2026/27 QOF support materials: PCIT Templates, OneMonitoring, Handy Protocols and Searches

Overview

Primary Care IT provides a range of QOF support materials to help practices identify outstanding activity, improve coding accuracy and support clinical review throughout the QOF year.

These resources work together across four main areas:

• PCIT Templates
• OneMonitoring
• PCIT Handy Protocols
• PCIT Searches

Together, these tools help practices act earlier, reduce year-end retrospective work and support users at the point of care.

The aim is to give practices assurance that difficult-to-achieve or commonly missed QOF areas are being supported in multiple ways: through searches, patient-level alerts, structured templates and point-of-care prompts.

How the QOF support materials work together

PCIT Searches

PCIT Searches support population-level QOF planning and monitoring.

They help practices identify groups of patients who may need review, coding, invitations, follow-up or further action. Searches are useful for proactive QOF work because they allow teams to find patients before they attend, plan recalls, review outstanding activity and support managed workflows.

Searches are particularly useful for identifying patients who may have missing information, incomplete coding or outstanding QOF activity across a wider cohort.

OneMonitoring

OneMonitoring gives users a patient-level view of outstanding QOF and monitoring activity.

It highlights information such as disease register status, outstanding reviews, results that are out of range, actions that are due now, actions that are due by year end, and prompts where coding or clinical review may be needed. For 2026/27, OneMonitoring has been reviewed against current QOF requirements and updated for QOF v51 register changes, frailty handling, obesity, 8 key care processes for diabetes, heart failure 4 pillars care and several indicator pathways.

OneMonitoring is most useful when users want a quick view of what may still need attention for the patient. Double-clicking OneMonitoring opens a template with the outstanding indicators shown, making it easier to complete the relevant activity.

PCIT Templates

PCIT Templates support structured clinical review and coding during consultations and long-term condition reviews.

The templates include QOF-specific sections that appear where relevant, helping users identify what needs to be reviewed, recorded or followed up. For 2026/27, template content has been refreshed to reflect updated QOF logic, including asthma age eligibility, COPD register changes, NDH/GDM, obesity indicators, blood pressure targets, diabetes care processes and heart failure four-pillar therapy.

Handy Protocols

Handy Protocols provide additional point-of-care support.

They help users act at the point where QOF-impacting information is being reviewed or recorded. This includes areas that are commonly missed, difficult to complete consistently, or likely to generate retrospective work if not handled at the time.  Additional handy protocols have been released for 2026/27 contract year to support with unique challenges posed by the changes to this years business rules.

The protocols are designed to support clinical teams, not replace clinical judgement. Users should only add codes, referrals, exceptions, personalised care adjustments or treatment decisions where they accurately reflect the patient’s clinical record.

PCIT Templates

OneTemplate Contract

OneTemplate Contract is designed for quick contractual data entry.

It is useful when the main aim is to complete contract-related work, including QOF, IIF or local enhanced services. It gives users a focused way to record the information needed for contractual requirements without needing to complete a broader long-term condition review.

When to use it:

Use OneTemplate Contract when the user wants quick data entry for anything related to a national or local contract.

OneTemplate Prescriber and OneTemplate NonPrescriber

QOF is also supported within the role-based templates:

• OneTemplate Prescriber
• OneTemplate NonPrescriber

These templates are designed for more thorough long-term condition reviews. As well as contractual information, they show more detailed disease-specific content based on the patient’s conditions.

When to use them:

Use the role-based templates when the user wants to cover QOF and other contractual information, but also wants a more holistic review of the patient’s long-term conditions.

What the 2026/27 template updates support

The QOF template release includes updated sections for:

• Asthma
• COPD
• NDH/GDM
• Cardiovascular disease
• CHD
• Stroke/TIA
• Obesity
• Hypertension
• Diabetes
• Heart failure

The templates help users:

• identify whether a QOF section is relevant to the patient
• review outstanding QOF activity
• record review codes, results, referrals or patient decisions
• apply appropriate exception or personalised care adjustment codes where clinically appropriate
• understand how age, frailty, diagnosis, register status or QOF timeframe affect the patient’s QOF status

Examples of 2026/27 changes include asthma resources updated for AST014 and AST015, COPD resources updated for revised register logic, NDH resources updated to include gestational diabetes pathways, new obesity support for OB004 and OB005, hypertension support for HYP010 and HYP011, diabetes support for DM037 and the 8 Key Care Processes, and heart failure support for HF009 and four-pillar therapy review.

OneMonitoring

OneMonitoring supports practices by summarising outstanding or relevant monitoring activity for a patient.

It may show:

• disease register status
• outstanding QOF activity
• reviews or monitoring not completed within the required timeframe
• results that are out of range
• actions that just need doing
• activity that may be due by year end
• prompts where coding or review may be needed

The 2026/27 OneMonitoring update includes changes to asthma register and review logic, COPD register and review logic, gestational diabetes visibility, obesity register logic, blood pressure target handling, frailty handling, DM037 8 Key Care Processes, HF009, patients on the heart failure register without reduced ejection fraction recorded, and refreshed due-now, out-of-range, just-needs-doing and due-by-year-end prompts.

OneMonitoring helps practices identify outstanding work while the patient is in front of the user, reducing reliance on retrospective searches alone.

PCIT Handy Protocols

Handy Protocols provide additional support for QOF-related workflows. They prompt users at relevant points in the patient journey, helping practices improve coding quality, reduce missed opportunities and manage areas of QOF that can be difficult to achieve consistently.

The following sections describe what each group of Handy Protocols supports and how they help practices with QOF.

Atrial fibrillation and anticoagulation

CHA2DS2-VASc anticoagulation support

This supports QOF achievement by identifying patients with atrial fibrillation who have a CHA2DS2-VASc score indicating that anticoagulation should be considered.

It helps ensure that patients who may benefit from anticoagulation are not missed and that clinicians are prompted to review, act or record the appropriate decision.

This supports both patient safety and QOF achievement by helping practices identify patients where stroke prevention treatment may need to be considered.

CHA2DS2-VASc score recording support

This helps practices identify patients with atrial fibrillation who need a CHA2DS2-VASc score recorded.

It supports bulk score recording as part of a managed practice process, helping practices improve data completeness and make sure patients can be assessed appropriately for anticoagulation indicators.

This reduces the risk of patients being missed from AF-related QOF activity because a score has not been recorded.

Asthma

New asthma diagnosis testing support

This helps ensure that newly diagnosed asthma patients have the required objective testing recorded.

It identifies patients where an asthma diagnosis has been added but the expected testing information is not present in the record. This supports more accurate asthma diagnosis recording and helps reduce the risk of missing QOF objective testing requirements.

This is particularly helpful because missing asthma testing can be a common data-quality issue.

Asthma review completion support

This helps ensure asthma reviews are fully completed.

Where part of an asthma review has been recorded, the protocol checks whether the required review elements have also been completed. If information is missing, the user is prompted to complete the outstanding items where appropriate.

This supports QOF achievement by reducing incomplete reviews and helping ensure asthma review activity is fully recorded.

Asthma action support in the final quarter of the QOF year

This helps identify patients who may be brought into scope for asthma review because asthma treatment has been issued late in the QOF year.

It alerts users where a patient may need an asthma review arranged, helping practices avoid late-year QOF gaps caused by treatment activity bringing a patient into the review cohort.

This supports more proactive asthma review planning and reduces the risk of unachieved asthma review indicators at year end.

COPD

COPD review completion support

This helps ensure COPD reviews are fully completed.

Where part of a COPD review has been recorded, the protocol checks whether the required elements of the review have also been completed. If information is missing, the user is prompted to add the outstanding review elements where clinically appropriate.

This supports QOF achievement by helping practices avoid incomplete COPD reviews.

COPD register review support

This supports COPD register accuracy following changes to QOF COPD register rules.

It identifies patients who appear to have been added to or removed from the COPD register under the updated QOF logic, allowing users to review the coding and decide whether any action is clinically appropriate.

This helps practices maintain a more accurate COPD register and reduces the risk of patients being incorrectly included or excluded from QOF review activity.

Diabetes

New diabetes structured education support

This helps identify newly diagnosed diabetic patients who have not yet been offered referral to a Structured Education Programme.

It supports timely referral and accurate recording of structured education activity, helping practices address a key area that can easily be missed during early diabetes management.

This supports both QOF achievement and good patient care by encouraging early education and self-management support.

Blood pressure and cardiovascular disease

High blood pressure support

This helps users respond appropriately when a blood pressure reading may affect QOF achievement.

It supports users by highlighting when a patient may not be achieving a relevant QOF blood pressure target and prompting consideration of appropriate follow-up, previous normal readings, maximal tolerated therapy, personalised care adjustment or clinician advice.

This is particularly important because blood pressure indicators can be difficult to achieve and may be affected by age, frailty, home readings, ambulatory readings and clinical decision-making.

By prompting users at the point the reading is recorded, this support helps reduce missed opportunities and avoid unnecessary year-end correction work.

Cholesterol and lipid management

Cholesterol exception support

This helps users record the correct QOF-counting personalised care adjustment when a statin or lipid-lowering therapy cannot be used.

It reduces the risk of users recording a general statin exception that does not count for the relevant QOF indicator. By prompting the correct coding at the time, it helps reduce duplicate work and retrospective correction later in the year.

This supports lipid and cholesterol QOF indicators where medication, contraindication, intolerance, decline or other personalised care adjustment coding may be relevant.

Previous lipid exception review support

This helps practices identify patients with outstanding lipid management requirements who have had previous personalised care adjustments recorded.

It gives users visibility of previous exceptions so they can consider whether the same issue still applies and whether current-year coding is clinically appropriate.

This supports QOF achievement by helping practices avoid missing patients who had a previous documented reason for non-treatment but need review or updated coding in the current year.

Frailty

Frailty status and assessment support

This helps users identify where frailty coding may affect QOF achievement, particularly for blood pressure and diabetes indicators.

It highlights where frailty may affect blood pressure targets and diabetes HbA1c targets. It also helps identify where Rockwood frailty coding or scoring is present but may not count as a QOF frailty code.

This supports accurate QOF logic by helping practices ensure frailty is recorded in a way that reflects the patient’s clinical status and is recognised for QOF reporting.

Frailty coding alignment support

This helps keep Rockwood frailty recording and QOF-counting frailty coding aligned.

Where frailty status has been recorded but the matching QOF frailty code appears to be missing, the user is prompted to add the appropriate QOF code where clinically correct.

This reduces the risk of a patient being clinically assessed as frail but not recognised as frail for QOF purposes.

Obesity

Obesity referral and eligibility support

This supports the new obesity QOF requirements by helping users act when a BMI suggests that obesity management activity may be needed.

It helps identify patients who may need referral to a weight management service, as well as patients who may be eligible for obesity pharmacotherapy and behavioural support.

It can also highlight where a patient appears close to eligibility but may have missing or incomplete coding, such as missing hypertension, diabetes, lipid or QRISK information.

This supports QOF achievement by helping practices act at the point BMI is recorded, rather than relying only on retrospective searches. The 2026/27 template release also includes support for OB004 and OB005, including weight management referrals, pharmacotherapy, behavioural support and appropriate exception or declined-care recording.

Heart failure

Heart failure review completion support

This helps ensure heart failure reviews are fully completed.

Where part of a heart failure review has been recorded, the protocol checks whether the required elements of the review have also been completed. If information is missing, the user is prompted to add the outstanding review elements where clinically appropriate.

This supports more complete heart failure review recording and helps reduce incomplete QOF activity.

Heart failure subtype review support

This helps identify patients who are on the heart failure register but do not currently appear to have heart failure with reduced ejection fraction recorded.

The alert supports review of heart failure subtype coding, echo information, ejection fraction values and previous left ventricular dysfunction coding. It can also support consideration of whether the patient may need treatment optimisation.

This is important because patients with HFrEF may be eligible for four-pillar heart failure management. The 2026/27 update includes support for HF009 and for identifying patients on the heart failure register who do not have reduced ejection fraction recorded.

PCIT Searches

PCIT Searches provide the population-level layer of QOF support.

They help practices identify cohorts of patients who may need attention, such as patients with missing coding, incomplete reviews, outstanding monitoring, or activity that needs completing before the end of the QOF year.

Searches are particularly useful for:

• planning QOF work across the practice
• identifying patients who need recall or review
• finding patients with missing or incomplete coding
• supporting managed batch processes where appropriate
• monitoring progress against difficult QOF areas
• identifying work that may not be visible from a single patient record alone

Searches work best when used alongside OneMonitoring, templates and Handy Protocols. Searches help identify the cohort, OneMonitoring highlights relevant patient-level prompts, templates support structured recording, and Handy Protocols help catch key issues at the point of care.

How to use these resources together

A practical approach is:

1. Use PCIT Searches for population-level planning
   Identify groups of patients who may need QOF review, coding, recall or follow-up.
2. Use OneMonitoring for patient-level visibility
   Check what is outstanding, out of range, due now or due by year end for the patient.
3. Use Templates to complete structured recording
   Record reviews, results, referrals, decisions, exceptions or personalised care adjustments in the appropriate template section.
4. Use Handy Protocols as point-of-care safety nets
   Allow prompts to support users when key QOF-related activity is being recorded or reviewed.

This gives practices support before, during and after patient contact.

Assurance for practices

The PCIT QOF support materials are designed to provide broad coverage across the areas of QOF that are often hardest to manage consistently.

This includes:

• patients entering or leaving registers because of rule changes
• incomplete long-term condition reviews
• missing objective testing
• missing blood pressure or HbA1c target achievement
• frailty coding that affects QOF logic
• lipid management and personalised care adjustments
• obesity referral and pharmacotherapy requirements
• heart failure subtype and treatment optimisation
• AF stroke prevention and CHA2DS2-VASc recording
• diabetes structured education and care processes

By combining searches, OneMonitoring, templates and Handy Protocols, practices have support at multiple levels:

At population level, searches help practices plan and prioritise work.

At patient level, OneMonitoring highlights what may still need action.

During review, templates support structured recording.

At key workflow points, Handy Protocols help catch issues that may otherwise be missed.

This gives practices greater assurance that difficult QOF areas are being actively monitored, supported and improved throughout the year.

Clinical judgement and coding accuracy

PCIT resources are designed to support users, not replace clinical judgement.

Where a prompt appears, users should review the patient’s clinical record and only add codes, referrals, personalised care adjustments or treatment decisions where they are clinically appropriate.

Accurate structured coding is important. Information recorded only in free text, scanned letters or documents may not always be recognised by QOF logic, searches or alerts.

Important note about QOF indicator names

Some Handy Protocols have existed across multiple QOF years and may historically reference older indicator names in their original support articles or descriptions.

Where QOF indicators have changed for 2026/27, the current PCIT Templates and OneMonitoring resources have been updated to reflect the latest QOF logic. Users should follow the latest in-system prompts and current support materials.

How these resources are accessed

Templates

QOF-related sections appear within the relevant PCIT Templates when the patient meets the logic for that section.

Use OneTemplate Contract for quick contract-focused data entry.

Use OneTemplate Prescriber or OneTemplate NonPrescriber for more holistic long-term condition reviews.

OneMonitoring

OneMonitoring displays patient-specific monitoring and QOF prompts when the alert is active and the patient meets the relevant criteria.

Double-clicking OneMonitoring opens a template with the outstanding indicators shown for ease of completion.

Handy Protocols

Most QOF-related Handy Protocols are automatically installed as part of the PCIT Handy Protocols set or base Handy Protocol installation.

If a protocol is expected but is not visible or does not appear to be installed, practices should submit a support ticket.

Searches

PCIT Searches are available to support population-level QOF work, recall planning and review of outstanding activity.

Practices should use searches as part of regular QOF planning and combine them with OneMonitoring, templates and Handy Protocols for patient-level completion.

Recommended practice approach

Practices should ensure clinical and administrative teams understand:

• which QOF resources are available
• when to use OneTemplate Contract, OneTemplate Prescriber and OneTemplate NonPrescriber
• how OneMonitoring supports patient-level review
• how Handy Protocols support point-of-care prompts
• how searches can be used for proactive planning
• that coding should only be added where it accurately reflects the patient’s clinical record
• that some prompts are designed to support review, not automatically instruct a coding action
• that structured coding is important, as free text or scanned documents may not trigger QOF logic

Clinical judgement remains central. PCIT resources are designed to support safe, consistent and timely review, but users should always consider the patient’s clinical context before adding codes, referrals, medication decisions or personalised care adjustments.

When raising a support request

When contacting support about QOF materials, please include:

• the resource involved, such as Template, OneMonitoring, Handy Protocol or Search
• the QOF indicator or clinical area involved
• what the user expected to happen
• what actually happened
• screenshots of the prompt, template section, search output or alert where appropriate
• relevant coded entries and dates, excluding unnecessary patient-identifiable information

This helps us investigate whether the behaviour relates to eligibility, coding, QOF timeframe, system configuration or resource logic.

Summary

PCIT QOF support materials are designed to help practices manage QOF activity throughout the year rather than relying on retrospective review.

Searches support population-level planning and cohort identification.

OneMonitoring highlights outstanding monitoring and QOF activity at patient level.

Templates support structured review and coding during consultations.

Handy Protocols prompt users at key points in the workflow.

Used together, these resources help practices identify outstanding work earlier, improve coding quality, support difficult-to-achieve QOF areas and deliver more consistent patient review throughout the year.