Pipeline / In review

QOF Indicators Explained: Who Is Due and What Counts as Complete

pipeline/03-review/new-qof-indicator-glossary.md · updated Sat 20 Oct, 02:46

Front matter

StageIn review
Typenew
Clusterqof
Personapractice-manager
Target queryqof indicators
OwnerTom
Proof refsnone, no register numbers used

Copy into Framer

Each field maps to the CMS item
TitleQOF Indicators Explained: Who Is Due and What Counts as Complete
Slugqof-indicator-glossary
Meta descriptionA plain-English guide to common QOF indicators for GP practices: who is eligible, what has to be recorded for the indicator to count, and how often. (148 chars)
BodyFormatted. H1 removed because the title has its own field.

Reviewer notes

Not for publication
REVIEWER NOTES (not for publication) THEO: every row below is a clinical eligibility rule or threshold. Source is our help centre glossary (exported 2026-08-29), not NHS England directly. Please check each row against the 2026/27 QOF guidance. Specific questions: 1. AST007 and AST015 have identical wording in our glossary, AST015 marked "(v51)". I have used AST007 only. Which code is current for 2026/27? 2. HYP008 to HYP011: are both the frailty and non-frailty versions live this year, or has one replaced the other? I have shown HYP008 and HYP009 only. 3. DM037 (8 care processes combined) is excluded: it reads as a local or NICE measure, not QOF. 4. The "income protected" marker from our glossary is excluded until its wording is confirmed. TOM: excluded deliberately are HIPPO_ codes, local indicators, CQC monitoring rows and product emoji. This is a reference page, not product copy. One soft product mention at the end only.

Body

Each QOF indicator has three parts that matter to your team: who is due, what has to be recorded for it to count, and how often it resets. This guide sets those out for the indicators practices ask about most.

Annual indicators reset on 1 April. Anything not recorded by 31 March does not count for that QOF year.

What does "treat to target" mean?

Some indicators need a result, not just an appointment. A treat-to-target indicator only counts when the latest reading is inside the threshold. If the last reading is above it, or there is no reading, the patient stays due.

These take longest to complete, because a patient may need more than one reading. Start them early in the year.

Asthma

Code What it is Who is due What counts as complete How often
AST007 Annual asthma review Patients aged 5 and over on the asthma register with no review in the last 12 months A review with a written personalised action plan on the same day, and an exacerbation count recorded within the month before the review Annual
AST008 Smoking status, young people with asthma Patients with asthma aged 19 and under with no smoking status in the last 12 months Personal smoking status or second-hand smoke exposure recorded Annual
AST014 Objective testing at diagnosis Patients diagnosed with asthma on or after 1 April 2025 with no objective test recorded within 3 months either side of diagnosis An age-appropriate objective test recorded in that window, such as FeNO or spirometry Once per diagnosis

The asthma review is the indicator most often lost to coding. The action plan has to be recorded on the same day as the review.

Hypertension

Code What it is Who is due What counts as complete How often
BP002 Blood pressure check Patients aged 45 and over with no blood pressure recorded in the last 5 years A blood pressure recorded Every 5 years
HYP008 Blood pressure control, aged 79 and under Patients with hypertension aged 79 and under with no reading at target in the last 12 months Clinic reading of 140/90 or lower, or 135/85 or lower on home monitoring Annual, treat to target
HYP009 Blood pressure control, aged 80 and over Patients with hypertension aged 80 and over with no reading at target in the last 12 months Clinic reading of 150/90 or lower, or 145/85 or lower on home monitoring Annual, treat to target

Diabetes

Code What it is Who is due What counts as complete How often
DM012 Foot examination Patients with diabetes with no foot check in the last 12 months Foot examination with a risk classification recorded Annual
DM014 Education referral Newly diagnosed patients with no referral to structured education A referral to structured education recorded Once per diagnosis
DM020 HbA1c control, not frail Patients with diabetes without moderate or severe frailty whose HbA1c is above 58 mmol/mol HbA1c of 58 mmol/mol or lower recorded Annual, treat to target
DM021 HbA1c control, frail Patients with diabetes with moderate or severe frailty whose HbA1c is above 75 mmol/mol HbA1c of 75 mmol/mol or lower recorded Annual, treat to target
DM036 Blood pressure control Patients with diabetes aged 79 and under without moderate or severe frailty, with no reading of 140/90 or lower in the last 12 months Clinic reading of 140/90 or lower recorded Annual, treat to target

Cervical screening

Code What it is Who is due What counts as complete How often
CS005 Screening, ages 25 to 49 Eligible patients aged 25 to 49 with no screening recorded in the last 3 years Screening recorded within the last 3 years and 6 months Every 3 years and 6 months
CS006 Screening, ages 50 to 64 Eligible patients aged 50 to 64 with no screening recorded in the last 5 years Screening recorded within the last 5 years and 6 months Every 5 years and 6 months

Smoking

Code What it is Who is due What counts as complete How often
SMOK002 Smoking status, long-term conditions Patients with conditions such as asthma, COPD, diabetes or heart disease with no smoking status in the last 12 months Smoking status recorded Annual
SMOK004 Cessation offer, all smokers Patients aged 15 and over who smoke, with no cessation offer in the last 24 months Cessation advice or referral recorded Every 24 months
SMOK005 Cessation offer, long-term conditions Smokers with long-term conditions with no cessation offer in the last 12 months Cessation support offer recorded Annual

Smoking indicators are among the quickest to complete. Many need only a status or an offer recorded, which a patient can often give by replying to a message.

How do you use this list?

Start with the treat-to-target indicators, because they take longest. Leave the single-item indicators, like smoking status, for a fast push later in the year. For a full year-end plan, read how to hit your QOF targets before 31 March.

Hippo tracks these indicators for every eligible patient each night and recalls the ones who are due. Get started or book a demo.