GPs unable to prescribe GLP-1s to patients who need to reduce BMI for lifesaving surgery

Exclusive Patients across England are being prevented from receiving life-saving operations – including organ transplants and cancer surgery – because strict NHS rules mean they cannot be prescribed GLP-1 weight-loss medications such as Mounjaro (tirzepatide).

GPs around the country have told Pulse they are unable to prescribe GLP-1 medications to patients whose BMI is preventing them accessing operations. It includes a patient who cannot be put on an organ transplant list until they have lost weight and in another case a patient with cancer has been told they must lose weight before surgery.

Despite the clear need in these cases, the NHS criteria for accessing weight loss drugs is so strict, GPs say their hands are tied.

ICBs have had to meet the costs of funding access to the weight-loss injections in primary care settings from 23 June this year but under a phased rollout, it is only as yet available to patients with a BMI of 40 or higher, and four or more weight-related comorbidities.

In many areas, Integrated Care Boards (ICBs) apply weight optimisation policies before elective surgery, effectively delaying patients until they meet a BMI target. While this is rare for cancer surgery, most transplant centres set BMI cut-offs between 35 and 40 for eligibility, and – although against NICE recommendations – NHS areas vary widely in applying BMI thresholds for joint replacements, often below 35.

Such patients are also often misleadingly told by specialists that they will be able to access weight-loss injections such as Mounjaro – putting GPs in a very difficult position.

Dr Laura Shaw, a GP in Liverpool, said she regularly gets requests from hospital colleagues to start weight loss medication in a patient.

‘I have just spoken to a patient who was told by their consultant I should be able to start them. This is despite them firstly not actually meeting the current NHS criteria and there not currently being a service in my area yet.  This has happened on multiple occasions.’

She added: ‘I have a patient who cannot go on the organ transplant until he loses weight but does not meet the current criteria, so I cannot prescribe him something that would potentially help to save his life in the long run.’

Dr Shaw said that the drugs did need to be used in the right patients and there is a clear need for criteria for accessing them but there is ‘no leeway or flexibility’ allowing clinicians to use their best judgement.

Another GP, who wished to remain anonymous, said they had a patient with cancer who cannot get surgery because they are too overweight but also cannot be prescribed weight loss injections.

She said: ‘The issue is that NHSE criteria for Mounjaro are helpful for people with obesity-related comorbidities and designed to meet their budget for it based on health economic modelling – but there is no flexibility allowed.

‘We have a fabulous, safe, cost-effective solution that could make the difference between life and an early death, being bed bound or mobile, or accessing essential surgery safely in patients with a long list of significant medical problems but may only have three obesity comorbidities. 

‘Commissioners are concerned about budgets being blown if there is any deviation from their criteria, which I do understand, but in tier 3 weight management services, we are considered the experts, working with complex obese patients and we are used to bariatric surgery MDT pathways.’

‘The hope was that we would be able to prescribe for extra complex patients with risk of death from obesity and urgent need for weight loss, who may not tick all of the obesity comorbidities or their BMI is too high for bariatric surgery and need help to reduce.’

However, trying to push the ICB to budge on criteria has been a waste of time, the GP added.

‘The recent complex cases that we have been negotiating to start, have all had other specialist services involved, all requesting we consider GLP1. The cases have a significant variety of reasons and factors which is why I think we are best placed to decide and manage based on risk assessment. 

‘The time spent advocating and communicating with ICB, staff and most importantly, patients, has been significant and wasteful. The situation has been traumatising for patients and staff.’ 

‘Accountants are not best placed to decide on patient care.’ 

Dr Stephanie de Giorgio, a GP with a special interest in obesity, said GPs have no discretion in prescribing weight loss drugs and services are not set up in many places even for those who are eligible.

‘Having something we know will almost certainly work, that can’t be prescribed, is massively frustrating for patients and GPs.

‘For people on waiting lists for surgery that they cannot have until they have lost weight, but not providing them with something to help them, is just the very definition of NHS stupidity.’

Dr Samuel Finnikin, a GP in Sutton Coldfield, said just this week he saw a patient who is waiting for a procedure and ‘is desperate’ but her BMI has to drop below 35 before she can have it.

‘She’s trying really hard but not winning and doesn’t meet the criteria for jabs. I agree that it is deeply unfair that this tool exists and could really reduce morbidity but we can’t use it. I’d love to have been able to have given her a prescription.’

He cautioned however that if exceptions were introduced – however well-meaning – it would inevitably lead to conflict and problems unless it was a national policy.

‘At the minute I can quite clearly say “no” and it’s not my decision. If this line is blurred it would put me in a difficult position, choosing whose story is worthy and whose is not.

‘The criteria could be tweaked to include people who are being denied surgery due to weight – but that would have to be done across the board.’

Dr Finnikin said he was also seeing many patients whose specialist told them their GP could prescribe GLP-1RA drugs revealing a ‘lack of understanding’ among secondary care colleagues.

Professor Azeem Majeed, a GP and professor of public health and primary care at Imperial College London, said the strict criteria set by NICE reflected the limited availability and high costs of the drugs, and the need to target them to groups where the evidence of benefit is strongest ‘but that can create difficult situations for patients and clinicians’.

‘There are some patients – such as those requiring surgery or organ transplantation – where weight loss would be of major clinical benefit but who do not meet the current NICE eligibility criteria.

‘In such cases, GPs generally cannot prescribe the medication outside of the NICE guidance, and this can cause frustration for both patients and doctors, particularly when hospital specialists may not always be aware of the limitations in primary care prescribing.’

He said some ICBs may have routes for requesting treatment outside of NICE guidance but this varies between areas and creates extra administrative work for GPs.

‘In the past, there may have been more discretion about prescribing, but supply shortages and rising demand have led to tighter restrictions on prescribing.

‘The current situation highlights the need for clearer communication between hospital specialists and primary care, as well as a more flexible framework that could allow prescribing in exceptional clinical circumstances without creating a high level of administrative work for primary care teams.’

Professor Majeed noted that the current system can lead to inequality where more affluent patients who are not eligible for NHS treatment could obtain the drugs privately.

An NHS England spokesperson said: ‘Weight-loss drugs have a vital role to play in helping many more people manage their weight and lead healthier lives, and the NHS is developing and rolling out a range of lifestyle support that will be available locally and online to ensure they can be prescribed by GPs as part of holistic care.

‘The NHS is fully supporting the phased rollout of tirzepatide for eligible patients, having issued guidance in line with the NICE guidance, and provided funding to local ICBs to support patient care in March 2025. These represent brand new services in primary care that are being established and scaled up over time, starting with those who are in the most need – and in the meantime, eligible patients can get weight-loss support from a range of other services including the NHS Digital Weight Management programme.’