QOF 2026/27: the operational changes practices cannot afford to miss
The 2026/27 QOF changes contain a number of themes that look relatively modest in isolation, but together they point to something much bigger: a continued shift away from narrow indicator compliance and towards operational delivery.
Focus areas
Obesity, diabetes, frailty, respiratory disease and heart failure
Core theme
Operational delivery now matters as much as indicator knowledge
Practical takeaway
Audit the cohort, check the coding, redesign the workflow, and do it early
Across obesity, diabetes, frailty, respiratory disease and heart failure, the common question is no longer simply “do we know the rules?”
It is “do we have the coding, recall, review and follow-up processes to deliver them consistently across the year?”
1. Obesity: from register logic to pathway logic
Back to topA key point of clarification is that OB003 was the previous obesity register indicator and was retired, while OB004 and OB005 are the live indicators for 2026/27.
That matters because this is not a case of one indicator simply being renamed. It is a change in structure.
OB004
Focused on identifying patients with raised BMI and referring eligible patients into weight management support within the required timeframe.
OB005
More demanding, with higher BMI thresholds, ethnicity-related thresholds, comorbidity requirements, behavioural support, pharmacotherapy considerations, shared decision-making requirements and more detailed exclusion logic.
Operationally, this means practices need more than coding awareness. They need:
- reliable case finding
- blood and comorbidity review
- clear referral pathways
- consistent documentation
- a shared understanding across admin and clinical teams
2. Diabetes: small wording changes, bigger delivery consequences
Back to topNDH003: not a new indicator, but an expanded one
NDH003 is not new. The key change is that gestational diabetes is now being added into scope alongside the existing non-diabetic hyperglycaemia cohort.
That sounds modest, but the operational consequences may be significant.
- whether historic gestational diabetes coding is complete enough to identify the right patients
- what extra recall volume this creates
- whether HbA1c capacity is sufficient
- whether the recall process already accommodates this new cohort
- how patients will respond when contacted unexpectedly
This is less a “new indicator” problem than a coding, recall and capacity problem.
DM037: no longer just a foot check story
The other major diabetes change is the move from DM012 to DM037.
Previously, the focus was much narrower and more closely associated with the foot risk check. Now, DM037 requires the full set of key care process elements to be recorded.
That changes the operational task completely.
Practices may need to review:
- template design
- review workflow
- task ownership
- incomplete review follow-up
- coding consistency
- clinical and nursing capacity
3. Frailty: coding changes with knock-on effects elsewhere
Back to topHistorically, many practices will have used Rockwood Clinical Frailty Scale coding as part of how frailty status was recorded and operationalised.
The 2026/27 change means that Rockwood scores no longer appear to drive eligibility or linked logic in the same way. What matters now is explicit coding of:
- moderate frailty
- severe frailty
This has wider consequences because frailty status can affect:
- blood pressure lead indicators
- HbA1c-related pathways
- other linked indicator logic where moderate or severe frailty changes the target or process applied
If the frailty code is wrong, the patient may not just be missing from a frailty cohort. They may be sitting in the wrong pathway elsewhere too.
4. Respiratory: asthma recall pressure and COPD register drift
Back to topAsthma: age threshold shifts from 6+ to 5+
All asthma indicators now apply from age 5, rather than age 6.
On paper, this looks like a very small rule change. In reality, it may alter:
- recall cohorts
- nursing workload
- review appointment demand
- new diagnosis follow-up processes
COPD: register composition may change unexpectedly
The COPD changes are more subtle and may be more disruptive.
The register can now be influenced by diagnosis codes and procedure/monitoring codes, including recent monitoring activity.
That means practices may see denominator movement compared with previous years, including:
- patients added because of historic procedure or monitoring codes
- patients whose coding does not reflect a clean diagnostic pathway
- register noise caused by older coding habits or template behaviour
5. Heart failure: register accuracy plus medicines optimisation
Back to topThe heart failure changes centred on HF009 are another example of how QOF is becoming more specific and more operationally demanding.
HF009 is focused on heart failure with reduced ejection fraction (HFrEF), not just general heart failure.
That means the first challenge is identifying the right denominator.
Practices need to know:
- who has echo evidence of reduced ejection fraction
- whether that has been translated into the right diagnosis code
- whether the HFrEF register is accurate
- whether general heart failure codes are masking patients who should sit in the more specific HFrEF cohort
Once that is correct, the second challenge is treatment optimisation.
Achievement depends on evidence of prescribing across the 4 therapy pillars in the last 6 months of the year:
- ACEi / ARB / ARNI
- licensed beta blocker
- mineralocorticoid receptor antagonist
- SGLT2 inhibitor
What ties all of this together?
Back to topEach of these changes is different, but the pattern is remarkably consistent.
The 2026/27 contract is pushing practices towards stronger operational discipline in five areas:
1. Coding accuracy
Not just “is there a code?”, but “is it the right code to drive the right pathway?”
2. Register quality
Multiple indicators now depend on whether the denominator genuinely reflects the intended clinical cohort.
3. Recall design
Changes in scope, eligibility and age thresholds mean recall systems may need redesign, not just minor adjustment.
4. Review workflow
Achievement is increasingly dependent on multiple steps being completed and recorded reliably across one pathway.
5. Early-year management
These are not indicators that lend themselves well to year-end rescue work. They reward practices that identify gaps early and work them systematically.
Final thought
The biggest risk with the 2026/27 QOF changes is not misunderstanding the contract wording.
It is assuming that small wording changes will only create small operational consequences.
In reality, several of this year’s changes affect:
- who is in the denominator
- what has to be coded
- what has to be reviewed
- what has to be prescribed
- what has to be followed up
- and how complete the process has to be before achievement happens
If there is one practical takeaway, it is this: audit the cohort, check the coding, redesign the workflow, and do it early.