Diabetes: annual general practice checks
Indicator
The percentage of patients with diabetes who have had the following care processes performed in the preceding 12 months: BMI measurement, BP measurement, HbA1c measurement, cholesterol measurement, record of smoking status, foot examination, albumin:creatinine ratio, eGFR creatinine measurement.
Indicator type
General practice indicator suitable for use in the Quality and Outcomes Framework.
This document does not represent formal NICE guidance. For a full list of NICE indicators, see our menu of indicators.
To find out how to use indicators and how we develop them, see our NICE indicator process guide.
Rationale
This indicator aims to support holistic and comprehensive care for people with diabetes.
The NICE guidelines on type 1 and type 2 diabetes recommend that people with a diagnosis of diabetes should receive all the indicated checks. The aim of measuring these once a year is to monitor and improve control of blood pressure, cholesterol and blood glucose levels and reduce the risk of any complications of diabetes, such as cardiovascular disease, kidney failure and lower limb amputation.
Source guidance
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Hypertension in adults: diagnosis and management. NICE guideline NG136 (2019, updated 2023), recommendations 1.2.11, and 1.4.15
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Type 1 diabetes in adults: diagnosis and management. NICE guideline NG17 (2016, updated 2022), recommendations 1.12.2 and 1.12.5
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Type 2 diabetes in adults: management. NICE guideline NG28 (2015, updated 2026), recommendation 1.5.1
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Diabetic foot problems: prevention and management. NICE guideline NG19 (2015, updated 2019), recommendations 1.3.3, 1.3.7 and 1.3.11
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Chronic kidney disease in adults: assessment and management. NICE guideline NG203 (2021), recommendations 1.1.14 and 1.1.21
Specification
Numerator: The number of patients in the denominator who have had the following care processes performed in the preceding 12 months: BMI measurement; BP measurement; HbA1c measurement; Cholesterol measurement; Record of smoking status; Foot examination; Albumin: creatinine ratio; eGFR creatinine measurement.
Denominator: The number of patients on the diabetes register.
Calculation: Numerator divided by the denominator, multiplied by 100.
Exclusions: None.
Personalised care adjustments or exception reporting should be considered to account for situations where the patient declines, does not attend or if an annual check is not appropriate.
Expected population size: National Diabetes Audit data for 2023 to 2024 and ONS mid-year population data for 2024 shows that 6.6% of people in England have a diagnosis of diabetes and should have all nine care processes: 658 patients for an average practice with 10,000 patients. To be suitable for use in QOF, there should be more than 20 patients eligible for inclusion in the denominator, per average practice with 10,000 patients, prior to application of personalised care adjustments.