Reviewed on : 16 Apr 2025

Reviewed by : Amy Wride & Gateway Editor & Prof Tom Barber

Expires : 16 Apr 2027

BOMSS Statement on Bariatric Tourism:

The below link will direct you to a statement from BOMSS on bariatric tourism:

https://bomss.org/bomss-statement-on-bariatric-tourism-2/

UHCW Specialist Weight Management Clinic (New Patients)

The Consultant overseeing the Weight Management Service at UHCW is Dr Tom Barber Consultant Endocrinologist

Please note: The DHSS has written to all GPs in England to say we are not able to initiate GLP1 therapies for any patient regardless of the indication due to the global supply issue, and this is likely to be the case well into the foreseeable future

Tier 3 & 4 Specialist Weight Management CWICB Statement November 2024

Re: Upcoming NICE TA on Tirzepatide for managing overweight and obesity

Summary

Coventry and Warwickshire ICB (CWICB) does not currently commission Tirzepatide (Mounjaro®) or other GLP-1 agonists (including semaglutide/liraglutide) for the management of obesity

General Practice should not initiate or prescribe these medications for the management of obesity until further notice

We are writing to the local trusts to ensure that patients are not started on these medications and patients requiring tier 3 or tier 4 weight management services should be referred via the usual route to the UHCW weight management service

We are imminently starting a complete recommissioning of the obesity service in Coventry and Warwickshire to ensure that it has sufficient capacity and ability to manage the likely demand, following the publication of the NICE Technology Appraisal for Tirzepatide and the other GLP-1 agonists.

However, this will take many months to complete and at present we are unable to give a firm date for its completion

The ICB is currently working on a patient information page on its website which patients can be directed to for information and this will be communicated to practices as soon as possible

Online tier 3 weight management services available under ‘Right to Choose’ are not commissioned by CWICB, so patients should not be referred to this service as it is not an integrated tier 3 / tier 4 service

Tirzepatide (Mounjaro®) and other GLP-1 agonists are commissioned for the management of Type 2 Diabetes and can be prescribed and initiated in primary care for this indication

Background

You may be aware of the upcoming NICE Technology Appraisal for Tirzepatide (Mounjaro®) for use as a treatment for obesity

The draft recommendations are:

Tirzepatide is recommended as an option for managing overweight and obesity, alongside a reduced-calorie diet and increased physical activity, in adults, only if they have:

• an initial body mass index (BMI) of at least 35 kg/m2* and
• at least 1 weight-related comorbidity

*Use lower BMI thresholds (usually reduced by 2.5 kg/m2 ) for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean ethnic backgrounds

Whilst we welcome this novel treatment for obesity the predicted demand for this and other injectable weight loss drugs is likely to be extremely high, given that 65% of adults in Coventry and Warwickshire are overweight or obese

NHS England have recognised the likely demand for Tirzepatide and have proposed a phased introduction over an unprecedented twelve (12) years with the patients most in need being prioritised

In the first year this is likely to include patients with a BMI>40 and three or more obesity related comorbidities. NHS England are also making specific additional funding available that will include funding for additional lifestyle management services in addition to the drug costs. However, this funding has not been finalised and may take many months to be agreed

Whilst the NICE TA recommends the possibility of prescribing and monitoring Tirzepatide in primary care we do not consider the current capacity in general practice to be sufficient to provide the additional lifestyle support that is recommended to accompany Tirzepatide

Therefore, we have concluded that a complete recommissioning of the obesity pathways in Coventry and Warwickshire is required to allow us to introduce these treatments in a fair, safe and sustainable way. This work will begin imminently but again will take many months to complete

Other GLP-1 agonists such as semaglutide and liraglutide are also not currently commissioned for the management of obesity.

Remote or Private Providers

We are aware that at least one third party provider (Oviva) has established themselves as providing a remote service for the management of obesity and the prescribing of GLP-1 agonists and are promoting themselves via the Right to Choose pathway

These services do not provide integrated tier 3 and 4 services and as such Coventry and Warwickshire ICB does not commission them and clinicians should NOT refer patients to them on the NHS under Right to Choose

Private clinicians who initiate GLP-1 agonists or other weight loss drugs are at liberty to do so but practices should not take over the prescribing of these medications on private clinics behalf since, again, they are unlikely to be integrated tier 3/4 services and we do not currently commission these drugs for the management of obesity

Referral to Tier 3 & 4 Support should be offered to patients as follows:

Eligibility Criteria

• Patient is aged 18 years or over
• BMI of 50 or more: surgery should be considered as a first-line treatment intervention
• BMI less than 50 should be referred for consideration of bariatric surgery if they meet the following criteria:

o   BMI of 40 kg/m2 or more, or between 35-40 kg/m2 with significant obesity-related complications likely to improve with weight loss (for example, type 2 diabetes, sleep apnoea or hypertension)

o   BMI of 30 kg/m2 or more with type 2 diabetes of less than 10 years duration (this BMI threshold should be reduced to 27.5 kg/m2 if the patient is of Asian family origin)

Classifying overweight, obesity and central adiposity in adults

• Healthy weight: BMI 18.5 kg/m²to 24.9 kg/m²
• Overweight: BMI 25 kg/m²to 29.9 kg/m²
• Obesity class 1: BMI 30 kg/m²to 34.9 kg/m²
• Obesity class 2: BMI 35 kg/m²to 39.9 kg/m²
• Obesity class 3: BMI 40 kg/m² or more.

Central adiposity

Use clinical judgement when interpreting the healthy weight category because a person in this category may nevertheless have central adiposity. See Public Health England’s guidance on obesity and weight management for people with learning disabilities for information on reasonable adjustments that may need to be made

People with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI, so use lower BMI thresholds as a practical measure of overweight and obesity:

• Overweight: BMI 23 kg/m²to 27.4 kg/m²
• Obesity: BMI 27.5 kg/m²or above.For people in these groups, obesity classes 2 and 3 are usually identified by reducing the thresholds highlighted in recommendation 1.2.7 by 2.5 kg/m²

Pre-referral requirements

• Motivated patient willing to be referred to the Specialist Weight Management Clinic
• Height and weight and calculated BMI in kg/m²
• A full list of medications including insulin doses
• HbA1c / fasting Glucose / U&E’s / Lipid Profile /TFTs / TSH / LFTs within last 2 months

UHCW Bariatric Surgery Services Primary Surgery Referral Criteria, Tier 4 (Bariatric Surgery)

• Patients will be referred by the tier 3 service after attendance and engagement within the Tier 3 service
• Patients will need to attend a medical, dietetic and psychological assessment within the tier 3 service to explore whether bariatric surgery is the most appropriate treatment choice
• After Multidisciplinary Team discussion patients will then enter the surgical pathway, unless a contraindication was found during assessments at their medical, psychological or dietetic appointments
• Attendance at a surgical options information session followed later by an appointment with the surgeon
• They will attend a pre-operative group session and will continue to receive input from the team whilst awaiting bariatric surgery

Please see link for the UHCW leaflet about various bariatric operations

Contact Details

Medical appointments: Medical Secretary Tel: 02476 965970

Dietetic appointments: Dietetic administrator Tel: 02476 966161

Bariatric queries: Bariatric Co-ordinator Tel: 02476 966994

Diabetes Specialist Nurses: 02476 965567

UHCW Bariatric Service Referral (previous bariatric surgery referral criteria)

This is a Referral Assessment Service and is called: Bariatric Service – General Surgery – UHCW – RKB Speciality GI and Liver (Medicine and Surgery)

Inclusion criteria

If you would like guidance on the interpretation or actioning of nutritional bloods related to bariatric surgery please send Advice and Guidance to: Adult Dietetics – Dietetics Department – University Hospital Coventry – RKB

Patients who have had previous bariatric surgery (post-procedure) such as gastric band (in-situ or removed), gastric bypass or sleeve gastrectomy with suspected complications

Commonly these patients may be experiencing, reflux, anaemia, malnutrition, difficulty swallowing, pain, vomiting

Patients upon assessment will then put on a pathway that will take them to:

• Nurse led clinic
• Consultant Surgeon Clinic
• Gastric Band Clinic
• Specialist Weight Management Psychology
• Specialist Weight Management Dietetics

Exclusion criteria

• Patients awaiting specialist weight management review or assessment
• Patients who have had surgery elsewhere without suspicion of surgical complications
• Patient with no history of previous weight loss / bariatric surgery
• Cancer patients awaiting gastrectomy or gastric bypass surgery

Pre-referral Investigations

Bloods:

HbA1c / fasting Glucose / U&E’s / Lipid Profile /TFTs / TSH / LFTs

Bariatric Surgery Post op Complications and Suggested Management

Advice for Patients

If you have had bariatric surgery or a gastric balloon procedure and are unable to tolerate any food or fluid please present to the emergency department at University Hospital Coventry & Warwickshire Hospital UHCW

If you have had a gastric balloon inserted and have a blue/green tinge to your urine, stool or vomit please present to the emergency department at University Hospital Coventry & Warwickshire Hospital UHCW

If you have had bariatric surgery or a gastric balloon procedure and are experiencing difficulty swallowing, reflux, vomiting, pain, constipation, fever or if you are otherwise concerned please seek advice from your GP

If you had your procedure under another provider, please also inform them

Additional Resources

Click on image to follow link to BOMSS GP Hub

Advice for GPs Please follow this link

Primary Care advice – follow this link to clinical resources published on British Obesity & Metabolic Surgery Society website

Patient Leaflets Information for People Thinking of Having Laparoscopic Weight Loss Surgery