Making the most of QOF 2026/27 – key tips

GP Dr Gavin Jamie explains which new indicators have been included in QOF this year and offers pointers on managing targets to boost income

While the changes to the Quality and Outcomes Framework (QOF) have been overshadowed by more dramatic changes elsewhere in the GP contract for 2026/27, there have been some significant updates.

As usual, the earlier in the year that these can be implemented in practices, the more smoothly things will go at the end of the year.

We have quite a bit of the guidance already but some of the rules are only in draft form at the moment and at the time of writing we don’t have the full code lists. Things may change through the year, particularly for the new indicators.

First of all something that has not changed – in fact has not changed for over eight years – the value of a QOF point. While the headline value of a point has gone up, a 1.1% increase to £227.95, this has been balanced by changes to the average list size meaning there has been no change in cash terms, and the value of a point continues to be eroded by inflation. QOF makes up a smaller proportion of the contract every year.

Key new indicators for this year include:

1. Obesity

After only one year out of the QOF, obesity has returned, although it looks very different to previously. There are two quite separate indicators. The first – OB004 – largely replaces the Weight Management Enhanced Service from 2025/26. The overall funding remains about the same but there is a much higher requirement for referrals and so the payment per patient referred to weight management is smaller.

The requirement is that if a patient has a measured BMI of over 30, or over 27.5 for patients with a non-white ethnicity, then there should be a referral to a weight management programme within 90 days. As usual it applies to patients who could have a referral during the year so that the actual measurement may have been in the previous QOF year.

The time limit may seem tight but a referral only needs to be within 90 days after any BMI reading. If you miss the window for referral you should make sure that the patient has a new, up to date, BMI recorded before a referral is made.

Exception reporting is available for this indicator. As well as the usual reasons for exception reporting including patients declining the referral or being unsuitable there is also the opportunity to exception report if the service is not available. It is unlikely that there is no service in most areas but, with higher numbers of referrals there is a chance that the service will become full and have periods of unavailability through the year. Patients are automatically excepted if they do not attend after two obesity care review invitations.

The thresholds are low for this indicator, running from 10% to 30% of patients being referred to get the full five points. Due to the low thresholds levels of exception reporting will need to be higher to have an effect on the final outcome.

Overall the payment per patient referred is likely to be around £4, so it is unlikely to justify a dedicated consultation. Throughout 2025 many practices have developed an efficient system over the last year for communicating with practices and this could be continued as the DES finishes.

The second obesity indicator – OB005 – is quite different. This only applies to those patients eligible for tirzepatide under the NHS England guidelines. For 2026/27, this is for patients with a BMI of 35 or over (32.5 in patients in non white groups) and four out of five specified chronic conditions:

• Type 2 diabetes
• Hypertension
• Obstructive sleep apnoea
• Hyperlipidaemia – either lipid lowering therapy, low HDL or high LDL or triglycerides
• Cardiovascular disease

Three things need to happen in the year and be coded to meet the criteria of this indicator. First, a shared decision making conversation should take place. Second, there should be a referral to a behavioural support programme and finally there should be a record of a prescription for weight management drugs (presumably tirzepatide).

As you might expect the exception reporting is extensive and covers patients who do not want one of the care processes (including medication) or where support services are unavailable. These are fairly straightforward and combinations of codes are not required. There is an enduring exception for patients who have had previous bariatric surgery. Patients who have two invitations to an obesity review specifically coded will also be excepted.

There are 13 points for reaching 80% on this indicator. While numbers are difficult to calculate at the moment the payment per patient is likely to be between £100 and £200. The important thing will be to identify these patients early in the year based on having four out of five of the chronic diseases and inviting them for a shared decision making consultation. Prescribing of injectable GLP1 agonists is likely to require some practical support through the surgery and this will need to be accounted for when costing this indicator.

Exception reporting is likely to have a large effect on this indicator. Patients will be excepted if they are recorded as not wanting to have tirzepatide for weight management. If there are large numbers (and this seems likely for an injectable therapy) this will have an effect on achievement levels, pushing the effective threshold higher. Careful recording of invitations and patients decisions will be required as well as meticulous coding of the decision making conversation and referral to behavioural support services.

2. Heart failure

The treatment for patients with heart failure with reduced ejection fraction (HFrEF) has changed significantly over the last few years and the QOF was starting to look quite out of date. Up to now it has only suggested the use of beta-blockers and an ACE inhibitor or similar drug.

The points have now been allocated to a new indicator – HF009 – which requires prescription of:

• A beta blocker – normally cardioselective
• ACE inhibitor, or ARB or sacubitril/valsartan
• Mineralocorticoid receptor antagonist – e.g. spironolactone or eplerenone
• An SGLT2 inhibitor.

Exception reporting is available. In the case of patients being unsuitable for medications or choosing not to take them they must be prescribed all of the other medications in order to be exception reported. For instance if a patient does not tolerate a beta blocker then there should be a prescription (or an exception) for ACE, MRA and SGLT2 inhibitors in order for the patient to be excepted from the indicator.

For many practices these may already be prescribed. Searching early in the year will allow you to see what needs to be done. The upper threshold for points is a relatively modest 50% so this looks quite achievable.

There is one other difference which is very important to know. In previous years the code to add to echocardiograms was ‘left ventricular systolic dysfunction’. That has changed and the only codes accepted now contain “heart failure with reduced ejection fraction”. You may need to look back through your patients with left ventricular systolic dysfunction and ensure that they have the new code if appropriate. This could be worth thousands of pounds of income to the practice.

3. Vaccination and immunisations

The only changes to the contents of the vaccination and immunisation indicators has been the addition of the MMRV vaccination which was introduced at the start of this year to add varicella to the MMR vaccine. Although the suggested timings of vaccinations have also changed this has not been reflected in the indicators and this is likely to remain the case as children work through the new schedule.

However, an important update has been the addition of new improvement thresholds to reward practices that can demonstrate an increase in uptake but that don’t hit the current targets.

The thresholds have always been high and steep for infant vaccinations, starting from a high level of achievement before any points are awarded. This has been difficult for many practices and really not provided much incentive to practices where these thresholds were unattainable. About one in seven practices could potentially benefit from this new system where an increase in achievement since the previous year will earn points and payments. In all cases the points are awarded where improvement is more than 5% of the eligible population. Points are gained more quickly in younger age groups than for pre-school boosters.

For all practices points will be calculated with both systems and the best score will be used for payment.

There is still very little in the way of exception reporting for these indicators and none at all regarding parental choice. Increasing uptake of childhood vaccines is not easy but at least there will be some reward for practices that manage this, although it may be even harder to increase further in future years.

4. New cardiovascular disease blood pressure area

There were previously very similar blood pressure indicators in the coronary heart disease and stroke and TIA areas. These have now been combined and the points pooled. There is no change to the blood pressure targets, which are 140/90 for patients under 80 years old and 150/90 for older patients. Thresholds also remain the same.

Patients recorded as having moderate or severe frailty are now excluded from these indicators. The last coded frailty entry before the end of the year is the one that is used. As the clinical requirements remain the same there does not need to be any change to normal processes. The financial effect on practices will be generally neutral, although the precise effect on practices will depend on how many patients appeared on both of the registers.

The coronary heart disease (CHD) and STIA areas now only have a single indicator each which concerns anti-platelet or anticoagulant therapy and these have not been merged.

5. Diabetes

Extra points have been added to the indicators for cholesterol lowering therapy in patients with diabetes. This applies to both the primary and secondary prevention indicators which now both have eight points. There is no change to the requirements of the indicators so this should be good news for most practices.

There is a new indicator – DM037 – with 10 points where 75% of patients have had all of eight care processes within the QOF year.  As with all of these combination indicators these incentivise focused treatment on patients.

The eight care processes are:

1. BMI recorded
2. Blood pressure recorded
3. HbA1c measurement
4. Total cholesterol measurement
5. Smoking status (patients with a ‘never smoked’ record aged over 25 and after their diabetes diagnosis or three consecutive years of ‘non smoker’ status automatically pass this one)
6. Foot examination
7. Albumin:creatinine ratio measurement
8. eGFR measurement.

Exception reporting is available but will primarily be for patients who do not attend their diabetes review after two invitations at least a week apart. As usual this will happen automatically as long as the invitations are coded.

Other minor but vital changes

Stroke

Antiplatelet agents included in the stroke indicator now include ticagrelor, which should make the indicator a little easier for practices.

Non diabetic hyperglycaemia

Patients with a history of gestational diabetes have a higher rate of diabetes diagnosis in later life. Many practices already monitor their HbA1c annually due to this raised risk and over half of these women already receive an annual check. This has now been merged into the non-diabetic hyperglycaemia register and a couple of points added to reflect this.

If your practice does not already have a mechanism to recall these women for an annual blood test then it is worth setting one up as soon as possible to ensure that they are all offered a blood test during the year.

Hypertension

Patients with moderate or severe frailty will no longer be included in the hypertension indicators to allow a more personal plan to be created with these patients.

Cholesterol

There are some cuts to the points for prescribing statins or other lipid lowering medications to patients with coronary heart disease, peripheral vascular disease, stroke or chronic kidney disease. This is now much more similar to the level of points for cholesterol lowering therapy in the diabetes indicators.

Atrial fibrillation

The upper threshold for patients with atrial fibrillation and a calculated CHA2DS2-

VASc score in the last year (excluding those who had a score or two or more in previous years) has been increased to 95%. This is primarily an administrative activity. Clinical systems can easily calculate the score and this should be easy to calculated without patient contact – although scores of two or more will need to be acted on.

Although the upper threshold is raised overall achievement in 2024/5 was nearly 98% so this is not likely to be a problem for most practices.

What are the priorities now?

1. Establishing a strategy for obesity. This might include decisions about how tirzepatide should be prescribed and recorded in practice systems. This may involve discussions with commissioners as well who may have restricted prescribing to specialist clinics in the past.
2. Making sure that historic echocardiograms for patients with heart failure are correctly coded according with regard to ejection fraction. This will make sure that patients are appropriately identified and that prevalence is accurately calculated for the practice.

What are the new indicators for 2026/27?

Further reading:

• NHS England’s Quality and Outcomes Framework guidance for 2026/27
• GMS Medical Services Statement of Financial Entitlements Directions 2026

Dr Gavin Jamie is a GP in Swindon and runs the QOF database website

A version of this article was first published by our sister title Management in Practice