This folder supports opportunistic and end-of-year QOF work across all diabetes indicators, including blood pressure (DM036), HbA1c control (DM020/DM021), statin use (DM034/DM035), nephropathy management (DM006), foot checks (DM012), structured education (DM014), and appropriate use of Personalised Care Adjustments (PCAs). These searches are ideal for systematically reviewing patients throughout the year and especially in QOF year-end clean-up.

The searches have been built to look at the contract year (1st April to 31st March), so it is recommended to run the search WITHOUT a relative run date.

🔍 [DM036] One invitation sent

Patients eligible for DM036 (BP ≤140/90 mmHg in patients aged 79 and under without frailty) who have had one invitation. A second invitation is required for exception coding if they do not attend. If the patient has had a raised blood pressure recorded this year, there must be at least two invitations after the most recent BP result.

🔍 [DM036] Two invitations sent

Patients eligible for DM036 who have had two invitations and are still not to BP target. These can now be exception-reported.

🔍 [DM] Outstanding indicator and one invitation sent

Patients with at least one unmet diabetes QOF indicator, including any of the following:

• DM006 – Nephropathy or micro-albuminuria on ACEi/ARB

• DM012 – Diabetic foot risk classification

• DM014 – Referral to structured education

• DM020 – HbA1c ≤58 (no frailty)

• DM021 – HbA1c ≤75 (frail)

• DM034 – Statin for patients without CVD/frailty

• DM035 – Statin for patients with CVD

• DM036 – BP ≤140/90 mmHg (under 80 and not frail)

These patients have had one invitation. A second invitation is needed to enable exception coding if they do not attend.

🔍 [DM] Outstanding indicator and two invitations sent

Patients with one or more outstanding diabetes indicators listed above and two invitations. These patients are now eligible for exception coding.

🧾 ACTION | Diabetes no HbA1c this year

Patients with no recorded HbA1c this QOF year. Will fail relevant HbA1c-related indicator (DM020/DM021) unless resolved.

🧾 ACTION | DM012 no diabetic foot check this year previously low risk

Patients with no foot check this year and a history of low foot risk. Likely to be quick to resolve — could secure DM012 with a simple review.

🧾 BORDERLINE | DM036 would have achieved surgery BP target

Patients under the age of 80 whose latest BP reading was home or ambulatory that would have been within target if taken in surgery. Home/ambulatory thresholds are lower than surgery thresholds, so these patients may achieve DM036 if a surgery reading is taken.

🧾 CHECK BORDERLINE | DM020 HbA1c this year and HbA1c >58 mmol/mol

Latest HbA1c this year is above 58. Worth monitoring or acting on before year-end.

🧾 CHECK BORDERLINE | DM021 HbA1c this year and HbA1c >75 mmol/mol

Latest HbA1c this year is above 75. These patients will fail DM021 unless treated or exception coded.

🧾 CHECK BORDERLINE | DM036 BP this year not to target NO previous PCAs

Patients under 80 whose latest blood pressure is raised this year but no history of PCAs recorded in the last 3 years. May not need escalation if next reading is normal — consider retesting.

🧾 DISENGAGED | Diabetes no HbA1c this year or last year

No HbA1c test in the last two QOF years. Likely disengaged — prioritise recall.

🧾 DISENGAGED | DM012 Foot risk not assessed last year

Patients missed their diabetic foot check last year. May be at clinical risk and miss DM012 if not reviewed this year.

🧾 HIGH RISK | DM012 diabetic foot check previously higher risk

Previously recorded moderate or high foot risk and no check this year. Prioritise to secure DM012 and ensure safe management.

🧾 HIGH RISK | DM036 no BP reading this QOF year but latest was raised

Patients eligible for DM036, no BP this year, and previously raised BP. Act now to avoid indicator failure.

🧾 PCA CHECK | DM006 proteinuria or microalbuminuria previously declined

Patients who previously declined proteinuria screening or treatment. Reconsider exception or offer again if clinically appropriate.

🧾 PCA CHECK | DM012 diabetic foot check previous PCA

Patients who had a PCA exception for DM012 and no review this year. Reassess for reapplication or engagement.

🧾 PCA CHECK | DM020 HbA1c this year >58 on 3+ medications

Patients with HbA1c >58 already on three or more diabetes medications. Likely appropriate for a PCA under DM020 (maximal tolerated therapy).

🧾 PCA CHECK | DM020 HbA1c this year >58 previous PCA

Patients with HbA1c >58 this year and previous PCA recorded within last 3 years. Reassess for ongoing exception or treatment change.

🧾 PCA CHECK | DM021 HbA1c this year >75 on 3+ medications

Patients with HbA1c >75 on multiple agents. Consider exception coding under DM021.

🧾 PCA CHECK | DM021 HbA1c this year >75 previous PCAs

Similar cohort, but with prior PCA recorded within last 3 years.  Consider reapplying exception.

🧾 PCA CHECK | DM034 Diabetes not on statin previous PCA

Patients eligible for DM034, not on statin, and PCA recorded previously. Reassess if statin is now suitable or exception still applies.

🧾 PCA CHECK | DM035 Diabetes not on statin previous PCA

Same as above but for DM035 (patients with CVD). Reassess suitability or reapply PCA.

🧾 PCA CHECK | DM036 BP this year not to target on 3+ antihypertensives

Patients with BP above target despite three or more antihypertensives. Appropriate for maximal tolerated therapy PCA under DM036.

🧾 PCA CHECK | DM036 BP this year not to target previous PCA

Patients aged ≤79, BP not to target, and PCA recorded with the last 3 years. Check if exception is still valid for DM036.

🧾 QUICK WIN CODING | DM034 Diabetes not on statin on other lipid lowering

Patients eligible for DM034, not on a statin, but taking other lipid-lowering medication (e.g. ezetimibe).

• Action: If a statin is not indicated, contraindicated, or declined, apply the appropriate exception code. This will achieve the indicator under QOF.

🧾 QUICK WIN CODING | DM035 Diabetes not on statin on other lipid lowering

Same as above but for DM035 (patients with CVD). Ensure statin exception coding is in place where appropriate.

🧾 QUICK WIN VALUE | DM036 no BP reading this QOF year and latest was normal

No BP recorded this year, but last reading was normal. Easy win if BP is measured — may achieve DM036.

🧾 REVIEW | Diabetes but no frailty coded

Patients with diabetes and no recorded frailty status. Coding mild/moderate/severe frailty can support tailored care and enable exception coding where applicable (e.g. DM036, DM020/21).