GPs would need to provide eight annual care checks to patients with diabetes to earn any points under the indicator, approved for development by NICE advisors last week.

Ministers want GPs to offer more diabetes care reviews, including foot checks and urinary albumin testing, following criticism that too few patients are receiving all the recommended checks.

But the 'all or nothing' target could see GPs lose QOF income if just a few patients missed out on all eight checks.

UK health departments had asked NICE's expert advisory panel to consider replacing the separate diabetes checks QOF indicators - worth around £10,000 - with one single composite indicator. A committee of MPs recently criticised the NHS and GPs for failing to offer diabetes patients all nine annual care checks recommended in NICE guidance.

But NICE advisors rejected ministers' calls for the full nine checks to be included, warning that retinopathy screening fell outside GPs' control. However, at a meeting in Manchester last week, NICE's advisory panel, consisting mostly of GPs, agreed to develop a composite indicator for piloting.

Not all panel members backed the move. One panel member said the idea was 'wrong in principle' and argued that, for some patients, providing the best care did not mean conducting all nine checks every year. Others warned the proposal would lead to mass exception reporting.

Advisors agreed to develop a bundled indicator that would exclude checks falling outside of GPs' control. They also said some points should remain in the current indicators for diabetes checks to protect part of practices' QOF income.

The work will pass to NICE's indicator development team, which will report back in June. If approved, the provisional indicator will then undergo piloting.