Big questions: GP tirzepatide prescribing and international medical graduates

Maya Dhillon takes on May’s talking points – how involved will GPs be in tirzepatide prescribing, and how do we approach conversations about ‘prioritising’ domestic medical graduates over international ones?

What role will GPs really play in weight-loss drugs?

The rollout of tirzepatide (Mounjaro) in primary care begins this month, a year since the initial NICE recommendations were made. GPs will be able to prescribe the weight-loss drug – unlike semaglutide, for which GPs need to refer patients to specialist weight management services.

The initial guidance would have put immense pressure on GPs, with around 3.4 million patients being eligible within months. Therefore, NHS England asked NICE to consider a slower phased rollout to avoid overwhelming GPs. Indeed, it is thought that around 1.5 million people in the UK are already using weight-loss medications via private routes.

And so, NICE revised and slowed down the tirzepatide rollout, reserving eligibility for those with the highest clinical need first. However even with these alterations, there will still be a quarter of a million people gaining access to tirzepatide within three years.

The revised rollout allows GPs to prescribe tirzepatide o to a prioritised patient cohort from 23 June. Patients eligible within the first year must have a BMI of 40 or above, alongside four or more ‘qualifying’ comorbidities. The next phase will be done over nine months, and the final phase over 15 months, ending in 2028. 

RCGP chair Dr Kamila Hawthorne made the point that even with the slower phased rollout, ‘serious consideration’ would have to be given to the impact on general practice. Any implementation of tirzepatide would need appropriate resource provided as well as ‘necessary training to safely take on any additional responsibility that comes their way.’

And it’s this ‘additional responsibility’ that sounds alarm bells. We know that tirzepatide is not a ‘one and done’ (and forever) fix. Firstly, there is no recommended treatment period – with semaglutide, NICE recommends a maximum of two years’ treatment but there is no similar guidance for tirzepatide, meaning that theoretically treatment can go on ad infinitum.

Secondly, patients prescribed tirzepatide in primary care must also receive wraparound care. This includes ‘nutritional and dietetic advice as a minimum and access to behavioural change components’. GPs will be responsible for providing holistic care and helping patients make lifestyle changes to ensure they don’t regain weight after coming off tirzepatide. 

In our most recent podcast episode, Pulse clinical adviser and GP Dr Keith Hopcroft pointed out that GPs will also be responsible for managing side effects – gastrointestinal ones are common with tirzepatide. This will require dose tweaking as the jabs are dose-dependent. Titration will also require monthly face-to-face appointments.

It should be pointed out that GPs may not necessarily be the designated point of contact for prescribing tirzepatide in primary care. NHS England’s interim commissioning guidance for tirzepatide set out four implementation models for ICBs to follow, only two of which directly involve general practice to deliver – one under a shared-care model. ICBs have until 23 June to decide how they will commission tirzepatide prescribing in primary care.

But regardless of whether or not GPs are the prescribers, it is overwhelmingly likely that they will have a part to play and it will make a significant impact on workload. Even if private providers were involved to speed up the rollout, it is inconceivable that GPs will be completely removed from a patient’s care. This isn’t just about a new drug; it’s about an entire system of wraparound care that GPs will be expected to deliver in an already overstretched environment.

If tirzepatide prescribing in primary care is to succeed, then it must come with the appropriate resources, infrastructure, and support that GPs need. It cannot just be a new responsibility quietly added to the pile. Otherwise, we risk undermining both the potential of the treatment and the sustainability of general practice staff.

Should British medical graduates be prioritised for specialty training?

It is no secret that we face a significant workforce challenge in general practice right now. We’ve reported extensively on the recruitment/unemployment crisis – the paradox of how we don’t have enough GP positions, yet are seeing a ridiculous number of GPs unemployed.

Bottlenecks like these however are not specific to general practice nor to those pre-CCT. Competition ratios are high across all specialties, and medical graduates are struggling to get places in the disciplines they want – despite the fact that their presence in the NHS workforce would be welcomed by patients.

Understandably, resident doctors are concerned. They have dedicated five-plus years of their lives to medicine. They were likely told that being a doctor guaranteed lifetime job security, yet this no longer seems the case. It begs the question as to how we best address the concerns of medical graduates.

In March, the BMA resident doctors committee passed a policy demanding that the UK governments ‘implement a specialty training recruitment process that lawfully prioritises UK medical graduates’. This was done to tackle high competition ratios and provide a clear route for doctors to develop their skills.

But at the UK LMC conference last month, GP leaders criticised the ‘protectionist’ policy, arguing that it disadvantages international medical graduates (IMGs). President of the British International Doctors Association (BIDA) Dr Chandra Kanneganti said that the policy sent a ‘damaging message that IMG doctors are somehow less welcome, less value, despite meeting the same standards’. 

There was opposition: Dr Chris Morris from the BMA GP registrars committee pointed out that other countries have similar policies with their own medical graduates. The UK not doing so therefore makes it an outlier and disadvantages its own graduates as there is ‘zero prioritisation’ for them.

It is hard to discuss this topic without bringing in wider political context from the last month. Prime Minister Sir Keir Starmer unveiled the Government’s plan to ‘restore control over the immigration system’ and was criticised for using language reminiscent of Enoch Powell. The Liverpool parade crash ignited an ugly wave of X accounts assuming that the perpetrator was a Muslim/immigrant/not white, leading Merseyside police to release the suspect’s race upon arrest – an unprecedented move. 

This is not to say that wanting to prioritise UK medical graduates is akin in the slightest to holding right-wing views. But it is part of the national conversation and some media outlets will conflate the NHS workforce to the topic of immigration. Last week The Times ran a piece with the headline: ‘British doctors chasing jobs will get priority over foreigners.’ It’s a deliberate ‘othering’ of IMGs.

This isn’t a topic that is going to go away. At the BMA’s annual representative meeting this month, doctor leaders will vote on whether UK medical school graduates should be ‘prioritised’ for foundation programme posts. There are two opposing motions: the first argues that the exponential rise in competition ratios is ‘driven primarily by overseas recruitment’; the second posits that ‘prioritising’ UK medical graduates over ‘equally qualified’ IMGs ‘undermines existing BMA policy’ on fairness, ‘weakens’ workforce retention.

Last year, a record number of graduates applied for GP training posts; 15,036 applicants applied for over 4,000 GP ST1 paces – the highest number of applications in ten years. It is understandable to want to drive down competition ratios when we have no detail (pending the refreshed workforce plan) on whether there will be more GP jobs available. 

But general practice is particularly indebted to IMGs. As a profession, it is disproportionately non-white. Last year, the GMC revealed that the number of non-UK graduate doctors in training increased across all specialties, but ‘especially’ in general practice. Many work in underserved areas, often in roles that struggle to attract UK graduates.

It’s reasonable to want a system that supports and values domestic graduates. But this must not come at the cost of disregarding the value and service that IMGs bring to general practice. If anything, the situation calls for a more holistic workforce strategy; one that addresses the structural failures in planning and funding, while working towards long-term sustainability for all doctors – regardless of where they trained.