even though it may not have 100% achievement overall.

GP 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 GP practice must provide a certain level of clinical care to 90% of patients on a particular clinical register to achieve the maximum points.

A GP practice can therefore deliver the required care to fewer than 100% of its patients (90% in this case) to achieve the full (100%) points available. There is an important distinction between percentage achievement in terms of QOF points available and the underlying achievement (net of PCAs) for specific indicators, the latter representing the indicator numerator as a percentage of the denominator.

Underlying achievement (net of PCAs) does not account for all patients covered by each indicator, as it takes no account of “PCAs” (patients to whom the indicator applies, but who are not included in the indicator denominator according to agreed Personalised Care Adjustment (PCA) 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 PCA status (i.e. indicator PCAs and indicator denominator).

For example,

100 patients on GP practice’s CHD register

10 patients have a PCA reported from CHD005

Therefore, the denominator for CHD005 is 90 patients

The GP practice delivers the CHD005 intervention to 80 patients

Underlying achievement (net of PCAs)

(Numerator / Denominator) * 100

(80 / 90) * 100 = 88.9%

Percentage of patients receiving the intervention 

(Numerator / (PCAs + Denominator)) * 100

(80 / (10 + 90)) * 100 = 80.0%

Not necessarily. The achievement of full points may not be possible or desirable for some GP practices. Participation in QOF is voluntary, and GP practices may aspire to achieve all, some, or none of the points available. It is important to note that for some GP practices it may be impossible to achieve all the points available in QOF.

For example, some clinical indicators relate to specific subgroups of patients, and if the GP practice does not have any such patients it cannot score points against the relevant indicators. A GP practice that exclusively serves a student population may not have patients on some of the clinical registers e.g. dementia, that are covered by QOF, and although its QOF points total would be less than 635 (or 100%), it may be providing all the appropriate care in respect of the clinical registers that it does hold.

In addition, GP practices with Personal Medical Services (PMS) 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.

In recognition of the fact that it is not always possible for GP practices to achieve all the points in QOF, NHS Digital has produced a further measure of GP practice achievement. This measure takes account of instances where GP practices cannot achieve points because they have no patients pertinent to an indicator.

For example: If there are 635 QOF points available and 45 of these points are for asthma indicators but if a GP practice does not have patients on their asthma register, (no patients meeting the established criteria) then it would not be possible to achieve any of the points allocated to the asthma indicators.

Therefore, even if the GP practice achieved all the other points available, they would only be able to attain 92.9% achievement (590 points achieved/ 635 points available) * 100.

In these circumstances, the standard ‘points achievement’ measure can be misrepresentative and may result in a GP 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 GP practice points achievement more fairly, NHS Digital calculates adjusted maximum points achievable for each GP practice, effectively removing points from the calculation denominator where both of the following conditions apply:

• the GP practice does not have any patients in the indicator denominator
• the GP practice has reported no PCAs for the indicator denominator

The indicator denominator plus indicator PCAs must equal zero. This ensures adjustment of maximum points achievable where there are patients on the relevant disease register (PCAs are included in the disease register, but not in the relevant denominator), who have not received the interventions.

For example, a GP practice with no patients on their asthma register, the GP practices maximum points available would be 533 (567 points minus the ‘unachievable’ 34 asthma points). In this case, the difference between the GP practice’s ‘points achievement’ and ‘points achieved as a percentage of QOF points available’ would be as follows:

(Points achieved / All QOF points) * 100 = Points achievement

(590 / 635) * 100 = 92.9%

(Points achieved / QOF points available) * 100 = Points achieved as percentage of QOF points available

(590 / 590) * 100 = 100%

Due to the complexities of calculating and presenting the ‘points achieved as a percentage of QOF points available’ figures, they are only provided for total points, not for any domain or group totals. 

Prevalence information in the publication is presented for the 6,470 GP practices that were in the QOF achievement dataset. For 20 indicator groups in the Clinical domain, CQRS captures the number of patients on the clinical register for each GP 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 GP practices' lists.

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 latest QOF data, there are 9 indicator groups with registers relating to specific age groups:

• Asthma – aged 6 and over
• Chronic kidney disease – aged 18 and over
• Depression – aged 18 and over
• Diabetes mellitus – aged 17 and over
• Epilepsy – aged 18 and over
• Non-diabetic hyperglycaemia - aged 18 and over
• Obesity – aged 18 and over
• Osteoporosis – aged 50 and over
• Rheumatoid arthritis – aged 16 and over

NHS Digital has produced prevalence rates for all these conditions based on appropriate sub-sets of the patient list size. Diabetes registers are expressed as a percentage of patients on GP 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.

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.

Differences may occur because QOF registers do not necessarily equate to prevalence as defined by epidemiologists. 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, when comparing QOF prevalence with expected prevalence rates using public health models.

QOF only provides recorded prevalence; it does not refer to or report on expected prevalence or estimated prevalence. Nor does it forecast future prevalence rates, as definitions for QOF registers and their associated indicators are always subject to change. To be on the QOF obesity register from 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, however 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.

The latest QOF information published by NHS Digital includes GP practice list size. This is sourced from the latest available Exeter National Health Application and Infrastructure Services (NHAIS) extract on or in the 3 months up to the end of the reporting year January, February or March), whichever is the later. In this publication, these list sizes are used as the basis for the calculation of raw clinical prevalence.

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 instance, 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, that is 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 GP practice and each QOF register is independent of all other QOF registers; there is no patient-specific data within CQRS which captures aggregated information for each GP 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.

NHS Digital do not have age-specific prevalence data from QOF as 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 GP practices’ lists who are aged 17 and over.

There are no patient-specific data in CQRS because it is not required to support QOF. Consequently, although CQRS captures aggregate information for each GP 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. Therefore, it is not possible to identify the number of patients with both diseases.

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 is captured according to this definition to support QOF payments, and the data capture is designed only to meet payment requirements.

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 GP practices based on QOF points achieved, either overall or with respect to areas within the QOF, may be inappropriate. QOF points do not reflect GP practice workload issues (e.g. around list sizes and disease prevalence), which is why GP 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 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 GP 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 GP practices), local recruitment and staffing issues, issues around GP practice premises, and local IT issues.
• Users of the data should be aware that different types of GP practice may serve different communities. Comparative analysis should therefore take account of local circumstances, such as numbers on GP 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 GP practice. There is no patient-specific data within CQRS which captures aggregated information for each GP practice on patients with coronary heart disease and on patients with asthma, although it is not possible to identify or analyse patients with both diseases.
• Underlying all this is the information held in CQRS, which is the source for the published tables and is dependent on diagnosis and recording within GP practices using the practices' clinical information systems.

The data is collected primarily to support QOF payments to GP practices which are calculated from the achievement scores allocated to each indicator. QOF rewards GP practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care.

QOF information is also valuable for many secondary uses:

• Department of Health and Social Care and NHS England and NHS Improvement - to inform policy
• Sub ICB Locations - 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
• General public – reviewing local GP care information

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: [email protected]

Scotland:

http://www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/

Wales:

https://gov.wales/general-medical-services-contract-quality-and-outcomes-framework

Northern Ireland:                                                                                  

https://www.health-ni.gov.uk/topics/dhssps-statistics-and-research/quality-outcomes-framework-qof

NHS organisation codes are managed by the Organisation Data Service (ODS), 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/

The QOF publication team has no role in the management of CQRS.

Any issues with CQRS or GPES systems should be referred to [email protected] (for CQRS) and [email protected] (for GPES).

NHS Digital does not publish data on QOF payments. For information on QOF payments it would be necessary to contact the relevant Sub ICB Locations or GP practice.

The QOF publication is based on an extract of data from the national CQRS system, taken on the 1 July 2022 and relates to the previous financial year.

However, many GP practices/ and Sub ICB Locations continue to review QOF achievement (and therefore payments) after the data has been extracted, and any amendments to achievement after the data has been extracted would not be included in NHS Digital’s publication database. The reason for not publishing financial information as at the date of extraction is that this would not always be a robust presentation of final payments, where payments are not agreed until after that time.