The Chasm in Obesity & Metabolic Care: The future we’re failing to build

When NICE approved Tirzepatide (Mounjaro) for NHS use in obesity, it was framed as progress — a step forward in tackling one of the biggest drivers of chronic disease, disability, and early death in the UK.

But as frontline clinicians and patients quickly discovered that approval came with no guarantee of access.

“I thought this might finally be the year I’d get help.”

This is what I heard this week, as patients are being turned away- again for treatment they were told was now available.  Across England people are being denied access to Tirzepatide, not because they don’t qualify, not because it won’t help but because systems to deliver it simply don’t exist in their area.

And it’s more than disappointment, it’s a familiar heartbreak, this isn’t just about one drug this is about a system that still isn’t built for the reality of obesity. NICE approval is often seen as the final step in a pathway to access. But in obesity, it’s just the beginning of another waiting game — a space where clinical guidance and real-world service delivery drift apart.

When systems can’t deliver, people carry the cost

Let’s be clear: this isn’t just a slow rollout, It’s a travesty of care. People who are already living with the complex burden of obesity, often compounded by type 2 diabetes, hypertension, metabolic liver disease and cardiovascular disease.  Many are carers, key workers or trying to live whilst silently managing pain, mobility issues , stigma and exhaustion.  But the reality- another year without support, another year of worsening health and another year internalising the belief that their weight is a personal failure- when in truth, it’s the system that keeps failing them.

The systemic failure behind the headlines

So, what’s gone wrong with Tirzepatide? NHS England proposed three models of delivery for Integrated Care Boards to adopt for the rollout of Tirzepatide:

1. Through Tier 3 specialist weight managements services

2. Shared care between Tier 3 and primary care

3. GP-led prescribing with MDT style support.

But here is the problem: in many areas there is no functioning Tier 3 service.  In others GP’s don’t have the training, time or infrastructure to safely manage treatment. Many ICB’s haven’t finalised commissioning – leaving frontline teams unable to prescribe at all.

The result is confusion, inequality and no access at all.

Stigma still shapes access

Obesity is still not treated as a chronic, relapsing condition in our health system.  It is still too often seen as a matter of willpower, lifestyle or moral failing, not a complex interaction of biology, environment, trauma, inequality and chronic disease.

This stigma is baked into how services are commissioned:

• 🚫There is no national funding mandate for Tier 3 services

• 🚫There is no protected training in obesity for GP's

• 🚫There is no urgency to deliver what NICE has already approved

Whilst private access has filled some of the demand, it has done so with:

• ⚠️Little integration with NHS records

• ⚠️Variable standards of care

• ⚠️Limited support for side effect management and long-term outcomes

As promising treatments appear on the horizon, and let’s be clear in the next few years we’ll see triple agonists entering clinical use, oral incretin formulations, combination therapies with cardiovascular, renal and metabolic liver disease we must redesign a system that can deliver safe, equitable holistic metabolic care.

We are on the edge of the most significant shift in obesity and metabolic care in a generation.  It will not be delivered by hype, or apps, or policy statements.  It will be delivered by people trained, supported and resources to meet patients where they are and to travel with them as they improve their health.

Without accountability, we repeat the same failures

Obesity care isn’t just under-resourced, its structurally deprioritised.  This is stigma in policy form.  We haven’t fully connected this to deprivation, ethnicity and working-class health.

We aren’t just talking about individuals being left behind- we’re talking about entire communities.

• How does this postcode lottery of obesity care overlap with increased exposure to pollution, food insecurity, housing precarity and racial health disparities?

• Why patients in marginalised communities have less access to obesity care and are most likely to be harmed by stigma.

• How these gaps fuel generational cycles of disease.

We talk about Core20Plus5, we talk about prevention, but we are not delivering this where it matters. This is not about weight, this is about health, about lives that have been waiting far too long.

Perhaps most importantly, we must move beyond the narrative that this is about “weight loss.” Tirzepatide and other incretins are not cosmetic tools. They are disease-modifying therapies that improve insulin sensitivity, reduce liver fat, and lower inflammation.

Many people with normal-range weight have underlying metabolic disease that goes undiagnosed. Without diagnostics that go beyond BMI, they are excluded from care. And many patients living with obesity are never offered investigations for liver disease, cardiovascular risk, or insulin resistance — until the disease has already progressed.

If we continue to treat weight as the entry point to care, we will continue to miss those most at risk.

What can the future offer

An opportunity not just to improve current models but to prototype new ones:

• A co-located metabolic health hub (with diagnostics, coaching and prescribing)

• Hybrid models of funding which engage employers with ICB funding

• Community-powered pathways with peer support and lived experience embedded

• Specialist community nurses and health coaches trained in metabolic and weight-inclusive care

But we need accountability to lead this, we cannot continue to defer responsibility to local systems whilst national policies remain toothless.  Here is what is required.

✅ National commissioning of obesity services — ensuring Tier 3 is available in every ICB, with minimum standards and protected funding.

✅ Integrated care models — bringing diagnostics, prescribing, behavioural support, and digital tracking into a single, accountable pathway.

✅ Transparent service mapping and outcomes reporting — so we can see where the gaps are, who is missing out and the impact of those in greatest need missing out.

✅ Workforce investment — with protected time, training, and development for the next generation of obesity and metabolic health specialists

✅ Lived experience in service design — not as an add-on, but as a core requirement for any commissioned pathway.

✅ A national strategy for metabolic health — beyond weight, beyond single-drug rollouts, rooted in prevention, equity, and long-term outcomes.

Final thoughts: The clock is ticking

If we don’t act now, the divide between health and access will continue to grow.

People will seek care wherever they can find it — even if it’s unregulated, unsafe, or unsustainable. Clinicians will burn out trying to fill the gaps in a system that was never designed for this scale of need. And the promise of new therapies — Tirzepatide, and all that follows — will become yet another story of what we could have delivered, if only we’d built for it.

The question is not: Can we roll this out? It’s: Do we have the will to finally treat obesity as the health priority it is?

The science is here. The need is overwhelming. What we build now will define what’s possible for a generation and more.