Hello and welcome to BJGP Interviews.

I'm Nada Khan and I'm one of the associate editors of the bjgp.

Thanks for taking the time today to listen to this podcast.

Today we're speaking to Judine Scragg, a researcher based at the University Oxford, and Sabrina Keating, a DPHIL student who's also based at the University of Oxford within the Nuffield Department of Primary Care Health Sciences.

We're here to talk about their recent paper, published here in the BJJP, titled GP's Perspectives on GLP1 Receptor Agonists for Obesity Management A Qualitative Study in England.

So, hi, Judine and Sabrina, it's great to meet you both for this chat.

I guess the first thing to say is that this work is really topical at the moment, especially given current plans to increase the rollout of GLP1 receptor agonists into the community.

But, Judine, I'll come to you first and I wonder if you could just tell us a bit more about what you wanted to do in this research and why.

Yeah, absolutely.

So, for a long time, as you've said, the GLP1s have been very topical, both in clinical groups and with patients as well.

So I'm first and foremost, I'm a weight management researcher and I've done work in populations with people living with type 2 diabetes and polycystic ovary syndrome.

And within those populations, one of the things they've constantly asked about is about GLP1s, when do I qualify?

When do I get it around?

And similarly with the gps GP groups as well, there's been a lot of questions, there's lots of media about, you know, both good and bad about GLPs and outlining different people's thought processes and are they good?

Are they bad?

So what we sought to do with this was to sort of more robustly work out what it is GPs actually feel about the perceived integration of the GLP1s into primary care to very kind of firmly focus on GP specifically.

And this ended up coming at a really timely point, as midway through the study, the NICE guidance was brought out on outlining the plans for how tirepatide would be rolled out.

So it was a really timely piece to find out exactly what they were thinking and feeling about how this may impact them and their patients.

So that's really what we set out to do.

Great.

And this was a qualitative interview study of 25 GPs across England working across different roles, and they all had different experience in weight management services.

But I really Just wanted to come on to what you found here.

And let's start with an area that's quite a common issue right now, and I certainly don't seem to go a day without a patient asking me about whether they can get a weight loss injection.

But what did gps think about navigating these patient requests when they.

When they get them?

Yeah.

So at kind of the moment we were conducting interviews, that was definitely a real source of sort of frustration and difficulty.

There were quite a few patients presenting, asking for GLP1s, the majority of whom were ineligible often, or would only be eligible through kind of this longer, more drawn out process of accessing specialist care, which in many of the regions just did not exist or was going to take kind of years and years.

So it was not necessarily an amazing option.

This kind of left the gps we spoke to in quite an uncomfortable position where they kind of had to play the role of gatekeeper, really manage those expectations and potentially kind of have that compromising sort of interaction with their patients.

So certainly the gps that we spoke to had some frustrations associated with that.

Yeah, absolutely.

And I suppose it's a little bit about how to manage those requests.

So did the gps talk about that at all?

Yeah, there were some different strategies that we heard about.

I would say the primary one was just around identifying other options that would be available.

That was more difficult in some cases where patients had already exhausted those options and were feeling quite frustrated.

One of the other strategies that we heard about was testing patients for type 2 diabetes to try to identify whether maybe there was another avenue that they could kind of come in through.

And did they talk at all about private prescribing or.

We might come on to this a bit later.

But did any of the gps talk about suggesting or dealing with patient requests for private prescriptions?

Because I think that's quite a big industry and a growing industry at the moment as well.

Yes, certainly our sample were very much aware of this going on and it had been kind of entering the remit of their practice, specifically kind of asking for prescriptions to be carried over into NHS care, which most of the time the answer was a pretty concrete and clear no on.

So that could also be quite disappointing, particularly for patients who had come in through other international health systems who are then like, oh, I thought I would surely be able to get this on the nhs.

And, yeah, a lot of the services didn't have, like, a great answer or kind of protocol to responding to those requests for private prescription.

So there was also kind of the frustration of okay.

This is taking up quite a lot of our time, quite a lot of our effort that could be put towards other things, especially at a time when we're so overstretched.

And I think that leads on to the next thing I wanted to talk about.

And I think that, as you say, one of the big concerns for GPs, especially given the increasing effort to provide GLP1 agonists to a wider community population, is how we're going to fit this in alongside all the other things that we're doing.

So what else did the GP say about this and about the different resource limitations in general practice?

Yeah.

So I think many had an awareness that in kind of an ideal world, this made a lot of sense to be carrying out in primary care.

A GP has that kind of connection, ideally to their patients, and is able to see kind of the broader context of where and how they live, who they are as an individual.

But within that, there was an awareness that that was going to be exceedingly difficult given the resource limitations of the time.

So a few of the gps we spoke to were essentially just like, we don't know how this is going to happen.

This needs to stay in secondary care.

It's just not kind of a viable model.

Others were really worried that some of the components that should be integral to GLP1 delivery, like wraparound care, behavioral and psychological support, were certainly not going to be easy to provide within primary care.

And there was a real discomfort of this is just simply not how the medications are or should be used.

Yeah, I guess that goes back to How Current Tier 3 weight management services are provided or were provided, perhaps, in the nhs.

And the fact that you're right, there's a bit of a wraparound system around it, and certainly GLP1 agonists would only have typically been prescribed in those services alongside, as you say, all of the different weight management services.

So that's quite a hefty burden for a GP or practice to pick up.

Judine, I don't know if you wanted to comment on that, given your background in weight management research as well.

Yeah, I mean, I think, as Sabrina said, there's definitely concerns, but I think as well, there's definitely some very strong themes of these GLP1 drugs coming in as a very helpful tool as well, in a few different ways.

So, for example, I think one of the gps that we spoke to voiced concerns about how sometimes it's quite tricky for people to navigate the best way to support themselves, to lose weight and to navigate that wraparound care, and they perceived that GLP1 is a really helpful tool to help, particularly some people will find it a bit more tricky to navigate.

You know, all the different referral systems that exist within wraparound care, such as try this dietary program, you might be eligible for this program.

And they saw that as a helpful tool to do that.

Yeah.

Thinking about some of the other patient groups that we've spoken with, so particularly I'm thinking patients here with type 2 diabetes or with polycystic ovary syndrome.

They have often told us when they've tried to access care and they ended up managing to get in through Tier 3 services.

And I used the word managing because obviously that is quite tricky to access.

And there are, as we know, very long wait lists across huge areas of the country.

They felt like they really had to advocate for themselves to get to those and have not necessarily found it the easiest setting to navigate from a patient perspective.

Another aspect your participants talked about was health equity, and this is certainly an area we've covered elsewhere in BJJP life.

I wrote an about this titled how to drug your way out of an obesity crisis.

And we know that there are other environmental and social determinants of obesity that really need to be a focus here.

And Sabrina, I'll come back to you.

What did the GP say here about that?

Yeah, I would say that was definitely front and center in many of the conversations that we had.

We did also kind of actively sample for general practices and general practitioners within kind of more deprived settings.

There certainly a discomfort of, okay, if these medications are becoming our first line treatment for obesity at kind of like an individual level, a political level, a medical level, does this become our sole solution to obesity and, you know, a real awareness of the consequences that that could have when obesity is a much more embedded issue and the kind of social factors that contributed to people being in these situations in the first place were not going to go.

And in that case, some of the momentum to actually addressing them may just be sort of smoothed over.

I guess those things don't really have an easy fix, do they really?

Yeah, which is why there was also that counterbalance.

Awareness of these things take time.

There might not be that political motivation to solve them in the short term.

We do need something immediate.

We just can't let that be everything.

Fair enough.

And I think finally some GPs were concerned about the misuse of these injections.

So can you talk us through that as well?

Yes.

Some of that concern about misuse, was it becoming this overriding treatment for everyone?

I think especially with everything going on in media and patient demand, it's easy to have kind of that kickback response of, oh, gosh, everyone wants these, everyone wants to be slimmer.

So that was a source of kind of discomfort, especially when social inequality might be taking the backseat.

There was also just awareness that these medications could cause some really uncomfortable dynamics in consultation, be that around requests or prescribing or discontinuation of the medications.

So there was kind of a view that in the future there might be problems to do with the appropriateness of prescribing.

And since patients are coming in and applying potentially actually significant pressure for the medications to be prescribed, GPs are in quite a difficult position to say no to that.

One of our participants referred to it as being called in as the policeman to kind of keep an eye on patients and be the one making those calls.

I think one thing that cropped up was sort of that concern there, that if they said no, that ultimately patients would seek to obtain these medications through other avenues, be it private use.

And then there was obviously that very real concern about how do GPs within an NHS setting look after patients who are obtaining these medicines through private resources?

I think some of the participants mentioned that sort of factoring into those dynamics where they couldn't provide the patients with what the patients were explicitly asking for, that there's this sort of sense that the patient will, you know, if they are able to financially, they'll.

They'll just simply try get it elsewhere.

And I think that was a source of anxiety for some of our participants about how do they best make sure that these patients are being looked after appropriately.

Yeah, and there's certainly no shortage of different quality of clinics that are providing these different injections as well.

And I guess this is sort of happening now and many local ICBs and PCNs are trying to figure out how to roll out GLP1 agonists and who should be eligible.

I just wonder, after doing this research, what you would say to them about the GP perspective here, given your research.

One thing that we are very looking forward to is getting the data on how many patients actually end up taking these, particularly in the first phase of the rollout, because it is quite a small group of people in primary care who are in the first phase.

So I think that's going to be really interesting to see, actually.

How many people are we talking in primary care?

How many people choose to do it?

We talk a lot about how patients really want this, but there are definitely groups of patients that don't want this.

We know, for example, when we think about diabetes One of the key drivers of often weight loss and remission is to take themselves off medicines.

So this might not be a thing that's of interest to everybody.

So in terms of advice, I think maybe it's not so much advice as in we are going to be learning a lot over the next few years about how patients actually feel about these.

Now they're on offer potentially to them.

And in terms of advice to gps, I think a lot of that is just keeping themselves as, I guess, kind of up to date with other things that they can offer patients in the meantime.

As Sabrina said, there's always going to be an influx of patients wanting these and they might not be eligible just yet.

So being able to offer patients something in the meantime is probably something that certainly patients have said to us in the past about.

The main thing they feel downhearted with is when they feel like they get nothing at all.

So, you know, something is better than nothing.

I mean, a lot of ICBs as well, I think are doing a really good job of putting on their social media or their websites kind of about some information.

So I've seen quite a lot of different ICPs put together.

Really lovely patient facing documents to advise them that, you know, when these drugs might make their way to the patients and to sort of help their patients advocate the system a little bit.

For example, you know, helpful tips and tricks.

If they're already in specialist weight management, they'll probably contact us about it very shortly and try.

I can see that ICPs are already making really, really helpful patient facing documentation, which I think is a really, of course, really useful trick to manage that patient demand.

I can see why that, you know, doing that potentially to stop, you know, dozens and dozens and dozens of patients coming to their doors every day.

But I think there's definitely something to be said for kind of reassuring the patients about when they may be eligible, what they can do in the meantime and that, you know, not to worry, you've not been forgotten.

We can't give it just yet, but no, it's happening soon.

And as you say, it's very interesting times around this and things are a bit in flux as different ICBs work out the best way to provide these services to the right patients.

So as I said before, I think this is really timely research.

So great to chat to you about it, but I think that's a great place to just wrap things up.

So I just really wanted to say thank you both for your time here.

Thanks so much and thank you all very much for your time here and for listening to this BJGP podcast.

Sabrina and Judine's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com and I just wanted to say a special thanks to Sabrina who is on the west coast of the US and had to wake up at 5am for this podcast.

So thanks again for joining us here today and thanks to you all again.

Bye.