The criteria has changed for this year, the indicator wording is:

DEM004 (002): The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months – 39 points (35-70%)

If the patient has an advanced care plan in place from secondary care, this will be acceptable. For those patients who do not have a care plan, the practice will be required to develop an acceptable care plan.

The review of the patient care plan regardless of who has initiated the plan is a face to face review in primary care – you cannot use a hospital review to achieve this indicator.

The new Read codes are as follows:

Dementia advance care plan agreed 8CSA. XabEk
Dementia care plan 8CMZ. XaaBZ
Review of dementia advance care plan 8CMG2 XabEl
Dementia advance care plan declined 8IAe0 XabEi
Dementia advance care plan review declined 8IAe2 XacM2
Dementia care plan review declined 8CMZ3 XacJ0


A Face to face review:

The Face to Face care plan/Advanced care plan review should have the following key issues:-

An appropriate physical, mental health and social review for the patient

A record of the patient’s wishes for the future.

Communication and co-ordination arrangements with secondary care (if applicable), identification of the patient’s carer(s):

  1. Obtain appropriate permissions to authorise the practice to speak directly to the nominated carer(s) and provide details of support services available to the patient and their family, if applicable, the carer’s needs for information commensurate with the stage of the illness and his or her and the patient’s health and social care needs,
  2. As appropriate, the carer should be included in the care plan or advanced care plan discussions,
  3. If applicable, the impact of caring on the care-giver,
  4. Offer the carer a health check98 to address any physical and mental health impacts, including signposting to any other relevant services to support their health and wellbeing

With DM014 ‘education for newly DM patients, in the preceding 1 April – 31st March’, the indicator is looking back 21 months (651 day’s*) from 31st March 2016. This is in line with the ‘data set rules’ guidance.


This will carry over all patients who were not achieved or declined last year. This has been passed over to the NHS Employers for re-consideration again this year.

The rules differ from the guidance, the reason given is:


Consideration has to be made for those patients diagnosed with diabetes within 9 months of the end of the QoF period i.e. the 9 month ‘window’ for the referral would then span 2 years. If the patient has not been referred to a structured education programme then it would be unreasonable for the patient to be considered unsuccessful until the full 9 months are checked which can only be done in the next QOF period.


This means that you will have to re-enter the patient’s wishes again if their diagnosis was on or after the 1st July 2015 and they refused the offer. I would suggest if you can, call the patient and ask again but if not  you back date to April of this year the refusal code with free text – patient declined within the QOF criteria see entry on xxxxx’ but insure when entering the Read code it is within nine months of the diagnosis. You can then discuss this again at their annual review.


* For a number of indicators, this year the rules will calculate months in days and it will be 31 days per month for ease of the queries calculating the practice achievement.



The table below is guidance for monitoring patient eGFR and ACR on a yearly basis for those with or at risk of CKD.

GFR ( ml/min/1.73 m^2) and ACR categories and risk of adverse outcomes A1

< 3 mg/mol (normal to mildly increased)


3 -30 mg/mol (moderately increased)


> 30mg/mol (severely increased)

G1 >= 90 ml/min/1.73 m^2

(Normal and High)

check eGFR <=1 time per year check eGFR 1 time per year check eGFR >=1 time per year
G2 60-89 ml/min/1.73 m^2

(Mild reduction related to normal range for young adult)

check eGFR <=1time per year check eGFR 1 time per year check eGFR >=1time per year
G3a 45-59 ml/min/1.73 m^2

(mild-moderate reduction)

check eGFR 1time per year check eGFR 1 time per year check eGFR 2 times per year
G3b 30-44 ml/min/1.73 m^2

(moderate-severe reduction)

check eGFR <=2 times per year check eGFR 2 times per year check eGFR >=2 times per year
G4 15-29 ml/min/1.73 m^2

(severe reduction)

check eGFR 2 times per year check eGFR 2 times per year check eGFR 3 times per year
G5 < 15 ml/min/1.73 m^2

(kidney failure)

check eGFR 4 times per year check eGFR >=4 times per year check eGFR >=4 times per yea

When the patient was initially referred to the memory clinic it was to confirm the diagnosis of Dementia as correct, so the answer would be to back date the diagnosis to the time you referred.

Please note – DEM005 – screening blood tests patients diagnosed in the current QOF year – 1st April – 31st March.

The business rules are now looking back 18 months to ensure patients who are diagnosed at the beginning of the QOF year will fulfil the blood screening criteria

You would need to record the patient as depression resolved and this will remove the patient from the QOF. The read code for this is:


Version 2                                                                                                  CVT3

212S.     Depression resolved                                   XaLG0   Depression resolved



There is no specific register for depression. The register sits in the background for calculating prevalence payments. To verify the register you would need to search for all patients who have an active diagnosis of depression who do not have a ‘New’ episode attached to the Read code. For patients to appear as part of the prevalence, patients will require a “New” or “First” episode attached to the Read Code.

: We asked a professor of Renal Medicine and the answer received was as follows:


I think the reasons for repeat testing of MA in DM even after establishing its presence are:

– In 30% of T1DM at least (T2DM less clear) MA will regress and disappear

– In some patients MA progresses to macroalbuminuria

Both of these events have implications for a patient’s renal function in the long term – one good, one bad – so probably some merit in knowing what’s happening in order to keep patient informed and health care staff on their toes in dealing with other modifiable risks as appropriate.

Yes the patients require a test to identify those DM patient who have a diagnosis of either nephropathy (clinical proteinuria) or micro albuminuria but the indicator itself is only looking for those patients with confirmation of nephropathy (clinical proteinuria) or micro albuminuria who are currently treated with an ACE or ARB, not those who have had the test done and are negative. I have checked two practices and for example one practice had 222 patients on their register of which only 59 appear in DM006 as they are the only ones with a confirmed diagnosis and of the 59 patients the practice has achieved the indicator for 52 patients as they are currently being treated with an ACE-I or ARB.

The exception code for patients who have declined to give a urine specimen

CTV3                   Version 2

Xaa3v                     9RX..               Declines to give urine specimen

Not just for diabetes but for 95% of the QOF, if you receive correspondence from secondary care, community care or even private care you should enter all the relevant information into the patients record using where at all possible a QOF read code if it is part of the QOF criteria.

This information includes BP, bloods, feet check, diagnostic test and blood tests etc. You are not expected to duplicate work that has already been done.

The thing to remember about the QOF is it does not matter where the intervention took place – primary care, community or secondary care as long as the patient receives all interventions that are appropriate for their care and well-being and the practice ensures the results are acted upon, if required.

The areas you cannot use secondary/community care information is

Cancer Review

Dementia review

RA review




Hospital cared DM patients cannot be excluded because the clinic did not review those areas of care.  If you find they have had all the care with the exception say for example their foot check. I would suggest you send a letter stating ‘you are aware they have had their annual review at the hospital but it would appear that their feet were not check’. Explain the importance of it in the body of the letter and then ask if they would make a ten minute appointment with the appropriate nurse/HCA. You will receive a  far better response than sending a generic letter


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