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Quality & outcomes framework guidanceM

May 2003 (updated August 2004)

Section 2: Clinical Indicators
1. General format
The clinical indicators are organised by disease category. The disease categories have been selected for the following reasons:

1. where the responsibility for ongoing management rests principally with the general practitioner and the primary care team
2. where there is good evidence of the health benefits likely to result from improved primary care – in particular if there is an accepted national clinical guideline
3. where the disease area is a priority in a number of the four nations.

Where evidence-based national guidance has not been included, this has usually either been to limit the size and complexity of the framework, or because it would be particularly hard for practices to record the relevant information in a reliable way.

A summary of the indicators for each disease category is provided at the beginning of each section.

Indicators across all disease categories are numbered. In the guidance they are prefixed by the disease category to which they belong and contained in a box eg


A number of patients will have multiple diseases: for instance, a significant number of patients with diabetes will also have coronary heart disease (CHD) or hypertension. While it could be argued that the quality framework fragments the care that one individual receives, in complex patients important process issues can be missed during follow-up. The separation of disease categories in the Quality and Outcomes Framework will allow clinicians to check that, for example, the hypertensive diabetic with developing CHD continues to have his or her diabetes monitored while the clinician focuses on the developing CHD.

The term PCO (Primary Care Organisation) is used throughout, as the structures responsible for the organisation and management of primary care differ in the four countries.

For each indicator, two descriptions are given. This differs from the first version of the Guidance as the preferred coding section has been removed. These have been replaced by the Logical Query Indicator Specification and the Dataset and Business Rules.

1.1 Rationale
This sub-section explains why the indicator has been selected. Wherever possible, the evidence source is described and if available a web address (hyperlink in the electronic version) is provided. When available, National Guidelines have been used as the main evidence source. A small number of individual papers are also quoted.

In some areas, more extensive information is provided. It has been difficult to achieve a balance of providing helpful information without providing a textbook of medicine or replicating guidelines.

The indicators are not intended to cover all the process issues or outcomes indicators for each disease category. The indicator sets are designed to encourage more structured care of patients with chronic diseases. Inevitably, in order to meet the requirement that indicators should be retrievable from GP computer systems, a significant number have been discarded which are not easily recorded in an IT format. In some instances, for example monitoring lifestyle factors in CHD, one indicator has been selected to reflect the care being undertaken by that practice.

In some areas, the indicators cover only a very small part of the care for those conditions. The most obvious example of this is mental health, where it was not possible to develop indicators that could be rewarded in this type of framework for many of the most important aspects of mental health care. Mental health care is however an example of a number of conditions where some markers of good clinical care have been included in the organisational indicators (eg through the inclusion of significant event auditing for mental health problems).

In many of the indicators an additional time factor is incorporated, recognising that in practice it may be difficult to ensure that all patients have attended for review and have completed the review process within any particular timescale. For example, concerning indicator BP5, national guidance recommends that all patients with hypertension should have their blood pressure measured every six months. The actual indicator looks at the number of patients with hypertension who have had a blood pressure measured in the last nine months.

1.2 Read Codes
The Logical Query Indicator Specification and the Dataset and Business Rules that support the reporting requirements of The Quality and Outcomes framework in each home country are based entirely on Read Codes (4 byte, version 2 and Clinical Terms Version 3) and associated dates. Read codes are an NHS standard. Practices using proprietary coding systems and/or local/practice specific codes need to be advised that these codes will not be recognised within QOF reporting. Practices utilising such systems should develop strategies to ensure that they are utilising appropriate Read codes in advicance of producing their achievement report.

1.3 Reporting and Verification
This section defines the audit information which practices will be required to submit annually. The term ‘notes’ is used throughout to indicate either electronic or paper records.

It is hoped that all reporting will be possible through the use of GP clinical systems and that practices will be able to run a report annually which can be submitted to the PCO. Separate guidance is being produced on the electronic queries which can be used to report on the Quality and Outcomes Framework. This can be found at on the Department of Healh website

Practices that do not hold all the required information on computer may utilise the reporting criteria to undertake a manual audit. However, it is recommended that information be transferred to an electronic format as part of that audit process.

Criteria are also provided under a number of indicators that may be used by a PCO on a verification visit to a practice. In general, those that have been chosen have an identifiable source in the clinical record.

In general, PCOs will not expect or be expected to conduct detailed or intrusive verification procedures, unless they suspect that incorrect figures may have been returned, or where there is suspicion of fraud. PCOs may, however, select cases for more detailed investigation from time to time on a random basis.