For over 3 years, RediCare has been delivering prevention and treatment services for Metabolic Conditions such as T2, NDH, PCOS, NAFLD and Overweight Conditions in an Integrated Neighbourhood Teams, Place Based Setting.
Why Should your INT Focus on Metabolic Health?
Metabolic health conditions, including Type 2 Diabetes and Obesity, account for a combined £16.4 billion of the NHS's annual healthcare spend
Metabolic Conditions are responsible for:
- Approximately 6 in 10 GP appointments
- Patients with chronic conditions see their GP nearly twice as often (5.5 vs 3 visits per year)
- Obesity contributes to over 1 million hospital admissions per year
- Rising levels of in Polypharmacy
Metabolic Conditions We Treat
Type 2 Diabetes
Non-Diabetic Hyperglycaemia
Hypertension
Obesity
Gestational Diabetes
Sleep Apnoea
Dyslipidemia
MASLD
P.C.O.S
How we Fit into an INT in Place Based Care
RediCare is designed to integrate seamlessly into existing INT structures, supporting local teams without adding to their workload:
- Delivered as adjunct to usual care
- No extra workload on the INT
- Regular reporting on all KPIs and all clinical outcomes
- Fully transparent service
- Integrated service (EMIS & SystemOne)
What does Success Look Like?
It's a Curve Bend
In order to prevent the rapid growth of chronic disease, we need to Bend the Curve. This means arresting the current trajectory and actually bending the curve downward. Look at the below two graphs.
- 1. Current Trajectory of NDH in a PCN we currently work with
- 2. What a curve bend looks like over a 5 year period
How is RediCare Bending the Curve?
Our evidence over the last 3 years is showing that place based delivery of care provides a structure to bend the curve on Chronic Illnesses. Place based care enables the following:
- Local Population Analysis: Understanding the historical trends and projections on people living with Type 2 Diabetes, NDH, or other metabolic conditions within the local population
- 5 Year Plan Development: Designing a long-term, structured plan to support all patients with a metabolic disorder across the neighbourhood.
- Prevention and Treatment: The plan needs to be a large population approach with a strong emphasis on disease prevention and progression with specific treatment plans for those who already suffer from long term chronic conditions.
- An Integrated Approach: This will allow clinically appropriate segmentation of patients who are suitable for a large population support model and for those who need a more intensive human touch approach, with the appropriate clinical protocol where medication adjustments and de-prescribing is required.
- Data Analytics: Regular measurement of The Curve Bend, IE analysis and reporting of all clinical outcomes that effect the patient population. (For example, how many T2 Diabetics were brought below threshold in the last quarter, how many patients with BMIs over 30 got below threshold).
The Model is Live and Recognised
In 2025, RediCare and Meon PCN were named one of the final 7 entries out of over 400 submissions in the HSJ Awards for Driving Prevention and Early Intervention through Digital.
Our shortlisted case study showcases how we tackled Type 2 diabetes at PCN level through a digitally led, population-based approach.
Preventing and Managing Chronic Disease at Scale through Digital with Meon PCN
View Case Study
Our Clinical Outcomes
These outcomes can be delivered at scale in Place Based Care:
Join Us on Our Mission using Large Populations Approach to Bend the Curve on Chronic Disease
The Darzi Review, Fuller Stocktake,and NHS People Plan all stress the need for urgent action on staff wellbeing to sustain the NHS and safeguard patient care.