This could suggest that the high level of points attributed to GPs for mental health services successfully rendered encourages patient selection and the deliberate exclusion of more difficult cases from the data. Concerns have also been expressed that GPs are directing attention away from activity not rewarded by the QOF, and as such care delivery quality is declining in some areas (Cashin, 2014). In June 2011, there were concerns raised about the depression indicators and their incentive to improve diagnoses of depression: the QOF indicators included incentives to follow up assessments and depression checks following diagnoses, and to perform depression screening for patients on the diabetes register, but they offer no incentives for increasing or improving depression screening across patients.