Despite regularly updated guidelines, new evidence generation and a growing awareness of the prevalence and burden of asthma and chronic obstructive pulmonary disease (COPD) in the community, both diseases place a major strain on healthcare resources, particularly in causing hospital admissions, demands on urgent healthcare resources and at a personal level, significant impact on school and work attendance, activities of daily living and mental health and well-being.1 2 Many factors contribute to persistent symptoms and undertreatment, particularly the normalisation of symptoms, reluctance to take medications day by day to reduce the risk of exacerbations which might occur only once a year and in the case of asthma in particular, poor understanding of the consequences of a rescue approach to management.3 4 Although this is costly at a systems level, much of it is preventable, but patients’ needs are not always met by conventional avenues of care and there is an immense strain on these systems as populations age and chronic disease management become the norm.5

Approaches to care that are holistic, that deliver personalised care and achieve measurable benefits for patients as well as ensuring an efficient use of limited healthcare resources are needed6 and integrated disease management (IDM) programmes may provide such a solution. Evidence has been accumulating over the last one to two decades that IDM programmes can improve health outcomes for patients with chronic disease and complex care needs. IDM is defined as ‘a group of coherent interventions designed to prevent or manage one or more chronic conditions using a systematic, multidisciplinary approach and potentially employing multiple treatment modalities. Programmes usually incorporate coordination of healthcare services, team-based care, a focus on individualised patients’ needs and patient education, including the development of self-management skills.7 Although some …