GMS Contract QOF Guidance 2019.pdf 

1. Chronic Disease Templates

Focus on the required elements for QOF when you see a patient with a QOF related condition by using the Ardens templates. All QOF related work is highlighted by a red star across all of our templates.


1.1 QOF Dashboard using Ardens Manager

Ardens Manager is our new health analytics platform that will offer advanced reporting for practices, PCNs, and CCGs across different disease areas. It includes a QOF dashboard that offers practice-level reporting on QOF performance and will highlight the most valuable QOF points so that you can focus your resources on achieving these areas. Please click here to sign up – it is free and easy to do.


2. General QOF Tips 

Review the 'End of Year' reports in 'Reporting > QOF Indicators > End of Year' to identify the patients that will be outstanding at the end of the QOF year. The 'Missing Patients' column for each domain are the ones you need to focus on as these are the patients who fall into the denominator but have not yet been review or perhaps have some coding issues. To access 'Missing Patients' right click on the indicator row and select "Show Missing Patients"

NB: It is important that you don’t use the “How am I Driving?” view as this give you data assuming QOF year-end is today.

2.1 SMOK004 and SMOK005
It is easy to achieve these indicators that relate to smoking cessation advice. Just send all patients in the “Missing Patients" a text message (using MJOG / iPlato / any other SMS service) that states

"Our records indicate that you are a smoker. We recommend you read about the benefits of stopping smoking at If you would like support to quit smoking please contact the surgery.
From <Insert Practice Name Here>

You can then batch-add the 'Smoking Cessation Advice (Ua1Nz)' code to the patient records.

NB: Please ensure that you comply with the Practice SMS consent policy

2.2 AST003 - Asthma Review in last 12 months
The GMS contract guidance does state that asthma reviews should be face to face. Many patients who have stable asthma do not wish to attend an appointment in person for an asthma review so practices are left with a dilemma of exempting the patient, potentially missing providing asthma care for the remainder of the QOF year, or offering a telephone review. According to Asthma UK it is perfectly acceptable to do this review over the telephone if the patient declines a face to face appointment. Please use the Ardens Asthma template and record the answers to the three RCP questions using the drop-down boxes.

There is an Asthma Review questionnaire which you can make available for your patients signed up to SystmOnline. A 'Questionnaire - Asthma Review' word document is also available that can be posted or emailed to patients who either don't respond to invites or are well controlled.

2.3 COPD 

COPD QOF alerts are being reset by the addition of any code within the diagnosis QOF cluster.

This means that when clinicians use any of the codes in the NHS Digital QOF diagnosis cluster (such as Mild chronic obstructive pulmonary disease (313296004)) then this counts as a new diagnosis and resets other QOF indicators.

We feel very strongly that recording activity specifically and correctly for clinical best practice reasons should come above recording imprecise activity for contractual payment reasons.

2.3.1COPD008 - Pulmonary Rehab

You may find that some patients are coded as having attended or completed pulmonary rehab who still have an outstanding QOF alert showing. The TPP QOF reports for this indicator are looking for whether the patient has been offered or referred using one of these two codes only; 

'Pulmonary rehabilitation offered (XabGM)'  

'Referral to pulmonary rehabilitation (XaIf9)'

NB: A report is available in 'Contracts | QOF 2019 2020 > Missed income | QOF 2019 2020' Called 'COPD008: Missing pulmonary rehab code (add XabGM)' 

If pulmonary rehab has already been recorded before the MRC 3-5 and there is still an outsanding QOF alert for COPD008 you may need to add one of the two codes above again to clear the alert. To justify adding the code again you should add a comment "Added for QOF purposes as the patient has already completed pulmonary rehab"   

2.4 Blood Pressure out of range
Many QOF indicators require a BP to be within a target range. It is often clinically inappropriate to achieve this target in very elderly patients due to the risk of side effects from polypharmacy or falls.

From the various BP indicators, you can either export the lists to excel or work from the screen. Before you try to export, right click and select 'Breakdown Missing patients' and under 'Registration' select 'Usual Carer' then click 'Refresh' and 'Close' the breakdown window. Export the 'Missing Patients' by right clicking 'Show Missing Patients' and anywhere on your list of patients right click and select 'Table > Open as CSV' and use 'Microsoft Excel' to sort data by 'age' and then by 'Usual GP' (you might choose to remove all patients from the list below age 80 years).

Send this spreadsheet to all GPs in your practice and ask them each to review their list of patients and consider which should be exception reported as 'Patient on maximal tolerated antihypertensive therapy (XaJ5h)' using our template.

NB: Remember to record a reason when you exception report a patient as CQC expects you to justify this decision.

2.5 Diabetes 

Diabetes QOF alerts are being reset by the addition of any code within the diagnosis QOF cluster. This means that when clinicians use any of the codes in the NHS Digital QOF diagnosis cluster (such as Type II diabetes mellitus uncontrolled (443694000)) then this counts as a new diagnosis and resets other QOF indicators.

We feel very strongly that recording activity specifically and correctly for clinical best practice reasons should come above recording imprecise activity for contractual payment reasons.

2.5.1 DM020 - HbA1c out of range. HbA1c targets are quite tight in QOF. This year the target is different depending on the patient's frailty status but you need to ensure this is correctly recorded in the patient record. You can either work from the screen or export the data for DM020 in the same way as described above and ask the Usual GP to review their patients over the age of 75 years and ensure the frailty status is correctly recorded
NB: These patients have not been recorded as moderate or severe frailty so by recording this where appropriate will remove them from the target

2.6 CVD-PP001
This QOF indicator identifies patients newly diagnosed with hypertension who have not had a QRISK2 score. It is probably the most lucrative QOF indicator that exists (in terms of QOF point value) and you MUST aim to achieve all 10 points for this as it is also the easiest indicator to achieve. Some practices struggle to achieve this as they have not diagnosed any new patients with hypertension in the previous 12 months. This is extremely unlikely - it is more likely that a newly diagnosed hypertensive has not been coded correctly. There are two reports available to help with this in 'Contracts | QOF 2019 2020 > Missed income | QOF 2019 2020'.

The first report identifies patients diagnosed with no episodicity set. To resolve this, right click on the diagnosis code in the journal and select 'Episodicity > New Episode'. The second report will identify patients who require a QRISK2 score recorded.

'CVD-PP001: Newly diagnosed hypertensives in last 1y - no episodicity'

'CVD-PP001: Newly diagnosed hypertensives - no QRISK2 risk assessment recorded'

2.7 MH002 Comprehensive care plan

If you record a care plan from the template and find that the QOF alert is still outstanding it could be either because the mental health diagnosis code has no episodicity set.

NB: In remission advice From GMS Contract - it is advised that clinicians should only consider using the remission codes if the patient has been in remission for at least five years, that is where there is:

no record of antipsychotic medication

no mental health in-patient episodes 

no secondary or community care mental health follow-up for at least five years

2.8 Obesity
Remember that your obesity register is worth 8 QOF points. Remind all your clinical staff to weigh anyone who looks like their BMI is greater than 30.

2.9 Quality Improvement Indicators - Prescribing Safety and End of Life

These new indicators are worth in total 74 QOF points. Please see our support articles which explain how we can assist with these areas.

Quality Improvement - Prescribing Safety 

Quality Improvement - End of Life

We have a highly trained support team who are able to support you by phone or e-mail should you require any assistance with achieving your QOF targets this year. This support is included within your subscription price and so please take advantage of it as we are keen to assist you and help you maximise your QOF achievement as efficiently as possible.

Our support e-mail address is

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