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LMC briefing: NEL obesity QOF and Tirzepatide
policy
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New QOF obesity indcators: summary for busy
people
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Two new obesity indicators have been
added to QOF for 2026/27: OB004 and OB005.
It is important to be clear about
what QOF is - and what it is not.
QOF is an incentive scheme. It
rewards coding and achievement against indicators. It does not fund
the delivery of a full clinical pathway or replace a properly
commissioned local service. Inclusion in QOF does not make the
associated work mandatory core general practice work, and practices
can choose not to undertake it.
NEL ICB has recently published an obesity policy. The LMC did not
have the opportunity to comment on the draft before
publication.
OB004: achievable
OB004 involves identifying patients
living with obesity and referring them into an appropriate weight
management programme.
The NEL policy helpfully lists local
Tier 2 obesity management services and other NHS-supported weight
management programmes. The LMC view is that OB004 appears
achievable for practices and broadly consistent with usual QOF
work: case finding, referral and coding.
OB005: problematic
OB005 however is different.
It appears to expect practices to
deliver the clinical management of the primary care Tirzepatide
pathway, including assessment, prescribing, dose titration,
monitoring, review and referral to behavioural support.
The LMC does not consider this to be
core general practice work. If commissioners want practices to
deliver this pathway, it should be funded through a properly
commissioned local service.
The financial modelling below
suggests that practices may, at best, break even in year one if
they achieve all available QOF points and use a mixed clinical
model. By year two, the work is likely to run at a clear loss. As
future cohorts widen, the losses are likely to increase.
Practices should therefore think
carefully before taking on OB005 work without a commissioned
service to fund the workload of the underlying clinical pathway. In
addition, if practices deliver this work in year one, it may become
increasingly difficult to hand the work back as the years progress
and the workload increases.
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New QOF Indicators 2026-2027: the detail
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OB004 - 5 points; thresholds
10–30%
This indicator rewards referral to
a weight management programme within 90 days for adults living
with obesity, using the appropriate ethnicity-adjusted BMI
thresholds.
OB005 - 13 points; thresholds
50–80%
This indicator rewards a recorded
shared decision-making discussion, offer of NICE-approved
pharmacotherapy for use in a primary care setting, and referral
to suitable behavioural support for eligible patients in the
NICE/NHSE Tirzepatide cohorts.
OB004 in the NEL policy
document
The
NEL policy lists local Tier 2 services in each borough and other
NHS-supported programmes, including the NHS Digital Weight
Management Programme, NHS Diabetes Prevention Programme and Type
2 Diabetes Path to Remission programme.
This should allow practices to
deliver OB004 through a relatively simple process:
- identify eligible
patients; this can be done opportunistically;
- offer referral to
an appropriate programme;
- code the referral
correctly within 90 days.
-
This would appear to be
straightforward and achievable.
OB005 in the NEL policy
document
The NEL policy sets out
eligibility criteria for Tirzepatide and Semaglutide.
However, OB005 only refers to the
use of Tirzepatide and not Semaglutide. This is not made explicit
in the somewhat confusing wording of OB005, but the intent to
restrict it to Tirzepatide is clear for two reasons.
Let us look at the wording of
OB005:
The
percentage of patients defined in the NICE TA1026 Funding
Variation Cohorts (accounting for ethnicity and comorbidity
status) who have a recorded shared decision-making discussion
about the management of obesity and are offered NICE approved
medicines management (pharmacotherapy) for use in a primary care
setting with accompanying referral to suitable behavioural
support programme in the preceding 12 months.
First, the cohort that is defined
by NICE TA 1026 is that set out for the phased introduction of
Tirzepatide. Second, the words ‘for use in a primary care
setting’ can only refer to Tirzepatide, because Semaglutide’s
NICE approval (TA 875) and extant NHSE guidance restricts its use
to specialist weight management services, and not primary care
settings.
Furthermore,
Semaglutide remains ‘Red’ (specialist or hospital prescribing
only) on the NEL Formulary.
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Specialist weight management services in NEL
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The
policy also states that NEL specialist weight management services
are no longer accepting new referrals for Tirzepatide prescribing,
although they will offer an advisory resource to support primary
care. They are still accepting new referrals for Semaglutide.
This
is a major concern for the LMC. Many patients eligible for
Tirzepatide will have obesity plus multiple comorbidities. Some
will be clinically very complex. An advisory service is not the
same as a specialist clinical pathway accepting referrals, and
clinical risk would remain with the prescriber.
The
expectation of OB005 in the NEL policy
OB005
is not simply a case-finding and coding exercise. It assumes the
existence of a comprehensive prescribing and clinical management
pathway.
The
expectation in OB005 appears to be that practices will deliver this
comprehensive weight loss pathway, with prescribing and oversight
of Tirzepatide taking place entirely in a primary care setting.
But
this service is not funded through QOF, and is not currently
commissioned from general practice.
Likely
workload for practices
The
NEL policy does not include a clinical pathway or process map for
delivering Tirzepatide in general practice. It does not specify
appointment frequency, staffing model, monitoring schedule,
escalation process, or review arrangements.
We
therefore have to infer workload from national guidance.
NHS
England interim commissioning guidance for NICE TA1026 says that,
in primary care, there should be monthly face-to-face appointments
during Tirzepatide titration, with structured medication reviews
for at least the first 12 months.
NICE
practical prescribing guidance says the initial assessment should
include eligibility, baseline measurements, investigations,
contraindications and cautions, medicines review, pregnancy and
contraception issues, injection counselling, adverse-effect
counselling, sharps arrangements and behavioural support. It also
says follow-up should occur every 4 weeks during dose
titration.
On
that basis, a newly initiated patient is likely to require around 7
appointments or clinical contacts in year one:
- initial assessment
and shared decision-making;
- monthly titration
reviews;
- review after 6
months on the highest tolerated dose.
The
year-two workload is less clearly defined. A reasonable planning
assumption is 4 reviews per patient per year, a quarterly review
covering weight, BMI, side effects, comorbidities, medicines
changes, ongoing benefit/risk and continuation.
These
figures do not include extra contacts for side effects,
non-attendance, anxiety, prescribing queries, clinical supervision,
searches or other associated admin tasks, complaints or the
management of patients who start treatment but do not continue.
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For
a typical 10,000-patient UK practice (and I appreciate NEL
practices look after very diverse populations) the following
figures apply:
- estimated Cohort 2
patients in 2026/27: 10.
- estimated Cohort 3
patients in 2027/28: 20.
- QOF point value:
approximately £228.
- OB004 value: 5 × £228 = £1,140.
- OB005 value: 13 × £228 = £2,964.
OB004
does not require the same appointment modelling, as it is primarily
case finding, referral and coding.
OB005
however does require further modelling.
Year
one: cohort 2 (as set out in the DHSC-NICE agreement)
Assume:
- 10 eligible
patients;
- 6 appointments per
patient as a best-case scenario;
- 100% achievement of
OB005 points.
That
gives:
- 10 × 6 = 60
appointments.
- £2,964 ÷ 60 = £49.40 per appointment.
If
seven appointments are required, which is more consistent with
national guidance:
- 10 × 7 = 70
appointments.
- £2,964 ÷ 70 = £42.34 per appointment.
A
20-minute appointment is a reasonable minimum for this work.
Londonwide LMCs' current figures for costing contracts put:
- 20 minutes of GP
time at approximately £60.24.
- 20 minutes of nurse
time at approximately £24.83.
A
GP-only model would therefore run at a loss even in year one.
A
mixed model using suitably trained non-GP clinicians might break
even in year one, but only on optimistic assumptions and only if
the practice achieves all available QOF points.
Year
two: cohort 2 continues and cohort 3 starts
Assume:
- Cohort 2: 10
patients × 4 reviews = 40 appointments.
- Cohort 3: 20
patients × 6 appointments = 120 appointments.
Total:
- 160 appointments.
- If OB005 income
remains £2,964:
- £2,964 ÷ 160 = £18.53 per
appointment
If
seven appointments are required for new patients:
- Cohort 2: 10 × 4 =
40.
- Cohort 3: 20 × 7 =
140.
Total:
- 180 appointments.
- £2,964 ÷ 180 = £16.47 per appointment.
It
is hard to see how any practice could deliver this safely at
anything other than a loss from year two onwards.
In
future years, further cohorts are expected to widen eligibility.
There is no reason to assume QOF funding will increase in line with
the workload.
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There
is also a contractual risk. If practices deliver Tirzepatide
obesity management for several years without a locally commissioned
service, commissioners may later argue that practices have accepted
the work as core general practice.
Practices
should therefore be cautious about taking on OB005 work without a
clear contract, service specification and realistic funding.
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The Londonwide LMCs and your NEL LMCs'
position
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The
LMC supports equitable access to effective obesity management.
However,
OB004 and OB005 should not be treated as equivalent.
OB004 appears
achievable: it is case finding, referral and coding.
OB005 is
different: it assumes a prescribing and clinical management pathway
that general practice is not commissioned or funded to
deliver.
QOF
does not fund the necessary clinical pathway. It is the view of the
LMC that if NEL wants practices to deliver Tirzepatide prescribing
and monitoring for obesity, this should be commissioned as a local
service with realistic funding, clear clinical governance,
training, templates, escalation routes and specialist
support.
Until
that is in place, practices should make an informed decision about
whether they can safely and sustainably undertake OB005.
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It
is perhaps worth noting that a number of other weight loss drugs
are currently in development (it is believed around 200), and a
significant number of these are oral drugs.
For
instance, the MHRA has recently approved oral semaglutide (a Wegovy
tablet) for weight management in the UK, but it has not yet been
NICE-recommended or routinely commissioned by the NHS for obesity.
The provision of weight loss services is a rapidly evolving
situation that is likely to change significantly in the next 18
months.
Best
wishes,
Dr
Darren Tymens
Medical
Director for North East London
Londonwide
LMCs
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