For the original QOF, there was relatively little dissent about the indicators that were selected. They were the low-hanging fruit; things that on the whole GPs probably felt they should be doing anyway. But indicators that have been introduced since then have been much more controversial.
Firstly, we have indicators such as the PHQ9 questionnaire for depression. These indicators were prompting GPs to change something, rather than incentivising what they did already, so they were more controversial.
Secondly, those related to productivity are a long way from the original QOF. They are an incentive to get GPs to reduce secondary care utilisation, for example by reviewing referrals. Incentivising GPs to take a look at their own work is fine, but the QOF has a different feel to it if it becomes about saving money rather than improving quality.
My view is that it is best suited to being a framework that focuses on clinical quality. The more it deviates from that, the more ambiguous and potentially problematic its role becomes.
Professor Martin Roland is professor of health services research at the University of Cambridge, and was a key adviser to the Government on implementing the QOF in 2004