Diabetes and Kidney Disease



General practice nurses (GPNs) are often involved in reviewing people with type 2 diabetes. An annual review is the minimal requirement of the Quality and Outcomes Framework (QOF), although more frequent reviews may be indicated for people who have started on new medication,1,2 or who have achieved significant lifestyle changes, such as weight loss. The requirements for a QOF review may be augmented with the recommendations from Diabetes UK’s ’15 Healthcare Essentials’ guidance.3 Both QOF and DUK are discussed in this module. In some areas of the UK, QOF no longer operates and the DUK document will provide a clear rationale for standards of care.

Learning objectives

By the end of this module you will have:

  • Recognised the basic areas of care that should be achieved in order to meet QOF requirements
  • Evaluated the recommendations made by DUK in the 15 Healthcare Essentials document
  • Considered your own role in supporting people to achieve these outcomes
  • Reflected upon when referral to the multidisciplinary team is required

Section 1. Case study & Requirements of the Quality and Outcomes Framework (QOF)

Section 2. The Diabetes UK 15 Healthcare Essentials

Section 3. The GPN’s role in supporting people with diabetes

Section 4. Recognising when to refer to the multidisciplinary team

Section 5. Key messages

Section 6. Reflection

Click ‘Start’ to open the CPD module

After completion of the module the reflection document can be filled in and printed out for your personal development plan. This can be presented at annual appraisal or revalidation. The downloaded module includes the completion stamp showing 30 minutes self -directed CPD undertaken.


Job Code: UK/DIA-19020e DOP: April 2020


  1. NHS England (2019) 2019/20 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) https://www.england.nhs.uk/wp-content/uploads/2019/05/gms-contract-qof-guidance-april-2019.pdf [Accessed April 2020]
  2. NICE NG28. Type 2 diabetes in adults: management; 2015 (updated 2016) https://www.nice.org.uk/guidance/ng28 [Accessed April 2020]
  3. Diabetes UK. Your 15 diabetes healthcare essentials; 2018 https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/15-healthcare-essentials [Accessed April 2020]