Dr Tim Stokes discusses the revised QOF 2013/14 and the new and revised indicators for COPD, depression, diabetes, hypertension, and rheumatoid arthritis

This article summarises the role of NICE in the development of the quality and outcomes framework (QOF) for general practice, and discusses the key changes in the clinical QOF indicator set for 2013/14 in England.1,2 In Scotland, Wales and Northern Ireland the agreed QOF contract for 2013/14 differs from that in England.3-5

NICE has managed the process for developing QOF indicators since April 2009. This has led to a number of significant changes to enable QOF to deliver more rigorously developed indicators and to act as a vehicle for quality improvement. The role of NICE is to manage the process of developing clinical and health improvement indicators for the QOF and to review the current indicator set.6,7 Key aspects of this process are to:

  • ensure consultation with individuals and stakeholder groups
  • publish an annual ‘menu’ of new, evidence-based indicators
  • make recommendations about existing indicators, including those which should be retired.

It is important to emphasise that NICE does not decide which indicators are to be included in the QOF, or what the set points and thresholds should be—this is the subject of a separate negotiation. NICE also has no involvement in decisions to retire organisational domain indicators, or in the development of quality and productivity indicators.

For 2013/14, the Government consulted on changes to the GMS contract, including implementation in full of all the NICE-recommended changes to the QOF and the removal of the organisational domain.8 The Government also consulted on increasing thresholds for all continuing fraction indicators in line with the 75th centile of achievement, phased in over 2 years. The British Medical Association (BMA) General Practitioners Committee (GPC) did not agree to, or support, all of these changes. Following the consultation, the Government decided to defer the introduction of two of the indicators recommended by NICE for 1 year (referral of patients with chronic obstructive pulmonary disease [COPD] and heart failure to rehabilitation programmes), to phase in thresholds for two new indicators, and to increase points for three new indicators.2

Changes to QOF for 2013/14

The public health (PH) domain was introduced to QOF in April 2013 for the purpose of including a section devoted to evidence-based public health and primary prevention indicators.9 This domain covers indicators on primary prevention of blood pressure, cardiovascular disease, obesity, and smoking; and public health additional services—cervical screening, child-health surveillance, maternity services, and contraception.2

New indicators and key indicator changes for QOF 2013/14 are summarised in Table 1.1,2 The indicators listed in Table 1 were the subject of piloting in a representative sample of GP practices and subject to public consultation in advance of their inclusion in the NICE menu of QOF indicators.

Retirement of existing QOF indicators

A key principle of the NICE-managed QOF is that indicators should be retired as appropriate. Eight indicators (i.e. BP4, CHD10, CKD2, DEP1, DM2, DM10, DM22, and EPILEPSY6) have been retired from the clinical domain, releasing points to fund new and replacement indicators.2 These indicators have been retired chiefly because they are either process measures that are already addressed in QOF with relevant outcome measures (e.g. BP4 requires a BP reading, which is already required to achieve blood-pressure [BP] targets—HYP002, HYP003), or because the evidence base does not support their use (e.g. DEP1 on case finding for depression).10

Table 1: Key changes to indicators for QOF 2013/141,2*
2013–14 QOF ID2012–13 QOF ID2013–14 indicator wordingPointsThreshold (%)
HYP003 NEW The percentage of patients aged 79 or under with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 140/90 mmHg or less 50 40–80
HYP004 NEW The percentage of patients with hypertension aged 16 or over who have not attained the age of 75 in whom there is an annual assessment of physical activity, using GPPAQ, in the preceding 12 months 5 40–80
HYP005 NEW The percentage of patients with hypertension aged 16 or over who have not attained the age of 75 who score ‘less than active’ on GPPAQ in the preceding 12 months, who also have a record of a brief intervention in the preceding 12 months 6 40–80
CVD-PP001 CVD-PP1 In those patients with a new diagnosis of hypertension aged 30 or over who have not attained the age of 75, recorded between the preceding 1 April to 31 March (excluding those with preexisting CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an assessment tool agreed with the NHS CB) of ≥20% in the preceding 12 months: the percentage who are currently treated with statins 10 40–90
DM013 NEW The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 12 months 3 40–90
DM014 NEW The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register 11 40–90
DM015 NEW The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 12 months 4 40–90
DM016 NEW The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months 6 40–90
COPD005 NEW The percentage of patients with COPD and Medical Research Council dyspnoea grade ≥3 at any time in the preceding 12 months, with a record of oxygen saturation value within the preceding 12 months 5 40–90
DEP001 DEP6 The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March who have had a bio-psychosocial assessment by the point of diagnosis. The completion of the assessment is to be recorded on the same day as the diagnosis is recorded 21 50–90
DEP002 DEP7 The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have been reviewed not earlier than 10 days after and not later than 35 days after the date of diagnosis 10 45–80
RA001 NEW The contractor establishes and maintains a register of all patients aged 16 and or over with rheumatoid arthritis 1
RA002 NEW The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months 5 40–90
RA003 NEW The percentage of patients with rheumatoid arthritis aged 30 or over and who have not attained the age of 85 who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 12 months 7 40–90
RA004 NEW The percentage of patients aged 50 or over and who have not attained the age of 91 with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 24 months 5 40–90
  • * Not all changes to the indicators are shown in this table
  • GPPAQ=general practice physical activity questionnaire; CHD=coronary heart disease; TIA=transient ischaemic attack; CVD=cardiovascular disease; CB=Commissioning Board; COPD=chronic obstructive pulmonary disease; RA=rheumatoid arthritis

New and replacement QOF indicators

Rheumatoid arthritis

A major change in QOF for 2013/14 is the introduction of a new clinical domain: rheumatoid arthritis (RA).2 Primary care has an important role to play in the ongoing management of RA, although confirmation of diagnosis and initiation of treatment usually takes place in secondary care. The register indicator (RA001) includes patients aged 16 years or over with established and recent-onset disease and in whom there is a definite diagnosis of RA, irrespective of evidence of positive serology and current disease activity status.2 The other RA indicators address the need for an annual review (RA002) and the specific need to assess cardiovascular (RA003) and fracture risk (RA004).2

The new indicator RA002 requires that patients with RA have a face-to-face annual review.2 As RA is a chronic long-term condition, there is a need for regular monitoring to determine disease status, assess severity, determine efficacy and toxicity of drug therapy, and to identify co-morbidities or complications. As a minimum, it is advised that this review covers:

  • disease activity and damage
  • the effect of the disease upon the patient’s life
  • whether they would benefit from any referrals to the multidisciplinary team.

Rheumatoid arthritis is a significant, independent risk factor for cardiovascular disease (CVD) and causes increased mortality compared with the general population.11 Indicator RA003 promotes the annual assessment of CVD risk using a tool adjusted for RA. At present, the only tool that adjusts for RA as an independent risk factor within the risk algorithm itself, is QRISK2 (see www.qrisk.org). 12 An annual risk assessment has the potential to improve the management of cardiovascular risk factors in people with RA who do not currently have established CVD.

Patients with RA are more likely to develop osteoporosis owing to reduced mobility, inflammation, and the effects of pharmacological treatments.13 Indicator RA004 promotes the assessment of fracture risk using a tool adjusted for RA.2 The risk tools FRAX14 (see www.shef.ac.uk/FRAX/tool.jsp) or QFracture15 (see www.qfracture.org) can be used to calculate a 10-year predicted absolute fracture risk. It is recommended that fracture risk assessment is not routinely performed in patients below the age of 50 years, unless the person has major risk factors, such as current or frequent use of oral or systemic glucocorticoids, untreated premature menopause, or previous fragility fracture. Thus the age range for this indicator has been set at 50 years or over and below the age of 91 years.2 These indicators are based on recommendations in the NICE Clinical Guideline (CG79) on rheumatoid arthritis16 (see www.nice.org.uk/guidance/cg79) and CG146 on osteoporosis (see www.nice.org.uk/guidance/cg146).17


There are three key changes to QOF that affect patients with hypertension. Firstly, patients under the age of 79 years with hypertension are to be managed with a tighter BP target than previously (140/90 mmHg or lower compared with the previous target of 150/90 mmHg—see HYP003).2 This brings QOF into line with NICE guideline recommendations on targets in patients treated for hypertension in CG127 (see www.nice.org.uk/guidance/cg127), 18 and should promote better control. Improved BP control brings with it the long-term benefits of a reduction in the risk of major adverse cardiac and cerebrovascular events (e.g. myocardial infarction [MI], stroke).

Secondly, two new indicators aim to encourage a key lifestyle intervention by increasing physical activity levels in patients with hypertension, and are based on NICE Public Health Guidance 2.19 Indicator HYP004 requires a formal assessment of physical activity using the general practice physical activity questionnaire (GPPAQ), and HYP005 encourages the delivery of a brief intervention to promote physical activity in those who score ‘less than active’ on the GPPAQ.2 The GPPAQ tool20 categorises patients’ level of activity, which is correlated to CVD risk. Patients are categorised as:

  • inactive—sedentary job and no physical exercise or cycling
  • moderately inactive—sedentary job and some but less than 1 hour of physical exercise and/or cycling per week, or standing job and no physical exercise or cycling
  • moderately active—sedentary job and 1 to 2.9 hours of physical exercise and/or cycling per week, or standing job and some but less than 1 hour of physical exercise and/or cycling per week, or physical job and no physical exercise or cycling
  • active—sedentary job and 3 hours or more of physical exercise and/or cycling per week, or standing job and 1 to 2.9 hours of physical exercise and/or cycling per week, or physical job and some but less than 1 hour of physical exercise and/or cycling per week, or heavy manual job.

It is advised that all patients who receive a score of ‘less than active’ are offered a brief intervention supporting behaviour change to increase physical activity so that they are moderately active for at least 30 minutes, 5 days of the week.2 Brief interventions may involve opportunistic advice, discussion, negotiation, or encouragement. They are commonly used in many areas of health promotion. The interventions vary from basic advice to more extended, individually focused attempts to identify and change factors that influence activity levels.

Thirdly, CVD-PP001 covers the initiation of statin therapy in newly diagnosed patients with hypertension (without pre-existing CVD or diabetes) who have a 10-year CVD risk recorded in the previous 12 months that is 20%. This indicator replaces an earlier indicator (CVD-PP1) that promoted the use of CVD risk assessment tools in newly diagnosed hypertensive people, but which did not directly promote the use of statins in those who would benefit.2

Indicator CVD-PP001 promotes the primary prevention of CVD—statin therapy is associated with a reduction in the risk of major adverse cardiac and cerebrovascular events (e.g. MI, stroke). The indicator is based on NICE CG67 (see www.nice.org.uk/guidance/cg67) on lipid modification, which recommends statin therapy for the primary prevention of CVD for adults who have an estimated ≥20% 10-year risk of developing CVD.21 It is, however, important that before patients with hypertension are offered lipid modification therapy for primary prevention, all other modifiable CVD risk factors are considered and their management optimised if possible. Baseline blood tests and clinical assessment should be performed and co-morbidities and secondary causes of dyslipidaemia should be treated.21


Four new diabetes indicators relate to three areas:

  • the need for a dietary review by a suitably competent professional (DM013)
  • the need to refer newly diagnosed patients with diabetes to a structured education programme (DM014), and
  • the identification and management of erectile dysfunction (ED) in men (DM015, DM016).2

The provision of high-quality dietary advice and nutritional information is important to help patients with diabetes manage their condition appropriately. The NICE diabetes quality standard (QS6)22 defines an appropriately trained healthcare professional as one with specific expertise and competencies in nutrition (see www.nice.org.uk/guidance/qs6). This may include, but is not limited to, a registered dietitian who delivers nutritional advice on an individual basis or as part of a structured educational programme.

There is also a need to promote self-care for patients with newly diagnosed diabetes. Structured educational programmes have been designed not only to improve people’s knowledge and skills, but also to encourage individuals with either type 1 or type 2 diabetes to take control of their condition and deliver effective self-management. Indicator DM014 requires that structured education is offered (preferably through a group-education programme) to every person with diabetes and/or their carer from the time of diagnosis, with annual reinforcement and dietary review (DM013).

Erectile dysfunction in men is a common complication of diabetes, which can have a significant impact on the quality of life for men with diabetes and their partners. Indicator DM015 aims to increase the identification of men with ED in primary care by ensuring they are asked about this disorder on an annual basis.2 Indicator DM016 aims to improve management of the condition by ensuring men with ED are offered an assessment of contributory factors, and a discussion of treatment options. Both indicators are based on recommendations in NICE CG87 on type 2 diabetes (see www.nice.org.uk/guidance/cg87). 23


Indicators on assessing severity of depression at diagnosis and at follow up, which required the use of formal assessment questionnaires, were introduced into the QOF in 2006 and 2009, respectively. In 2011, the NICE QOF Advisory Committee reviewed the evidence base for these indicators10,24 and recommended that they be retired.10 Two new indicators have been developed in their place, which promote the holistic assessment (DEP001) and management (DEP002) of depression in general practice.2 Both indicators are based on recommendations in NICE CG90 on depression in adults (see www.nice.org.uk/guidance/cg90). 25

The first indicator (DEP001) requires that patients with a new diagnosis of depression have a bio-psychosocial assessment (BPA) by the point of diagnosis.2 A BPA is a qualitative assessment of a patient presenting with suspected depression, which considers physical, psychological, and social aspects of the condition. While the assessment can be carried out over more than one consultation (as clinically appropriate), the indicator requires that the assessment is recorded as completed on the same date as the diagnosis of depression is recorded in the patient record. Clinicians may optionally continue to use formal assessment questionnaires (e.g. PHQ-926) to assess the duration and severity of the current episode.

The second indicator (DEP002) requires that patients with a new diagnosis of depression are reviewed 10–35 days after diagnosis.2 It promotes regular follow up to ensure that the patient’s response to treatment is monitored, any adherence issues are identified, and ongoing support is provided.

Chronic obstructive pulmonary disease

A new indicator COPD005 has been introduced in 2013/14, which complements existing indicators on the assessment of patients with COPD. It is based on NICE CG10127 and requires that patients with COPD and dyspnoea graded as ≥3 using the Medical Research Council scale, have a record of their oxygen saturation value.2 This can easily be done in primary care using pulse oximetry. The use of pulse oximetry allows GPs to identify patients with COPD who are appropriate for referral to secondary care for possible long-term oxygen therapy. As already noted, two indicators to promote the referral of patients to pulmonary rehabilitation programmes have been deferred until 2014/15. The NHS Employers website states that the points originally identified for these two indicators will in due course be added to HYP003, HYP004, and HYP005.28


The 2013/14 QOF sees a new clinical domain (rheumatoid arthritis) and major changes to the hypertension, diabetes, and depression domains.2 While concern has been expressed about the imposition of a number of these indicators,29 it needs to be emphasised that these new indicators were piloted in a representative sample of UK general practices. It is hoped that their inclusion in QOF will lead to improved health outcomes for patients with few or no unintended consequences.

  1. British Medical Association, NHS Employers. Summary of QOF 2013/14 changes for England. Available at: www.nhsemployers.org/SiteCollectionDocuments/Summary%20of%20QOF%20changes%202013-14_ja250313.pdf
  2. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2013/14. London: BMA, NHS Employers, 2013. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/qof-2013-14.pdf
  3. British Medical Association website. Scotland GP contract: agreed variation from UK and English NICE recommended QOF changes. bma.org.uk/working-for-change/negotiating-for-the-profession/general-practitioners-committee/contract-negotiations-scotland-details-letter/scotland-details-letter-annex-a (accessed 8 May 2013).
  4. British Medical Association. Proposed changes to the GMS contract 2013/14. Available at: www.wales.nhs.uk/sites3/Documents/480/Contract%20Revisions%202013-14.pdf
  5. British Medical Association website. Agreement reached on Northern Ireland GP contract 2013–2014. bma.org.uk/working-for-change/negotiating-for-the-profession/gp-contract/gp-contract-northern-ireland (accessed 8 May 2013).
  6. NICE. Developing clinical and health improvement indicators for the quality and outcomes framework (QOF). Interim process guide. NICE: Manchester, 2009. Available at: www.nice.org.uk/media/742/32/QOFProcessGuide.pdf
  7. Sutcliffe D, Lester H, Hutton J, Stokes T. NICE and the quality and outcomes framework (QOF) 2009–2011. Qual Prim Care 2012; 20 (1): 47–55.
  8. NHS Employers website. GMS contract changes. www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/GMSContractChanges/Pages/GMS-Background.aspx (accessed 8 May 2013).
  9. Department of Health. Healthy lives, healthy people. London: DH, 2010. Available at: www.gov.uk/government/publications/healthy-lives-healthy-people-our-strategy-for-public-health-in-england
  10. NICE website. Primary care QOF Advisory Committee. June 2011. Available at: www.nice.org.uk/media/E19/EA/NICEIndependent (accessed 1 May 2013).
  11. Peters M, van Halm V, Voskuyl A et al. Does rheumatoid arthritis equal diabetes mellitus as an independent risk factor for cardiovascular disease? A prospective study. Arthritis Rheum 2009; 61 (11): 1571–1579.
  12. Q-RISK2 website. www.qrisk.org (accessed 29 April 2013).
  13. National Rheumatoid Arthritis Society website. Osteoporosis in rheumatoid arthritis. www.nras.org.uk/about_rheumatoid_arthritis/established_disease/possible_complications/osteoporosis_in_ra.aspx (accessed 29 April 2013).
  14. WHO Fracture Risk Assessment Tool website. FRAX. www.shef.ac.uk/FRAX/tool.jsp (accessed 29 April 2013).
  15. QFracture 2012 website. www.qfracture.org (accessed 30 April 2013).
  16. NICE. Rheumatoid arthritis: the management of rheumatoid arthritis in adults. Clinical Guideline 79. London: NICE, 2009. Available at: publications.nice.org.uk/rheumatoid-arthritis-cg79 nhs_accreditation
  17. NICE. Osteoporosis: assessing the risk of fragility fracture. Clinical Guideline 146. London: NICE, 2012. Available at: publications.nice.org.uk/osteoporosis-assessing-the-risk-of-fragility-fracture-cg146 nhs_accreditation
  18. NICE. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127. London: NICE, 2011. Available at: publications.nice.org.uk/hypertension-cg127 nhs_accreditation
  19. NICE. Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling. Public Health Guidance 2. London: NICE, 2006. Available at: www.nice.org.uk/guidance/PH2
  20. GPPAQ questionnaire website. www.patient.co.uk/doctor/General-Practice-Physical-Activity-Questionnaire-(GPPAQ).htm (accessed 30 April 2013).
  21. NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 67. London: NICE, 2008. Available at: publications.nice.org.uk/lipid-modification-cg67 nhs_accreditation
  22. NICE. Diabetes in adults quality standard. Quality Standard 6. London: NICE, 2011. Available at: publications.nice.org.uk/diabetes-in-adults-quality-standard-qs6 (accessed 30 April 2013).
  23. NICE. Type 2 diabetes: the management of type 2 diabetes. Clinical Guideline 87. London: NICE, 2009. Available at: publications.nice.org.uk/type-2-diabetes-cg87/guidance nhs_accreditation
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  25. NICE. Depression in adults: the treatment and management of depression in adults. Clinical Guideline 90. London: NICE, 2009. Available at: publications.nice.org.uk/depression-in-adults-cg90 nhs_accreditation
  26. Psycho-oncology (UK) information and help website. Patient Health Questionnaire—PHQ-9. Available at: www.psycho-oncology.info/PHQ9_depression.pdf
  27. NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 101. London: NICE, 2010. Available at: publications.nice.org.uk/chronic-obstructive-pulmonary-disease-cg101 nhs_accreditation
  28. NHS Employers website. Changes to QOF 2013/14. www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/ChangestoQOF201314.aspx (accessed 1 May 2013).
  29. British Medical Association website. GP contract survival guide. bma.org.uk/practical-support-at-work/contracts/gp-contract-survival-guide/survival-guide-qof-clinical-changes (accessed 8 May 2013). G