Overview

With the 2025/26 QOF contract changes, there is an increased emphasis on cardiovascular disease (CVD) prevention. This guide provides a step-by-step approach for practices to adapt workflows and ensure optimal management of high-risk patients.

 Key QOF Changes for CVD Prevention

1. More points allocated to getting patients with CHD/PAD/STIA and CKD onto a statin or other lipid lowering therapy
   
2. Increased thresholds and more points for:
   
3. Hitting cholesterol targets for patients with CHD/PAD/STIA
   

Achieving blood pressure targets for:

1. Hypertensives
   
2. STIA
   
3. CHD
   
4. Diabetes (for <80 without frailty only now)
   

Action Points:

1. Identify eligible patient cohorts for intervention.
   
2. Implement structured recall systems and start early in the year with these targets.
   
3. Train staff on updated QOF criteria and targets.
   

Step-by-Step Implementation Guide

1. Identify High-Risk Patient Cohorts

1. Review previous performance for CHOL003 bearing in mind this is now worth 38 points instead of 14.
   
2. Use QOF searches to identify patients with CHD, PAD, stroke/TIA or CKD who need lipid-lowering therapy.
   
3. Depending on previous performance decide how much work is needed to engage with patients not year achieving the target
   

Checklist:

1. Run searches for eligible patients requiring statin therapy.
   
2. Review at-risk patients who are currently unmanaged.
   
3. Develop a prioritised recall plan.
   

2. Implement Proactive Reviews to focus on lipid lowering

1. You now have to achieve lipid targets of ≤ 2.0 mmol/L if it was an LDL (Low-density Lipoprotein) cholesterol reading or ≤ 2.6 mmol/L if it was a non-HDL in 50% of your patients compared with 35% last year
   
2. Review your performance in this area last year
   
3. Identify how many additional patients you need to achieve the target for this year compared with last year
   
4. Set up automated recall systems for the required number of CVD risk assessment reviews.
   
5. Use clinical audits to track patients not reaching LDL/non-HDL targets.
   

Checklist:

1. Calculate the gap between last years 35% threshold and this years 50% target, identifying the additional number of patients needed
   
2. Develop a plan to systematically identify and manage these patients to maximise achievement of the available 44 points
   
3. Schedule annual reviews for high-risk patients.
   
4. Assign clinical staff to oversee lipid optimisation programmes.
   

3. Improve Blood Pressure Control & Hypertension Management

1. For each of the blood pressure areas (Hypertension, STIA, CHD, Diabetes) undertake a gap analysis to look at performance last year compared to the required achievement for the current year (understanding how many had PCAs last year)
   
2. For each KPI work out the number of additional patients needed this year to achieve the target
   
3. Create a plan on how to achieve each of the numbers identified above
   
4. Promote home BP monitoring for patients with difficult-to-control hypertension.
   
5. Ensure medication adjustments are made where targets are not met.
   

Checklist:

1. Monitor patients not achieving BP control.
   
2. Offer ambulatory/home BP monitoring where required.
   
3. Conduct blood pressure medication reviews at regular intervals.

4. Staff Training & Patient Education

1. Train staff on new QOF targets for CVD prevention.
   
2. Educate patients on lifestyle interventions alongside medication.
   
3. Use SMS campaigns to encourage uptake of CVD prevention services.
   

Checklist:

1. Deliver clinical training on QOF CVD indicators.
   
2. Update patient education materials on lipid management.
   
3. Implement digital reminders for follow-ups.
   

Next Steps & Deadlines

1. April 2025 – QOF changes take effect.
   
2. Ongoing – Monitor performance, exception reporting, and uptake.
   

Immediate Actions:

1. Identify at-risk patients and schedule reviews.
   
2. Ensure all eligible patients are optimised for lipid therapy.
   
3. Monitor progress towards QOF cholesterol and BP targets.