🎯 Hippo Targets Glossary | Hippo Labs Help Centre

Each row tells you the target's code, who's eligible, what counts as complete (including the SNOMED codes where relevant), and how often it fires.

Cadence values: Annual (resets 1 April), Seasonal (per campaign season), One-off (age- or event-triggered), One-off catch-up (time-limited — check for the programme end date), Dose-dependent, Event-based, or Continuous (CQC safety monitoring that re-evaluates each cycle).

💡 Can I select multiple targets?

Yes — Hippo recalls patients who are due for at least one of the targets you select. Once they've received the care, they drop off the list.

💨 Asthma [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
AST007	Annual asthma review	Patients aged 6+ on the asthma register, no review in last 12m	Asthma review incl. control assessment, medication check, inhaler technique	Annual
AST008	Smoking status (young asthmatics)	Asthma patients aged ≤19, no smoking status in last 12m	Smoking status recorded	Annual

❤️ Cardiovascular – AF Atrial Fibrillation [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
AF006	Stroke risk assessment	AF patients with no CHA₂DS₂-VASc score in the last 12m	CHA₂DS₂-VASc score recorded	Annual
AF008	Anticoagulants for high-risk AF	AF patients with CHA₂DS₂-VASc ≥2 and no anticoagulant prescribed	Anticoagulant (DOAC or warfarin) prescription recorded	One-off (until prescribed)

❤️ Cardiovascular – CHD Coronary Heart Disease [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
CHD005	Antiplatelets or anticoagulants	Patients on the CHD register with no antiplatelet / anticoagulant prescribed	Aspirin, clopidogrel, or anticoagulant prescription recorded	One-off (until prescribed)
CHD015	BP control (age ≤79)	CHD patients aged 79 or under, no BP ≤140/90 in last 12m	BP ≤140/90 mmHg recorded	Annual
CHD016	BP control (age 80+)	CHD patients aged 80+, no BP ≤150/90 in last 12m	BP ≤150/90 mmHg recorded	Annual

💡 Treat to Target (TTT) indicators
These indicators have a defined measurement target (e.g. blood pressure or HbA1c) that the patient must meet.

If the latest reading on the patient’s record does not meet the target, or if no reading is recorded at all, the patient will continue to be recalled until the target is achieved and recorded.

❤️ Cardiovascular – HF Heart Failure [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
HF003	ACE-I or ARB for LVSD	Patients with HF due to LVSD, no ACE-I or ARB prescribed	ACE-I or ARB prescription recorded	One-off (until prescribed)
HF006	Beta-blocker for LVSD	Patients with HF due to LVSD, no licensed beta-blocker prescribed	Licensed beta-blocker (e.g. bisoprolol, carvedilol) prescription recorded	One-off (until prescribed)
HF007	Annual HF review	Patients on the HF register, no review in last 12m	Review covering symptoms, functional status, meds, self-management advice	Annual
HF008	HF diagnosis confirmation	Patients with a new HF diagnosis on or after 1 April 2023 with no echo or specialist assessment recorded in the 6m before the diagnosis (or, if registered after diagnosis, no echo/specialist assessment within 6m of registration)	Echocardiogram or specialist assessment recorded	Event-based (per diagnosis)

❤️ Cardiovascular – Hypertension [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
BP002	BP check (age ≥45)	Patients aged 45+ with no BP recorded in last 5 years	Blood pressure recorded	Every 5 years
HYP008	BP control – hypertension (age ≤79)	Hypertensive patients aged ≤79, no BP ≤140/90 (clinic) or ≤135/85 (HBPM) in last 12m	BP at target recorded	Annual
HYP009	BP control – hypertension (age 80+)	Hypertensive patients aged 80+, no BP ≤150/90 (clinic) or ≤145/85 (HBPM) in last 12m	BP at target recorded	Annual

💡 Treat to Target (TTT) indicators
These indicators have a defined measurement target (e.g. blood pressure or HbA1c) that the patient must meet.

If the latest reading on the patient’s record does not meet the target, or if no reading is recorded at all, the patient will continue to be recalled until the target is achieved and recorded.

❤️ Cardiovascular – Stroke / TIA [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
STIA007	Antiplatelets or anticoagulants	Stroke/TIA patients with no antiplatelet / anticoagulant prescribed	Aspirin, clopidogrel, or anticoagulant prescription recorded	One-off (until prescribed)
STIA014	BP control (age ≤79)	Stroke/TIA patients aged ≤79, no BP ≤140/90 in last 12m	BP ≤140/90 mmHg recorded	Annual
STIA015	BP control (age 80+)	Stroke/TIA patients aged 80+, no BP ≤150/90 in last 12m	BP ≤150/90 mmHg recorded	Annual

💡 Treat to Target (TTT) indicators
These indicators have a defined measurement target (e.g. blood pressure or HbA1c) that the patient must meet.

If the latest reading on the patient’s record does not meet the target, or if no reading is recorded at all, the patient will continue to be recalled until the target is achieved and recorded.

🧫 Cervical Smears [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
CS005	Cervical screening (ages 25–49)	Women aged 25–49 with no smear recorded in last 3 years	Cervical screening recorded within the last 3y6m	Every 3y6m
CS006	Cervical screening (ages 50–64)	Women aged 50–64 with no smear recorded in last 5 years	Cervical screening recorded within the last 5y6m	Every 5y6m

👶 Childhood Immunisations [QOF + Local]

This area has both QOF standard milestone indicators and Hippo's more granular per-schedule indicators. Both sets are selectable in the app.

VI001 / VI002 / VI003* — standard QOF Vaccinations & Immunisations indicators. They check coverage at a few key milestones (8 months, 18 months, age 5) and respect QOF contraindication codes. Use these for QOF coverage tracking.

HIPPO_8WEEK_IMMS / 12WEEK_IMMS / 16WEEK_IMMS / 1Y_IMMS / PRIMARY_IMMS / 18M_MMR etc.* — Hippo's operational schedule indicators, broken out per-visit so each invitation slot has its own indicator. Use these when running a recall list against the routine NHS schedule.

Code	Name	Who & when to recall	What counts as complete	Cadence
VI001	QOF DTaP – 8-month check	Children aged 8–20 months on search date, no DTaP3 recorded by 248 days, not registered too late	3rd DTaP dose recorded before 248 days of age	One-off (age trigger)
VI002	QOF MMR – 18-month check	Children crossing 18 months, no MMR1 recorded by 558 days	1st MMR dose recorded before 558 days of age	One-off (age trigger)
VI003	QOF Five-year booster check	Children aged 5, missing 2nd MMR and/or DTaP/IPV booster	Both 2nd MMR and DTaP/IPV booster recorded before age 5	One-off (age trigger)
8WEEK_IMMS	8-week immunisations	Children aged 8–12 weeks (registered)	1st DTaP, 1st MenB, 1st Rotavirus all recorded (or coded exclusion)	One-off (age trigger)
12WEEK_IMMS	12-week immunisations	Children aged 12–16 weeks	12-week schedule complete	One-off (age trigger)
16WEEK_IMMS	16-week immunisations	Children aged 16–20 weeks	16-week schedule complete	One-off (age trigger)
1Y_IMMS	1-year boosters	Children aged 1–2	1st MMR, Hib/MenC, MenB booster, PCV booster recorded	One-off (age trigger)
1Y_IMMS_CATCHUP	1-year catch-up	Children aged 2–9 with incomplete 1-year imms	Outstanding 1-year imms recorded	One-off catch-up
PRIMARY_IMMS	Primary imms	Children >20 weeks and <2 years	Full primary schedule recorded	One-off (age trigger)
PRIMARY_IMMS_CATCHUP	Primary imms catch-up	Older children with incomplete primary imms	Outstanding primary imms recorded	One-off catch-up
18M_MMR	18-month MMR (2nd dose)	Children >18 months, born on/after 01/07/2024	2nd MMR dose recorded	One-off (age trigger)
MMR_BROUGHTFORWARD	MMR brought-forward campaign	Children turning 1y6m–2y6m on 01/01/2026 (DOB 01/07/2023–01/07/2024). Invites stop 31 Oct 2026.	2nd MMR dose recorded	One-off catch-up
3Y4M_OLDSCHEDULE_CATCHUP	Old-schedule catch-up (ages 6–10)	Children aged 6–9 missing MMR2 and/or DTaP/IPV booster	2 MMR doses + DTaP/IPV booster recorded before age 10	One-off catch-up
RUNOFF_3Y4M_MMRandDTaP	Legacy run-off cohort	Closing out the old 3y4m cohort	2 MMR + DTaP/IPV booster recorded	One-off catch-up

🧬 Cholesterol [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
CHOL003	Statin prescription	Patients on cardiovascular or diabetes register with no statin prescribed	Statin (e.g. atorvastatin) prescription recorded	One-off (until prescribed)
CHOL004	Cholesterol control	Patients with no cholesterol test in last 12m, or with a result above target	Cholesterol test recorded with result within target range	Annual

💡 Treat to Target (TTT) indicators

CHOL004 is a Treat to Target indicator. These indicators have a defined clinical target (e.g. LDL or non-HDL level) that must be achieved.

If the patient’s latest cholesterol result is above the QOF threshold, or if no cholesterol reading is recorded in the last 12 months, they will continue to be recalled until a result within target is recorded.

🫁 COPD [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
COPD010	COPD annual review	Patients on the COPD register, no review in last 12m	Review incl. MRC scale, medication check, inhaler technique, smoking support if needed	Annual
COPD014	Pulmonary rehab offer	COPD patients with MRC score ≥3, not previously offered rehab	Offer of referral to pulmonary rehab recorded	One-off (per MRC trigger)

🦠 COVID [Vaccinations]

Code	Name	Who & when to recall	What counts as complete	Cadence
COVID_SPRING25_001	Spring booster – aged 75+	Patients aged 75+ at the gov reference date (17 June) with no booster recorded in the last 3 months	COVID vaccine recorded in the 3 months prior to spring PPED	Seasonal (spring)
COVID_SPRING25_002	Spring booster – care home residents	Patients <75 at the gov reference date who are care-home residents	COVID vaccine recorded in the 3 months prior to spring PPED	Seasonal (spring)
COVID_SPRING25_003	Spring booster – immunocompromised	Patients <75 with persistent immunocompromise, on immunosuppressive drugs, or with a temporary immunocompromise code in the last 9 months	COVID vaccine recorded in the 3 months prior to spring PPED	Seasonal (spring)
COVID_WINTER_ENHANCED_001	Winter booster – aged 75+	Patients aged 75+ at PPED (31/01/2026) with no booster recorded in the last 4 months	COVID vaccine recorded in the 4 months prior to winter PPED	Seasonal (autumn/winter)
COVID_WINTER_ENHANCED_003	Winter booster – immunocompromised	Patients <75 at PPED who are immunocompromised per Green Book 25/26: persistent immunosuppression (and not since resolved), immunodeficiency, solid organ transplant, immunosuppressive drugs in last 12m, or chemo/radiotherapy in last 6m	COVID vaccine recorded in the 4 months prior to winter PPED (31/01/2026)	Seasonal (autumn/winter)

🧪 CQC Quality Monitoring – DMARDs [CQC]

All three DMARD indicators share the same shape: patients issued the drug in the last 6 months should have a defined panel of bloods within the last 12 weeks. The panels differ slightly — leflunomide adds BP and weight to the standard FBC/U&Es/LFTs.

Code	Name	Who & when to recall	What counts as complete	Cadence
CQCAZA001	Azathioprine monitoring	Patients issued azathioprine in last 6m	FBC + U&Es + LFTs all recorded in last 12 weeks	Continuous
CQCLEF001	Leflunomide monitoring	Patients issued leflunomide in last 6m	FBC + U&Es + LFTs + BP + weight all recorded in last 12 weeks	Continuous
CQCMET001	Methotrexate monitoring	Patients issued methotrexate in last 6m	FBC + U&Es + LFTs all recorded in last 12 weeks	Continuous

💊 CQC Quality Monitoring – DOAC Anticoagulants [CQC]

The DOAC family stacks two dimensions: the number sets the time window and patient sub-cohort; the suffix sets which kidney measurement is checked (none = CrCl, A = serum creatinine, B = CrCl calculated where weight + serum creatinine are up-to-date). Practices select whichever variant matches the data their team actually records.

Code	Name	Who & when to recall	What counts as complete	Cadence
CQCDOAC000	DOAC – weight recorded	All patients on a DOAC	Weight recorded in last 12m	Continuous
CQCDOAC001	DOAC – CrCl ever recorded	All patients on a DOAC	Creatinine clearance recorded at least once	Continuous
CQCDOAC001A	DOAC – serum creatinine ever recorded	All patients on a DOAC	Serum creatinine recorded at least once	Continuous
CQCDOAC001B	DOAC – CrCl calculable, ever	DOAC patients with weight (last 12m) + serum creatinine	Creatinine clearance recorded at least once	Continuous
CQCDOAC002	DOAC – CrCl in last 12m	All patients on a DOAC	Creatinine clearance recorded in last 12m	Continuous
CQCDOAC002A	DOAC – serum creatinine in last 12m	All patients on a DOAC	Serum creatinine recorded in last 12m	Continuous
CQCDOAC002B	DOAC – CrCl calculable in last 12m	DOAC patients with weight + serum creatinine in last 12m	Creatinine clearance recorded in last 12m	Continuous
CQCDOAC003	DOAC + CKD4/5 – CrCl in last 3m	DOAC patients with current CKD4/5 (no CKD3 code)	Creatinine clearance recorded in last 3m	Continuous
CQCDOAC003A	DOAC + CKD4/5 – serum creatinine in last 3m	DOAC patients with current CKD4/5	Serum creatinine recorded in last 3m	Continuous
CQCDOAC003B	DOAC + CKD4/5 – CrCl calculable in last 3m	DOAC + CKD4/5 patients with weight (12m) + serum creatinine (3m)	Creatinine clearance recorded in last 3m	Continuous
CQCDOAC004	DOAC + CKD3 – CrCl in last 6m	DOAC patients with current CKD3 (not resolved)	Creatinine clearance recorded in last 6m	Continuous
CQCDOAC004A	DOAC + CKD3 – serum creatinine in last 6m	DOAC patients with current CKD3	Serum creatinine recorded in last 6m	Continuous
CQCDOAC004B	DOAC + CKD3 – CrCl calculable in last 6m	DOAC + CKD3 patients with weight (12m) + serum creatinine (6m)	Creatinine clearance recorded in last 6m	Continuous
CQCDOAC005	DOAC – haemoglobin in last 12m	All patients on a DOAC	Haemoglobin recorded in last 12m	Continuous
CQCDOAC006	DOAC – low-Hb anticoag review	DOAC patients whose last Hb was <90	Anticoagulation review recorded after the low-Hb result	Event-based (per low Hb)
CQCDOAC007	DOAC – appropriate kidney function	All patients on a DOAC	CrCl ≥30 if on dabigatran; CrCl ≥15 otherwise	Continuous

💊 CQC Quality Monitoring – Other Meds Monitoring [CQC]

Code	Name	Who & when to recall	What counts as complete	Cadence
CQCWARFARIN001	Warfarin – INR monitoring	All patients on warfarin	INR recorded in last 3m, or patient flagged as INR self-monitor in last 12m	Continuous
CQCWARFARIN002	Warfarin – high INR review	Warfarin patients with one INR >8 in last 6m, or two INR >5 in last 6m	Anticoagulation review recorded after the triggering high INR	Event-based (per high INR)
CQCACEARB001	ACE-I / ARB – kidney function	All patients on ACE-I or ARB	U&Es (creatinine or eGFR) recorded in last 12m	Continuous
CQCLI001	Lithium – level monitoring	All patients on lithium	Lithium level recorded in last 3m	Continuous
CQCLI002	Lithium – calcium / kidney / thyroid	All patients on lithium	U&Es + calcium + thyroid function all recorded in last 6m	Continuous
CQCMETFORMIN001	Metformin – kidney function	All patients on metformin	eGFR recorded in last 12m	Continuous
CQCMETFORMIN002	Metformin – satisfactory kidney function	Metformin patients with an eGFR in last 12m	Most recent eGFR ≥30	Continuous
CQCALDANT001	Aldosterone antagonist + HF – kidney function	Patients on spironolactone/eplerenone with current HF (not resolved)	U&Es recorded in last 6m	Continuous
CQCAMIODERONE001	Amiodarone – kidney / liver / thyroid	All patients on amiodarone	U&Es + LFTs + TFTs all recorded in last 6m	Continuous

🚨 CQC Quality Monitoring – Safety Alerts [CQC]

MHRA-driven safety alerts. Each indicator targets a specific drug-pair / drug-cohort combination flagged for adverse-event monitoring.

Code	Name	Who & when to recall	What counts as complete	Cadence
CQCSAFETYALERT001	Hydrochlorothiazide – skin cancer info	Patients prescribed hydrochlorothiazide in last 6m	Skin cancer risk information recorded after first HCTZ issue	Continuous
CQCSAFETYALERT002	High-dose SSRI in 65+	Patients aged 65+ issued high-dose SSRI (citalopram 40mg or escitalopram 20mg) in last 3m	Medication review in last 3m	Continuous
CQCSAFETYALERT003	Clopidogrel + PPI interaction	Patients issued clopidogrel and omeprazole/esomeprazole in last 3m	Medication review in last 3m	Continuous
CQCSAFETYALERT004	Febuxostat with CVD	Patients issued febuxostat in last 3m and with PAD/CHD/stroke/TIA	Medication review in last 3m	Continuous
CQCSAFETYALERT005	Fentanyl patch started without prior opioid	Patients started on fentanyl patch in last 12m, no other opioid in the 3m before	Medication review since starting the fentanyl patch	Event-based (per new start)
CQCSAFETYALERT006	Mirabegron – BP monitoring	Patients issued mirabegron in last 3m	BP recorded in last 12m	Continuous
CQCSAFETYALERT008	SGLT-2i – ketoacidosis & Fournier's education	Patients issued an SGLT-2 inhibitor in last 6m	Ketoacidosis education and Fournier's gangrene education recorded after SGLT-2i start	Continuous
CQCSAFETYALERT009	Simvastatin 40/80mg + CYP3A4 CCB	Patients issued simvastatin 40/80mg and amlodipine/diltiazem/verapamil in last 3m	Medication review in last 3m	Continuous
CQCSAFETYALERT010	Teratogenic drugs in women of childbearing potential	Female patients aged 8–<55 issued teratogenic drugs in last 3m, no confirmed infertility	Medication review in last 3m	Continuous

📋 CQC Quality Monitoring – Missed Diagnoses [CQC]

Code	Name	Who & when to recall	What counts as complete	Cadence
CQC_MISDIAG_CKD	Missed CKD diagnosis	Patients with most recent eGFR <60 plus a 2nd low eGFR in last 2 years, no CKD diagnosis coded	CKD-resolved code, CKD 1–2 code, or CKD 3–5 diagnosis recorded after the diagnostic result	Continuous
CQC_MISDIAG_DM	Missed diabetes diagnosis	Patients with two HbA1c results ≥48 mmol/mol in last 2 years, no diabetes diagnosis coded	DM-resolved, prediabetes (after the diagnostic result), gestational/steroid-induced DM (last 12m), haemoglobinopathy, or current DM diagnosis recorded	Continuous

🧠 Dementia [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
DEM004	Face-to-face dementia review	Patients with dementia and no care plan review in last 12m	Face-to-face care plan review covering physical, mental, social needs	Annual

💉 Diabetes - [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
DM006	ACE-I/ARB for microalbuminuric diabetics	Diabetics with microalbuminuria/proteinuria, no ACE-I/ARB prescribed	ACE-I or ARB prescription recorded	One-off (until prescribed)
DM012	Foot examination	Diabetics with no foot check in last 12m	Foot exam with risk classification recorded	Annual
DM014	Diabetes education referral	Newly diagnosed diabetics with no referral to structured education	Referral to structured education recorded	One-off (per diagnosis)
DM020	HbA1c control (non-frail)	Non-frail diabetics with HbA1c >58 mmol/mol in last 12m	HbA1c ≤58 mmol/mol recorded	Annual
DM021	HbA1c control (frail)	Frail diabetics with HbA1c >75 mmol/mol	HbA1c ≤75 mmol/mol recorded	Annual
DM034	Statins for diabetics (no CVD, no frailty)	Diabetics aged ≥40 with no CVD, no moderate/severe frailty, not on a statin (excludes type 2 with CVD risk <10% in last 3 years)	Statin prescription recorded (or alternative lipid-lowering therapy if statin declined/clinically unsuitable)	One-off (until prescribed)
DM035	Statins for diabetics with CVD	Diabetics with CVD (excluding haemorrhagic stroke) and no statin	Statin prescription recorded (or alternative lipid-lowering therapy if statin declined/clinically unsuitable)	One-off (until prescribed)
DM036	BP control – diabetes (age ≤79, non-frail)	Diabetics aged ≤79 without moderate/severe frailty, no BP ≤140/90 in last 12m	BP ≤140/90 mmHg recorded (clinic) — equivalent HBPM target 135/85	Annual

💡 Treat to Target (TTT) indicators
These indicators have a defined measurement target (e.g. blood pressure or HbA1c) that the patient must meet.

If the latest reading on the patient’s record does not meet the target, or if no reading is recorded at all, the patient will continue to be recalled until the target is achieved and recorded.

🩸 Diabetes - 8 Care Processes [Local]

All follow the same logic: patient is on the diabetes register and missing the result in the last 12 months.

Code	Name	Who & when to recall	What counts as complete	Cadence
HIPPODM8CP001a	HbA1c	Diabetics with no HbA1c in last 12m	HbA1c result recorded	Annual
HIPPODM8CP001b	Blood Pressure	Diabetics with no BP in last 12m	BP recorded	Annual
HIPPODM8CP001c	Cholesterol	Diabetics with no serum cholesterol in last 12m	Cholesterol result recorded	Annual
HIPPODM8CP001d	Creatinine	Diabetics with no creatinine in last 12m	Creatinine result recorded	Annual
HIPPODM8CP001e	Urine ACR	Diabetics with no albumin:creatinine ratio in last 12m	ACR result recorded	Annual
HIPPODM8CP001f	Foot Check	Diabetics with no foot check or risk score in last 12m	Foot check + risk score recorded	Annual
HIPPODM8CP001g	BMI	Diabetics with no BMI in last 12m	BMI recorded	Annual
HIPPODM8CP001h	Smoking Status	Diabetics with no smoking status in last 12m	Smoking status recorded	Annual

💉 Flu [Vaccinations]

This area has two parallel sets of indicators because they answer different questions.

*SFVI* ("Flu jab — …")* — sourced from the QOF/IIF Enhanced Service business rules. These measure raw coverage: did the patient get vaccinated? They keep flagging a patient even if they've declined, have a clinical contraindication, or have already been invited twice with no response. Use these if you want headline coverage figures that mirror the QOF/IIF target.

*VI*W25 ("Enhanced winter flu vaccine — …")* — Hippo's operational recall rules, aligned to the Ardens Winter 2025 searches. These respect patient choice and clinical context: a patient is excluded once they've declined, been coded with a contraindication, or failed to respond to ≥2 invitations 7 days apart. Use these when you want a recall list that won't keep chasing patients who've already said no or shouldn't be vaccinated.

The at-risk cohort definition (the 18–64 indicators) also differs slightly: SFVI002 includes pregnancy and Addison's; VI02W25 instead includes carer status, "lives with immunocompromised", endocrine disease, splenic dysfunction, and care-home residency.

Code	Name	Who & when to recall	What counts as complete	Cadence
SFVI001	Flu jab – >65s	Patients aged 65+ at flu QSED with no flu vaccine this season	Flu vaccine recorded for the current season	Seasonal (annual)
SFVI002	Flu jab – at-risk patients	Patients aged 18–64 with at-risk codes (chronic resp/heart disease, asthma on treatment, CKD3+, diabetes, immunosuppression, BMI ≥40, pregnancy, LD, Addison's), no flu vaccine this season	Flu vaccine recorded this season	Seasonal (annual)
SFVI003	Flu jab – 2–3s	Children aged 2 or 3 on 31 Aug, no flu vaccine recorded this season (legacy 2022 rule, retained)	Flu vaccine recorded (usually nasal spray)	Seasonal (annual)
VI01W25	Enhanced winter flu vaccine – >65s	Patients aged 65+ at QSED, no flu vaccine this season; excludes contraindications, declines, and patients invited ≥2 times 7 days apart	Flu vaccine recorded between 1 Oct and 31 Mar	Seasonal (annual)
VI02W25	Enhanced winter flu vaccine – 18–64 at-risk	Patients 18–64 with at-risk codes (chronic resp/heart/liver/neuro disease, asthma on treatment, CKD3+, diabetes, immunosuppression, BMI ≥40, LD, asplenia, care home, carer, lives with immunocompromised, "needs flu imm this season"), no flu vaccine this season; excludes contraindications, declines, and 2-invite no-response	Flu vaccine recorded between 1 Sep and 31 Mar	Seasonal (annual)
VI03W25	Enhanced winter flu vaccine – children	Children aged ≥2 and <4 the day before flu service start, no flu vaccine this season; excludes contraindications, declines, and 2-invite no-response	Flu vaccine recorded (usually nasal spray)	Seasonal (annual)

💉 HPV Catch-Up [Vaccinations]

Code	Name	Who & when to recall	What counts as complete	Cadence
HPV_16TO17_CATCHUP	HPV catch-up (ages 16–17)	Females aged 16–17. Males aged 16–17 born on/after 01/09/2006. Eligibility ends at the patient's 18th birthday.	HPV vaccination recorded	One-off catch-up
HPV_18TO24_CATCHUP	HPV catch-up (ages 18–24)	Females aged 18–24. Males aged 18–24 born on/after 01/09/2006. Eligibility ends 1 year after 18th birthday.	HPV vaccination recorded	One-off catch-up

🧠 Learning Disabilities [DES]

Code	Name	Who & when to recall	What counts as complete	Cadence
HI-01	Annual health check (LD)	LD patients with no health check recorded since 1 April	Health check completed and recorded, including an action plan	Annual

🫀 Long-Term Conditions (LTCs)

Structured-review indicators per disease register, fired alongside the disease-specific QOF entries to coordinate combined reviews.

✅ Generic Annual Review Codes

These codes will complete care across all LTC indicators if entered:

525711000000101 – General practice annual review completed
170557005 – Annual review (generic)

⚠️ Use with caution: if you use these generic codes, Hippo will assume care is complete for all LTCs, not just one condition.

Code	Name	Who & when to recall	What counts as complete
HLTC_AF_RVW	AF patients receiving annual review	Patients on the AF register (AFIBLAT, not resolved), no review or general LTC review recorded this FY	Annual review recorded — accepted SNOMED codes: `713678009`, `248411000000105`, `793851000000102`, `735259005`, `735258002` (or any GEN_RVW code)
HLTC_AST_RVW	Asthma patients receiving annual review	Patients on the asthma register, no asthma or general LTC review recorded this FY	Annual review recorded — accepted SNOMED codes: `394700004`, `390872009`, `390878008`, `390877003`, `394701000`, `754061000000100`, `401182001`, `401183006`, `394720003`, `270442000` (or any GEN_RVW code)
HLTC_CHD_RVW	CHD patients receiving annual review	Patients on the CHD register, no CHD or general LTC review recorded this FY	Annual review recorded — accepted SNOMED code: `315614006` (or any GEN_RVW code)
HLTC_COPD_RVW	COPD patients receiving annual review	Patients on the COPD register, no COPD or general LTC review recorded this FY	Annual review recorded — accepted SNOMED code: `394703002` (or any GEN_RVW code)
HLTC_DM_RVW	Diabetes patients receiving annual review	Patients on the diabetes register, no diabetes or general LTC review recorded this FY	Annual review recorded — accepted SNOMED codes: `170777000`, `887861000000105`, `1842001000006102` (or any GEN_RVW code)
HLTC_HF_RVW	Heart failure patients receiving review	Patients on the HF register, no HF or general LTC review recorded this FY	Annual review recorded — accepted SNOMED codes: `134378009`, `390885007`, `202231000000106`, `872361000000105`, `247361000000100`, `810971000000105`, `813991000000101`, `851071000000108`, `871681000000102` (or any GEN_RVW code)
HLTC_HYP_RVW	Hypertension patients receiving review	Patients on the hypertension register, no hypertension or general LTC review recorded this FY	Annual review recorded — accepted SNOMED code: `401118009` (or any GEN_RVW code). A simple BP reading on its own won't complete this indicator — the actual hypertension annual review code must be recorded in EMIS.
HLTC_MH_RVW	Mental health patients reviewed	Patients on the SMI register, no MH or general LTC review recorded this FY	Annual review recorded — accepted SNOMED codes: `408404002`, `401061005`, `867871000000100` (or any GEN_RVW code)
HLTC_NDH_RVW	NDH patients reviewed	Adults on the NDH (pre-diabetes) register, no NDH or general LTC review recorded this FY. Excludes patients with current diabetes diagnosis.	Recent HbA1c or fasting glucose result counts — accepted SNOMED codes: `999791000000106`, `1049301000000100`, `1049321000000109`, `1003141000000105`, `58111000237107` (or any GEN_RVW code). Note: lab result codes, not just review codes
HLTC_PAD_RVW	PAD patients receiving review	Patients with PAD diagnosis (not excluded), no PAD or general LTC review recorded this FY	Annual review or recent lipid result counts — accepted SNOMED codes: `1696201000006100` (PAD annual review), `1006191000000100`, `1030411000000100`, `1102851000000100`, `1010591000000100`, `1022191000000100`, `1028851000000100`, `1108541000000100`, `1108551000000100`, `1014501000000100`, `1026471000000100`, `1026481000000100`, `1028861000000100` (or any GEN_RVW code)
HLTC_STIA_RVW	Stroke/TIA patients receiving review	Patients on the stroke/TIA register, no STIA or general LTC review recorded this FY	Annual review recorded — accepted SNOMED code: `699270006` (or any GEN_RVW code)
HLTC_RESP_RVW	Respiratory bundle review	Patients on the asthma OR COPD register, no review recorded this FY	Numerator passes if either HLTC_AST_RVW or HLTC_COPD_RVW would pass — i.e. any accepted asthma OR COPD review code (or any GEN_RVW code)

🧠 Mental Health [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
MH002	Care plan review	Patients with psychosis/bipolar and no care plan in last 12m	Care plan review covering physical and mental health needs	Annual
MH003	Blood Pressure	SMI patients with no BP in last 12m	BP recorded	Annual
MH006	BMI	SMI patients with no BMI in last 12m	BMI recorded	Annual
MH007	Alcohol	SMI patients with no alcohol use recorded in last 12m	Alcohol use recorded	Annual
MH011	Lipids	SMI patients with no lipid profile in last 12m	Lipid profile recorded	Annual
MH012	HbA1c	SMI patients with no HbA1c in last 12m	HbA1c result recorded	Annual
MH021	SMI annual health check (all 6)	SMI patients missing ≥1 of: BP, BMI, alcohol, smoking, lipids, HbA1c	All 6 checks completed and recorded in last 12m	Annual

🩺 NHS Health Checks [Local]

Code	Name	Who & when to recall	What counts as complete	Cadence
HIPPONHSHC001	Overall coverage	Patients aged 40–74 with no NHS HC in last 5 years	Full NHS HC recorded incl. risk score, BP, BMI, cholesterol, lifestyle	Every 5 years
HIPPONHSHC002	Current-year invite	Patients eligible this year, no check recorded yet	NHS HC recorded during the current financial year	Per FY
HIPPONHSHC002a	BP (NHS HC)	NHS HC patients this year with no BP recorded	BP reading recorded	Per FY
HIPPONHSHC002b	BMI (NHS HC)	NHS HC patients with no BMI recorded	BMI recorded	Per FY
HIPPONHSHC002c	Cholesterol (NHS HC)	NHS HC patients with no total cholesterol recorded	Cholesterol result recorded	Per FY
HIPPONHSHC002d	HbA1c (NHS HC)	NHS HC patients with no HbA1c recorded	HbA1c result recorded	Per FY
HIPPONHSHC002e	All components completed	NHS HC patients missing one or more of: BP, BMI, cholesterol, HbA1c, lifestyle	All checks and lifestyle components completed	Per FY

💉 Pneumococcal [Vaccinations]

Code	Name	Who & when to recall	What counts as complete	Cadence
HIPPOPNEU001A/B	Lifetime pneumo vaccine (age 65+)	Patients aged 65+ with no PPV23 ever recorded	Pneumococcal vaccine (PPV23) recorded	One-off (age trigger)
HIPPOPNEU002A/B	First pneumo vaccine (at-risk <65)	Patients aged 2–64 with LTCs and no PPV23 recorded	Pneumococcal vaccine recorded	One-off (until vaccinated)
HIPPOPNEU003A/B	5-year pneumo booster (high-risk)	High-risk patients (e.g. asplenia) due a booster dose	Pneumococcal booster recorded within past 5 years	Every 5 years

🧪 Pre-diabetes [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
NDH002	Blood glucose monitoring	Patients with NDH (pre-diabetes), no HbA1c or fasting glucose in last 12m	HbA1c or FPG result recorded	Annual

👨 Prostate Cancer [Local]

Code	Name	Who & when to recall	What counts as complete	Cadence
PCHR001	PSA screening invitation	Men aged 50–70 (or 45–70 if Black or family history) with no invite in last 12m	PSA screening invitation recorded	Annual

🦠 RSV (Respiratory Syncytial Virus) [Vaccinations]

Code	Name	Who & when to recall	What counts as complete	Cadence
RSV001	RSV – older adult routine	Patients aged ≥75 with no RSV vaccine; rejects contraindications and 12m declines. Eligibility ends at age 80.	RSV vaccine recorded	One-off (age 75 trigger)
RSV002	RSV – older adult catch-up	Patients aged 75–79 on 31 Aug 2024, no RSV vaccine; rejects contraindications and declines. Catch-up programme ends 31 Aug 2026.	RSV vaccine recorded	One-off catch-up

💉 Shingles [Vaccinations]

Code	Name	Who & when to recall	What counts as complete	Cadence
HIPPOSHING_IC_01	Shingrix dose 1 (immunocompetent)	Immunocompetent patients with no Zostavax post-2013. New cohort: born ≥01/09/1958 and aged ≥65. Catch-up: born <01/09/1958 and aged 70–79 (excluded if any shingles vaccine before 31/10/2024). Programme ends 31 Aug 2028.	1st Shingrix dose recorded	One-off (age trigger)
HIPPOSHING_IC_02	Shingrix dose 2 (immunocompetent)	Same cohort as IC_01 (catch-up extended to age 80) with 1st Shingrix recorded ≥6 months ago. Programme ends 31 Aug 2028.	2nd Shingrix dose recorded ≥8 weeks after 1st	Dose-dependent (≥6m after dose 1)
HIPPOSHING_CX_01	Shingrix dose 1 (immunocompromised, 18+)	Patients aged ≥18 flagged by practice as 'requires shingles vaccine' (REQSHVAC code)	1st Shingrix dose recorded	One-off (until vaccinated)
HIPPOSHING_CX_02	Shingrix dose 2 (immunocompromised, 18+)	Same cohort as CX_01 with 1st Shingrix recorded ≥8 weeks (56 days) ago	2nd Shingrix dose recorded ≥8 weeks after 1st	Dose-dependent (≥8w after dose 1)

🚬 Smoking [QOF]

Code	Name	Who & when to recall	What counts as complete	Cadence
SMOK002	Smoking status – at-risk patients	LTC patients (asthma, COPD, diabetes, CVD, SMI, etc.) with no status recorded in last 12m	Smoking status recorded	Annual
SMOK004	Cessation offer – general smokers	Patients aged 15+ who smoke and have had no cessation offer in last 24m	Smoking cessation advice or referral recorded	Every 24 months
SMOK005	Cessation offer – at-risk smokers	Smokers with LTCs (diabetes, CVD, COPD, SMI, etc.) and no cessation offer in last 12m	Cessation support offer recorded	Annual

🎯 Treat to Target Indicators

These indicators have a defined measurement target (e.g. blood pressure or HbA1c) that the patient must meet.

If the latest reading on the patient’s record does not meet the target, or if no reading is recorded at all, the patient will continue to be recalled until the target is achieved and recorded.

Code	Indicator Description
DM020	HbA1c at or below target (≤ 58 mmol/mol) — diabetes, no moderate/severe frailty
DM021	HbA1c at or below higher target (≤ 75 mmol/mol) — diabetes, with moderate/severe frailty
DM033	BP at or below target (≤ 140/90 mmHg or equivalent home reading) — diabetes, no moderate/severe frailty
HYP008	BP at or below target (≤ 140/90 mmHg or equivalent home reading) — hypertension, < 80 yrs
HYP009	BP at or below target (≤ 150/90 mmHg or equivalent home reading) — hypertension, ≥ 80 yrs
CHD015	BP at or below target (≤ 140/90 mmHg or equivalent home reading) — CHD, < 80 yrs
CHD016	BP at or below target (≤ 150/90 mmHg or equivalent home reading) — CHD, ≥ 80 yrs
STIA014	BP at or below target (≤ 140/90 mmHg or equivalent home reading) — stroke/TIA, < 80 yrs
STIA015	BP at or below target (≤ 150/90 mmHg or equivalent home reading) — stroke/TIA, ≥ 80 yrs
CHOL004	Cholesterol at or below target: latest LDL ≤ 2.0 mmol/L or latest non-HDL ≤ 2.6 mmol/L (LDL takes priority if both exist on the same date). Applies to patients on the CHD, PAD, or Stroke/TIA registers with a cholesterol reading in the last 12 months.

🍬 Diabetes Indicators - QOF

🍯 Non-Diabetic Hyperglycaemia Indicator - QOF

💉 Pneumococcal Indicators - Hippo

🍬 Diabetes (NICE 8 Care Processes) - Hippo

🩺 NHS Health Check Indicators - Hippo