The Big Interview – Tarja Stenvall

Tarja Stenvall is the general manager for the Diabetes and Cardiovascular Business Unit and UK Country Chair for Sanofi.

The pharmaceutical company has an 85-year commitment to improving the health and wellbeing of people with diabetes and strives to improve global diabetes management through its integrated offering of treatments.

How does Sanofi help people with diabetes?

Sanofi has a long standing history in diabetes care, having been involved in treating diabetes for nearly a century. We are at the origin of some of the major scientific and medical advances that have helped transform the lives of people with diabetes, including the first production of insulin in 1923.

Over the years we have built a strong understanding of the world of those both with diabetes, and those who treat diabetes. We are as committed as ever to supporting people with diabetes and their carers’, and the health professionals who look after them.

In a traditional sense, we research, develop and provide medicines, support and services which we hope helps to empower and support people with diabetes, their families and carers’ to live their lives to the fullest.

But we also support many broader programmes and initiatives, both nationally and locally, which we hope helps to improve the environment for people living with diabetes in the UK.

What sort of programmes do you invest in?

Nationally, we work with partners across the diabetes spectrum, including patient groups such as Diabetes UK, JDRF, Input Diabetes, Diabetes with Eating Disorders, Diabetes Research & Wellness Foundation and Flying with Diabetes.

We also work with professional groups including BSPED, ABCD and PCDS, and since 2008, we have supported the Diabetes Think Tank, which meets in Parliament three times a year.

The aim of programmes such as these is to ensure that diabetes continues to be a national priority for Government and the NHS.

We also work with the NHS and Diabetes UK to support local programmes. These range from funding to help educate commissioners and other health professionals on diabetes pathways, to supporting local health services to identify potential cost savings: by providing research and analyses to help make decisions on spending, such as the IMPACT 2 study on diabetes.

In addition, we are the proud sponsor of the Quality in Care Diabetes Awards. It is so important to recognise and reward those individuals, teams, Trusts and partnerships who work tirelessly to improve care for people with diabetes, which is why we are sponsoring it for the 6th year.

What’s the biggest challenge today in diabetes care?

Firstly, we are concerned about the lack of clear differentiation between those with type 1 and type 2 diabetes, particularly in primary care services.

People who have type 1 diabetes need a high level of expertise and technical help as quickly as possible, yet misdiagnosis still takes place.

More education is needed, backed up by clear requirements around coding, to help ensure that there is understanding across the whole NHS, and wider public, about the differences between these two conditions.

Secondly, we have continuing pressures in the health service. We know there is excellent care in many parts of the country, but there is concern around the time capacity and experience in primary care; particularly when you take into consideration the rapidly increasing numbers of people with type 2 diabetes.

This can lead to delays in diagnosis, and therefore, delays in referral to specialists, and also delays in intensification of treatment.

Despite well-documented benefits of reducing complications through timely control of blood glucose, in the UK levels are too high before additional interventions are provided.

On average, people in the UK with type 2 diabetes have the highest blood glucose levels (HbA1c 9.8 per cent) when compared to nine other developed countries, at the point of insulin initiation.

It can also mean that people are not supported appropriately in terms of taking medication. It is not clear how many health professionals in primary care are confident in identifying the appropriate time for a person to move onto insulin or other injectables, or whether there is a need for intensifying or titrating the therapy.

By not appropriately titrating, it will mean that the treatment will not be doing the best job it can for the individual taking it.

What, if anything, can be done to help overcome this?

We know the vast majority of doctors and nurses go into the profession because they want to help people to feel, and be, better.

But the current pressures on the system and the growth of chronic conditions, such as diabetes, are making it more challenging to provide optimal care for each individual; especially as care is driven more and more into the primary care setting.

More support must be given to doctors and nurses who are not specialists in diabetes; either in direct education, or by getting CCGs to bring in specialists to support and advise GPs and practice nurses in the community on the management of people with diabetes in their area.

What are your views on the early treatment intensification in type 2 diabetes?

Ultimately we believe that everyone should be treated as an individual, in line with the recently updated type 2 NICE Guidelines.

It is essential that people with diabetes understand why treatment targets, including blood glucose levels, are important. Particularly in terms of the impact on potential complications in the long run; such as foot disease and kidney problems.

However, it is incredibly important that the person with diabetes and their doctor or nurse agree what the appropriate blood glucose level is for them, as there are often rational reasons why people are not at the NICE defined ‘target’ HbA1c.

We are also concerned that some health professionals, and indeed people with diabetes, approach diabetes with a ‘treat to fail’ approach; where people are put on the defined treatment in a clinical pathway, then when their blood sugars creep up, as often happens as part of the natural progression of diabetes, they are deemed to have failed on that treatment.

They then move onto the next one, where the same process occurs, leaving the person to feel that, ultimately, they are ‘failing’.

We want people with diabetes to feel empowered that the treatment they are on is the right one for them and is supporting them to live the life they want to live, but to understand that part of this process is to intensify treatments or try different ones.

It is essential that all is done, in partnership with the person with diabetes, to ensure that they have the best possible outcomes for them in the long term, as well as the short term, both physically and psychologically.

How much of an issue is clinical inertia in the treatment of type 2 diabetes?

An important milestone for people with Type 2 diabetes is that the new NICE guidelines support an individualised approach to diabetes care.

In some areas, there has been a tendency to delay putting people with type 2 diabetes onto treatments such as insulin, and then titrating that insulin properly. There can also be a systematic approach to the treatment pathway, rather than focussing on that individual person’s needs.

As I have previously mentioned, the average HbA1c for initiating people onto insulin in the UK is 9.8 per cent – this will undoubtedly have an impact on the complications these people may experience later on in life.

A recent study we commissioned alongside Diabetes UK and JDRF, the analysis of which was completed by IMS and York Health Economic Consortium, found that, if sustained, even modest improvement in blood glucose levels can provide significantly improved outcomes.

Why do you think this is?

We believe this is down to several factors. Firstly, for people with type 2 there is a fear of being put onto an insulin – we believe, due to existing knowledge, which can be compounded by discussions earlier down the line in people’s diabetes care, there is a feeling that insulin is a last resort.

Insulin is a life saving treatment and, with regard to the current medicines available and the fact that many people are living longer with diabetes, many people with type 2 diabetes may need to use it at some point in their life.

We understand that getting to a point where you will need to inject yourself daily is a life changing event. However, for the benefits it can afford you; both in terms of how you feel on a daily basis, and your quality of life in the long term, it is such a shame that it can be pitched as a negative last resort.

As well as potentially leading to a delay in that individual receiving what may be the most appropriate treatment, it can also negatively impact how well a person manages their insulin in the early weeks.

This can affect how that person feels psychologically, but also, if not taken properly, the benefits may be reduced. This can lead to a complex relationship between that individual and their medicine.

Secondly, our research has shown that around 30% of titration happens in primary care, yet, as I have already said, we know there is a lack of confidence in some health professionals to deliver this.

As more care is driven into primary care services, it is essential that those health professionals are supported to deliver care to people with diabetes in the best way possible; especially as the numbers of people with diabetes, particularly type 2, is so great now.

It is important that they are supported to recognise the people who need titration or treatment intensification and are able to support this in a timely way.

What do you think to the new the CCG Improvement and Assessment Framework and what it will mean for diabetes?

We are delighted that diabetes features in this important measure for the local NHS and believe it keeps a vital focus on the importance of diabetes care at CCG level.

The critical piece will be how CCGs are supported to improve. We have been well supported in terms of diabetes metrics over the years, with the National Diabetes Audit and the QOF.

But measuring the ‘numbers’ is not enough – it is essential that areas identified as ‘needing support’ are then actively supported to improve.

We are reassured to hear that the Right Care programme may be involved in this programme. However, we would like to see the framework include clear ambitions to deliver progress.

We would also like to see the indicators differentiating between type 1 and type 2 diabetes.

This would help ensure better local data collection around these two different conditions and would help drive increased understanding across the broader NHS about the important differences between them.

Implemented in the right way, we think this could be a game changer in terms of further driving up quality of local diabetes services across the UK.

What’s the most exciting achievement at Sanofi over the past few years?

We are really excited about the recent announcement of a partnership with Verily (previously Google Life Sciences). The collaboration is aimed at improving care and outcomes for people with type 1 and type 2 diabetes.

The companies are currently exploring how to improve diabetes care by developing new tools that bring together many of the previously separate pieces of diabetes management and enable new kinds of interventions.

The partnership is looking at better ways to collect, analyse and understand the multiple sources of information impacting diabetes. The hope is that it will be easier for people to successfully manage their diabetes, which would reduce the risk of complications, improve outcomes and ultimately lower costs.

We believe diabetes management can be simpler and more convenient, which will help people with diabetes to achieve an improved quality of life.

This programme of work will not only help manage healthcare costs more effectively but will, crucially, help improve the experience and outcomes for people with diabetes.