GPs should not prescribe tirzepatide for weight loss until advised to do so by their local ICB, NHS England has said.
This was clarified by the commissioner during a webinar for GPs earlier this month, after NICE accepted a request from NHS England to slow down the rollout of the drug, reserving eligibility for those with the highest clinical need at first.
NHS England was asked to come up with a more detailed plan of who exactly would be eligible in the first pilot phases based on clinical need rather than BMI alone.
This would include immediately prioritising patients already receiving care in specialist weight management services where wraparound care is available.
NHS England clarified that ICBs will be designing their own models in line with the requirements of the NICE technology appraisal, which was published in December, and that GPs should therefore wait for ICB guidance before prescribing.
NICE will review the impact of rollout in three years and ‘inform the NHS of any proposed amendments to their decision’.
NHSE’s clinical director for diabetes and obesity Dr Clare Hambling, who is a GP in Norfolk, told the webinar: ‘NICE has asked NHS England to define the cohorts that should be prioritised for eligibility to the therapy for that early implementation phase over those first three years, and at that three year mark, we anticipate that NICE will evaluate the implementation.
‘We’ve been specifically asked to do some clinical prioritisation. This is all about making sure that the people with the highest need can access therapies first.
‘This is in the hope that we will implement on the basis of clinical prioritised need. So just wait until everything is in place before you prescribe – no prescribing just yet.’
GPs attending the webinar told NHS England that the rollout will mean more workload and costs for practices, and that extra funding is needed to offset these.
NICE’s final draft guidance on use of the weekly injection means that around a quarter of a million people could gain access to the drug over the next three years.
The RCGP warned that a rollout at the proposed scale would have a ‘significant’ impact on primary care, with ‘serious consideration’ needed to be given to the impact on general practice as even more patients become eligible.
One GP attending the webinar told NHS England: ‘Prescribing tirzepatide will surely cause extra appointments for this drug and monitoring of it.
‘We are already, unfunded, having to follow up lots of patients with annual tests who have had bariatric surgery on NHS or privately.’
Another GP said: ‘We haven’t got the capacity in primary care to take on weight loss prescribing. The numbers are massive. There needs to be separate commissioned services to provide this.’
NHS England had previously warned that the first set of guidance – published last summer – would have had a ‘profound impact’ on GPs with millions of patients eligible for treatment within months.
Under NICE recommendations, tirzepatide is recommended as an option for managing overweight and obesity, alongside a reduced-calorie diet and increased physical activity, in adults, with a BMI of at least 35 kg/m2 and at least one weight-related comorbidity.
Lower BMI thresholds (usually reduced by 2.5 kg/m2) should be used for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean ethnic backgrounds, NICE said.
It was found to be cost effective after data from the SURMOUNT-1 study reported that after 72 weeks 96.3% of those on tirzepatide had lost 5% or more body weight, compared with 27.9% in the placebo group who also received diet and exercise advice.
As GPs we need to be clear
– this is extra work, and is not part of core contractual work
– if we are to take it on, it will require significant *extra* funding (guaranteed over the longterm) in order to build capacity to undertake it
– rebadging existing funding will not be enough
– if we choose not to take it on then other commissioned services must fill the gap: it cannot be ‘GP by default’
ICBs also need to understand
– we can only deliver this if each ICB has a properly funded tier 2 and tier 3 weight management service. In most places they are inadequate or already overwhelmed. We cannot deliver a service in general practice unless ‘wrap-around’ weight loss services are also available to the same cohort of patients.
NHSE needs to understand
– ICBs almost certainly can’t afford to deliver this service within their existing budgets, and if that is the expectation then many will be effectively bankrupted by this.
The NHS simply cannot afford to prescribe these drugs. But politicians like the easy win of promising them. Until they come off patent, these drugs need to private only outside of (e.g.) diabetes or BMI>50.
But once the dam breaks on NHS prescribing, GPs will be swamped.
Once again demonstrating how a major function of the NHS is not to enable access, but to obstruct access to effective and lifesaving treatments.
The Left’s and the BMA’s opposition to genuine reform of the NHS is reminiscent of Ignaz Semmelweiss’ s colleagues telling him to cut-out the hand washing Quatsch.
If it only reduces weight by 5% at 18 months, one has to wonder if any work might be better directed to something else!
Prescribing these drugs without other lifestyle changes could be a very bad idea. Resistance activity is required to mitigate the significant muscle loss (30-40% of total weight loss). Combine that with fat cell hyperplasia and a person could end up on worse metabolic health in the long run. There’s also the impact on mental health with anhedonia and suicidal ideation. And, don’t forget the risk of gastroparesis.
These drugs have a role. They are a tool, not a solution. I suspect an NHS mass roll out of these drugs would not come with funding and resource for the wider support that people should receive. As such, we could end up with more harm than good with a lot of opportunity cost along the way.
Yet again GP representatives fall into the trap. Narrative now “GPs refuse to prescribe fat busting drug”
We should be championing these medications for our patients. Keep an eye on the tubby hospital consultants. rapidly losing weight-how do you think they are doing it?
@David Church
I thought about 20% weight loss at 18 months. Compared to 5% in the placebo group.
So 15% of body mass extra weight loss through the medicine.
Of if starting with a BMI of 38 typically going down to a BMI of 30.
This is definitely extra work. It should be an enhanced service if they roll it out.