New clinical pathway for treating and managing obesity (WHC/2025/043)

Status:

Action.

Category:

Workforce and public health.

Title:

New clinical pathway for treating and managing obesity (WHC/2025/043).

Summary:

An update on the use of weight loss drugs within the NHS in Wales.

Date of expiry or review:

1 July 2026.

Action by:

Local health boards.

Required by:

With immediate effect.

Sender:

• Sioned Rees, Director of Public Health.
• Andrew Evans, Chief Pharmaceutical Officer, Welsh Government.

Welsh Government contacts:

Anwen Jones,
Healthy and Active Branch,
Health Improvement,
Prevention and Inequalities,
Public Health Division.

Enclosures:

None.

Dear colleagues,

In 2024, an addendum to the All Wales Weight Management Pathway (AWWMP) was published (WHC/2024/030) regarding the use of Glucagon-Like Peptide-1 Receptor Agonists (GLP1RAs) including semaglutide (Wegovy®) and liraglutide (Saxenda®) for weight loss in those patients in Wales who meet the relevant clinical criteria described in the addendum.

The addendum made clear the prescribing of these medicines should take place only within the appropriate level of the AWWMP, which in most cases would be level three, with limited but appropriate use in levels two and four, in accordance with the National Institute for Health and Care Excellence (NICE) guidance referenced within the addendum.

In December 2024, NICE published its technology appraisal on the use of tirzepatide for managing overweight and obesity in adults. In its appraisal, NICE concluded that unlike other weight loss medications, tirzepatide could be made available by the NHS alongside a reduced-calorie diet and increased physical activity, in both secondary and primary care settings for adults with a BMI of at least 35 kg/m2 (or a lower threshold, usually reduced by 2.5 kg/m2, for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean ethnic backgrounds) and at least one weight-related comorbidity. NICE estimate around 186,000 people in Wales could meet the eligibility criteria in its resource impact template on the NICE website.

Directions to health boards and NHS trusts in Wales generally require a medicine approved by NICE to be made available within 2 months of publication of its final draft guidance. However, health boards and NHS trusts are exempted from this requirement where a funding variation request, on behalf of NHS providers and integrated care boards in England, is agreed by NICE to extend the period within which the NHS needs to comply with its recommendations.

Given the potentially very large eligible cohort and the variation between providers in the availability of the wrap-around infrastructure required to deliver its recommendations, NICE has extended the implementation period for tirzepatide for managing overweight and obesity in adults, providing up to 12 years to implement the recommendations in full.

However, NICE has also indicated that it will evaluate any relevant evidence generated during the initial guidance implementation period of up to 3 years and review the effectiveness of the initial approach adopted in England. NICE may then set a revised timeline for the second phase of the guidance implementation period which would apply in Wales. The expectation is that a review drawing on implementation experience will provide evidence on the most clinically and cost-effective service delivery models which could be used to shorten the total guidance implementation timeframe.

Welsh Health Circular 2025/018 Tirzepatide (Mounjaro®) for the management of obesity and overweight confirmed plans for work intended to determine if and how tirzepatide and other weight loss medications licensed in the future, will be made available in the NHS in Wales, including considering implementation arrangements in primary care. This work has been undertaken and highlighted the need for the development of a new implementation model for weight management services across Wales, which seeks to both increase capacity and capability across the system to respond to the scale of the challenge of managing and treating obesity. The new model will include the development of a new clinical pathway with the aims of treating and managing obesity as a chronic, recurring condition and to support equitable access to weight loss drugs and associated wrap-around support, including in appropriate primary care and community settings. It will also ensure that prevention and early intervention is at the heart of the overall approach to managing obesity in Wales.

Welsh Ministers will make a decision regarding any extended deployment of tirzepatide and the wider use of weight loss drugs as part of the development of the new clinical pathway. We will write to NICE, local health boards and primary care contractors, outlining those arrangements in due course.

In the interim, tirzepatide, semaglutide and liraglutide, for weight loss should only be prescribed through specialist weight management services in the NHS in Wales ^{[footnote 1] [footnote 2]}, with the exception of prescribing by suitably competent prescribers alongside a reduced-calorie diet and increased physical activity in people with a BMI of at least 35 kg/m2 (or a lower threshold, usually reduced by 2.5 kg/m2, for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean ethnic backgrounds) and at least one weight-related comorbidity:

• and who meet the following criteria in phase 1 of the 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* December 2023 for:
  • precancerous or cancerous conditions in which weight loss would improve outcomes or aid access to therapies
  • patients requiring urgent weight loss for organ transplant
  • idiopathic intracranial hypertension (IIH) requiring frequent lumbar punctures and/or with visual compromise
  • patients undergoing planned time-sensitive surgery (including bariatric surgery) for life-limiting conditions, where high BMI is the primary barrier to surgery and weight loss would be beneficial
  • weight loss required for assisted conception in women under the care of a fertility service, in cases where weight loss would be beneficial; or
  • severe obstructive sleep apnoea (OSA), obesity hypoventilation syndrome (OHS) or severe asthma and
  • where the clinician and service providing care for these conditions takes responsibility for prescribing the weight loss medication.
• or where the prescribing is part of any proposal (subject to the proposal being approved) put forward by Public Health Wales or health boards in Wales through the obesity pathway innovation programme on gov.uk ^{[footnote 3]}

We appreciate there is considerable demand for specialist weight management services and a growing pressure for access to these medications through the NHS. The work being undertaken to develop a new clinical pathway will support building capacity and capability across Wales across specialist, primary care and community settings. These pathways will ensure tirzepatide and other weight loss medications can be made available in the NHS in Wales in a seamless, equitable, safe and effective way, by providing access to treatment through local services delivered in accordance with a nationally agreed implementation approach.

[1] Nothing in this circular is intended to affect treatment with tirzepatide started in the NHS before this circular was published. Anyone having treatment outside these recommendations may continue until they and their NHS healthcare professional consider it appropriate to stop. Anyone already receiving treatment should not be referred to specialist weight management services for continuation of prescriptions.

[2] This circular does not apply to the prescribing of tirzepatide for its other licensed indications.

[3] The cost of obesity medicines prescribed through any such proposal will need to be met by the health boards making the application. Proposals approved through the obesity pathway innovation programme will also help inform the development of the new clinical pathway.