QOF 2026/27: what your clinical system can't tell you yet

The v51 QOF business rules have not been published. Your clinical system supplier has not released updated templates. The SNOMED code clusters, extraction logic, and exception categories are all pending.

But the clinical definitions behind the new indicators are already knowable. They come from NICE guidance that has been public for months. If you wait for the business rules before you start preparing, you will lose 6 weeks. Here is what we already know, and what your QOF lead can do right now.

The new indicators at a glance

Additionally, the three childhood vaccination indicators (VI001, VI002, VI003) are updated. They now include the MMRV vaccine (measles, mumps, rubella, and varicella) and gain new improvement thresholds.

DM037: the 8 diabetes care processes

This is the indicator that will catch the most practices out. It requires delivery of all 8 NICE-recommended care processes for Type 2 diabetes, drawn from NICE guideline NG28 and tracked by the National Diabetes Audit.

The 8 processes are:

1. HbA1c measurement

2. Blood pressure measurement

3. Serum cholesterol measurement

4. Serum creatinine (eGFR)

5. Urine albumin-to-creatinine ratio (ACR)

6. Foot examination

7. BMI or weight measurement

8. Smoking status recording

This is an all-or-nothing indicator. A patient who receives 7 of the 8 processes does not count. Only patients who complete all 8 contribute to your numerator.

National Diabetes Audit data suggests that only around 50 to 55% of Type 2 diabetes patients currently receive all 8 processes. The most commonly missed are urine ACR testing and foot examination, both of which require specific appointment actions rather than just a blood test.

Retinal screening is not included. It is the ninth care process tracked by the National Diabetes Audit, but it is delivered by the national screening programme rather than by GP practices. Do not let confusion about this distract your recall planning.

What to do now: Run a search for all diabetic patients missing any of the 8 processes in the last 12 months. Identify the specific gaps. In most practices, the biggest opportunities will be in catching up on urine ACR and foot checks.

Ensure your annual diabetes review template captures all 8 processes with extractable SNOMED codes. If it does not, raise this with your clinical system supplier now, before the April rush.

The 40–90% threshold range is relatively generous at the lower end. Even getting from 50% to 65% complete care will earn meaningful points. The challenge is the all-or-nothing design, which rewards systematic recall over individual clinical effort.

HF009: the 4 pillars of heart failure therapy

NICE published indicator specification IND317 in November 2025, which maps directly to this QOF indicator. The 4 pillars of treatment for heart failure with reduced ejection fraction (HFrEF, defined as left ventricular ejection fraction of 40% or less) are:

1. ACE inhibitor, ARB, or ARNI (sacubitril-valsartan)

2. Beta-blocker licensed for heart failure (bisoprolol, carvedilol, or nebivolol)

3. Mineralocorticoid receptor antagonist (spironolactone or eplerenone)

4. SGLT2 inhibitor (dapagliflozin or empagliflozin)

Current national data suggests that only around 15% of HFrEF patients are on all 4 pillars. The threshold range of 20–50% reflects this reality. The upper threshold is deliberately achievable rather than aspirational.

The fourth pillar, SGLT2 inhibitors, is the most commonly missing. Many HFrEF patients were stabilised on 3 pillars before SGLT2 inhibitors were added to NICE guidance, and optimisation has been gradual.

What to do now: Search your heart failure register for patients coded with HFrEF. For each patient, check how many of the 4 pillars they are currently prescribed. Identify patients on 2 or 3 pillars who could be optimised with the addition of a missing drug class. Your clinical pharmacist is the natural lead for this work.

Where a pillar is contraindicated or not tolerated, document this clearly in the patient record. Exception reporting will almost certainly be available for genuine clinical reasons, but only if the reason is recorded.

OB004 and OB005: obesity indicators

These two indicators replace the retired Weight Management Enhanced Service. Together they are worth 18 QOF points, making obesity a meaningful new domain within the framework.

OB004 (5 points, thresholds 10–30%) measures referral to a structured weight management programme for adults living with obesity. This means Tier 2 (community lifestyle) or Tier 3 (specialist multidisciplinary) weight management services. The low upper threshold reflects that structured weight management services are not available everywhere. Check what pathways exist in your area before assuming you can achieve this indicator.

NICE guideline NG246 provides clinical referral criteria, including ethnicity-adjusted BMI thresholds. For most adults, obesity is defined as BMI of 30 or above. For people of South Asian, Chinese, and other ethnic backgrounds, the adjusted threshold is 27.5.

OB005 (13 points, thresholds 50–80%) measures shared decision-making and pharmacotherapy for obesity. NICE-approved medications include orlistat, liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Mounjaro), each with specific BMI thresholds and prescribing criteria.

There is a significant unknown here. The contract letter and Annex B describe this as a "shared decision-making and pharmacotherapy indicator," but the QOF business rules have not been published.

The question is whether OB005 requires the patient to actually be prescribed an obesity medication, or whether a documented shared decision-making conversation (including a mutual decision not to prescribe) is sufficient. The difference in achievability is enormous.

A practice where many patients decline medication or are not eligible could still achieve a high rate if documented conversations count. If only actual prescriptions count, the indicator becomes much harder. We will not know until the business rules are published.

What to do now: Identify your obesity register. Map the local weight management referral pathways for both Tier 2 and Tier 3 services. Review your current prescribing of obesity medications to understand who is already on them and who might be eligible. Prepare a shared decision-making template for obesity consultations that records the conversation in a way your clinical system can extract.

CD001 and CD002: consolidated blood pressure control

These new indicators combine and replace the separate CHD, stroke/TIA, and hypertension blood pressure control indicators. The change is conceptually simpler (one set of BP indicators instead of several) but introduces a new dependency on frailty coding.

CD001 (41 points) and CD002 (20 points) both apply to patients aged 79 or under without frailty. The exact frailty definition for QOF purposes has not been confirmed, but historically, frailty exclusions in QOF use the Electronic Frailty Index (eFI):

• Fit: eFI 0 to 0.12

• Mild frailty: 0.13 to 0.24

• Moderate frailty: 0.25 to 0.36

• Severe frailty: above 0.36

Typically, moderate and severe frailty trigger QOF exclusions. Patients with moderate or severe frailty would therefore be excluded from CD001 and CD002.

The practical issue is that many practices have incomplete frailty coding. If a patient genuinely has moderate frailty but it is not coded in the clinical system, they will be included in the indicator denominator with a potentially higher BP target that is inappropriate for them. Poor frailty coding loses you points in two ways: it includes patients who should be excluded, and it makes your achievement rate look worse than it is.

What to do now: Run your eFI calculation if your clinical system supports it. Check how many patients on your cardiovascular registers have frailty status coded. Prioritise coding for patients aged 65 and over on CVD registers. This is a data quality exercise as much as a clinical one, and it will pay dividends across multiple indicators.

Vaccination improvement thresholds: a genuinely new mechanism

The childhood vaccination indicators now include the MMRV vaccine, but the more interesting change is the introduction of improvement thresholds.

Currently, practices earn points based on absolute achievement against fixed thresholds (89–96%, 86–96%, 81–96%). Many practices in deprived areas with vaccine-hesitant populations have never hit these thresholds and have effectively written off the points.

From 2026/27, practices can earn points through either route, whichever is higher:

• The traditional achievement thresholds, or

• A sliding scale based on improvement from their own 2-year baseline

The improvement lower threshold starts at just 5 percentage points above your practice's 2-year average. The upper thresholds are 18 (VI001), 23 (VI002), and 30 (VI003) percentage points above baseline. At year-end, practices receive whichever allocation is higher: the traditional route or the improvement route.

This is specifically designed for practices that have historically been unable to hit the standard thresholds. A practice with a 2-year average of 70% for VI001 would start earning improvement points at 75% and earn maximum improvement points at 88%. That is achievable with sustained effort.

What to do now: Get your 2-year vaccination averages for VI001, VI002, and VI003 from your clinical system. Calculate what your improvement thresholds would be. If the improvement route offers a realistic path to points that the standard route does not, build a vaccination improvement plan targeting those cohorts.

Other QOF changes to model

Beyond the new indicators, several existing indicators have changed point allocations:

• CHOL003 drops from 38 to 20 points. If you were achieving well, this is a significant income reduction.

• DM034 (primary prevention statin use) rises from 4 to 8 points.

• DM035 (secondary prevention statin use) rises from 2 to 8 points.

• NDH003 (non-diabetic hyperglycaemia) rises from 18 to 20 points and adds gestational diabetes.

• AF006 upper threshold increases from 90% to 95%.

• The asthma register now includes patients from age 5.

• The COPD register business rules are updated to address under- and over-recording identified by audit.

The preparation timeline

The practices that prepare now will have a 6-week head start on those that wait for the business rules. The clinical definitions are clear. The register audits can start today. The business rules will confirm the technical detail, but the clinical work is the same either way.

Disclaimer: This article is for informational purposes only and reflects understanding as of 26 February 2026. It does not constitute legal, financial, or medical advice. Practices should refer to the latest official NHS England guidance and contractual documents.

Published by myPM, 26 February 2026.