Blacksheep, in the UK the QFE will be calculated to take account of the difference between the observation point and the aerodrome.
Without getting the books out, as I recall the QFE will be calculated for the highest point on the aerodrome and if the elevation of any threshold is 7ft or more less than the highest point on the aerodrome a threshold QFE will be calculated and passed by ATC if that runway is used.
The QFE will be updated at the time of a routine observation (typically every hour at least) or if a significant change in the ambient pressure occurs (i.e. more than 1.0 hPa) before the next routine observation is due.
As I say, this is UK practice.
Speaking as a controller, I don't really care which setting a pilot choses to use - I'll use the relevant procedures whatever. I recall when QNH landing was introduced by some operators - it seemed like a bit of a nuisance to have to remember more procedures but after a couple of weeks it became second nature.