Check if you could be referred
Our free checker asks a few questions about where you live and your health, then shows whether you’re likely to meet the criteria for Second Nature’s NHS tier 3 service.
The four tiers of NHS weight management
NHS weight management in England is described in four tiers: general public health advice (tier 1), lifestyle programmes (tier 2), specialist weight-management services (tier 3), and weight-loss surgery (tier 4).1
| Tier |
What it is |
Who provides it |
| Tier 1 |
General advice on eating well and moving more, including public health campaigns |
GPs, pharmacies and local councils |
| Tier 2 |
Lifestyle weight-management programmes, run in groups or online, often for around 12 weeks |
Local councils, and the NHS Digital Weight Management Programme for adults living with obesity who also have diabetes or high blood pressure5 |
| Tier 3 |
Specialist support from a team that usually includes a doctor, dietitian, psychologist and exercise specialist, with weight-loss medication in some services |
NHS specialist weight-management services |
| Tier 4 |
Weight-loss (bariatric) surgery and the care before and after it |
NHS hospital surgical teams |
Your local integrated care board (ICB), the NHS organisation that plans health services for your area, funds Tier 3 and Tier 4 services.
The tiers come from a 2014 NHS England report, which described them as a guide rather than a fixed definition.1
NICE’s 2025 guideline on overweight and obesity (NG246), which replaced its 2014 guideline (CG189), doesn’t use tiers in its recommendations. It refers instead to specialist overweight and obesity management services, which can include tier 3 and tier 4.6
NHS England describes this as removing the tiered system, but local services, GPs, and referral forms still use the tier names, so you’re still likely to hear ‘tier 3’ when you’re referred.7
Tier 3 is also different from class 3 obesity. Class 3 obesity describes a BMI of 40 or more, while tier 3 describes the type of service you’re referred to.6
How tier 3 differs from tier 2
Tier 2 programmes help adults change their eating and activity habits, while tier 3 adds a medical assessment and specialist treatment for people whose weight is affecting their health in more complex ways.
|
Tier 2 |
Tier 3 |
| Who it’s for |
Adults living with overweight or obesity, with criteria set locally |
Adults living with obesity, most often with a BMI of 35 or more and a weight-related condition |
| How you join |
Some council programmes accept self-referral; your GP or pharmacist can refer you to the NHS Digital Weight Management Programme |
A referral, usually from your GP |
| Who supports you |
Trained coaches or health advisers |
A team that usually includes a doctor, dietitian, psychologist and exercise specialist |
| How long it lasts |
Often around 12 weeks |
Usually 12 to 24 months |
| Medication |
Not offered |
Wegovy or Mounjaro in some services, depending on local funding |
| Cost |
Free |
Free |
Our guide to getting Second Nature free on the NHS covers the tier 2 and tier 3 programmes we deliver and who’s eligible for each.
Who can be referred to tier 3
Each local NHS area sets its own tier 3 criteria, and the most common is a BMI of 35 or more with at least one weight-related condition.3
NICE’s guidance doesn’t set a BMI threshold for referral. Instead, it recommends that GPs consider a referral to specialist weight-management services if:6
- the underlying causes of someone’s weight need to be assessed
- they have complex health needs that a lifestyle programme can’t manage, such as the extra support some people with learning disabilities need
- less intensive support hasn’t worked
- they may need a specialist treatment, such as a very-low-calorie diet
- weight-loss surgery or certain medicines are being considered
In the North East and North Cumbria, for example, the October 2024 policy asks for a BMI of 35 or more with a weight-related condition, or 40 or more without one.8
It also requires at least 6 months of diet and activity changes that haven’t led to enough weight loss or haven’t been maintained. These can be changes made independently, with your GP’s support, or through a tier 2 or commercial programme.8
People with a BMI of 50 or more can be referred sooner if their GP thinks it’s appropriate.8
These BMI thresholds are usually 2.5 lower for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family backgrounds, because weight-related conditions such as type 2 diabetes develop at a lower BMI in these groups.6
The requirement to try other support first comes from local policies rather than from NICE. NICE lists less intensive support not working as a reason for referral, but other reasons, such as needing an assessment for medication or surgery, don’t depend on it.6
NICE also says there should be no upper limit on BMI or age for a referral, so being over 65 or having a very high BMI shouldn’t stop you from being referred.6
Our guide on how to talk to your GP about your weight covers how to prepare for the appointment and what to ask about a referral.
What happens at tier 3
At tier 3, a specialist team assesses you and supports you for around 12 to 24 months, helping with eating habits, activity, and the emotional side of eating, plus weight-loss medication or a surgery assessment if either is suitable.1
The first assessment usually covers weight history, health conditions and medicines, and what has made losing weight difficult in the past.
The team usually includes a doctor, a specialist dietitian, a psychologist, and a physiotherapist or exercise specialist, and sometimes a specialist nurse.1
Psychological support is part of tier 3 because, for many of us, eating is tied to stress, low mood and tiredness as well as to hunger, and those links are hard to change with nutrition advice alone.
In NHS England’s 2024 survey, the average tier 3 pathway lasted 18 months.3
In the same survey, 77% of tier 3 care involved a mix of face-to-face and digital appointments, and NICE recommends that people can choose between in-person and digital services where both are available.3,6
Can you get Wegovy or Mounjaro through tier 3?
Some tier 3 services prescribe Wegovy or Mounjaro (tirzepatide), depending on what the local service is funded to provide, and the two medications reach patients by different routes.
NICE recommends Wegovy on the NHS only within specialist weight-management services (tier 3), for a maximum of 2 years.2
To qualify, you need at least one weight-related condition, plus either a BMI of 35 or more, or a BMI of 30 to 34.9 if you also meet the criteria for a specialist referral. The lower thresholds for the family backgrounds listed above also apply.2
Mounjaro has two NHS routes. Specialist weight-management services have been able to prescribe it since 24th March 2025, and GPs began prescribing it in phases from 23rd June 2025.7
The GP rollout started with people who have a BMI of 40 or more and at least 4 of 5 weight-related conditions.7
In its second year (2026 to 2027), the rollout adds people with a BMI of 35 to 39.9 and at least 4 of those conditions.7
The five conditions are type 2 diabetes, high blood pressure, abnormal cholesterol or blood fat levels (dyslipidaemia), obstructive sleep apnoea, and heart or circulatory disease caused by narrowed arteries.7
In specialist services, NICE’s criteria for Mounjaro are a BMI of 35 or more with at least one weight-related condition. The lower BMI thresholds for the family backgrounds listed above apply to both NHS routes.7
Local NHS areas can choose to prioritise the same groups as the GP rollout within their specialist services, so access to Mounjaro through tier 3 varies by area.7
Our guides to Wegovy on the NHS and Mounjaro on the NHS cover each medication’s criteria in more detail.
Not every tier 3 service can prescribe these medications. The City and Hackney service in east London, for example, says it isn’t currently funded to offer Wegovy, Saxenda or Mounjaro.9
NHS Wegovy stops after a maximum of 2 years.2 NICE recommends offering support to help maintain weight loss when people stop weight-loss medication, so ask your prescriber and tier 3 team what support continues after NHS Wegovy ends.6
A private prescription doesn’t automatically transfer to the NHS, so you’d need to meet the NHS criteria and be referred like anyone else.
In south-east Essex, for example, people already paying privately for Mounjaro join the end of the existing NHS waiting list if they qualify.10
How long the wait for tier 3 is
In an NHS England survey of specialist weight-management services in April 2024, the average wait for tier 3 treatment was 16 months. Of England’s 42 integrated care boards, 34 responded.3
In around 40% of responses, weight-loss medication had its own waiting list, with a wait of about 2 years, compared with about 1 year for support without medication.3
No national figures are regularly published, so ask your GP or the service about the current wait in your area.
A study published in 2025 found that 5 of England’s 42 integrated care boards didn’t provide a tier 3 service in 2022 to 2023.11
The same study estimated that only 0% to 1.1% of the people eligible for tier 3 were referred, depending on the region.11
While you wait, you can ask your GP about tier 2 support, such as the NHS Digital Weight Management Programme for adults living with obesity who also have diabetes or high blood pressure.5
You can also ask whether you’re eligible for Mounjaro through the GP route.7
In England, Right to Choose lets you ask your GP to refer you to a different NHS provider, including remote tier 3 services outside your area.4
Do you need tier 3 before weight-loss surgery?
NICE’s current guidance doesn’t require you to complete tier 3 before you’re assessed for weight-loss surgery.6
NICE recommends offering adults a referral to a specialist weight-management service for a surgery assessment if they have a BMI of 40 or more, or a BMI of 35 to 39.9 with a significant health condition that could improve with weight loss.6
The person also needs to commit to long-term follow-up after surgery, and the lower BMI thresholds for the family backgrounds listed above apply here too.6
The committee that wrote the guideline said that making people try specific treatments, such as a tier 3 programme, before referral for surgery would create an unjustified barrier to effective treatment.6
It also noted that specialist services aren’t available everywhere in the country.6
NHS England’s 2014 report described tier 3 as a step before surgery, and some local policies still follow that order, so ask your GP or specialist team which pathway applies in your area.1
Choosing your tier 3 provider under Right to Choose
In England, Right to Choose lets you choose which provider you’re referred to for a first appointment with a consultant-led team, as long as your GP agrees the referral is clinically appropriate, and the provider holds an NHS contract covering the service.4
That contract has to be with an integrated care board or NHS England, be signed and in effect before you’re referred, and cover how the service is delivered, including remote care.4
Providers can deliver this care remotely, so you can choose a service based outside your local area.4
You can ask about Right to Choose when you discuss a specialist referral with your GP.
NICE has assessed digital weight-management services that prescribe medication, and says seven of them, including Second Nature, can be used in the NHS while more evidence is gathered.12
Second Nature’s NHS tier 3 service
Second Nature runs an NHS tier 3 service that takes GP referrals from 28 NHS areas in England. The NHS funds it, so there’s no cost to you and no prescription charge.
Your first appointment is a video call.
Your care team includes consultant doctors, specialist dietitians, psychologists, pharmacists and exercise specialists, and support lasts for up to 24 months.
If Wegovy injections are suitable for you, we prescribe them and deliver them to your home each month.
If medication isn’t suitable, or you’d rather not take it, you get a personalised plan for eating, behaviour change and activity, with regular check-ins from the same team, and access to our app with recipes and weekly educational articles.
A published study of our earlier 12-month remote programme included 1,130 adults referred by NHS primary care between 2017 and 2021, before medication was part of it.13
Of the 281 people (25%) who recorded their weight 2 years later, they lost an average of 11.8% of their body weight.13
If you live in an area with referrals and meet the criteria, you can ask your GP to refer you to us under Right to Choose.
Our eligibility checker at the top of this page shows whether you’re likely to qualify, and our referral guide explains what to say to your GP.
Once your GP’s referral reaches us, we confirm receipt and book your first appointment.
Take home message
Tier 3 weight management is the NHS’s specialist service for adults living with obesity, supported by a team of doctors, dietitians, psychologists, and exercise specialists for around 12 to 24 months.
Each local NHS area sets its own criteria, and the most common threshold is a BMI of 35 or more with a weight-related condition.
NICE’s 2025 guideline doesn’t require a tier 2 programme first and sets no upper limit on BMI or age, although some local policies still ask for previous attempts to lose weight.
Tier 3 is the main NHS route to Wegovy and one of two NHS routes to Mounjaro, but only some services are funded to prescribe them.
In NHS England’s 2024 survey, the average wait was 16 months.
In England, Right to Choose lets you ask your GP to refer you to another NHS provider, including Second Nature’s free tier 3 service if we take referrals in your area and you meet its criteria.
If you don’t meet the NHS criteria, or you’d rather not wait, our private programme combines weight-loss medication with one-to-one support from registered dietitians and nutritionists.
Our nutrition support is built around a balanced plate of half vegetables, a quarter protein, a quarter complex carbohydrates, plus a serving of fat.
In our published evaluation of our private semaglutide-supported programme, members who kept an active subscription for 12 months had an average weight loss of 19.1%.14
Of the members with 12-month data, 77.7% lost at least 10% of their starting weight.14
Frequently asked questions
Is tier 3 weight management free?
Yes, tier 3 is an NHS service, so the appointments and support are free.
If your service prescribes medication, you may pay the standard prescription charge in England, which is £9.90 per item, unless you’re exempt.15 Second Nature’s tier 3 service has no prescription charge.
Can I refer myself to tier 3 weight management?
Tier 3 needs a referral, usually from your GP, so you can’t normally sign up yourself, although some tier 2 programmes run by local councils accept self-referrals.
Can you get Mounjaro on tier 3 weight management?
You can get Mounjaro through tier 3 in some areas, depending on whether your local service offers it and which groups it prescribes for.7
GPs also prescribe Mounjaro for people in the rollout groups, so you may not need a tier 3 referral to get it on the NHS.7
What’s the difference between tier 3 and tier 4?
Tier 3 offers specialist support for eating habits, activity, and psychology, plus weight-loss medication in some services, while tier 4 includes weight-loss surgery and the care around it. NICE no longer requires people to complete tier 3 before they’re assessed for surgery.6
Is tier 3 the same as class 3 obesity?
Tier 3 and class 3 obesity are different things. Class 3 obesity means a BMI of 40 or more, while tier 3 is an NHS service.6
You don’t need class 3 obesity to be referred to tier 3, because the most common threshold is a BMI of 35 or more with a weight-related condition.3
How long does tier 3 weight management last?
Most tier 3 programmes last 12 to 24 months, and NHS England’s 2024 survey found an average pathway length of 18 months.1,3 Second Nature’s tier 3 service provides support for up to 24 months.
Can I pay for weight-loss medication privately while I wait for tier 3?
You can see a private prescriber while you’re on the waiting list, and they’ll assess whether medication is suitable for you. Tell your GP about any private weight-loss medication, because it can affect other treatment decisions.10
In south-east Essex, for example, people paying privately for Mounjaro join the end of the existing NHS waiting list if they qualify.10
Is a remote tier 3 service a real NHS service?
A remote tier 3 service is an NHS service when the NHS funds it. Providers that accept Right to Choose referrals hold NHS contracts, and their care is free in the same way as a local clinic.4
What can I do if my GP won’t refer me to tier 3?
Ask which criteria you don’t meet, and whether a tier 2 programme or Mounjaro through your GP is an option in the meantime.7
Right to Choose applies only once your GP agrees a referral is clinically appropriate, so it doesn’t replace meeting the criteria.4
What happens when NHS Wegovy stops after 2 years?
When NHS Wegovy stops, NICE recommends offering support to help maintain weight loss, so talk to your prescriber and tier 3 team about what support continues before the prescription ends.6
NICE recommends NHS Wegovy for up to 2 years.2
