Improving asthma services is challenging in an environment where financial drivers can predominate over creating frameworks of excellence. Respiratory services generally are also under-funded compared with other disease areas. However, the foundations for quality improvement initiatives are already to hand. Demonstrating improvement with existing resources is also a pre-requisite of demanding further financial support from governments. Currently HCPs and clinicians can base their actions on frameworks for the diagnosis of asthma (62), individual-level management (19, 32), and system standards for primary, secondary and asthma specialist care (3, 63, 64). Tools to diagnose and monitor asthma, such as exhaled nitric oxide monitors, oscillometry, and smart inhaler devices, are becoming cheaper and more widely available. Despite this, few primary care practices – and indeed not all secondary care respiratory units- utilise them, often because of difficulties with reimbursement. Digital tools which identify high-risk patients are being more widely implemented primary care. One example is the Optimum Patient Care (OPC) service, a well-established UK audit scheme recently rolled out in Australia and designed to facilitate detection of suboptimal asthma control or treatment and facilitate onward specialist referral (65). Figure 5 illustrates the key indications for referral to an asthma specialist as mentioned in GINA and BTS/NICE/SIGN guidelines. This figure also highlights the factors associated with increased asthma-related deaths warranting urgent referral.

As the overwhelming majority of asthma care in the UK is delivered through the National Health Service (NHS), there is also clear scope to expand and act on regional and national data reporting (66), something that is challenging in other countries.

There is strong evidence that implementing consistent and widespread system changes can lead to marked improvement in clinical outcomes. The 10-year, country-wide program in Finland (67) was based on simple principles such as early diagnosis, proactive use of guideline-based treatment, education, tobacco avoidance, rehabilitation and research. It achieved its aim to lessen the burden of asthma on individuals and society, with a reduced number of days spent in hospital for asthma, and costs for both asthma care and disability benefits decreased. The Finnish programme viewed asthma as a public health problem that required public health solutions, and this is perhaps a key message for change. Improvements have not been sustained as there was no continuing investment – a common occurrence also in the UK.

Another potential solution to the variability in care provision is to systematically accredit clinics for the provision of airways disease care. This has been done in southern Sweden, an initiative that is now being rolled out across the country (68). Using a system of accredited centres also allows use of a standardized approach to diagnosis and treatment, potentially supported by clinical decision aids, as has been applied in the Netherlands for COPD (69). This also avoids the current difficulties potentially introduced by conflicts in treatment guidelines.

To produce positive change, any major issue must be broken into discrete targets that require well-defined actions by specific groups. We believe that these could potentially be summarized as action points (Table 2) for clinicians and healthcare management working collectively at local and regional levels.

Success at scale will be achieved when invested parties work together in a coordinated fashion across provider boundaries. This was central to the progress made in Finland (67), but appears a barrier to improving outcomes in other countries such as the United States (70). Increased collaboration has been evident in the UK with the advent of severe asthma networks for adult services (71), with some progress through Primary Care Networks, and the National Asthma and COPD Audit Programme (NACAP).

Active patient involvement is important; however, we cannot rely on self-educated patients to drive change in a sub-optimally functioning system. Despite readily available quality asthma information, patients are facing an increasingly complex online environment with pervasive and sophisticated mis- and disinformation (72, 73), which may have deleterious social and health-impacts depending on the individual's online health literacy (74).

Efforts to initiate reform should avoid any perception of blaming colleagues and patients, which can fracture public confidence in HCPs. This is analogous to the car industry switching from criticizing “the nut behind the wheel” (in this case, “non-adherent patients” and “lazy GPs”) to collating better data and introducing subsequent safety advancements, such as anti-lock brakes and airbags, that require minimal user input and make allowances for real-world behaviours. Indeed, we have already taken first steps in this direction, as the concepts behind NRAD and NACAP are similar to the successful Fatality Analysis Reporting System in the car industry (75). This coordinated reporting should also facilitate the use of common language to describe types of asthma and common comorbidities.

The management of asthma has largely been based on secondary prevention (17, 51), whereas other specialties have been successful in managing risk factors. For example, the rate of fatal heart attacks in England fell by about half between 2002 and 2010, (76) coinciding with widespread deployment of risk assessments. Emphasising both primary prevention and the use of specialised therapies to reduce harm has the potential to clarify the roles of primary and hospital providers. The majority of people with asthma have modifiable risk factors for future attacks, such as suboptimal inhaler technique (77). These factors could be identified and addressed in primary care in a more systematic fashion by leveraging electronic medical records, potentially with decision-support tools (78). However, decision-support tools are often ineffective if they are not incentivized (79). In the medium term a potentially promising avenue is the development of more community respiratory clinics that bring asthma specialists and quality assured diagnostics closer to patients (60, 80). Such services can improve cross-provider communication and facilitate training as Respiratory teams and GPs work alongside each other (81). Digital innovations such as remote sensors, telehealth solutions and mobile apps offer the opportunity to gather novel real-time data and radically redesign and decentralize asthma care in the future (82). This area is beyond the scope of discussion of this article. However, as there is no current consensus on the most effective or safest way to deploy such technology-based solutions, in the short term they risk introducing additional complexity and increased workload for healthcare providers (7, 83).

A key aspect requiring further study relates to understanding the barriers to referral to a hospital asthma clinic (7). However, two likely contributors to low referral rates could be relatively readily addressed. Firstly, the use of structured reviews can identify patients for whom control is not achieved (84), and can be undertaken by appropriately trained nursing staff when GP resources are stretched. Using standardized criteria should also facilitate the provision of appropriate details in a referral (85), including information such as prescription fulfilment rates that may not be accessible from secondary care. Secondly, systematic assessment at a dedicated severe asthma centre has been shown to improve quality of life and asthma control whilst reducing primary care/emergency department visits, hospital admissions and OCS use (86). It should be straightforward to create an online resource that ensures that GPs and, crucially, patients know where their nearest centre is (71)—indeed respiratory care maps have been developed by the NHS but inexplicably abandoned. This will avoid the unnecessary delays and loss of user confidence that occurs when people with difficult-to-treat asthma are referred to general respiratory clinics, as around half of people in the UK appear to be (87).

In this article, we have highlighted issues in existing systems that could be addressed to achieve incremental improvements in the overall care of individuals with asthma. However, drivers need to be developed by those at the highest level of provider organisations to ensure that transparency and accountability are upheld. This could include incentives to ensure that improvements in minimum standards are consistently achieved, such as the accreditation and appropriate renumeration of community respiratory clinics, with providers being obliged to publish rates of concordance with standards and statistical process control charts replacing less informative red-amber-green ratings. Recurrent central data collection (such as those provided by NRAD, NACAP and the RCEM audit) and quality improvement activities are fundamental, as are clear routes to access the data collected and stored at great expense.