Skip to main content
Back to the Project Library

Identifying Poor Asthma Control

Estimated time for a practice with 10,000 patients:
10-20 hours for the initial project (excluding re-audit)

Can be done by a GP, Pharmacist, Nurse, Trainee or Student

Green Impact for Health Toolkit area: Prescribing & Quality Improvement

CQC Areas

  • Well-Led (Environmental Sustainability)
  • Effective (Delivering Evidence-Based Care and Treatment)
  • Caring (Independence, Choice, and Control)

On this page

The benefits of this project

Project benefits for Your Patients

Benefits for Your Patients

  • Reduces risk of asthma attacks and deaths
  • Improves quality of life by reducing symptoms and increasing ability for physical activity
  • Reduces health inequalities as poorly controlled asthma more common in disadvantaged communities.
Project benefits for Your Practice

Benefits for Your Practice

  • Reduces workload by reducing unscheduled care related to poorly controlled asthma
  • Maximises opportunities for patients at highest risk to attend asthma review
  • Costs of poorly controlled asthma estimated as 52% higher that well controlled asthma
Project benefits for The Planet

Benefits for The Planet

  • Well controlled asthma has 1/3rd of the carbon footprint of poorly controlled asthma

  1. Search for patients with asthma who are at high risk of adverse clinical outcomes.

    Search for patients with asthma who are at high risk of adverse clinical outcomes.

    We have collaborated with Primary Care IT who have created bespoke searches for all our asthma toolkit projects for SystmOne and EMIS users.

    For practices using SystmOne, request here: SystmOne free resources – Primary Care IT

    For practice using EMIS, request here: EMIS free resources – Primary Care IT

    The search for this project is called Disease control project 1.

    Use the search to make a list of patients aged 5yrs and over who have a diagnosis of asthma who:

    • have used 3 (or 6) or more SABA in last 12 months
    • OR have received 1 or more courses of oral steroids in last 12 months
    • OR have code ‘asthma exacerbation’ in last 12 months

    The reports will also show you whether patients have 1, 2 or 3 of the above risk factor

    • Data collection table for risk factors

  2. Invite identified patients to asthma review consultation.

    Invite identified patients to  an Asthma Review Consultation. Engage the team members who will undertake these asthma reviews and inform them of the rationale for reviews (some patients may not yet be due their yearly review).

     

    Resource: Example text for patients with SABA overuse.

    It looks like you have needed 3 or more reliever (blue) inhalers in the past year – this may mean that your asthma treatment needs reviewing. Please book an asthma review. To learn more read this leaflet https://bit.ly/4mT5DPn or watch this video https://bit.ly/3TiNoVL.

  3. High-risk patient text invite

    Resource: Example text to high-risk patients

    From your notes it looks like your asthma may not be well controlled. Please book an asthma review so we can review your treatment, reduce your symptoms and reduce your risk of asthma attacks. To get the most out of your review see: https://www.asthma.org.uk/advice/manage-your-asthma/adult-review/ To learn more read this leaflet https://bit.ly/4mT5DPn or watch this video https://bit.ly/3TiNoVL. Remember to bring if you can to your asthma review: your inhalers and spacer, your Personalised Asthma Action Plan and your peak flow meter.

  4. Letter invite

    Resource: Invitation letter template

    Dear [Patient], Our records show that your asthma may not be well controlled. This may be because you have had an asthma attack or exacerbation recently, or because you are needing more or less than the recommended amount of medication. Please call to book an asthma review appointment as soon as possible. Asthma reviews are essential to help ensure you’re on the right treatment. Being on the right treatment should reduce your symptoms and lower your risk of future asthma attack. Many people don’t realise their asthma could be better controlled. Did you know that good asthma control means you will rarely or never have symptoms? Or that if you need more than two salbutamol (blue) inhalers a year, this could mean your asthma control needs improvement? This website explains how to get the most out of your review: https://www.asthma.org.uk/advice/manage-your-asthma/adult-review/ To learn more read this leaflet https://bit.ly/4mT5DPn or watch this video https://bit.ly/3TiNoVL. We look forward to seeing you soon for your asthma review. Please remember to bring these things to your appointment if you can: your inhalers and spacer, your Personalised Asthma Action Plan and your peak flow meter. Many thanks, [Practice name/ lead clinician]

  5. Conduct asthma review consultations with patient.

    We recommend watching the education videos on disease control, device choice and asthma reviews, as well as looking at the Visual Aid for Improving Asthma reviews, before commencing this project. You could watch these as a whole team or share your learning with the whole practice.

  6. Consider if any patients need referral to secondary care.

    The majority of patients with poor asthma control will improve with better adherence to preventer medication and optimal technique with the best inhaler device for them. However, if they still have symptoms suggesting severe asthma, they may benefit from a referral to secondary care. Patients with severe asthma may be eligible for newer therapies such as biologics.

    SPECTRA has referral template tools.

    Review the results, summarise learning, share with practice team, and decide if any changes are needed to improve the process.

    Decide when to re-audit again to ensure the change has lasted e.g. 3-6 months and use the Project Monitoring form to keep track.

    Many practices run automatic searches at regular intervals – speak to your practice team about including this project in those searches.

  7. Follow up patients who do not respond to invite

    Send list of identified patients to asthma nurse/ asthma lead/ reception/admin to chase up reviews or set scheduled task for [x] months’ time to re-invite if not yet attended. You may wish to set alerts for those at highest risk so that they can be reviewed opportunistically.

  8. Re-audit

    Re-rerun your search again in 6 or 12 months time.

    We recommend this search is done every year to risk stratify asthma patients and focus follow up efforts on patients at highest risk of poor control.

Opportunity for improvement

  • The 2024 BTS/NICE/SIGN guideline NG245, recommend risk stratification in primary care to improve asthma care. Overuse of SABA inhalers, courses of oral corticosteroids and previous exacerbations requiring unscheduled care, are all listed as relevant factors. The searches for this project include all these risk factors.
  • Prioritising asthma reviews for patients at the highest risk of poor asthma control, ensures that those who need care the most are seen early and ensures plenty of opportunity for follow up. For this reason, you may wish to incorporate this risk stratification into your yearly asthma reviews.
  • Familiarise yourself with the evidence for improved asthma control with combination ICS-formoterol inhalers as AIR or MART therapy for people 12 years and over.  We recommend watching our disease control, device choice and asthma review videos before starting this project.
  • Pressurised metered dose inhalers have a very high carbon footprint and are responsible for 13% of the emissions of the NHS that it directly control. For patients with asthma, most of these emissions are from the overuse of SABA inhalers directly linked to poor asthma control.
  • (see disclaimers)
  • You might like to make a SMART goal for this project, such as auto-flagging all SABA prescriptions exceeding 5 prescriptions/year.

How to carry out this project

Top tip

Raise expections for patients! If their asthma is well controlled they will be symptom-free and will rarely need to use their inhaler for symptom relief.

Explain to patients (12 years and over), that the new UK asthma guidance recommends combination inhalers and these have been shown to reduce the risk of asthma attacks. They contain a rescue treatment (formoterol) which works just as fast as salbutamol but lasts longer. This can help patients feel reassured about trialling a change in inhaler from their SABA (blue) inhaler, to combination ICS-formoterol inhaler regimes.

Case study

In 2024, Lucy Dowd, a 4th year BSMS Medical Student, used this QIP for her Independent Research Project at Mile Oak Medical Centre in Brighton. She discovered 39 of our 8,500 patients had requested 12 or more SABA inhalers over the previous 12 months. She reaudited 12 months later, and discovered that this had been reduced to 5 patients.

How to scale this project up and down

Please note – Use of this project requires NetworkPLUS membership. If you would like to share this project with others, please invite them to purchase their own membership—access must not be shared with non-members.

You could upscale this project by taking it to your PCN pharmacy team to implement across all practices in your PCN. This would require all practices purchasing access to the project.

Have you completed this QIP?

Tell us a little about your project and enter your data in order to generate a certificate showing the cost and carbon savings and other probable benefits. This project may help with CQC evidence submission (see disclaimers).

Get your certificate

More project guides

View all
NetworkPLUS content

Our Project Library is only available to NetworkPLUS members. Please log in or sign up to continue.

Register
Login
Find out more about membership