THIS WEEK AT A GLANCE
Here's what's inside:
ALSO, if you missed our mid-week feature article, get it here: RARE DISEASE IN UK PRIMARYCARE: WHY “MORE EDUCATION”ISN’T ENOUGH
Before we dive in, what are are your major concerns with reagrd to GLP-1s?
Isn’t it crazy that anyone with a social account can say anything they want about health. NO WONDER there is such a vast amount of misinformation everywhere.
We know you have compliance barriers, but there is still a way you can create a name for yourself and become a key/digital opinion leader (DOL). I have worked with pharma for over 14 years now, and I know how valuble DOLs are!
Sign up for the free seminar! 7th March - https://www.digitalhealthcareleaders.com/ehv-registration
RESEARCH
QOF is about to payout for obesity care; the liability comes free
Medicine Central original research.
Loosened eligibility thresholds, BMJ weight regain data,(January 2026) and added liability exposures are now all carried by primary care.
The Two Pathways: T2DM and Obesity
HOWEVER, GPs are flagging that a patient with T2DM may qualify under TA924; however, a patient with a higher BMI and no diabetes does not qualify under TA1026. Where both pathways apply, documentation must reflect glycaemic management as the primary rationale. This matters for TA924 continuation decisions at six months, which require both ≥11 mmol/mol HbA1c reduction and ≥3% weight loss to be recorded.
Sound confusing? That’s because it is and it isn’t aligned: Here is a breakdown for reference:
Obesity — TA1026 (year 1 commissioning) | |
|---|---|
BMI threshold | ≥40 (or ≥35 for high-risk ethnic groups) |
Comorbidities required | 4+ from: T2DM, hypertension, dyslipidaemia, OSA, CVD |
Max duration | None specified for tirzepatide |
Type 2 diabetes — TA924 | |
|---|---|
BMI threshold | ≥35 (or ≥30 for high-risk ethnic groups) |
HbA1c entry criterion | ≥53 mmol/mol on dual therapy, or ≥58 on single agent |
Continuation at 6 months | ≥11 mmol/mol HbA1c reduction AND ≥3% weight loss |
Weight Regain
The January 2026 BMJ Meta-Analysis. West et al. (BMJ, January 2026; 37 studies, n=9,341):
8 kg/month regain rate after stopping; return to baseline projected within 1.5–1.7 years
Cardiometabolic benefits attenuate in parallel: HbA1c, blood pressure, lipids, including the SELECT trial's 20% MACE reduction, diminish as weight returns
Behavioural programmes: slower regain (baseline at ~4 years), lower initial weight loss
5% of patients stop within 12 months in real-world data
"Weight regain isn't a failing of the medicines, it reflects the nature of obesity as a chronic, relapsing condition. It sounds a cautionary note for short-term use without a more comprehensive approach to weight management."
Althought the research suggests lif-long use, NICE specifies a two-year maximum for semaglutide but no duration limit for tirzepatide. The rationale for the semaglutide limit is under active scrutiny; no guidance change has been issued.
QOF and The Commercial and Commissioning Landscape
Private price rise (September 2025): Eli Lilly increased UK list prices from 1 September. Highest doses (12.5mg/15mg) rose up to 170%; lower doses rose 30–100%.
QOF from April 2026: Two new obesity indicators in the 2026/27 contract (18 QOF points, ~£25m ring-fenced) cover BMI recording, evidence-based advice, referrals, and prescribing where appropriate. The £3,000 figure is practice-level, approximately £800 per GP for an average-sized practice, plus ~£1,000 per practice for weight management referrals. The Weight Management Enhanced Service (WMES) is retired as part of the same contract change.
Eligibility loosens from April: year-one criteria (BMI ≥40 + 4 comorbidities) expand to BMI ≥35 + 4 comorbidities or BMI ≥40 + 3 comorbidities. Thresholds reduce by 2.5 kg/m² for South Asian, Chinese, Middle Eastern and Black African backgrounds.
The QOF tension
The new indicators incentivise identifying patients and offering treatment. But as of January 2026, one in five ICBs still had no functioning tirzepatide prescribing pathway (West et al.). A GP who identifies a patient under the new QOF but cannot prescribe because local commissioning is not ready needs to document both the offer and the barrier. The QOF rewards the clinical process, not the prescription.
The legal bit:
On private prescribing notifications: review contraception and oral HRT immediately on notification — not at the next annual review. Document advice given. The FSRH four-week barrier method rule applies at initiation and at every dose increase.
On secondary care referrals implying tirzepatide should be started: document that the NHS pathway is not yet available locally (if applicable) and what signposting was provided. Liability for patient expectations sits with the referring clinician; your documentation establishes your own position.
On online pharmacy requests for patient information: the MDU has flagged that ignoring these creates exposure. A practice policy is worth implementing. BMA template letter available via the BMA website.
What exactly do we need to do!?
Update QOF obesity register searches from April: BMI ≥35 + 4 comorbidities or BMI ≥40 + 3 comorbidities (thresholds reduce by 2.5 kg/m² for high-risk ethnic groups). Patients excluded under year-one criteria may now qualify.
Check ICB pathway status before April go-live. If you identify a patient under the new QOF indicator but cannot prescribe because local commissioning is not ready, document the offer and barrier.
Net off WMES income before treating QOF as additional revenue. The WMES is retired in the same contract change.
For private-to-NHS transfers: assess against current commissioning criteria at point of transfer and document criteria applied. Prior private use creates no NHS entitlement.
For T2DM via TA924: document glycaemic management as primary clinical rationale. Record both HbA1c reduction and weight loss at six months for continuation decisions.
Monitoring
NICE QS253 (August 2025): minimum one year of monitoring after treatment completion, whether NHS or private. For patients who have stopped privately-prescribed GLP-1s, a weight and cardiometabolic review is appropriate where cardiovascular risk was part of the indication.
No maximum duration for tirzepatide; annual review of continued benefit is good practice. For semaglutide, the two-year maximum remains in guidance.
QUICK UPDATE
Shingles uptake is still falling short
Fewer than half of newly eligible adults have received their first Shingrix dose, according to figures published by UKHSA last week.
Among those turning 66 (eligible since their 65th birthday) uptake stands at just 42.1%.
Among those turning 71, it reaches 53.5%.
That’s a lot of patients sitting who haven’t yet come forward.
The programme offers two doses of Shingrix to all immunocompetent individuals turning 65 or 70, and to severely immunosuppressed individuals aged 18 and over. Those aged 70–80 who missed out should also be offered a catch-up. The vaccine is efficacious against shingles and its complications, including post-herpetic neuralgia, which can persist for months after the rash clears. UKHSA has ready-made patient-facing waiting room posters, free to download or order.
FEATURE ARTICLE
Testosterone deficiency: the diagnosis that’s probably already sitting in the waiting room
One in eight men over 40 has testosterone deficiency. That's not a rare disease figure, that's a significant chunk and most of them haven't been diagnosed.
If you’re interested in learning more about xxx
The European Male Aging Study, which followed over 3,000 men, put the prevalence of secondary TD at around 12%, with rates climbing alongside age, obesity, and comorbidities.¹ The risk factor profile:¹
Type 2 diabetes
Metabolic syndrome
CKD, atrial fibrillation
Obstructive sleep apnoea
Chronic heart failure
Long-term opioid use
Antipsychotics, anticonvulsants, or finasterid.¹
The symptoms aren't dramatic, which is part of why it gets missed:
Reduced libido
Erectile dysfunction
Fatigue
Low mood
Poor concentration
Reduced muscle mass
Central weight
None of those are specific to TD in isolation, but the BSSM guidelines make the point well: the more symptoms present together alongside a low testosterone, the more confident you can be that you're looking at genuine hypogonadism.¹ If a man has consistent symptoms and any of those risk factors, routine screening (including a blood testosterone) is warranted.
Getting the biochemistry right matters here:
Measure total testosterone (TT) on a morning sample between 7 and 11am, and repeat it at least once, at least four weeks later
A single measurement is too easily confounded by stress, illness, or lab variation.
A TT below 8 nmol/L confirms TD.
Between 8 and 12 nmol/L is borderline and needs SHBG to calculate free testosterone.
This is worth noting for men with pre-diabetes: borderline levels up to 14 nmol/L are clinically significant
Round off with LH and FSH to classify primary versus secondary TD,
Measure prolactin if pituitary pathology is on your radar
Plus the standard thyroid/HbA1c/lipid screen.
Where TD is confirmed and there are no contraindications — prostate cancer, male breast cancer, desire for children, haematocrit above 54%, or severe heart failure, a trial of TRT is indicated.¹
Transdermal gels are first-line for most patients: stable levels, adjustable dosing, and easy to withdraw if needed.¹ Intramuscular injections are a well-evidenced alternative, particularly testosterone undecanoate if less frequent dosing is preferable. Before prescribing, check your local ICB formulary — testosterone sits under shared care protocols in many areas, and the requirements vary.
Two things are always worth doing first, regardless of where you land on treatment.
Address lifestyle — the relationship between obesity and low testosterone is strong, and meaningful weight loss can move the needle on TT without any medication.
Review the medication list carefully. Long-term opioids and TD symptoms in the same patient are rarely a coincidence.
Useful resources for further reading:
Book: Understanding testosterone, TRT and male hormone health: From the fantastic Dr Maxim Draper. A heartfelt and practical guide to the importance of testosterone for health and the consequences of deficiency - and how to restore balance.
Thanks all folks! Until next time! Please do reply to this email if you have any requests for content going forward. We love engaging with our audience!
