Following the release of the recent changes to QOF around protected income, the Ardens SystmOne templates and resources have been updated and are based on the QOF Business Rules v45.0. Below is a summary of the changes, along with some outstanding comments that we have fed back to the NHS England QOF team. Please also see our PCN DES 2020/21 Support Article.

Please also see the following QOF Support Articles:


Protected Income

The QOF templates with protected income indicators now have a p next to the red star.


Covid-19 At Risk Cohorts

A number of additional reports have been created to assist practices to identify and prioritise patients at risk of poor health including patients from BAME groups, those with poorly controlled LTCs and those with missing reviews.

It is not possible on SystmOne to easily identify patients from the 20% most deprived neighborhoods nationally (LSOAs), so these have not been included within Ardens.

To find these reports, go to Clinical Reporting > Contracts | Current Financial Year | QOF

NB: These reports are very complex so will take longer than usual to run. You may want to set them to run in the morning and come back to them at a later time that day.    

Poorly Controlled LTC Criteria

There has not been any national guidance on the criteria for what determines a poorly controlled LTC, so we have based the reports on the following:

  • Diabetes + HbA1c >58
  • Asthma + exacerbations >1 or admission in last 1y or ACT score <19
  • COPD + exacerbations >1 or admission in last 1y or MRC 3 or 4 
  • CHD + worsening or poor angina control
  • Hypertension + BP >180/120
  • Heart failure + NYHA 3 or 4
  • CKD + stage 5

Missed Annual Reviews

There again has not been any national guidance that we are aware of to define what constitutes a 'missed annual review'. We have therefore based this on not having one of the above poorly controlled LTC criteria recorded in the last year.


Quality Improvement

Reports and resources have also been built to assist with the NHS England QOF QI.

Early Cancer Diagnosis

QIECD005: Quality Improvement Activity focused on early cancer diagnosis

QIECD006: Network activity and peer review meetings


  • Cancer screening uptake for bowel, breast and cervical screening
  • Fast track referrals guidelines and safety netting


Go to Clinical Reporting > Ardens > Conditions | Cancer

Go to Clinical Reporting > Ardens > Contracts | PCN DES

For safety netting, please see this Support Article 


Learning Disability

QILD007: Quality Improvement Activity focused on Learning Disability

QILD008: Network activity and peer review meetings


  • Register Accuracy
  • Annual Health Check Uptake
  • Medication Optimisation + STOMP initiative
  • Reasonable Adjustments (no SNOMED-CT code exists for this)
  • Engagement with local services and population

Go to Clinical Reporting > Ardens > Conditions | Mental Health

For the Learning Disability template, please see this Support Article

Outstanding Comments

We have a number of outstanding comments and requests with regards to some of the indicators on the QOF Business Rules v45.0 that we have raised with the NHS England QOF Team. We will therefore potentially be making further updates once we hear their response.

AST007 - Dates

The criteria states that the asthma review, ACT score, number of exacerbations and care plan have to be recorded on the same date. We don’t think this is appropriate as often then the ACT score is done first along with recording the number of exacerbations via a patient questionnaire or by the HCA. The review and care plan are then often completed at a later date

Request: Remove same date requirement



A report is available in the 'Contracts I Current Financial Year I QOF > Missed income I Indicators' called 'AST007 | Asthma review since 1/4/20 + missing data on same date (use Asthma QOF report output to view data and dates)' to identify patients affected.  

AST007 - Description 

The description mentions an ‘assessment of inhaler technique’ but not code’s mentioned.

Request: Remove ‘assessment of inhaler technique’ from the description (or codes added if this is needed).


A screenshot of a cell phone

Description automatically generated


AST007 - Care Plan Codes

There are a couple of care plan codes which we believe should be included

Request: Add the following codes into the WRITPASTP cluster

                - Asthma management plan given 406162001

                - Asthma self-management plan agreed 811921000000103

Practices that have these codes recorded as part of the review since 1st April can carryout a bulk read code replacement to 'Asthma self-management plan review XaYZB'.  A report is available in the 'Contracts I Current Financial Year I QOF > Missed income I Indicators' called 'AST007 | Asthma review + non QOF codes used since 1/4/20 (amend care plan code to XaYZB)' to identify patients affected.  


AST008 – Passive smoker

There isn’t an option to record ‘not a passive smoker’

Request: Add ‘Not a passive smoker 315213009’ to the SMOKEXPO cluster



HF007 - Description

The description mentions ‘assessment of functional capacity’ but no codes are mentioned.

Request: Removed ‘assessment of functional capacity’ from description (or add required codes, e.g. NYHA)




HF007 – Medication Review

There are a number of codes that would be useful to add to this cluster

Request: Add the following codes to either the HFMEDRVW or MEDRVW cluster


Cardiac medication review


Optimisation of drug dosage


Medication satisfactory


Medication changed


Medication decreased 


Medication increased 


Medication stopped - side effect


Medication stopped - ineffective


Medication stopped - interaction


Medication stopped - contra-indication




NDH001 – Diagnosis resolved codes

If a patient has been previously diagnosed with NDH/Pre-DM, if their condition then resolves due to a number of years with a normal HbA1c, they should be removed from the register to avoid being recalled inappropriately for an annual HbA1c. This has been an issue for some time, but now as this is a QOF indicator then not only will it have an impact on the patient but will also negatively impact a practice’s QOF points for this indicator.

Request: Please can you consider adding a ‘non-diabetic hyperglycaemia resolved’ and a ‘pre-diabetes resolved’ code to the exclude patients from the NDH register. I’m unaware of a code that exists for this at present, so a new SNOMED-CT code may need to be requested for this.