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
Updated: Friday 28 June 2024
GP practice article illustration
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.


Changes to the framework in England 2023/24

Changes to the QOF framework for 2023/24 were imposed by NHS England, following GPC England’s rejection of the contract offer for that year. GPC England argued for the removal of all QOF targets and for the associated monies to be reallocated to core practice funding, to allow practices to focus on providing patient care rather than “chasing targets”. This proposal was in line with several recent reports, including The Future of General Practice published by the Health and Social Care Committee, but was not accepted.

NHS England has committed to a review of QOF with a view to making it more streamlined and focussed. The profession, patients and the wider system will be consulted on this in due course.

There are still 635 total points in QOF for 2023/24, with 81 of these subject to income protection. The value of a QOF point in 2023/24 is £213.43, and the national average practice population figure is 9,639.


Income protection for disease register indicators (81 points)

NHS England has provided income protection for all register indicators, worth £97m. These will be paid to all practices based on 2022/23 performance once the outturn is finalised.

However, NHS England guidance has also indicated that practices will still be required to maintain these registers. Disease registers will still be used for the purpose of calculating disease prevalence. It is important that practices are aware that the £/point value for each clinical area is impacted by the adjusted practice disease factor (APDF), which is calculated using the disease registers; therefore, failing to maintain the registers could result in a reduction in QOF income.

GPC England disagrees with NHS England about the extent to which these measures amount to a meaningful reduction in bureaucratic tasks that practices are required to undertake

New indicators

Two new cholesterol indicators have been added (CHOL001 and CHOL002), worth 30 points. There is also a new overarching mental health indicator (MH021) achieved based on the percentage of patients with serious mental illness who have received all six elements of the Physical Health Check. These have been funded via a retirement a rheumatoid arthritis indicator (RA002) and the reduction of the value of the annual dementia review indicator (DEM004).

Atrial fibrillation indicator AF007 has been replaced with ex-IIF indicator CVD-05 (now designated AF008), relating to the prescription of a direct-acting oral anticoagulant or where declined/clinically unsuitable, a Vitamin K antagonist.

The Rheumatoid Arthritis face-to-face review has been retired, and the Dementia indicator can be done remotely or face to face.

Quality Improvement (QI) Modules

NHS England has introduced two new QI modules in 2023/24.

  • Workforce and wellbeing – two new indicators (QI013, QI014) have been introduced, designed to incentivise practices to “demonstrate continuous quality improvement activity focussed on workforce and wellbeing” and the participation in network activity to “regularly share and discuss learning” on this theme. These are worth 36 points together.
  • Optimising demand and capacity in general practice – four new indicators have been introduced. Three (QI016-QI018) are focussed on encouraging practices to understand, act on, and share insights relating to capacity. QI019 has been introduced to incentivise a reduction in avoidable appointments.

Childhood vaccinations

GPC England secured some minor concessions on the thresholds for these indicators, which have been widely criticised for being unachievable; the lower thresholds are now 89% for VI001, 86% for VI002, and 81% VI003, but the upper thresholds have been raised to 96%.

NHS England has agreed to introduce provisions so that patients vaccinated overseas in accordance with the UK national schedule can be coded as a success for the purposes of QOF achievement. It has also agreed to make allowances for patients who have registered with a practice too late (either in age, or in terms of the financial year) to be vaccinated in line with the UK national schedule.

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.