Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN)

  • NICE guideline
  • NG245
  • Published: 
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Implementing NICE guidelines to improve children and young people’s asthma care

Overview

Organisation: Brent Integrated Care Partnership

Organisation type: North-West London integrated care system

Brent is one of 8 boroughs in North-West London (NWL) integrated care system. Whole Systems Integrated Care Data for NWL (July 2024) revealed that only 2.3% (1,969) of Brent's children and young people have a diagnosis of asthma, with 29% of those diagnosed living in highly deprived neighbourhoods. Brent also has one of the highest hospital admission rates for asthma among children under 9 in London, with 302.2 admissions per 100,000 children. Brent accounted for over 20% of NWL admissions in the first 2 months of 2025. Brent has high levels of health inequalities with over 149 languages spoken; 37% of residents do not have English as their first language, and an estimated 71.57% of adults are below health literacy and numeracy thresholds.

The recent GIRFT (getting it right first time) review for asthma in Brent uncovered the following key issues: 

  • Low diagnosis rate. Across NWL, the asthma diagnosis rate is 4.1% compared with a national average of 6.8%. Brent is below the NWL diagnosis rate.

  • High-risk prescribing (high use of short-acting beta-2 agonist relievers compared with low use of inhaled corticosteroid preventers). Brent has the lowest percentage of children prescribed inhaled corticosteroids across NWL. The borough is above the integrated care board average for the number of children with 6 or more SABA prescriptions within a year.

  • Low number of asthma reviews. Brent has low levels of children and young people having their inhaler technique reviewed in primary care relative to the NWL average, suggesting many asthma reviews in Brent are currently conducted by telephone. 

  • High rate of asthma-related emergency care activities. Brent has the highest hospital admissions for children with asthma among all NWL integrated care system boroughs. 

The timing of the GIRFT review coincided with the release of the new BTS, NICE and SIGN guideline on asthma, and the National Child Mortality Database asthma and anaphylaxis report, which together reinforced health inequalities as key drivers for change. Local intelligence by the Brent Health Matters (BHM) health inequalities team also identified inconsistencies in coding, gaps in data flow between hospital and primary care, and missed 48-hour post-A&E reviews. This prompted the borough leadership to prioritise asthma care as part of their Locally Enhanced Services (LES) programme. These are additional primary care services commissioned locally to address specific community health priorities beyond the core GP contract.

The borough team subsequently developed 2 LES initiatives aimed at accelerating the adoption of the BTS, NICE and SIGN asthma guideline, with a specific focus on improving the diagnosis and management of asthma in children aged 5 to 17 years.

The primary objectives of the LES were: 

  • Improved identification and diagnosis: to assess children with suspected asthma, review them to decide if objective testing is appropriate, refer for objective diagnostic testing and review the child following testing with a view to confirming a diagnosis. The aim is to improve the asthma diagnosis rate and ensure that children benefit from the long-term condition management frameworks available in primary care. The following case-finding searches were used to identify suspected asthmatics, and 1,877 children in Brent were identified.

    • suspected asthma coded in the last 5 years 

    • wheeze coded in the last 2 years 

    • 2 or more SABA inhalers issued in the last 1 year 

    • 2 or more corticosteroid inhalers issued in the last 2 years, or 1 or more corticosteroid inhalers issued in the last 1 year 

    • oral prednisolone in the last 1 year and no associated condition requiring prednisolone 

    • asthma review coded in the last 5 years, despite no asthma diagnosis 

  • Improved management of children and young people with high-risk asthma: to identify children with high-risk asthma and provide an extended face-to-face asthma review, ensuring their treatment aligns with NICE guidelines. The following search criteria was used:

    • asthma and an EpiPen prescribed  

    • oral steroids prescribed in the last year 

    • 4 or more SABA prescriptions issued in the last year  

    • SABA-only regime (2 or more SABA prescriptions in 12 months with no integrated care system).  

The high-risk asthmatic search has identified 922 children eligible for this review. Crucially, this also involves addressing contributing socioeconomic factors, such as mould, poor housing conditions and household smoking by offering appropriate signposting, support or intervention to manage these risks effectively. 

There is also a complementary paediatric Core20 health check LES, which includes mandatory asthma symptom screening and household smoker screening.

The EMIS templates developed for the LES schemes embed direct links to the relevant NICE guidance, including the full asthma diagnostic investigation sequence. By integrating the guidance within the clinical workflow, the templates prompt clinicians in real time and encourage adherence to NICE guidelines by actively supporting this during consultations.

The schemes were commissioned at a primary care network (PCN) level rather than as a practice-based LES to promote a population health approach, strengthen collaboration between practices and secure PCN-wide engagement. This design creates shared accountability which, in turn, drives mutual support and collective responsibility for delivering the scheme.

A number of support services and additional resources were mobilised to support the LES schemes. These included:

  • The launch of a children and young people asthma diagnostic service which provides FeNO, spirometry and blood testing as per the BTS, NICE and SIGN guideline, which support objective testing for asthma diagnosis.

  • Local GPs and clinicians received tier 3 asthma training, a programme aimed at healthcare professionals directly involved in diagnosing and managing asthma. The training focused on advanced aspects of asthma care, including updates on the latest NICE guidelines, to support consistent, evidence-based management across primary care. BHM identified and targeted attendees delivering care in the most deprived communities. Following its success in Brent, the training model was adopted and rolled out by the NWL integrated care board.

  • Promoting GP attendance at a multi-borough children and young people asthma monthly learning meeting where tricky cases could be discussed with a paediatric consultant.

  • The borough's approach further supports the BTS, NICE and SIGN asthma guideline by improving rapid post-discharge follow-up with multilingual resources and community asthma champions, distribution of spacer packs, strengthening self-management through a healthy child leaflet, VCSE links, digital tools and guidance on damp and mould, widening access to specialist care through an expanded community nurse role with a new self-referral pathway. Brent adopted an integrated approach to asthma across the borough monthly meetings with attendance from school nursing, health inequalities teams, primary care, and others. Initiatives as a result of this included rolling out the asthma-friendly schools scheme and running an asthma community fair.

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