Hippo Labs uses the official NHS England QOF Business Rules to help practices manage dementia care systematically — from maintaining an accurate register to ensuring every patient’s care plan is reviewed annually.
💬 Just a reminder: these indicators aren’t clinical guidelines — they’re operational definitions used for QOF measurement. They define which patients appear for recall, how achievement is calculated, and where gaps may occur.
📋 The Dementia Register (DEM001)
The dementia register includes all patients with a diagnosis of dementia, forming the foundation for all dementia indicators.
Patients appear on the register if they:
Have a coded diagnosis of dementia recorded in their medical record (any time up to the achievement date).
✅ In short: all patients with an active dementia diagnosis should appear on the register.
🩺 The Indicators
These indicators apply only to patients on the dementia register. Together, they ensure every person with dementia has a structured, up-to-date care plan reviewed each year.
🗂️ DEM004 — Annual Dementia Care Plan Review
Measures:
% of patients with dementia whose care plan has been reviewed in the last 12 months.
Counts as complete if:
Either of the following is recorded on or after the date of diagnosis, within the past 12 months:
A dementia care plan, or
A review of a dementia care plan.
Exclusions (Personalised Care Adjustments):
Dementia care unsuitable (clinical reason)
Declined dementia care plan or review
Declined dementia quality indicator care
Two invitations ≥7 days apart with no attendance (removed for payment only — Hippo continues to flag for recall)
Newly diagnosed or registered within 3 months
⚠️ Common pitfalls:
Care plan recorded but not reviewed in the past 12 months
Using non-coded or free-text documentation (won’t count)
Care plan review recorded before the original diagnosis date
Missing decline or unsuitable codes (leaving apparent gaps in QOF)
✅ In short: every patient with dementia should have a coded care plan or review within the last 12 months.
🧩 Putting It All Together
Indicator | Focus | Who It Applies To | What It Shows | What to Do |
DEM004 | Annual care plan review | All patients on the dementia register | Quality and frequency of ongoing dementia care | Record a care plan or review within 12 months of last entry |
🌟 Why This Matters
Following these indicators helps practices:
Maintain an accurate dementia register
Ensure every patient has an up-to-date, personalised care plan
Improve communication between carers, clinicians, and support teams
Demonstrate QOF compliance and high-quality, person-centred dementia care
✅ In short: the Dementia Indicators ensure that every patient with dementia is supported through an annual, structured care plan review.
📚 Sources
NHS England QOF Business Rules v50.0 (Dementia, April 2025)
Primary Care Domain Reference Sets (TRUD Portal)