Tier 3 Weight Management (Interim)

Threshold

General Principles

This threshold policy for Tier 3 Specialist weight management support applies to patients registered with a Norfolk and Waveney GP.

Significant transformation to obesity care is expected in the medium term. Therefore, this clinical threshold policy has been developed as an interim measure and will continue to be reviewed in the light of important new guidance or changes to care pathways.

On a case-to-case basis, patients might be eligible for this intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.

This policy is intended for suitably qualified referring clinicians working in primary care. Clinicians should assess their patients against the criteria within this policy prior to a referral and/or treatment.

Clinical Threshold

Tier 3 specialist weight management services can support access to intensive behavioural interventions, bariatric surgery, specialist psychological and dietetic support and the higher strength GLP-1 RAs treatment options, including Saxenda® (liraglutide), Wegovy® (semaglutide), and Mounjaro® (tirzepatide).

For all people requesting referral, clinicians should use shared decision making to determine with the individual that they feel ready to engage with the programme and would like to be referred at this time. Ability to adhere to weight loss programmes correlates with weight loss achieved. People living with obesity and medical conditions such as malabsorption syndrome or nutritional deficiencies from other causes should have access to dietary advice prior to weight management intervention to ensure that these are appropriately addressed prior to weight management intervention.

Currently, it is not possible to provide access to SWMS for all eligible people in line with NG246. To address this, a joint position statement was developed by national clinical bodies, building on the 2023 guidance^2* and incorporating more detailed prioritisation criteria and new therapies such as tirzepatide (Mounjaro®), approved under NICE TA1026. This policy supports a phased framework with prioritised access to SWMS based on clinical need, in line with NHSE phased implementation guidance and the joint position statement ensuring those with the greatest need can access treatment first.

Inclusions:

Patients aged 18 years and over with BOTH of the following criteria

BMI of ≥35 kg/m² (usually reduced by 2.5 kg/m² for people from Black, Asian and ethnic minority backgrounds)

BMI between 30-34.9 kg/m² (usually reduced by 2.5 kg/m² for people from Black, Asian and ethnic minority backgrounds) who meet the criteria for referral to specialist weight management services in NICE’s guideline on obesity ^1∗

AND

Prioritised in the following phased cohorts, as underpinned by ‘A joint position statement by the Society for Endocrinology and Obesity Management Collaborative UK’ and ‘Proposed referral criteria for Specialist Weight Management’ ²^*; providing a nationally endorsed, multidisciplinary consensus on prioritisation criteria for specialist weight management referrals – aiming to reduce variation and improve equity in service access across the system. Currently, access will be provided for phase 1 priority cohort only. Additional cohorts will be considered as the financial position evolves.

Phase 1: ≥ONE of the following conditions, which could be improved by weight loss:

Type 1 diabetes mellitus
Precancerous or cancerous conditions in which weight loss would improve outcomes or aid access to therapies. ^3*
Patients requiring urgent weight loss for organ transplant
Idiopathic intracranial hypertension (IIH) requiring frequent lumbar punctures and/or with visual compromise
Heart failure NYHA class III/IV requiring hospitalisation
Patients requiring planned, time-sensitive surgery (including bariatric surgery) for reversible, life-limiting conditions or who have severely restricted activities of daily living (ADLs), where high BMI is the primary barrier to surgery (according to latest clinical trial data) and weight loss is essential to access treatment
Assisted conception: where individual otherwise meets local referral criteria, but weight loss is required to access treatment. Consideration should be given to age at referral and predicted weight loss outcomes depending on intervention. ^4*
Severe obstructive sleep apnoea (OSA), obesity hypoventilation syndrome (OHS) – where the severity has been indicated by an Apnoea Hypopnea Index (AHI) of >30A and/or severe asthma
Chronic kidney disease (stages 4 and 5)
Confirmed metabolic dysfunction-associated steatotic liver disease (MASLD) where a specialist has confirmed moderate/severe liver fibrosis (i.e. the individual should have been seen and assessed by a specialist hepatologist).
Suspicion of, or confirmed, rare monogenic or hypothalamic cause of obesity. Complex neuropsychological conditions that impair everyday functioning, such as severe and enduring mental illness or learning disabilities and autism with complex needs that cannot be met in primary care. ^5*
Young adults (18-24) requiring ongoing support, transitioning from paediatric tier 3 obesity services, or with significant weight related complications. ^6*
Patients on weight loss medical therapies who despite maximum tolerated doses, have ongoing weight-related complications and would benefit from evaluation for alternative weight loss intervention.
Patients who meet the criteria and are eligible for access to tirzepatide in Primary Care from 23rd June 2025 (as set out in the Interim commissioning guidance) but the registered practice is not offering the service, or the patient has additional complex medical, psychological or social care needs requiring specialist input and support. Such referral shall be at clinician discretion.

Phase 2: ≥THREE of the following conditions, which could be improved by weight loss:

Chronic kidney disease (stages 3 or 4)
Hypertension (established diagnosis and requiring blood pressure lowering therapy)
Idiopathic Intracranial Hypertension (IIH)
Metabolic dysfunction-associated steatohepatitis (MASH) ^7*
Moderate obstructive sleep apnoea (OSA)
Polycystic Ovary Syndrome (PCOS)
Type 2 Diabetes Mellitus (T2DM)
Established cardiovascular disease (angina, coronary artery disease, heart failure, cerebrovascular disease, peripheral vascular disease)
Complex social needs e.g. people who are housebound or have severe functional restriction contributed to by their obesity.

Phase 3: ≥TWO of the following conditions, which could be improved by weight loss:

Chronic kidney disease (stages 3 or 4)
Dyslipidaemia
Hidradenitis suppurativa or psoriasis
Hypertension
Idiopathic Intracranial Hypertension (IIH)
Metabolic dysfunction-associated steatohepatitis (MASH) ^7*
Mild obstructive sleep apnoea (OSA)
Osteoarthritis
Polycystic Ovary Syndrome (PCOS)
Pre-diabetes/NDH or Type 2 Diabetes Mellitus (T2DM)
Established cardiovascular disease (angina, coronary artery disease, heart failure, cerebrovascular disease, peripheral vascular disease)
Complex social needs e.g. people who are housebound or have severe functional restriction contributed to by their obesity

Phase 4

All other eligible patients as defined in NG246.

^1*NICE NG246: Overweight and obesity management – Referring adults to specialist services

Referral to specialist overweight and obesity management services if:

the underlying causes of overweight or obesity need to be assessed
the person has complex disease states or needs that cannot be managed adequately in behavioral overweight and obesity management services (for example, the extra support needs of people with learning disabilities)
less intensive management has been unsuccessful
specialist interventions (such as a very-low-calorie diet) may be neededsurgery or certain medicines is being considered.

^2*Guidance for the phased introduction of new medical therapies for weight management: A joint position statement by the Society for Endocrinology and Obesity Management Collaborative UK (Dec 2023) https://www.omc-uk.org/sites/default/files/2024-01/2023-12-Joint-Position-Statement-on-Medical-Therapies-for-Obesity.pdf

Revised guidance for the Proposed Referral Criteria for Specialist Weight Management Services in England: A joint position statement by the Society for Endocrinology and Obesity Management Collaborative UK (June 2025) proposed-referral-criteria-for-specialist-weight-management-services-in-england-june-2025.pdf

^3*Considered at clinical discretion in relation to individuals’ current condition and status where appetite suppression and weight loss can be managed at this time.

^4*Contraception is required while taking semaglutide (Wegovy®) and Mounjaro® (tirzepatide) ahead of planned assisted conception.

^5*People with SMI, and people with LD, are at particularly high risk for cardiometabolic disease and premature mortality, and for this reason, should be considered as having greater priority and fall into the phase above where they meet the eligibility criteria.

^6* At point of exiting paediatric services, some young people may already be using obesity medications and will need ongoing support, and review of their management. Many young people under the age of 18 and at high risk of complications from severe obesity may not have been able to access specialist weight management services or obesity medications. Additionally, young adults between the ages of 18 and 25 years may not yet have developed multiple complications to prioritise their entry to adult services. However, obesity at a young age poses a significant lifetime risk to health and compromise to education and future employment. For this reason, young adults presenting with weight-related comorbidities should be prioritised at a lower clinical threshold.

^7*There has been recent change in the nomenclature in liver diseases related to fat accumulation. All people with evidence of metabolic liver disease due to fat accumulation should be encouraged to lose weight. Those with the more serious form of Non-Alcoholic Fatty Liver Disease (NAFLD), previously known as Non-Alcoholic Steatohepatitis (NASH) but now known as Metabolic-associated steatohepatitis (MASH) can be referred.

Exclusions:

Under the age of 18
Currently pregnant or breastfeeding
Palliative care / end of life
Current diagnosis of severe active eating disorders.
Current diagnosis of unstable serious mental illness which prevents engagement with interventions provided. Once the condition is stabilised and the patient is well enough, referral can be considered (see inclusion criteria in phase 1).
Have been previously referred into the service and have left the pathway early or have disengaged from the services, who are seeking to re-enter as a re-referral will not be eligible within 24 months (Please supply supplementary information if disengagement was due to a legitimate reason such as surgery, bereavement, caring responsibilities etc, with an assurance that they are now able to proceed and engage).

OR are unwilling to participate fully and comply with the weight management service