Quality and outcomes framework (QOF)

QOF is a voluntary annual reward and incentive programme for GP practices in England, Wales and Northern Ireland. Find the latest frameworks for 2020/21.

Location: England Wales Northern Ireland
Audience: GPs Practice managers
Last reviewed: 20 December 2021
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COVID adjustments

Our guidance on COVID funding for practices summarises any previous changes to QOF during the pandemic.

Find the latest changes to the quality and outcomes framework (QOF) or equivalent by nation.

QOF has not been in operation in Scotland since 2016.


December 2021 suspension of QOF

NHS England has made the following changes to QOF for all practices in 2021/22 which will be reflected in an amended SFE (statement of financial entitlement).

  1. Practices should focus on the four vaccination and immunisation indicators, the two cervical screening indicators, the register indicators and the eight prescribing indicators (see appendix 1). These will continue to operate on the basis of practice performance in 2021/22.
  2. 46 QOF points (the 8 points associated with the new for 2021/22 cancer indicators, 20 points from the new for 2021/22 mental health indicators and 18 points from the non-diabetic hyperglycaemia indicator that was introduced for 2020/21) will be reallocated toward increasing the total points available for the eight prescribing indicators, reflecting the continued importance of effective prescribing in the management of long term conditions.
  3. The remaining indicators will be income protected using a similar methodology to the one applied in 2020/21. Most income-protected indicators for 2021/22 will be paid based on achievement in 2018/19, while the income-protected indicators relating to diabetes and hypertension will be based on 2019/20 achievement.

    Points will be subject to a list size and prevalence adjustment calculated in the usual way at year end.

    Practices are expected to continue to apply their clinical judgement and deliver as much patient care as they can, with a focus on the highest risk patients, but their income will not be dependent on recorded QOF achievement for the income-protected indicators.
  4. The QI domain will be paid to practices in full.
  5. To be eligible for income protection, practices will need to agree with their commissioner a plan that will set out how QOF care will be delivered wherever possible, but with priority according to clinical risk and accounting for inequalities.
  6. All activity undertaken should continue to be coded where possible. CQRS will continue to operate in 2021/22 and achievement data will be collected and reported for all indicators.

    Aspiration payments will continue as at present.

    Payment for QOF may be made later than usual for 2021/22, given that the proposed changes to the scheme are being made towards the end of the year.
  7. QOF will recommence in full from April 2022.


Changes to the framework in England 2021/22

To support practice stability and recovery, QOF 2021/22 is based on the indicator set agreed for 2020/21, with very limited changes only. Most QOF indicators have now been suspended until April 2022.

The size of QOF increased from 567 to 635 points in 2021/22. The value of a QOF point in 2021/22 is £201.16 and the national average practice population figure is 9,085. There are no changes to payment thresholds for indicators carried forward from 2020/21.

Virtual and face-to-face patient reviews

For 2021/22, practices may deliver patient reviews remotely where clinically appropriate to do so, unless otherwise specified. Face-to-face reviews have been recommended for patients with dementia to allow GPs to fully assess the changing needs of the patient.

Practices should continue to apply their clinical judgement to the appropriate management of affected patients and the decision to provide a virtual or face-to-face review should be made on a patient-by patient basis.

Further detailed information on the data recording requirements and payment is included in the QOF guidance for 2021/22.

Updates for 2021/22

  • A new vaccination and immunisation domain (as previously agreed in the update to the GP contract agreement) consisting of four indicators to replace the current childhood immunisation directed enhanced service. Three of these indicators focus on routine childhood vaccinations and one on incentivising the delivery of shingles vaccinations.
  • The reintroduction of three indicators focused on patients with a serious mental illness to promote improved 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 with incentives relating to flu vaccination for target groups being introduced in the investment and impact fund.
  • 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). This is with some slight modifications to account for the impact of the pandemic on care.

Further information is detailed in the quality and outcomes framework guidance for 2020/21.


Changes to the framework in England 2020/21

The value of a QOF point was £194.83

NHSE/I agreed to adopt a more relaxed approach to QOF and to protect income in response to COVID-19.

Changes from April 2020

97 points were recycled into 11 more appropriate indicators. This, with an additional £10m investment from NHS England, brings the total available points to 567.

Changes to existing domains

A number of changes have been made to the asthma, COPD and heart failure domains, including:


  • A requirement to establish and maintain a register of patients aged six years and over with a diagnosis of asthma, in line with NICE guidance.
  • The use of a minimum of two diagnostic tests to confirm an asthma diagnosis. These tests should be performed up to three months before any date of diagnosis and up to six months after this date.
  • The content of the asthma review has been amended to incorporate aspects of care positively associated with better patient outcomes and self-management.
  • Practices will be required to record smoking exposure in children and young people under the age of 19 years.


  • Entry to the COPD register will be determined by the presence of a clinical diagnosis plus a record of post bronchodilator spirometry FEV1/FVC ratio below 0.7 recorded between three months before or six months after diagnosis in diagnoses made on of after 1 April 2020.
  • The annual review will include a requirement to record the number of exacerbations in order to help guide future management and potentially avoidable emergency admissions.

Heart failure

  • Any new diagnosis of heart failure should be confirmed by an echocardiogram or specialist assessment between three months before or six months after diagnosis.
  • Changes to the denominator for treatment with beta-blockers.
  • An annual review indicator has been agreed to provide a focus upon functional assessment and the up-titration of medication to address symptoms.

New indicators

A new indicator has been added to incentivise practices to offer an annual HbA1c test for people known to have non-diabetic hyperglycaemia.

Quality improvement

In 2019/20 a new 74-point quality improvement domain was added, comprising two modules on prescribing safety and end of life care. These modules have now been replaced, though NHS England encourages practices to continue to bed-down improvements made in line with these.

Two new quality improvement modules have been added, on early cancer diagnosis and the care of people with a learning disability.

Ongoing amendments

NHS England and the BMA GP committee agreed to an ongoing programme of indicator review in key priority areas, including mental health, in 2020/21.

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