004B Contract Pro QOF

004B Contract Pro QOF

004B Routine QOF work

The 004B Routine QOF work search folder is located within PCIT Reporting Group in  004 Contracts folder. The 004 Routine QOF work folder is divided into 8 main folders (shown in the screenshot below).
Throughout this article PCA is mentioned, this stands for Personalised Care Adjustment and with regards to QOF, has replaced the term ‘exception reporting’. A PCA is when a patient is not included in a QOF target because they have declined a review/drug or a review/drug is not indicated, etc. By coding a PCA, it will reduce the number of patients eligible for the QOF target (decreasing the prevalence), making it easier to meet the QOF target.  For more information about PCAs see our separate support article.


We have produced some helpful searches and reports which will highlight patients where work needs to be done, either as a one-off exercise to improve a denominator (eligible) population, or where there is a time-critical period to achieve the indicator. 

We recommend checking the folder on a regular basis into your business as usual processes.

a ) Early contract actions

  1. These four searches cover areas where the patient has been declined in previous years. It may be worth reviewing these patients early on in the QOF year to see if the same conditions apply.

AF with no CHA2DS2-VASc

This search includes patients with AF who do not have a valid code for CHA2DS2-VACs score.

The below 3 reports all show whether the drug has been declined, contraindicated, not indicated or not tolerated in previous QOF years and the date associated with these codes. After running the reports, you can work through the patients included to check whether the appropriate code can be added to exception report them again for this QOF year, making it easier to meet the QOF targets stated below.

Diabetic proteinuria or microalbuminuria previously declined ACEI/ARB

This report is in relation with DM006. When run, it includes diabetic patients with proteinuria or microalbuminuria who in previous years have declined, been contraindicated, or not tolerated ACE inhibitors or angiotensin II receptor blockers (ARBs).

Heart failure not on a B-blocker previous PCAs

This report is in relation to HF006. When this report is run, it will include heart failure patients who in previous years have declined, been contraindicated, or not tolerated a beta blocker, therefore have been exception reported with regards to QOF. PCAs stand for personalised care adjustments. It is advised to review these patients to check if they become eligible, if they are not eligible they may be suitable for exception reporting, using the relevant code.

Heart failure not on ACEI/ARB and previously declined

This report will show Heart Failure patients who are not on ACEI or ARBs because they have declined them in previous QOF years.

b ) Weekly activities

The reports in this folder can be run and reviewed weekly to keep up to date with QOF targets.


Asthma with incomplete review

Have been built to identify where a review has been carried out and coded (eg: Asthma annual review) but other components have not been completed. For asthma this means there should be an ACT score, recording of the number of exacerbations, and a written personalised asthma action plan. There are critical windows of time when this information must be coded. 

COPD with incomplete review

Once run, this report will include patients with an incomplete COPD review, you will be able to identify from the report which section on the COPD review is incomplete so you can then action accordingly. Unlike the asthma with incomplete review, there are not critical timeframes for recording the additional information of the number of COPD exacerbations or the MRC score. Therefore, by running this report regularly/weekly you can keep on top of these reviews and action it as soon as possible after their COPD review.

Dementia review or care plan but not QOF code

Once run, this report will include patients who have a new depression diagnosis within the last 56 days, but have not had a review within the specified timeframe (10 – 56 days after the date of diagnosis). This may help to identify any coding issues or to help improve practice prevalence.

Heart failure with incomplete review

This report differs from asthma and COPD above as there is no dependence on having the heart failure review coded. QOF HF007 requires a patient to have a heart failure review AND a medication review, but not necessarily at the same time. This search picks up patients who have either a Heart Failure review OR a medication review coded this year (but not both). Use the report to identify which component needs completing.

New depression diagnosis but no review done

These searches picks up patients for DEP003. Patients should be reviewed between 10 and 56 days after the date of diagnosis, and the time limited search will show patients who were diagnosed in this short timeframe. The time expired search includes patients who were diagnosed from 15 months ago up to 56 days ago. Neither the time limited nor the time expired searches will include any patients who have been diagnosed in the past 9 days.
Coding 'Excepted from depression quality indicators - informed dissent' would remove a patient from the indicator.

c ) Monthly activities



New asthma diagnosis without objective tests

These patients have been diagnosed with Asthma within the last 6 months or have a recent diagnosis of asthma and have registered with the practice recently, but they do not have a Spirometry or FeNO / Peak Flow coded (objective tests). This relates to the AST011 QOF indicator. You can review the records for the patients included in this report to double check they haven’t had the objective tests or to invite patients for these tests within the inclusion timeframe (3 months before or 6 months after diagnosis). 

AF needs CHA2DS2-VASc
This report supports AF006, it displays patients with AF and who still need a CHA2DS2-VASc score calculating completed. 

COPD and MRC >=3 NOT offered pulmonary rehab

 These searches are effectively the Population Excluded for indicator COPD008. Target these patients for referring to pulmonary rehab. If the patient declines, add the code 'Pulmonary rehabilitation declined' as it will help to reduce the denominator and increase achievement. By coding this, it will ensure QOF indicator COPD014 is more easily achieved.

New cancer diagnosis but support not yet offered

These searches covers the 'new' CAN005 indicator. An discussion of support should be offered to the patient within 3 months of diagnosis. Unlike the above indicator, CAN005 has a short timeframe of just 3 months from the date of diagnosis. The time limited search will only show patients diagnosed in the past 3 months, while the time expired search will show any patients diagnosed 4-15 months ago.

Recent cancer diagnosis but no care review

This report is similar to the above report, however, a cancer care review is due within 12 months of the cancer diagnosis, which is relating to indicator CAN004. The time expired searches shows patients who were diagnosed between 24 and 13 months ago, although they can still be eligible for this year's QOF indicator as the year-long timeframe extends into this QOF year. 

Recent diabetes diagnosis but not referred to structured education

Identifies patients who have not achieved DM014. An offer of referral to a structured education programme within 9 months of diagnosis. The time limited search displays patients diagnosed in the past 9 months while the time expired search includes patients diagnosed 10-21 months ago. 
It is possible to remove a patient from the indicator by coding 'Diabetes structured education programme declined'

Recent heart failure diagnosis but not yet referred for echo

Supports HF005. An echocardiogram (or specialist assessment) must be done between 3 months prior to the heart failure diagnosis, and up to 6 months after diagnosis. Patients who recently registered with a recent heart failure diagnosis where the echo had not previously been done have 6 months from the date of registration to complete the assessment. The time limited search will display patients who were diagnosed in the past 6 months, while the time expired search shows patients who were diagnosed after 01/04/2021, up to 6 months ago. Coding 'Echocardiogram declined' or 'Angiocardiography declined' will remove a patient from the indicator.

d ) Expired Time Limited QOF


Unlike QOF denominators, the denominators of these searches have been built to include patients who have been recently diagnosed or recently registered. Each indicator has an associated report which will help identify diagnosis dates.

The below reports all show the time expired QOF indicators. The patients included in the reports are those who have gone beyond the time limit and are overdue a review, referral, or necessary action to meet the QOF targets. We would recommend you review these reports regularly and if the patient declined, is unsuitable, or has another reason to warrant a PCA, the appropriate code can be added for this. Some declined, etc. codes will need to be backdated to the correct date, depending on the time restriction for the specific indicator (it is mentioned below which indicators require the code to be backdated). Sometimes, these time limited actions have been completed, but not coded, in this case a backdated review or the appropriate code can be added to correctly record the review, referral, or other necessary action (helping to achieve the QOF indicators).

Asthma, diabetes, and heart failure only pick up patients whose first ever diagnosis code was in the specified timeframe. Cancer and depression pick up the most recent problem diagnosis (First, New) so consider incorrect problem management before trying to achieve the indicator

Time expired Cancer diagnosis but no care review 

This search is to support to the CAN004 QOF indicator. A cancer care review is due 12 months post diagnosis. We have created this report to include patients who were not been offered a cancer care review within the timeframe specified.

Time expired Cancer diagnosis but support not offered 

This search is to support to the CAN005 QOF indicator. Cancer support must be offered within 3 months post diagnosis. The patients included in this report were not offered support within the timeframe specified. 

Time expired Depression diagnosis but no review done 

This report is to support to the DEP004 QOF indicator. The report includes patients ages 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March who have not yet received a review. A depression review must have been completed within 10 – 56 days post diagnosis.

Time expired diabetes dx but not referred to struct. education

These searches show the number of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have no record yet of being referred to a structured education programme within 9 months after entry on to the diabetes register.

Time expired Heart failure diagnosis but no echo

These identify the number of patients with a diagnosis of heart failure on or after 1 April 2023 which still require:
1. Confirmation by an echocardiogram or by specialist assessment in the 6 months before entering on to the register; or 
2. If registered at the practice after diagnosis, with no record of the diagnosis originally being confirmed either by echocardiogram or by specialist assessment, no record of an echocardiogram or a specialist assessment within 6 months of the date of registration.

Time expired New asthma diagnosis

Supports AST006. Patients with a new diagnosis of asthma should have two objective tests; the first is spirometry and the second can either be a Fractional exhaled Nitrous Oxide (FeNO) test, or a peak flow. Both tests must be done between 3 months prior to the diagnosis, and up to 6 months after diagnosis. Patients who recently registered with a recent asthma diagnosis where the objective tests were not previously done have 6 months from the date of registration to complete the tests. The time limited search will display patients who were diagnosed in the past 6 months, while the time expired search shows patients who were diagnosed after 01/04/2021, up to 6 months ago.
Due to the dual eligibility criteria of diagnosis date and registration date, the objective tests have an open-ended date, so any test shown may exceed the 6 month limit.
Coding 'Spirometry test declined' or 'Asthma monitoring refused' will remove a patient from the indicator.

e ) Remote data collection



AST008 Smoking questionnaires to send out

This search identifies patients with Asthma, aged 19 or under who require a smoking questionnaire to be sent out because there is no smoking status or exposure coded on their records. Recording the smoking status for these patients will help to achieve the AST008 QOF indicator. 

CHD005 Antiplatelet questionnaire to send out (later in contract year)

This search includes patients with coronary heart disease with no record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken. Therefore, they require a questionnaire to be sent out. It is advised to do this later in the contract year. This is relating to the CHD005 QOF indicator. 

STIA007 Antiplatelet questionnaire to send out (later in contract year)

This search identifies non-haemorrhagic stroke or TIA patients who have no record in the preceding 12 months that an anti-platelet agent, or anti-coagulant has been taken. It is advised to do this later in the contract year. This is relating to the STIA007 QOF indicator.

f ) QOF targeted help



These searches and reports are helpful to use as you get further into the QOF year. They are broken up into the following areas:
  1. ACTION - where a specific action just needs be done
  2. HIGH RISK - where patients have had results or values in previous contract years that are out of range but haven't been followed up in the current year
  3. QUICK WIN - these are further broken up into :
    1. Bloods - where a blood test is just needed (usually HbA1c)
    2. Coding - where a simple code being added will achieve an indicator
    3. Value - where values last year were normal (for BP, cholesterol or HbA1c) but haven't been done in the current contract year
  4. REVIEW - where patients need more detailed review

ACTION | Diabetes no HbA1c this QOF year

This report gives you a list of patients who have diabetes but haven't had an HbA1c within the current QOF year.

HIGH RISK | CHD no BP reading this QOF year but latest was raised

This report gives you a list of patients who have CHD who haven't had a BP within the current QOF year where the most recent BP reading on record was raised.  This helps to identify patients for CH015 and CHD016.  

HIGH RISK | Chol not on therapy, no result this year but previously raised

This report gives you a list of patients who are NOT on lipid lowering therapy. Patients included haven't had a cholesterol coded within the current QOF year, but the most recent value on record was above the threshold.  The report helps to identify patients for CHOL002.  

HIGH RISK | Chol on therapy, no result this QOF year but previously raised

This report gives you a list of patients who are on lipid lowering therapy, patients included haven't had a cholesterol coded within the current QOF year, but the most recent value on record was above the threshold.  The report helps to identify patients for CHOL002.  

HIGH RISK | Diabetes no BP reading this QOF year but latest reading was raised

This report gives you a list of patients who have Diabetes, patients included are not coded as moderately or severely frail, they haven't had a BP within the current QOF year, but the most recent BP reading on record was raised.  This helps to identify patients for DM033.  You may also want to consider if the patient is frail, in which case a BP target doesn't apply.  

HIGH RISK | Hypertension no BP reading this QOF year but latest was raised

This report gives you a list of patients who have Hypertension, patients included don't have a BP recorded within the current QOF year but the most recent BP reading on record was raised.  This helps to identify patients for HYP008 and HYP009.  Don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

HIGH RISK | Stroke no BP reading this QOF year but latest was raised

This report gives you a list of patients who have a history of stroke or TIA. Patient included haven't had a BP within the current QOF year but the most recent BP reading on record was raised.  This helps to identify patients for STIA014 and STIA015.  Don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

QUICK WIN BLOODS | Non-Diabetic Hyperglycaemia no HbA1c this QOF year

This report gives you a list of patients who have a history of NDH who haven't had an HbA1c within the current QOF year.  This helps to identify patients for NDH002.  

QUICK WIN CODING | Chol on alternative lipid-lowering therapy without statin PCA

This report gives you a list of patients who are not achieving CHOL001. Patients included are on a lipid lowering therapy that isn't a statin, therefore, need a statin PCA adding in order to achieve CHOL001.  

QUICK WIN VALUE | CHD no BP reading this QOF year and latest was normal

This report gives you a list of patients who have CHD and haven't had a BP within the current QOF year, but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check it will be within the normal range again and make it easy to improve your performance for CH015 and CHD016.  Don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

QUICK WIN VALUE | Chol not on therapy, no result this year and previously normal

This report gives you a list of patients who are eligible for CHOL002. The patients included haven't had a cholesterol within the current QOF year, but the most recent value on record was normal.  The likelihood is if you get these patients in for a cholesterol check, it will be within the normal range again which makes it easy to improve your performance for CHOL002.  

QUICK WIN VALUE | Chol on therapy, no result this year and previously normal

This report gives you a list of patients who are eligible for CHOL002. The patients included are on lipid lowering therapy, they haven't had a cholesterol within the current QOF but the most recent value on record was normal.  The likelihood is if you get these patients in for a cholesterol check the result will be within the normal range again, which makes it easy to improve your performance for CHOL002.  

QUICK WIN VALUE | Diabetes no BP reading this QOF year and latest was normal

This report gives you a list of patients who have Diabetes and are not moderately or severely frail. These patients haven't had a BP within the current QOF year but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check this will be within the normal range again and make it easy to improve your performance for DM033.  You may also want to consider if the patient is frail, in which case a BP target doesn't apply. The BP target is less than 140/90.

QUICK WIN VALUE | Hypertension no BP reading this QOF year and latest was normal

This report gives you a list of patients who have Hypertension and haven't had a BP within the current QOF year, but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check this will be within the normal range again and make it easy to improve your performance for HYP008 and HYP009.  Don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

QUICK WIN VALUE | Stroke no BP reading this QOF year and latest was normal

This report gives you a list of patients who have a history of Stroke or TIA. The patients included haven't had a BP within the current QOF year but the most recent BP reading on record was normal.  The likelihood is if you get these patients in for a BP check, it will be within the normal range again and make it easy to improve your performance for STIA014 and STIA015.  Don't forget that for under 80 year olds the BP target is less than 140/90 and for over 80 year olds it's 150/90.

REVIEW | Last BMI >30 but not on obesity register

This search identifies patients who have previously had a raised BMI but haven't had one calculated during the current contract year.  This means they will not be included on your obesity register. Adding patients to the obesity register will increase the population count for the OB003 indicator and is in line with best practice.

REVIEW | Mental health review elements missing for this QOF year

This report will help you with achievement of MH021.  For this, you need all 6 review elements to be completed - including:
  1. BP
  2. BMI
  3. Alcohol
  4. Lipids
  5. HbA1c
  6. Smoking

g ) Clinical review searches


CHECK BORDERLINE | Cholesterol non-HDL this year >2.5

This report includes patients with cholesterol whose latest non-HDL reading (taken in the last 12 months) is above target threshold (greater than or equal to 2.5). Some patients will also appear in the report below. 

CHECK BORDERLINE | Cholesterol non-HDL this year borderline

This report includes patients with cholesterol whose latest non-HDL reading (taken in the last 12 months) is marginally above target threshold (non-HDL 2.5 - 3.5 or LDL 1.7 - 2.8). Some patients will also appear in the report above.

CHECK BORDERLINE | Diabetes HbA1c this year and HbA10c >58 mmol/mol (not frail)

This report will include patients on the diabetes register without moderate or severe frailty who have an IFCC-HbA1c of above 58 mmol/mol in the preceding 12 months. These patients included may be eligible to have this code added again for this QOF year, reducing the prevalence for DM020, subsequently making the target easier to achieve.

CHECK BORDERLINE | Diabetes HbA1c this year and HbA1c >75 mmol/mol (frail)

This report will include patients on the diabetes register who are moderately or severely frail and have an IFCC-HbA1c of above 75 mmol/mol in the preceding 12 months. These patients included may be eligible to have this code added again for this QOF year, reducing the prevalence for DM020, subsequently making the target easier to achieve.

CHECK BORDERLINE | Hypertension aged 79 or under BP this year not to target NO previous PCAs

This report will show patients aged 79 years or under with hypertension whose latest blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or more but with no previous PCAs recorded. 

CHECK BORDERLINE | Hypertension aged over 80 BP this year not to target NO previous PCAs

This report will show patients aged 80 year or over with hypertension whose latest blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or more but with no previous PCAs recorded. 

CONTROL | Cholesterol not on a statin NO previous PCAs

This report includes patients with cholesterol who are not on a statin and have no previous PCA recorded. You can review the patients’ to add a PCS this QOF year, if necessary, or action as appropriate to help achieve the CHOL001 QOF target, or lower the prevalence.

PCA CHECK | Cholesterol not on a statin previous PCAs

This report includes patients with cholesterol who are not on a statin and have a previous PCA recorded. 0You can review the patients’ to add a PCS again this QOF year, if necessary, or action as appropriate to help achieve the CHOL001 QOF target, or lower the prevalence.

PCA CHECK | Hypertension aged 79 or under BP this year not to target previous PCAs

This report includes patients aged 79 years or under with hypertension whose latest blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or more and with a previous PCA recorded.  These reports can help you take the necessary action (if appropriate re-code the PCA) to help achieve the HP008 QOF indicator.

PCA CHECK | Hypertension aged over 80 BP this year not to target previous PCAs

This report includes patients aged 80 year or over with hypertension whose latest blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or more and with a previous PCA recorded. These reports can help take the necessary action (if appropriate re-code the PCA) to help achieve the HP009 QOF indicator.

REVIEW | AF with CHADS2VASC raised but no DOAC

This report shows patients on the QOF Atrial Fibrillation register and with a CHA2DS2-VASc score of 2 or more, who have not been prescribed a direct-acting oral anticoagulant (DOAC), or coded declined, contraindicated, etc. These reports will help to improve prevalence for the AF008 QOF indicator.

REVIEW | Diabetes but no frailty coded

This report includes all non-frail diabetic patients.  Diabetic patients who are frail have more relaxed treatment targets, they:
  1. don't need a statin
  2. don't have a BP target
  3. have a higher HbA1c target (75 or more)
You can review the patients included in the report and consider whether they need a frailty code added. Adding a frailty code to these patients will remove them from the following indicators: DM020 (HbA1c target of 58), DM022 (need to be on a statin), and DM033 (BP needing to be less than 140/90).

h ) Code reviews



We have identified a number of coding issues during the 2023/24 QOF contract year.  These searches help practices to identify if they are affected and then take action with these.

COPD Pulmonary rehabilitation issues

These searches will show you patients who require recoding because of the removal of "Pulmonary rehabilitation offered" and the persistence of "Pulmonary rehabilitation declined"

Learning disability coding issues

 These searches will show you patients who have been removed from or added to the Learning disabilities register.  You can also see your old register for learning disabilities "LD LD004 - Patients on the learning disabilities register [PCIT]" to allow you to confidently recall patients for review at this time of the year.  

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