Quality and Outcomes Framework, 2021-22

The Quality and Outcomes Framework (QOF) was introduced as part of the General Medical Services (GMS) contract on 1 April 2004. The objective of QOF is to improve the quality of care patients are given by rewarding GP practices for the quality of care they provide to their patients and is therefore, an incentive payment scheme, not a performance management tool.

A key principle is that QOF indicators should be based on the best available research evidence. Participation by GP practices in QOF is voluntary, though participation rates are very high, with most Personal Medical Services (PMS) practices taking part.

The QOF contains five main components, known as domains, these are:

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

Each domain consists of a set of achievement measures, known as indicators, against which GP practices score points according to their level of achievement.

The indicators included in the current reporting year are detailed in the accompanying 'Indicator definitions' file (available on the publication homepage) and details of changes to indicators by year are shown in the relevant section of this document.

QOF information from previous years has been published by NHS Digital and is available at https://digital.nhs.uk/data-and-information/publications/statistical/quality-and-outcomes-framework-achievement-prevalence-and-exceptions-data, and via an online search function at https://qof.digital.nhs.uk/.

QOF data was collected from GP practices by GPES. GPES is a centrally managed service that extracts information from GP IT systems for a range of purposes at a national level. The GPES relays data to CQRS.

CQRS calculates achievement and payments on quality services, including the Quality and Outcomes Framework (QOF), as well as Enhanced Services (ESs) and some other clinical services (e.g. health checks).

Summary of changes for 2021-22

The following changes have been implemented in 2021-22:

• A new vaccination and immunisation domain consisting of four indicators. Three of these indicators focus on routine childhood vaccinations and one on the delivery of shingles vaccinations.
• The reintroduction of three indicators focused on patients with a serious mental illness in relation to uptake in all six elements of the SMI physical health check.
• A new indicator focused on cancer care has been introduced and amendments made to the timeframe and requirements for the cancer care review indicator.
• The four flu indicators have been retired.
• The date of diagnosis has been amended to ‘on or after April 2021’ for the asthma, heart failure and COPD diagnostic indicators.
• To account for the impact of the COVID-19 pandemic on care, the Learning Disabilities and Supporting Early Cancer Diagnosis Quality Improvement modules are to be repeated in their intended format (prior to amendments for the refocusing of QOF in September 2020) with some slight modifications to account for the impact of the pandemic on care.

The total points available to practices is 635 and all payments will be subject to prevalence and list size adjustments.

Additional information can be found in NHS England » Update on Quality Outcomes Framework changes for 2021/22

PMS practices can negotiate local contracts with their commissioning organisations for the provision of all services. PMS practices may also participate in QOF, and they may either follow the national QOF framework or become part of local QOF arrangements.

PMS practices with local contractual arrangements are included in the published QOF information, and in the figures presented in the report.

Where PMS practices use the national QOF, their achievement (in terms of the maximum QOF points available) is subject to a deduction (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 the report 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 –where GMS and PMS practices have maximum QOF achievement, both are regarded as having achieved the maximum points.

There is no patient-specific data in CQRS because it is not required to support the QOF.

For example: GPES captures aggregate data on patients with coronary heart disease and on patients with diabetes, but it is not possible to identify or analyse information about individual patients and therefore not possible to identify the number of patients with both diseases.

QOF data is extracted from CQRS and in years prior to 2019-20 was processed and then passed to external regional local office representatives for validation.

The following validation rules are applied to the data sequentially for each GP practice:

1. The total number of points achieved by a GP practice was less than or equal to the total number of QOF points that can be achieved for indicators which require a manual response (usually ‘yes’ or ‘no’) only.
2. The GP practice closed before 1 April in the year of publication and this closure was recorded in the NHS Digital reference data before 1 July in the year of publication. 
3. The GP practice status in NHS Digital reference data on 31 March of the reporting period was not equal to ‘A’ (Active).
4. The number of registered patients at the GP practice was not available for any of the 3 months prior to 31 March of the reporting year.

The first validation rule that excludes a GP practice is recorded 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 data published for years from 2015-16 by NHS Digital uses GP practice list sizes on 1 April immediately following the reporting year end (31 March). In the context of this publication, these list sizes are used as the basis for the calculation of raw clinical prevalence.

Prior to 2015-16, GP practice list sizes on 1 January of the reporting year were used. These figures are still used in CQRS for list size adjustments in QOF payment calculations.

The sum of the GP practice list sizes for the GP practices included in the QOF publication can be found in the Data quality annex which is part of this publication. This number may contain duplicate patients where a patient has moved GP practice during the financial year; this is due to time lags in updates to organisation reference data.

Primary Care Networks (PCNs) were introduced into the National Health Service in England as part of the NHS Long Term Plan, published in January 2019, and form the building blocks of Integrated Care Systems. A PCN consists of a group of GP practices working together with a range of local providers (pharmacy, mental health, social care, community, and voluntary sector), serving a population of at least 30,000 and not tending to exceed 50,000. They build on the core of current primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care. PCNs have been included as a mapped GP practice geography from 1 April 2020.

On 1 July 2022 Integrated Care Boards (ICBs) were established as statutory bodies, consequently this publication will no longer present data at CCG and STP level. 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

GP practices have been mapped to their respective PCNs, Sub ICB Locations, ICBs and Regions using reference data current on 7 July in the year of publication. This mapping has been applied to data for both the current and previous reporting year; this should be borne in mind when making comparisons between years (please see the section ‘Comparing QOF data over time’).

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.

There is a distinction between:

• Numbers of patients on disease registers for QOF indicator groups.
• Numbers of patients relevant to specific indicators within these indicator groups.
• Numbers of patients relevant to specific indicators who are included in the indicator denominator when measuring QOF achievement. 

Most indicator groups have an associated disease register (e.g. the atrial fibrillation indicator group is based on a register of patients with atrial fibrillation).

Some conditions do not have a disease register (e.g. the blood pressure indicator group is based on a count of those who have had their blood pressure taken, which is not a disease register).

The information systems which underpin QOF hold the numbers of patients on each of these registers, for each participating GP practice.

Indicator denominators are the numbers of patients from the appropriate disease register who are counted for QOF achievement against a specific QOF indicator.

Indicator numerator is the number of those in the denominator who meet the specific indicator success criteria.

Differences between an indicator denominator and the number on a register can be due to indicator definition.

Patients who are on the disease register, but not included in the indicator denominator for definitional reasons, are referred to as exclusions. Some indicators refer to subsets of patients on a disease register e.g. they may only refer to patients who smoke. In this instance, any non-smoking patient on the disease register is excluded.

Differences between an indicator denominator and the number on a register not due to indicator definition, but rather due to individual circumstances, are referred to as PCAs. PCAs relate to patients who are on the disease register, and who would ordinarily be included in the indicator denominator. However, they are omitted from the indicator denominator because they meet at least one of the specified PCA criteria (these are detailed under 'Background to PCA reporting').

The normal relationship between registers, denominators, exclusions and PCAs is therefore:

Register = Denominator + Exclusions + PCAs

Reference to ‘QOF achievement’ often refers to the percentage of available QOF points achieved. If a GP practice achieves the full QOF points, 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 QOF points available for indicators in the clinical domain 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 delivered 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 specific clinical register to achieve the maximum points.

Underlying achievement (net of PCAs) data is provided in the spreadsheets associated with the report. Since a GP practice can deliver the required care to fewer than 100% of its patients (often around 90%) 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.

Underlying achievement (net of PCAs) presents the indicator numerator as a percentage of the denominator and is calculated as:

Underlying achievement net of PCAs = (Indicator numerator / Indicator denominator) * 100

Underlying achievement (net of PCAs) does not account for all patients covered by an 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 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 the indicator applies to, regardless of PCA status (i.e. indicator PCAs and indicator denominator). This measure is calculated as follows:

Percentage of patients receiving the intervention = (Indicator numerator /  (Indicator denominator + indicator PCAs)) * 100          

Percentage of patients receiving the intervention figures are not covered in the main report, but are presented in the excel tables at national, regional, ICB, Sub ICB Loc and GP practice level.

It is not always possible for GP practices to achieve all the points available in QOF. Therefore, NHS Digital produces a further measure of GP practice achievement. This measure takes account of instances where GP practices cannot achieve points because they have no patients relevant to an indicator and can be found in the achievement tables at GP practice level.

For example: if in a given financial year there are 559 QOF points available and 45 of these points are for asthma indicators but the 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 other points available they would only be able to attain 91.9% overall achievement (points achieved / points available) * 100.

In these circumstances, the standard ‘points achievement’ measure may not be representative 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: if in a given financial year there are 559 QOF points available and 45 of these points are for asthma indicators but the GP practice does not have patients on their asthma register then points available would be QOF points available minus the ‘unachievable’ 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 achievement = (Points achieved / All QOF points)  * 100

91.9% = (514 / 559)  * 100

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

100% = (514 / 514)  * 100

'Points achieved as a percentage of QOF points available’ figures are calculated for overall achievement and can be found in the achievement tables.

QOF registers are constructed to underpin indicators on quality of care, and they do not necessarily equate to prevalence as defined by epidemiologists.

Prevalence figures based on QOF registers may differ from prevalence figures from other sources because of coding or definitional issues. 

It is difficult to interpret year-on-year changes in the size of QOF registers, as a gradual rise in QOF prevalence could be due partly to epidemiological factors (such as an ageing population) or to increased case finding and recording. Other factors in interpreting information on specific registers include:

• Some clinical areas have ‘resolution codes’ to reflect the nature of diseases. Others, such as the cancer register, do not.
• Some indicator groups for which there is a disease register are based on a specific age group (see table below). Prevalence for these indicator groups is calculated using a sub-set of the patient list size relating to the equivalent age group.

Many patients are likely to suffer from co-morbidity (diagnosed with more than one clinical condition in QOF clinical domain). Robust analysis of co-morbidity is not possible using QOF data because it is collected at an aggregate level for each GP practice.

There is no patient-specific data in 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 those diseases.

Some disease registers have more specific definitions extending beyond a patient having a record 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. Full register definitions can be found in the ‘Indicator definitions’ file.

The number of patients on indicator registers in the clinical domain can be used to calculate recorded disease prevalence, expressing the number of patients on each register as a percentage of the number of patients on GP practices’ lists, as described below:

Disease prevalence = (Number of patients on clinical register / Number of patients on GP practice list) ∗ 100

Where age-specific registers are used, disease prevalence can be calculated as:

Disease prevalence = (Number of patients on clinical register / Number of patients in relevant age band on GP practice list) ∗ 100

PCA reporting rates reflect the percentage of patients who are not included when determining QOF achievement and are presented for applicable indicators in QOF. For 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’).

Personalised care adjustments can be applied to patients for a number of specified reasons and are usually the result of a patient or a GP decision at a personal level.

Examples of PCAs could be patient or carer refusal of treatment, a patient cancels or does not attend a consultation appointment, or a GP’s advice that two types of medication or treatment methodology should not be administered simultaneously.

PCAs are only measured at indicator level, not condition level, as a patient could be omitted from more than one indicator within a condition but would be counted more than once if these omissions were summed.

These are usually due to the type of patient and can be considered as non-inclusion in a denominator due to indicator definition e.g. all men are excluded from the cervical screening indicator, which is a female only measure. This affects the denominator and is not shown in this publication.

Patient PCA reporting applies to those indicators in the QOF where level of achievement is determined by the percentage of patients receiving the specified level of care. The GMS 2019-20 contract Section 6: Personalised care adjustment contains the following:

“As of 1 April 2019, exception reporting is being replaced with a Personalised Care Adjustment (PCA). This will allow practices to differentiate between the following reasons for adjusting care and removing a patient from the indicator denominator:

• unsuitability for the patient, e.g. because of medicine intolerance or allergy, or contra-indicated polypharmacy
• patient choice, following a shared decision-making conversation
• the patient did not respond to offers of care – recording of this will change to capture actual invitations sent to patients
• the specific service is not available (in relation to a limited number of indicators only)
• newly diagnosed or newly registered patients, as per existing rules.

As with exception reporting applying a PCA to the patient record will remove that patient from an indicator denominator if the QOF defined intervention has not been delivered. It will not result in patients being removed from the disease register or other target population.

The associated changes to data recording and extraction should result in a redistribution of coding work away from year-end and provide better information about why patients are not receiving interventions.

Principles when considering whether a PCA applies to an individual patient practices are reminded that:

• the duty of care remains for all patients,
• the decision to apply a PCA should be based on clinical judgement, informed by patient preferences, and underpinned by shared decision-making principles, with clear and auditable reasons coded or entered in free text on the patient record,
• there should be no blanket PCAs: the relevant issues with each patient should be considered by the clinician at each level of the clinical indicator set and this decision reviewed on a regular basis.

In each case where a PCA is applied then in addition to what needs to be reported for payment purposes (in accordance with the Business Rules), the contractor should also ensure that the reason for the adjustment is fully recorded in a way that can facilitate both safe and effective patient care and audit of the patient record.

Personalisation of care can occur for the following reasons which are listed in the order in which they will be extracted in the business rules:

1. The investigative service or secondary care service is unavailable (where relevant to the indicator).
2. Intervention described in the indicator is clinically unsuitable.
3. The patient has chosen not to receive the intervention described in the indicator.
4. The patient has not responded to invitations for the intervention described in the indicator (a minimum of two invitations for the intervention in the preceding 12 months, except for the cervical screening indicators. where women should receive a total of three invitations for screening).
5. The patient has registered with the practice or has been newly diagnosed with the condition of interest in the preceding 3 months and has not received the defined clinical measurements e.g. blood pressure measurement.
6. The patient has registered with the practice or has been newly diagnosed with the condition of interest in the preceding 9 months and has not achieved the defined clinical standards e.g. blood pressure control within target levels.

It is recognised that patients may meet more than one of these criteria and in these circumstances all reasons for PCA should be recorded in the patient’s record. However, as a patient can only be acknowledged as having a PCA once within the Business Rules for a given indicator, they will be allocated to the first criterion they meet in the hierarchy listed above. For example, where a patient is recorded as having registered with the practice in the preceding 3 months and has also chosen not to receive the intervention described in the indicator, they would be identified in the Business Rules as having chosen not to receive the care.

The hierarchy listed above seeks to prioritise clinical judgement and patient choice over other criteria. Applying this hierarchy consistently in the Business Rules in conjunction with the recording changes support better attribution of the reason for care being personalised, allowing for more meaningful conversations between clinicians, commissioners, and regulators.”

For each indicator in the clinical domain, the PCA rate is calculated as follows:

PCA rate = (Number of PCAs  / Number of PCAs + indicator denominator) ∗ 100

The recorded number of PCAs is expressed as a percentage of the number of patients on a disease register who were qualified to be part of the indicator denominator i.e. not counted as PCAs for definitional reasons.

A small number of GP practices who participate in the QOF make manual submissions to CQRS or are otherwise unable to make an electronic submission of PCA data. For this small number of GP practices, no PCA data is available. To maintain consistency with the report annexes, which are based on aggregated data from individual GP practices, they are included in the overall PCA calculations.

This has the impact of slightly reducing the PCA rates (because there are no indicator PCAs for these GP practices in the calculation numerator, but their indicator denominator data is included in the calculation denominator). The impact of this is minimal, less than 1.0% of data submitted at GP practice level.

Information captured by CQRS relating to PCAs and exclusions cannot be amended on the CQRS system. CQRS is primarily a system to support QOF payments, and PCA reporting is recorded as part of that process. CQRS was not designed to deliver specific management information about PCA reporting but does allow summary information on the levels of PCA reporting to be generated. This information is the basis for this publication and is presented at GP practice level in the PRACTICE_PCA_EXCL csv.

CQRS does not allow a presentation of PCAs broken down by each of the six personalisations outlined above. There are three reasons for this:

• CQRS uses an internal set of PCA ID codes that do not map directly into the six PCA reporting criteria in the SFE; rather, these PCA ID codes relate to PCA reporting coding ‘clusters’ in QOF business rules, often specific to individual QOF indicators. Fewer than nine of the criteria in the SFE may apply to an indicator.
• CQRS reporting functionality does not make a distinction between PCA reporting and definitional exclusions – both types of omission from indicator denominators are included on reports available to CQRS users.

The CQRS system was established as a mechanism to support the calculation of GP practice QOF payments. It is not a totally comprehensive source of data on quality of care in GP practices, but it is potentially a rich and valuable source of information for healthcare organisations, analysts and researchers, providing the limitations of the data are acknowledged.

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:

Prevalence and achievement

• The ranking of GP practices based on QOF points achieved, either overall or with respect to areas within QOF, may be inappropriate. QOF points do not reflect GP practice workload issues (e.g. around list sizes and disease prevalence), that is why GP practices’ QOF payments include adjustments for such factors.
• Comparative analysis of GP practice-level or Sub ICB Location-level 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 instance, 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 as it is collected at an aggregate level for each GP practice. For example, CQRS captures aggregated information for each GP practice on patients with coronary heart disease and on patients with asthma, but it is not possible to identify or analyse patients with both diseases.
• Information held in CQRS, and the source for the published data, is dependent on diagnosis and recording (case finding) within GP practices using GP practices’ clinical information systems.
• Measuring the quality of care is not a simple process. Within the clinical domain, QOF does not cover every clinical condition, and only describes some aspects of the care for the clinical areas that are included. However, QOF does provide valuable information (for instance on prevalence, cholesterol levels and blood pressure) on a scale unavailable before 2004-05 and provides a measure of improvement in the delivery of care.

PCAs

An important aim of QOF is to encourage appropriate and high-quality clinical care for key long-term conditions. Potentially, PCA reporting could influence the level of financial reward to GP practices.

The availability of high-level information on PCA reporting provides an indication of the variations in PCA rates that are found between specific indicators, and between NHS organisational areas.

It is also important to emphasise some of the limitations of the available data. These include GP practices missing from the analysis; the derivation of PCA counts; and the potential for amendments to indicator denominators not mirrored by changes to counts of PCAs.

Additionally, care should be taken when interpreting high level analysis in the context of local primary care service delivery, notably in terms of the numbers of patients associated with relatively high or low PCA rates. Sub ICB Locations will have access to more detailed local information, and knowledge of local circumstances, to enable unusual levels of PCA reporting to be investigated further.

1. 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 the following 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.

2. The tables for QOF 2021-22 present data from  both the current reporting year and the previous reporting year.  The aggregated (i.e. non-GP practice level) figures presented for the previous year in this release will not match those published last year, as all figures have been recalculated using GP practice level data that can be mapped to current NHS geographies.

3. An additional indicator specific PCA has been added to indicator AST006 consequently this indicator is not comparable with previous years.