Greater Manchester Integrated Care Partnership

ICB 4. Mr R complains despite being an eligible patient under NICE TA 1026 from January 2025, the ICB has not enabled him to receive an NHS-funded liraglutide, semaglutide or tirzepatide prescription. He also complains on 27 February 2025 the ICB said it would fund his treatment on an exceptional basis when it instead asked the Practice to make the exceptional funding request.

Practice 5. Mr R complains when asked by the ICB in March 2025 to refer him into a service to provide an NHS-funded tirzepatide prescription on the grounds of clinical exceptionality, the Practice did not do so. He also complains the Practice continued to refuse to prescribe him tirzepatide despite letters of support in June 2025 from clinical specialists involved in his care.

Claimed impact 6. Mr R says these failings have left him without a liraglutide, semaglutide or tirzepatide prescription and this has caused him significant anxiety, and a considerable and avoidable deterioration in both his mental and physical health. He says he has experienced a financial impact, as he started self-funding tirzepatide in March 2025 on the understanding the ICB would continue to fund this on an exceptional basis. He says if the Practice had made the referral in March 2025 or prescribed tirzepatide on receiving clinical letters of support in June 2025, he would also not have incurred the costs of continuing to self-fund. Mr R says he has lost confidence in both ICB and Practice processes.

Outcomes sought 7. To resolve his complaint, Mr R would like the ICB and the Practice to acknowledge these failings and to apologise for the impact. He seeks a financial payment to recompense the costs he has incurred and to recognise the impact on his emotional, mental and physical health. Mr R would also like the ICB and the Practice to reconsider their decision to provide him with an NHS-funded tirzepatide prescription.

8. After a prior referral from the Practice, Mr R was started on an NHS-funded Tier 3 adult weight management programme on 27 January 2025. Tier 3 weight management is a multidisciplinary approach to weight loss, providing a person with diet and exercise advice, psychological support, and sometimes medication. At the time Mr R commenced his programme, the provider advised it was not offering weight loss medication.

9. One month earlier, on 23 December 2024, the National Institute for Health and Care Excellence published Technology Appraisal (NICE TA) 1026: ‘Tirzepatide for managing overweight and obesity’. Tirzepatide is a glucagon-like peptide 1 receptor agonist, commonly known as a GLP-1, a class of medications that help to promote weight loss.

10. At the time Mr R started his Tier 3 weight management programme, he was pursuing a complaint with the ICB about his lack of access to NHS-funded weight loss medication. Mr R raised concern that under the NICE TA 1026, he was eligible.

11. He also raised concern of his eligibility under NICE TA 664 ‘Liraglutide for managing overweight and obesity’ published on 9 December 2020 and NICE TA 875 ‘Semaglutide for managing overweight and obesity’, published on 8 March 2023. Liraglutide and semaglutide are different types of GLP-1s.

12. As part of the complaint resolution process, the ICB held a meeting with Mr R on 27 February 2025. At the meeting, the ICB’s programme director for commissioning development said they would look to see if they could consider Mr R’s individual case on an exceptional basis.

13. Mr R told us he left the meeting with the understanding that the ICB had agreed to fund weight loss medication for him. He says soon after, in anticipation of the NHS-funded prescription he thought would shortly commence, he started taking a privately issued dose of tirzepatide and lost a considerable amount of weight in the first month alone.

14. On 25 March 2025, NHS England published interim commissioning guidance, advising on the implementation of NICE TA 1026 and the funding variation for tirzepatide.

15. On 7 April 2025, the ICB emailed the Practice, asking that it consider referring Mr R to a different provider for weight loss medication: ‘if there is felt to be clinical exceptionality on the basis of the impact on his physical and emotional wellbeing’.

16. The Practice responded to advise many of its patients fit the criteria of clinical exceptionality described in the ICB’s email. It asked the ICB to confirm it would be happy if it referred all patients in this circumstance as it could not be seen to be partial.

17. The ICB replied to say it would shortly be issuing guidance to all GPs on the provision of specialist weight management services which would answer the specific question raised. The Practice documented it was awaiting this guidance before taking any further action.

18. On 11 June 2025 Mr R’s endocrinology consultant wrote to the Practice asking that it reconsider providing a prescription. On 19 June 2025, Mr R’s HIV consultant wrote to the Practice to explain he had been ‘doing extremely well with the weight loss injectables’, that Mr R said he had lost more than 15kg over eight weeks but ‘is concerned that he is not able to afford these long-term privately’. The consultant asked the Practice ‘if these could be continued on the NHS if possible’.

19. The Practice responded to the endocrinologist, explaining it was bound by NHS England’s interim commissioning guidance which said the first year’s cohort of patients must have a BMI of over 40 and four or more of the qualifying conditions. It said sadly it was not therefore able to prescribe weight loss medication to Mr R.

20. Remaining unhappy with the responses he received, Mr R asked us to consider his complaint.

ICB

Clinical eligibility 24. Mr R complains despite being an eligible patient under NICE TA 1026 from January 2025, the ICB has not enabled him to receive an NHS-funded liraglutide, semaglutide or tirzepatide prescription.

25. In response to Mr R’s complaint the ICB said it, like many other ICBs, was facing challenges in implementing the NICE TA guidance. It said whilst tirzepatide had obtained NICE TA approval, it was awaiting specific commissioning guidance from NHS England to inform the holistic package it needed to commission, and about allocation of funding.

26. The ICB said it had a responsibility to develop a model to meet the needs of patients with the highest clinical need, and the initial review identified that demand for these services exceeded the capacity available. It said it had taken the decision to pause the prescribing of weight loss medication whilst awaiting clarification from NHS England and until its review was completed.

27. From the information available to us, we consider Mr R did meet the clinical eligibility criteria described within NICE TA 1026. This recommends tirzepatide as an option for managing overweight and obesity in adults where the patient has a BMI of at least 35kg/m², at least one weight-related comorbidity, and is participating in a specialist weight management service.

28. The evidence indicates Mr R had a BMI of at least 35, his obstructive sleep apnoea was a weight-related condition and from 27 January 2025 he was enrolled into a Tier 3 specialist weight management service. We consider that at this time, Mr R also met the broad clinical eligibility criteria described within NICE TA664 on semaglutide and NICE TA875 on liraglutide, both of which require delivery of this medication within a specialist multidisciplinary weight management pathway.

29. We recognise Mr R is very concerned that the ICB did not act by providing him with an NHS-funded weight loss medication prescription from 27 January 2025, considering he was eligible under the NICE TAs.

30. Our commissioning adviser explained the importance of distinguishing between clinical eligibility and immediate access to NHS-funded treatment. Where NICE TAs establish the clinical circumstances in which a treatment is recommended and create a funding obligation, our commissioning adviser explains implementation may legitimately be phased where supported by national commissioning arrangements.

31. During 2025, NHS England issued interim commissioning guidance setting out a phased implementation programme and prioritisation of access to tirzepatide, because national demand exceeded available service capacity. Our commissioning adviser explains whilst Mr R was clinically eligible for consideration, this did not automatically confer an immediate entitlement to NHS-funded prescribing outside the nationally agreed implementation arrangements.

32. We know how strongly Mr R feels about the ICB’s decision to pause the prescribing of weight loss medication at that time, and in his view, this demonstrates a service failure. Our commissioning adviser does not see that the evidence shows the ICB simply refused to implement the NICE guidance. Rather, they find the evidence shows the ICB was attempting to implement NICE TA 1026 within the context of NHS England’s interim commissioning arrangements and local service development.

33. In response to Mr R’s complaint, we can see the ICB consistently explained that further national commissioning guidance was awaited, specialist service models required development, implementation would need to occur within available commissioned capacity, and access would initially be prioritised in accordance with NHS England guidance.

34. These explanations are consistent with NHS England’s interim commissioning guidance published in March 2025, which recognised phased implementation over several years because immediate national implementation was not operationally achievable. In line with our commissioning adviser’s views, we think the ICB’s decision-making here was reasonable. We do not consider the evidence indicates a service failure in the ICB’s approach to complying with the NICE TA guidance.

Exceptional funding 35. Mr R complains on 27 February 2025 the ICB said it would fund his treatment on an exceptional basis when it instead asked the Practice to make the exceptional funding request.

36. We have carefully reviewed the transcript from the meeting in question. This shows the programme director for commissioning development at NHS Greater Manchester said they would ‘personally speak to [the Chief Medical Officer for NHS Greater Manchester]… and I’m going to see if there is some way that, without prejudice, that we are able to look at your individual case on exceptionality…’.

37. The programme director said: ‘I can’t make any promises here and now I would do this on an exceptionality without prejudice, but I will personally speak to the medical director…’, and: ‘…we will come back with an answer about whether we can do something on a without prejudice on an exceptional basis as well for yourself’.

38. The transcript demonstrates that the programme director repeatedly stated they would explore whether funding might be possible on an exceptional basis but explicitly stated that no promises could be made. There was a commitment to finding out, but not to fund. Whilst it appears Mr R interpreted the ICB’s comments as agreement to fund we find the language used was exploratory and did not constitute a commitment to fund medication.

39. In response to Mr R’s complaint, the ICB confirmed that discussion with the Chief Medical Officer did take place where it was determined Mr R’s circumstances would not meet the individual funding request panel’s criteria. The ICB explained it therefore contacted the Practice directly, to request that it consider a referral: ‘if there is felt to be clinical exceptionality on the basis of the impact on [Mr R’s] physical and emotional wellbeing’.

40. We recognise Mr R’s unhappiness that the ICB contacted the Practice. We consider it reasonable the ICB did so, to ask the Practice whether there were genuinely exceptional clinical circumstances that distinguished Mr R from other patients requiring the same treatment.

41. As explained above, we do not find the ICB said it would fund Mr R’s treatment, but that it would look into Mr R’s case. This contact with the Practice shows the ICB acted in line with the commitments it did make at the meeting, by appropriately exploring via seeking advice from the Practice, whether an exceptional route existed. We do not see anything to indicate any service failure here.

Practice

Clinical exceptionality referral 42. Mr R complains when asked by the ICB in March 2025 to refer him into a service to provide an NHS-funded tirzepatide prescription on the grounds of clinical exceptionality, the Practice did not do so.

43. Records of the email in question show the ICB wrote: ‘Please can I request that consideration be given to a referral… if there is felt to be clinical exceptionality on the basis of the impact on his physical and emotional wellbeing’. The language used clearly asks the Practice to consider a referral. There was no mandate that it must refer, nor any requirement for the Practice to have made a referral here.

44. Records show the Practice acted appropriately in response to the ICB’s request. Staff met to discuss it, before returning to the ICB with a further enquiry. The Practice said whilst it did feel this was having an impact on Mr R’s physical and emotional wellbeing, it had many other patients in the same situation, inferring in turn that Mr R’s case was not explicitly exceptional.

45. This was an appropriate conclusion, in line NHS England’s commissioning policy on individual funding requests. This explains that ‘exceptional’ in this circumstance means a person to whom the general rule should not apply. It says very few patients have clinical circumstances which are genuinely exceptional, and to justify funding on this basis, the clinician must demonstrate that this patient’s individual clinical circumstances are clearly different from those of other patients.

46. The Practice appropriately sought clarification and assurance from the ICB that if it proceeded with a referral for Mr R for these reasons, that other such referrals would also be agreeable to the ICB. When the ICB responded to state it was awaiting further clarification from guidance to answer this, the Practice held a multidisciplinary meeting to discuss the matter further and felt it was most appropriate to await further guidance.

47. Our GP adviser considers the Practice acted with the appropriate weight, in meeting to discuss the matter twice, demonstrating the request was given the consideration it deserved. They consider it was reasonable the Practice then returned to seek clarification from the ICB, considering there appeared nothing specifically exceptional in Mr R’s case to distinguish him from numerous other patients. Our GP adviser confirms it was equally appropriate the Practice awaited further clarification, on receiving the ICB’s response.

48. We do not find any requirement for the Practice to have made a referral on clinical exceptionality. We also find no evidence to suggest Mr R’s case met clinical exceptionality grounds when considering the content of the NHS England commissioning policy. For this reason we do not criticise the Practice that it did not do so. We do not see anything to indicate any service failure here.

Refusal to prescribe 49. Mr R complains the Practice continued to refuse to prescribe him tirzepatide despite letters of support in June 2025 from clinical specialists involved in his care.

50. We have read these consultants’ letters and recognise the impact on Mr R, both of him remaining without a weight loss medication prescription, and him experiencing considerable weight loss after taking a privately issued dose. It remains we do not see anything to indicate service failure in the Practice’s actions here.

51. This is because Mr R did not meet the criteria for the first cohort for access under the NHS England interim commissioning guidance. When published on 27 March 2025, our GP adviser explains this became the applicable guidance over NICE TA 1026 recommendations.

52. The interim commissioning guidance says patient eligibility and the associated funding mandate within primary (GP) care needs to be in line with the prioritised patient cohorts set out within the table in the guidance. It explained the approach to implementation within primary care focused on managing capacity, and so enabling access for patients with the highest clinical need.

53. The table sets out the phasing proposal for the first three years of tirzepatide implementation. For year one, the first twelve months commencing from the publication of the guidance, the cohort required having a BMI of at least or greater than 40kg/m² and at least or more than four qualifying comorbidities, of which there was an exhaustive list.

54. Our GP adviser explains that irrespective of the letters from specialists involved in his care, Mr R did not meet the eligibility criteria for the first-year cohort. As such, we do not see anything to indicate a service failure, in the Practice maintaining its stance regarding Mr R’s request for NHS-funded weight loss medication.

1. We were sorry to learn of Mr R’s concerns that he was not provided an NHS-funded prescription for weight loss injectable medication in 2025.

2. We have considered the evidence carefully and we do not see any indication of failings in the complaints raised with us. As we have seen no indication of wrongdoing, we have decided not to investigate further.

3. We recognise how important this complaint is to Mr R. We were sorry to learn of the impact this had on him, and we thank Mr R for bringing his complaint for our consideration. We hope this statement explains the reasons for our decision.