Improving cross-sector comparisons: Beyond QALY


The Quality Adjusted Life Year (QALY) is used to inform decision making in health technology assessment and beyond. The premise is that the desired outcome of specific interventions in healthcare is their impact on both the quality and length of patients’ lives. The most widely used instrument for estimating the health related quality of life component of the QALY has been the EQ-5D, which is designed to measure an individual’s generic health status across five dimensions: mobility, self-care, usual activities, pain or discomfort and anxiety or depression.  It is the only instrument to have an accompanying preference-based value set obtained from the general public using a variant of time trade-off.  The EQ-5D is therefore currently the preferred instrument for capturing health benefits in assessing the cost-effectiveness of health technologies for NICE and is used in NHS England’s PROM programme.

However, there is an increasing recognition of the need to make decisions that may impact on a number of sectors, such as social care and public health, where interventions may have outcomes and effects other than on health. Health-related quality of life measures such as the EQ-5D will not capture all the outcomes of interest. Furthermore, even in health care, the suitability of the EQ-5D has been questioned because it may not capture all the aspects of quality of life that matter to patients with certain conditions. 

There are a number of proposed sector-specific tools available; in social care, the Adult Social Care Outcome Tool (ASCOT) has been developed for routine use in social services.  In public health, there is no single measure, but there are a number of broader measures that could be used. These include measures of wellbeing such as the preference-weighted ICECAP capability index, WEMWBS and the ONS-4.

None of these tools are sufficient to meet the needs of decision makers and there is no consensus on what the outcomes of interest are that should be measured. Most do not have any preference weighting. Furthermore,  the use of multiple outcome measures across different sectors causes problems for decision-makers (such as NICE) when they try to use such measures to make comparisons across sectors, or when they wish to combine them to provide an overall measure of benefit whilst avoiding double counting. 

As further background to this notice, applicants should read the commissioned vignette paper “Improving cross-sector comparisons using QALYs and other measures: a review of alternative approaches and future research (PDF, 410KB)” by John Brazier and Aki Tsuchiya, University of Sheffield.

More information is available on the NICE website.

It is advisable to get in touch as early as possible, at least 12 weeks before the submission deadline to discuss proposals. 

Highlight notice

The MRC/NIHR invite applications through the Methodology Research Programme to conduct research into the possibility of creating a measure of quality of life or wellbeing, which would have utility across health and social care.

Applications will be particularly welcome which focus on the following areas:

1. Understanding what are the outcomes of interest

Research is required to provide a better method for making meaningful comparisons across health and social care. Particularly to understand what should be captured in order to assess the value of particular interventions and services.  This should explore individual components and the suitability of constructs such as ‘wellbeing’, capabilities and measures such as EQ5D.  An essential part of the research will be to explore whether individual elements can be measured and then used in analytical approaches to support decisions about resource allocation across sectors.  Specific attention should be given to exploring the context and practical application of these instruments in decision-making at a national level to define the characteristics of an outcome which would be fit for purpose. This investigation may contrast cross-sector measures such as wellbeing with sector specific measures such as EQ5D and ASCOT with specific attention to the trade-offs involved.

2. Valuing by association with wellbeing

The use of wellbeing measures is currently limited by their mathematical deficiencies. The measures are often comprised of unscored single items, or where there are multiple items, they are simply summed together or valued using the output of psychometric techniques such as Rasch. They are not anchored on the ‘zero to one’ scale like quality of life scales and so the relationship cannot be modelled. This is a crucial limitation as a scale covering death and good health/wellbeing is essential for quality-adjusting survival duration whether this is health or wellbeing. Research is required to explore whether it is possible to generate a multi-item wellbeing instrument which generates a cardinal score that has interval properties (taking into account anchoring issues).  Such an instrument would provide a basis for making comparison between wellbeing instruments and other measures.

3. Valuing on a common scale using preferences

QALYs are based on the elicitation of the preferences of the population for living in different health states. The EQ5D and ASCOT are the only instruments that have been valued. Both studies used TTO but there were crucial methodological differences; the upper anchors differed. Furthermore the TTO techniques used have been questioned. Research is required into valuation techniques that can be used for instruments that have multi-level single item dimensions such as the EQ5D. This will enable creation of an ‘exchanges rate’ between instruments.

Furthermore, choice based methods such as TTO, can be argued to infer wellbeing because the valuation technique adjusts a quality of life measure by also taking into account everything that is of value to a particular individual.  This theory assumes that individuals are able to predict the likely impact of the health state being described on their future lives and no adaptation occurs. This theory needs to be tested with an exploration of whether direct measurement of wellbeing is more appropriate.

Successfully funded proposals

For details of successfully funded proposals under the improving cross-sector comparisons: beyond QALY highlight click here.

Related research

Work is on-going in subject areas overlapping with, related to, and synergistic with the subject of this highlight notice, notably through the Department of Health's Policy Research Unit in Economic Evaluation of Health and Care Interventions and the What Works Centre for Wellbeing.  It is recommended that applicants to this highlight notice familiarise themselves with, and where appropriate work with, these centres to ensure complementarity and/or a unique niche for their proposal.

Application process and schedule

Applications for projects are invited through the normal MRC funding grant schemes (research grant, new investigator research grant etc.) and will be considered at the regular Methodology Research Programme Panel meetings. These will be in competition with other applications received, but the Panel will be mindful of the strategic importance of this area.

Contact and guidance


The titles of all applications in response to this highlight should be prefixed with HBQ: when filling out the Je-S form, and on any attachments, eg “HBQ: A method for…”


It is essential to discuss your proposals with MRC Head Office at an early stage. All applications must be approved by the Methodology Programme Manager prior to submission. Please contact:

Dr Sam Rowley

Additionally, prospective applicants are also strongly encouraged to discuss their proposed work with NICE, to ensure it will most effectively address the relevant challenges and to explore possibilities for interaction.

The appropriate contact is Professor Sarah Garner: