Hippo Labs uses the official NHS England QOF Business Rules v50.0 to help practices manage patients with diabetes effectively — from structured education after diagnosis to blood pressure, HbA1c, lipid management, and foot checks.
💬 Just a reminder: these indicators aren’t clinical guidelines — they define how QOF achievement is calculated, who appears for recall, and what counts as complete.
📋 The Diabetes Register (DM017)
Includes all patients aged 17 and over with a current diabetes diagnosis (Type 1 or Type 2).
Patients are included if:
They have a coded diagnosis of diabetes (no resolved code recorded).
They are 17+ years old on the achievement date.
✅ In short: every adult with a confirmed, unresolved diabetes diagnosis is on the register.
🩺 The Indicators
These indicators monitor the quality of diabetes care — from education and foot checks to blood pressure and HbA1c control.
💉 DM006 — ACE/ARB for Proteinuria or Microalbuminuria
Measures:
% of diabetes patients with proteinuria or microalbuminuria who are treated with an ACE inhibitor or ARB.
Counts as complete if:
Prescribed ACE-I or ARB in the last 6 months.
Exclusions (PCAs):
ACE/ARB contraindicated or declined.
Diabetes care unsuitable or declined.
Two invites for review with no response (removed for payment only).
Newly diagnosed or registered within 3 months.
✅ In short: if a diabetic patient has proteinuria or microalbuminuria, they should be on an ACE-I or ARB (unless unsuitable or declined).
🦶 DM012 — Foot Examination & Risk Classification
Measures:
% of diabetes patients with a foot examination and risk classification recorded in the last 12 months.
Counts as complete if:
Foot risk classification (low, increased, high, or ulcerated) recorded within 12 months.
Exclusions (PCAs):
Amputation or congenital foot absence.
Foot exam or neuropathy test unsuitable or declined.
Diabetes care unsuitable or declined.
Two invites with no response (removed for payment only).
✅ In short: all diabetes patients should have a coded foot exam and risk classification every year.
🎓 DM014 — Structured Education Referral
Measures:
% of newly diagnosed diabetes patients referred to a structured education programme within 9 months of diagnosis.
Counts as complete if:
Referral to a structured education programme recorded within 279 days (≈9 months) of diagnosis.
Exclusions (PCAs):
Service unavailable.
Education unsuitable or declined.
Diabetes care unsuitable or declined.
Two invites with no response (removed for payment only).
✅ In short: newly diagnosed patients must be referred to a diabetes education programme within 9 months.
🧪 DM020 — HbA1c ≤58 mmol/mol (Non-Frailty)
Measures:
% of diabetes patients without moderate/severe frailty whose latest HbA1c ≤58 mmol/mol in the last 12 months.
Counts as complete if:
Latest IFCC HbA1c ≤58 recorded within 12 months.
Exclusions (PCAs):
Moderate or severe frailty.
On maximum tolerated therapy.
Blood test unsuitable or declined.
Two invites with no response (removed for payment only).
Newly diagnosed/registered within 9 months.
✅ In short: most adults with diabetes (without significant frailty) should have HbA1c ≤58 mmol/mol.
🧬 DM021 — HbA1c ≤75 mmol/mol (With Frailty)
Measures:
% of diabetes patients with moderate or severe frailty whose latest HbA1c ≤75 mmol/mol in the last 12 months.
Counts as complete if:
Latest IFCC HbA1c ≤75 recorded within 12 months.
Exclusions (PCAs):
On maximum tolerated therapy.
Blood test unsuitable or declined.
Two invites with no response (removed for payment only).
Newly diagnosed/registered within 9 months.
✅ In short: more flexible HbA1c target for patients with moderate/severe frailty (≤75 mmol/mol).
💊 DM034 — Statin or LLT (No CVD History)
Measures:
% of diabetes patients aged ≥40, without CVD or CKD3–5, and without frailty, who are:
On a statin, or
On another lipid-lowering therapy (LLT) if statins declined/contraindicated.
Counts as complete if:
Statin prescribed in last 6 months,
orAlternative LLT (bempedoic acid, ezetimibe, inclisiran, PCSK9i) prescribed if statin unsuitable.
Exclusions (PCAs):
Statin and all other LLTs contraindicated or declined.
CKD3–5, CVD, familial hypercholesterolaemia.
Diabetes care unsuitable or declined.
✅ In short: all diabetic patients ≥40 without CVD should be on lipid-lowering therapy unless excluded.
❤️ DM035 — Statin or LLT (With CVD History)
Measures:
% of diabetes patients with CVD (except haemorrhagic stroke) on a statin or other LLT.
Counts as complete if:
Statin prescribed in last 6 months,
orAlternative LLT prescribed if statin unsuitable.
Exclusions (PCAs):
Statin/LLT contraindicated or declined.
Maximum tolerated cholesterol therapy.
Diabetes care unsuitable or declined.
✅ In short: diabetic patients with CVD should be on a statin or alternative LLT.
💓 DM036 — Blood Pressure ≤140/90 mmHg
Measures:
% of diabetes patients aged ≤79 without moderate/severe frailty whose latest BP ≤140/90 mmHg (or equivalent home BP ≤135/85).
Counts as complete if:
Latest clinical BP ≤140/90, or
Latest home/ambulatory BP ≤135/85,
recorded in last 12 months.
Exclusions (PCAs):
Frailty, unsuitable or declined care.
Maximum tolerated BP therapy.
Two invites with no response (removed for payment only).
✅ In short: all diabetic patients under 80 without frailty should have controlled BP ≤140/90 (or ≤135/85 at home).
🧩 Summary Table
Indicator | Focus | Who It Applies To | What It Measures | What Counts as Complete |
DM006 | Kidney protection | Diabetes + proteinuria/microalbuminuria | ACE-I or ARB use | Prescription in last 6 months |
DM012 | Foot care | All diabetes patients | Annual foot exam + risk classification | Foot exam within 12 months |
DM014 | Structured education | Newly diagnosed | Referral within 9 months | Education referral recorded |
DM020 | HbA1c ≤58 | No/moderate frailty | Glycaemic control | HbA1c ≤58 in last 12 months |
DM021 | HbA1c ≤75 | Moderate/severe frailty | Glycaemic control | HbA1c ≤75 in last 12 months |
DM034 | Lipid therapy (no CVD) | ≥40 yrs, no CVD/CKD | Statin or LLT use | Statin/LLT in last 6 months |
DM035 | Lipid therapy (with CVD) | Diabetes + CVD | Statin or LLT use | Statin/LLT in last 6 months |
DM036 | Blood pressure | ≤79 yrs, no frailty | BP control | BP ≤140/90 (clinic) or ≤135/85 (home) |
🌟 Why This Matters
Following these indicators helps practices:
Ensure consistent, holistic diabetes care.
Identify patients with missing annual checks.
Reduce cardiovascular risk and improve long-term outcomes.
Demonstrate QOF achievement and proactive chronic disease management.
✅ In short: these indicators cover every key element of diabetes management — from education and foot care to blood pressure, HbA1c, and lipid control.
📚 Sources
NHS England QOF Business Rules v50.0 (Diabetes, April 2025)
Primary Care Domain Reference Sets (TRUD Portal)