NHS England has asked NICE to consider approving a slow phased rollout of tirzepatide (Mounjaro) for weight loss in primary care to avoid overwhelming GPs.
It follows draft recommendations from NICE this summer for the weekly injection to be provided in primary care alongside diet and exercise advice for people with a BMI of at least 35kg/m2 and one weight-related comorbidity.
But in response, NHS England has said it will need longer than the 90 days usually required for health services to implement NICE guidelines because the impact on general practice would be ‘profound’.
It also wants to raise the threshold BMI to 40 for the first two or three years of the phased rollout.
According to NHS England calculations, around 2.8 million patients would be eligible for tirzepatide as the recommendations currently stood.
If everyone came forward and 70% of those were started on treatment around 18% of GP appointments would be taken up just initiating and managing the medicine, NHSE has predicted.
The cost of the medicine alone in the second year of use would come in around £2.9bn, equivalent to 28% of the entire primary care medicines budget, it added.
Nine in ten ICBs surveyed as part of the proposal development said it could not safely and appropriately be offered in primary care within the 90-day period. Concerns were raised that demand could risk access to services for other conditions.
Instead NHSE has put forward ‘a realistic but challenging uptake trajectory that satisfies the requirement to make this clinical and cost-effective drug available to as many patients as possible without overwhelming providers, including general practice’.
NICE has put the plans out for consultation with full approval expected at the end of this year.
Under the planned phased tirzepatide rollout, NHSE would use the first 180 days to:
- Begin procurement of digital weight management support services to accommodate some of the dietetic and psychological care needed
- Identify and agree any additional funding packages to support implementation
- Introduce contractual frameworks for the creation of a new Primary Care Weight Management service.
- Upskill existing staff in the requirements of wider tirzepatide treatment
The proposals set out three cohorts based on clinical need and benefit that would be able to access treatment in the first three years, equating to 220,000 patients.
It would start with those with a BMI of 40 or more and at least three other related comorbidities. Cohorts two and three are also those with a BMI more than 40, but with two other conditions; or one as well as type two diabetes.
This will enable ICBs to expand access gradually without ‘major disruption’ to existing services and build the wider multidisciplinary team needed to support those on tirzepatide.
It would also enable the NHS to build up ‘real-world evidence’ to consider the feasibility of accelerated roll out to the wider patient populations in a ‘safe and effective way’, it said.
Further implementation to the full eligible group will be done over a nine-year period, ‘to manage the impact upon primary care services and avoid the risks associated with a significant displacement of appointment volume to deliver tirzepatide’, NHSE added.
It will mean new ways of delivering obesity medicines, including digital services, will need to be established.
Dr Sam Roberts, chief executive of NICE, said: ‘This new generation of weight loss medications has the potential to achieve important health and wellbeing benefits for people living with obesity. They can also prevent serious health problems from developing, reducing the long-term risks to individuals.
‘Our independent committee found this medicine to be both effective and good value for money.
‘Because of the very large number of people who could potentially benefit, NICE accepts that a phased roll out is required. However, we now need to hear from stakeholders on the proposals we have received from NHS England.’
NHS national medical director Professor Sir Stephen Powis said the phased rollout would ensure those with the greatest clinical need can access it as a while new and innovative services are developed through which other weight loss treatments can also be delivered.
‘With the sheer number of people potentially eligible for these treatments and GP teams already delivering record numbers of appointments, the NHS is developing a range of community-based and digital services to provide the benefits of weight loss drugs while continuing to ensure GPs can deliver all other vital services patients rely on.’
Dr Simon Cork, senior lecturer in physiology at Anglia Ruskin University, said this would be no small task for the NHS because it will be ‘difficult to provide the level of wraparound care seen in patients who took part in the clinical trial’.
Patients will need exercise support as well as targeted and personalised dietary advice, he added.
‘Without this high level of wraparound care, the NHS risks wasting money on these medications by not achieving the highest levels of weight loss possible. It is not clear whether the NHS has the capacity to provide this high level of wraparound care in the community to achieve this.’
Professor Azeem Majeed, a GP and professor of primary care and public health at Imperial College London said the approach NHS England was taking was sensible.
‘While tirzepatide offers significant potential benefits for managing obesity and improving health outcomes, the large size of the eligible population requires a phased and carefully managed rollout to avoid overwhelming primary care services.
‘This will help ensure that general practices can balance the demands of delivering this new treatment with the ongoing delivery of other primary care services.’
But he added we also need to consider the financial viability of the service given that the costs of prescribing tirzepatide could eventually approach nearly £3 billion annually.
‘This raises important questions about the long-term sustainability of funding obesity treatments such as tirzepatide, more so given the many other pressure on NHS funding and calls for investment in other health services. My own view is that the UK can’t inject itself out of an obesity crisis and that medical treatments need to be supplemented with investment in public health and preventive approaches to obesity.’
The first head-to-head study recently found that use of tirzepatide is associated with significantly greater weight loss than semaglutide.
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These drugs are transformative. In my practice our latest statistics show being of healthy weight is no a minority among adults. At least 25% of adults are obese; 10% BMI > 35; 4% > 40.
Our local tier 3 service has turned from an attempt at a biopsychosocial approach to weight loss to a will/will not give GLP-1 service, and in the time required to make an accepted referral and follow up on their recommendations, issue the drugs they recommend, you might as well just start the meds in primary care.
As the retirement age goes up to late 60s for some, it seems medical retirement secondary to the obesity epidemic is around age 50 for many, in the form of pain and loss of function.
1. It’s great that someone in NHSE is considering the impact of a NICE recommendation on services but
2. It’s crazy that someone in NHSE is HAVING to do this – IE that NICE is allowed to make recommendations WITHOUT considering the impact on services.
This is a Public Health measure, and all counselling and decisions should be performed by Public Health Staff, previously PHE, but now trhe UKHealthSecurity Agency, as public health measures are their job.
previously District Medical Officers might get involved, but no GPs are currently paid to cover that role any more. (unless the odd one has escaped my attention, outwith any minute isolated health economies)
I find this the most devastating news. It is utterly essential for the future of general practice that these drugs are mainly used in primary care. We finally have transformative treatments for those patients we have slogged at hard over the years to try and help and it seems we are not going to get to be the ones that finally sort them.
GPs need to respond en masse to the consultation because otherwise useless locally commissioned services will do the fun and truly rewarding work and we will be left with god knows what.
There is an enormous private sector provision of this drug with remote co silting snd prescription, typically by nurse prescribers. The customers seem content to manage the adverse effects as well as to pay for the medications as they do for weight watchers, gym membership and special foods. If that private market is transferred to the NHS it will more than destabilise primary care (for which read general practice”) perhaps it should be put on sale as a pharmacy drug?
Spelling! Should be * remote consulting and prescription*
Dimbelby report anyone; ultra processed foods? proper public health measures; ban advertising, tax heavily; ring fence taxes to subsidise fruit and veg.
No; support both the Pharmaceutical industry and Industrial Food industry and sell the population shite to ear while giving them all injections to suppress their appetite/make them feel sick so they can’t eat said food.
21st century solutions for 21st century politicians. Bought and owned by the multinational corporations.
Agree with the sceptics. Are Eli Lilly execs laughing all the way to the bank? Isn’t this typical supply-side fundamentalism that suits the corporatocracy. I foresee Tirzepatide engineered weight loss leading to a “eat what you like then go to the GP for your wt loss jab” culture.. The private capital market is trying to hugely expand its customer base and to let the NHS pick up the tab. The fact that NICE is being politicised by pressure from the Pharma lobby and under this new Labour Govt tells me that for Wes and the boys it’s business as usual. No different to their predecessors in their economic theory thinking.
It’s now worth considering if all the different bits of pointless work they ask GPs to do is worth it:
– CQC stuff
– report writing
– letters to anyone who is interested
– DWP reports
– DVLA reports
– and hot topic of the day all the workload dump from hospitals.
Because of all of that and more, a treatment with actual proven benefit cannot be given to thousands of people who would benefit from it.
So if NICE approves this drug as a technology assessment guidance (TAG) NHS i.e ICBs have to fund it’s provision and supply within 3 months. If this comes out as NICE guidance they can ignore it effectively.
NICE cannot compel GPs to provide it , only ICBs to commission it
In my opinion GPs should seek funding for the time and effort in prescribing , counselling and educating patients involved , or maybe offer it as pharmacy first but make sure they do all the counselling and monitoring .
I would rather see the money spent on public health or GP services than this!
Wonderful how the NHS restricts access to lifesaving treatments to avoid inconvenience for the staff.
Any chance of replacing the NHS with something that works a little better for patients?
@David J
My understanding is this will be coming as an enhanced service. It should be anyway.
My modest proposal would be to train our ARRS colleagues such as PAs to run primary care weight management clinics. We could move beyond the current debate about whether they can or should deal with high risk acute presentations while giving them an important and intellectually challenging job.
Or we can just go along with the proposed plan and throw multimorbid obese patients under the bus and tell them to go private if they can afford it.