Health promotion For all patients aged ≤45y at least 65%/80%
have had BP recorded in last 5 years (more
points for 80% target). Hypertension
Those with newly diagnosed hypertension
(without CVD) aged 30– 74 who have had a
face-to-face CV risk assessment within 3m of diagnosis. Percentage diagnosed after 1/4/09 given
lifestyle advice in previous 15m relating to:
exercise, smoking cessation, alcohol and diet. Percentage with hypertension who:
Have had a BP recorded in the last 9m
And in whom that BP is ≤150/90 Secondary prevention of CV disease
Percentage with angina referred for exercise
testing and/or specialist assessment. Percentage with coronary heart disease who
have:
BP recorded in last 15m
BP is <150/90
Cholesterol measured in last 15m
Cholesterol is ≤5
On aspirin/other antiplatelet/anticoagulant
On a beta-blocker, ACE inhibitor, statin
and anti-platelet therapy
Received a flu jab in the last flu season Those with a history of MI need to be on an
ACE inhibitor/ARB. Stroke and TIA
The percentage of new patients with CVA/TIA
referred for further investigations. The percentage of patients with CVA/TIA:
Who have had a BP in the last 15m
Blood pressure is ≤150/90
Cholesterol recorded in the last 15m
And that cholesterol is ≤5
Have had flu jab in the last flu season Percentage with a non-haemorrhagic stroke/
TIA on antiplatelet agent or anticoagulant. Atrial fibrillation
Percentage where diagnosis confirmed by
ECG/specialist. Percentage on anticoagulants/antiplatelets. MRC dyspnoea score in last 15m
Flu jab in previous flu season Asthma
Note: asthma register excludes those who
have had no asthma-related drugs in last 12m. If diagnoses after 1/4/2006, percentage
aged ≥8y who've had tests for variability or
reversibility. Those aged 14– 19y who have had a smoking
status recorded in last 15m. Percentage of all asthmatics who have had an
asthma review in last 15m. Hypothyroidism
Percentage with TSH recorded in last 15m. Depression
Percentage with CHD/diabetes who have
been screened for depression using the two
question test. Percentage with depression who have had
assessment of severity using validated tool
(e.g. HAD/PHQ-9) (see Mental Health chapter). For those newly diagnosed with depression, a
reassessment of severity (using same tool) 4
5– 12 weeks after first questionnaire. Mental health
Note: register is of those with schizophrenia,
bipolar disorder & other psychoses. Percentage of people with schizophrenia,
bipolar disorder & other psychoses who have
had (last 15m):
Alcohol consumption recorded
BMI recorded
BP recorded
Chol:HDL ratio recorded A smear in the last 5y if within national
screening age
Had a review in the last 15m (including
relevant health promotion advice) Have a documented care plan
If DNA annual review are contacted in 14d For those on lithium, percentage with:
Creatinine & TSH in last 9m 15m
Li level in therapeutic range in last 4m 6m Dementia
Review in past 15m New diagnosis dementia: FBC, Glu, U&Es,
LFTs, calcium, B12 and folate levels in 6m
before or after diagnosis Epilepsy (those ≥18y only) | Heart failure Percentage whose diagnosis is confirmed by
echo/specialist. The percentage of people with LVSD who:
Are on an ACE inhibitor/ARB
Are on an ACE/ARB and a cardioselective
beta-blocker. Diabetes
Note: register is for those aged ≥17y and must
specify whether type 1 or type 2. Patients with diabetes of any type who:
Have had a BMI recorded in last 15m
HbA1c recorded in last 15m
HbA1c is ≤ 7 ≤7.5 (56mmol/mol)
HbA1c is ≤ 8 (64mmol/mol)
HbA1c is ≤ 9 (75mmol/mol)
Have had retinal screening in last 15m
Peripheral pulses recorded in last 15m Foot exam in last 15m and foot classified as
low, increased, high risk or ulcer present.
Neuropathy testing in last 15m
BP recorded in last 15m
And that BP is ≤145/85
BP is ≤140/80
BP is ≤150/90
Microalbuminuria test in last 15m (unless
proteinuria) and if microalbuminuria/
proteinuria, percentage on ACE/ARBs
eGFR or creatinine in last 15m
Cholesterol in last 15m
And that cholesterol is ≤5
Flu jab given in last flu season Chronic kidney disease (CKD)
Note: register includes only those ≥ 18y with
CKD 3– 5. Percentage with CKD 3– 5 with:
BP recorded in last 15m
And that BP is ≤140/85
ACR or PCR in last 15m Of those with hypertension and proteinuria:
Percentage on ACE or ARB COPD
New diagnosis: post-bronchodilator
spirometry required Percentage of patients with:
An FEV1 recorded in last 15m Percentage on drug treatment who have:
Record of seizure frequency in last 15m
Been seizure free in last 12m
Medication review in last 15m
Women <55y on anti-epileptics who have
had contraceptive/pre-conception
advice in last 15m Cancer Note: excludes non-melanotic skin cancers. Percentage of patients with cancer diagnosed
within the last 18m who have a review within
6m of practice being notified of diagnosis. Practice has a complete register available of
all patients in need of palliative care/support. Practice discusses all on palliative register at
least every 3m at multidisciplinary meeting. Obesity
Register of ≥16y with a BMI ≥30 in last 15m. Learning disability
Register: ≥18y with learning disabilities. If Down's syndrome & ≥18y have had a TSH
in last 15m. Smoking
Smoking status of all patients aged 15 and
over is recorded in the last 27m. Percentage of patients with any of the
following conditions who have had
smoking status recorded in last 15m: CVD,
hypertension, diabetes, COPD, asthma, CKD,
asthma, schizophrenia, bipolar affective
disorder or other psychoses. Percentage of above who have been offered
smoking cessation advice in last 15m. Medicines management
For those on repeat medicines, a medication
review is recorded in the notes in the last 15m
(target >80%). Sexual health and contraception
Percentage of women aged 25– 64y (21– 60y in
Scotland) who have had smear in last 5y. Percentage on oral/patch contraception given
advice on long-acting reversible contraception
(LARC) in last 15m. Percentage of women given emergency
hormonal contraception (EC) by the practice
in the last year who have received information
about LARC within 1m of EC prescription. Summarised from Quality and Outcomes
Framework Guidance for GMS Contract, BMA
and NHS Employers, March 2011. |
