As part of our 2025-26 Respiratory Review, Asthma + Lung UK surveyed every Integrated Care System (ICS) in England on respiratory diagnostic provision and governance. Thirty eight of the forty two systems in place during 2025/26 responded, either directly through a survey or from a Freedom of Information request.
We also analysed emergency respiratory admissions for children aged 15 and under across every ICS in England in 2025/26.
Collectively the results reveal that children’s respiratory care across England is fragmented, ICS clinical leadership is in retreat, and there are signs that children are missing out on vital asthma tests.
Over one million children in England are living with asthma, making it one of the most common medical conditions among children and young people. It can impact children and young people’s ability to live a normal, healthy life. Children and young people with asthma are more likely to have special educational needs relating to poor mental health, and perform worse in exams.
Children’s emergency admissions
Children and young people with respiratory conditions face stark inequalities depending on which region of England they live in and the level of deprivation in their communities. This variation is borne out in our analysis.
There is substantial variation in childhood asthma emergency admission rates between Integrated Care Systems. The highest rate, reported in Shropshire, Telford and Wrekin is 446% higher than the lowest rate, in Frimley (equivalent to 5.5 times the rate). The same two Integrated Care Systems have the lowest and highest rates for childhood respiratory emergency admission rates with a rate observed in Shropshire, Telford and Wrekin that is 241% higher than Frimley (equivalent to 3.4 times the rate).
The variation seen across the country is not random; it is closely linked to an area’s concentration of deprivation. For asthma emergency admissions among children, the rate in the ICS with the highest concentration of deprivation (Birmingham and Solihull) is 93% (or 1.9 times) higher than the rate seen in the ICS with lowest concentration of deprivation (Surrey Heartlands). For respiratory emergency admissions, the rate is 72 % higher.
Previously published Asthma + Lung UK research shows that over a third of childhood emergency asthma admissions in September 2025 were for children from the most deprived areas of England.
While distressing for both child and parent, a hospital admission can also be a signal of poor condition management. The National Child Mortality Database found that almost two-thirds of the 54 children who died from asthma between April 2019 and March 2023 had attended an emergency department for their symptoms in the year before their death. It also found the death rate to be four times higher among children from the most deprived communities than the least.
Furthermore, the National Respiratory Audit Programme (NRAP) shows that discharge practices for children and young people admitted for asthma remain below what should be expected. Only 63% of children had their inhaler technique checked at discharge in 2024/25 and only 52% received a personalised asthma action plan. These are key interventions, as recommended by NICE, to support children and parents to best manage their condition.
Accurate diagnosis is the cornerstone of good respiratory health in children
Opportunities to improve outcomes and reduce inequalities start with an early and accurate diagnosis.
The NICE/BTS/SIGN Asthma guidelines recommend that children should be diagnosed with Fractional Exhaled Nitric Oxide (FeNO) as the first line test, with spirometry as the second line test. However, our data found significant variation and low compliance with the NICE guidelines for objective diagnostic testing.
Fractional Exhaled Nitric Oxide (FeNO)
Improved access to FeNO testing means faster, more accurate diagnosis of asthma in children and young people (CYP).
In turn, timely and more accurate diagnosis may reduce the risk of asthma exacerbations, emergency admissions and preventable deaths. It could also reduce costs across the health system and ease pressure on emergency care.
Research commissioned by Asthma + Lung UK shows that if FeNO testing for the adult population was made available to all GPs in England, almost £100 million could be saved by optimising asthma diagnosis and treatment.
Even where FeNO and spirometry are being commissioned for children in primary care, our findings show that systems are not confident that enough tests can be delivered to meet demand.
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59% of ICSs who responded to our survey reported that they did not commission FeNO testing in primary care for children to the extent that the whole ICS footprint is covered (22/37 ICSs).
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Of the 15 ICSs who reported that they are commissioning FeNO testing in primary care for children, only seven ICSs are confident that they have enough capacity to meet the demand to diagnose new referrals and to address any backlog.
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In total, 69% of surveyed ICSs do not have sufficient FeNO capacity to meet the demand for new referrals. This percentage is derived from survey replies from ICSs who commission FeNO in primary care for children who told us that they cannot meet demand, and from our premise that that ICSs who are not commissioning FeNO do not have sufficient capacity (24/35 ICS).
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FeNO testing is also useful for monitoring condition management. However, again, its availability is not widespread for this purpose. Only six of the 15 ICSs who are commissioning FeNO testing for children reported that they are confident that they have capacity to meet the demand to monitor new referrals and to address any backlog.
Spirometry
Spirometry is important as a second line objective test for children. While our research shows a modest increase in the numbers of ICSs who are commissioning spirometry for children (up from just 11 out of 32 ICSs in our last Respiratory Review), there has not been a recovery to pre-pandemic rates. The workforce to perform and interpret paediatric spirometry remains insufficient. Many ICSs continue to commission spirometry for adults and children separately, rather than take an all-age approach that would encompass younger patients with a respiratory condition.
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Almost half of the Integrated Care Systems who responded to the survey are not commissioning spirometry in primary care for children to the extent that the whole ICS footprint is covered (18/38 ICSs).
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Only six of the 20 ICSs who are commissioning spirometry for diagnosis in primary care for children are confident that they have enough capacity to meet demand of new referrals and to address any backlog.
What is Asthma + Lung UK calling for?
Together with the Taskforce for Lung Health we are calling for a Modern Service Framework (MSF) for respiratory. A respiratory MSF would support a co-ordinated, system-wide approach, beginning with diagnostics, that would improve children’s lung health and address inequity across England.
All Integrated Care Systems should provide access to comprehensive diagnostic testing within primary care, in line with the NICE/BTS/SIGN Asthma guidelines. This could be done by:
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Providing access to point-of-care FeNO testing in all Primary Care Networks (PCNs). This is essential for the optimal diagnosis of asthma in children and young people and will improve access to diagnostic testing for adults.
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Maintaining funding for ongoing FeNO costs, including for paid, protected staff training, consumables such as mouthpieces, and FeNO machine maintenance.
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Commissioning quality assured spirometry services and ensuring every health system has adequate access and sufficient capacity to support their local population.
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Expanding quality assured spirometry provision for diagnosing asthma in children and young people to ensure access improves alongside spirometry access for adult diagnosis.
Lack of respiratory data
Integrated Care Systems struggled to provide us with respiratory data, despite lung conditions being the third biggest cause of death in England. Even among those ICSs who responded, there was an inability to provide accurate figures for diagnostic testing for children, with most Integrated Care Systems who responded to our survey unable to say how many FeNO or spirometry tests had been performed for children.
Some ICSs who submitted answers to the survey said data was unavailable. Others could only provide all-age or combined adult/CYP testing figures, meaning that it was not possible to determine how many FeNO or tests were being carried out on children and young people alone. Other ICSs only had partial information, so they could say how many tests there had been in limited settings, but not across the whole ICS area.
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Only five out of the 26 ICSs who answered a question about FeNO test numbers were able to tell us how many had been performed in their area for children.
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There is a similar lack of data for spirometry, where only seven out of 33 ICSs could say how many tests for children had been conducted.
What is Asthma + Lung UK calling for?
Over one million children are living with asthma in England. Yet we do not know how many have been diagnosed with an objective diagnostic test.
Health systems must be able to report how many spirometry and FeNO tests have been carried out on children and young people in their area. More complete, high-quality data would provide a robust basis for local and regional quality improvement work and workforce planning. At a national level, it would also provide a clearer picture of diagnostic capacity and help identify gaps in access.
Who advocates for children’s lung health locally?
We have heard anecdotally how ICS budget cuts and restructuring are leading to a loss of clinical leadership roles in respiratory. Our data adds to these concerns.
The number of ICSs who told us they did not have a respiratory clinical lead for children and young people (CYP) has increased from five in last year’s survey to 13 this year.
Our data found only 25 of the 38 ICSs who responded have a long term dedicated, standalone clinical lead for children and young people’s respiratory care. Of these, three ICSs said that the post would cease. Many clinical leadership roles, including within respiratory, were stood down as part of ICS restructures and so it possible that more of these roles have been cut since the data was collected.
What is Asthma + Lung UK calling for?
Children with asthma receive care in schools and community services as well as primary care and hospitals. This deserves coordinated, holistic clinical leadership. The National Bundle of Care for Children and Young People with Asthma stresses the need for each Integrated Care System to have a named, accountable lead who can coordinate services across organisational boundaries.
Every ICS should have a clinical respiratory lead for children and young people. A discrete role would help ensure that respiratory health for children and young people is prioritised locally, and effective care pathways are clearly defined and implemented, from diagnosis to treatment.
We believe that dedicated clinical leadership within every ICS can improve care for children and young people with respiratory conditions by helping to:
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advocate for them as a distinct patient group,
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promote better, more consistent care across the ICS, including increasing annual reviews and inhaler technique checks, and
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lead the development of effective, well-utilised clinical pathways.
We are calling on the government and the National Quality Board to introduce a Modern Service Framework for respiratory as soon as possible.
To improve respiratory care an effective Modern Services Framework should require:
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All ICSs to provide comprehensive diagnostic testing within primary care, in line with the NICE/BTS/SIGN Asthma guidelines through:
- Access to point-of-care FeNO testing in all Primary Care Networks (PCNs).
- Providing sustainable funding for ongoing FeNO costs and training.
- Enabling every ICS to have adequate access and sufficient capacity to spirometry.
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All ICSs to retain and have a clinical respiratory lead for children and young people.
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All ICSs to support the whole workforce to achieve the capabilities and skills outlined in the National Capabilities Framework for Professionals who care for Children and Young People with Asthma.
Responses by Integrated Care System
Survey and FOI data provided by Integrated Care Systems is self-reported and unvalidated.
Data can be filtered and displayed by selecting a heading or a group of ICSs (by NHS England region). You can search each table and scroll through the pages using the arrow at the top and the bottom of the table. Data can be downloaded.
Integrated Care Systems that reported they did not commission FENO or spirometry in primary care have been presumed to not have sufficient testing capacity to meet demand of new referrals.
Additional contextual information from ICSs for children + young people
Many ICSs, including those who responded to a smaller subset of questions via a Freedom of Information (FOI) request, chose to provide additional contextual information. For FOIs where ICSs changed due to mergers, we asked for data on the former ICS footprint.
Spirometry: Spirometry is commissioned via a Locally Commissioned Service with primary care, from the Community Diagnostic Centres and from the Acute Trusts.
FeNO: 81 out of 83 practices provide a FeNO Locally Commissioned Service for adults and children over the age of 5 yrs old.
Data on number of tests performed: Primary Care Providers: FeNO and Spirometry LCS were not commissioned in all of our three localities in 2024/25, and in the areas that they were commissioned they were included within population-based services and basket of services, therefore the individual activity for either adults or children is unknown. Acute contracts: The ICB does not hold this information. Spirometry testing is included within the Block funding element of the Acute contracts - we do not hold data on numbers of tests carried out.
Spirometry and FeNO: The only spirometry and FeNO for children is via secondary care (who do not take primary care referrals for diagnostics) and via an East locality project reviewing children with uncontrolled asthma at Washwood Heath Community Diagnostic Centre. Community Diagnostic Pathway Development funding has been awarded to Birmingham Community Healthcare to deliver the Paediatric Asthma Pathway in Washwood Heath Community Diagnostic Centre.
CYP Respiratory Clinical Lead response: 2 x clinical leads until end of June 2026, 1 x primary care/diagnostics 1 x secondary care. Covers mostly adult but some work on paediatrics. A new clinical lead for the new cluster, NHS Birmingham, Black Country and Solihull, will be appointed after June 2026 (with less clinical time).
Spirometry is commissioned as a Local Enhanced Service part of the services delivered under the Supplementary Services basket.
Spirometry and FeNO: Through a Locally Commissioned Service (5 years and over). One Community Diagnostic Centre within the former Buckinghamshire, Oxford and Berkshire West ICS footprint offers a CYP Respiratory Diagnostic service for Spirometry and FeNO. Patients registered at practices who are not offering the spirometry Locally Commissioned Service are referred to the Community Diagnostic Centre.
CYP Respiratory Clinical Lead response is for Thames Valley ICS. CYP Clinical Lead role includes CYP Long Term Conditions.
Spirometry: Direct access child spirometry available at Community Diagnostic Centres.
CYP Respiratory Clinical Lead response is for Central East ICS.
The ICS has 4 clinical leads across the cluster [with Herefordshire + Worcestershire]:
1 x Elective, Cancer, Diagnostic, and Specialised Commissioning, 1 x Children and Young People, Local Maternity and Neonatal System and Mental Health, 1 x Urgent and Emergency Care, Neighbourhood Health, and Community, and 1 x Quality and Primary Care.
Spirometry: NHSE funded children's asthma pathway in the Community Diagnostic Centres that provides diagnostics for asthma (and other respiratory conditions).
Spirometry: Not consistent across the ICS but some delivery at GP/PCN through a local change to GP contract, and through the Community Diagnostic Centre (CDC). There are isolated pockets where CYP spirometry is available, depending on training. We are piloting CYP spirometry through our CDC currently and hoping to roll that out across the county over the next few years, resource permitting.
FeNO: GPs delivering locally as part of their contract (and access within PCN). Also available at respiratory diagnostic hub.
Spirometry: Some GP access via Community Diagnostic Centre (CDC). Some separate CDC activity.
FeNO: Some GP access via CDC. Some separate CDC activity.
Spirometry: The LES for 2026/27 will be all-age, to encompass children.
Housing for damp proofing for children and young people.
Spirometry: Access to CYP spirometry has improved through the LES but due to inconsistent access to staff training, meaning provision for CYP spirometry is more variable than for adults. A proposal has been submitted to extend asthma diagnostics to include CYP provision at Community Diagnostic Centres.
CYP Respiratory Clinical Lead response: The CYP lead roles were recently lost.
Spirometry: GPs have spirometry access to Community Diagnostic Centres.
FeNO: GP surgeries have FeNO access to Community Diagnostic Centres.
There are CYP asthma MDTs.
We have a CYP respiratory working group with membership from health, the local authority, environmental health and air quality teams.
Spirometry: Not the full ICS footprint, but we are progressing this work.
Spirometry: For adults, there is 100% coverage for spirometry. For children, there is not. However, some GP surgeries have the capability to carry out spirometry. The commissioned Paediatric Community Asthma Team and secondary care settings have the ability to do spirometry to support monitoring their caseload, but referrals solely for diagnostic spirometry are not accepted. Community Diagnostic Centre currently being planned/mobilised will offer increased capacity.
FeNO: FeNO testing for children can be received in some GP practices who have equipment. The ICB has recently secured 16 machines and distributed these based on various factors including deprivation, inequalities, prevalence etc. The Paediatric Community Asthma Service and Secondary Care services perform FeNO tests, but do not accept referrals for standalone FeNO.
Spirometry: We are still implementing a paediatric model, and as ARTP accreditation is undertaken, the percentage access [to different settings such as respiratory diagnostic hubs] will increase across NCL. At the present time, spirometry is available for 12+ years at 100% of sites, however, 6-12 years is not in place.
FeNO: Available in respiratory diagnostic hubs, as well as GP surgeries.
Spirometry: Locally Commissioned Service offered to all Norfolk and Waveney GP Practices.
CYP Respiratory Clinical Lead response is for Norfolk and Suffolk ICS.
Spirometry: There are no children’s services via primary care in any of the Places across NEL.
FeNO: There is no primary care provision for children.
In 2024/25, asthma diagnosis in children was mainly clinical and judgement-based, using symptoms (like wheeze), examination, and supporting tests such as bronchodilator response or peak flow variability, with emphasis on careful differential diagnosis rather than strict criteria. In 2025/26, the approach became much more structured and test-driven, with a clear stepwise pathway using defined thresholds for FeNO, spirometry, peak flow variability, and, if needed, allergy and eosinophil testing, followed by specialist referral if uncertainty remains.
CYP Respiratory Clinical Lead response: We are recruiting for a number of Clinical Director roles, one of which will be for Proactive Care which will cover respiratory (all-age).
Spirometry: Within SEL ICS there are no primary care establishments commissioned to provide spirometry for primary care for adults or children. It is provided by our three Acute Trusts and one Community Provider.
FeNO: Within SEL ICS there are no primary care establishments commissioned to provide FeNO for primary care for adults or children. It is provided by our three Acute Trusts and one Community Provider.
Spirometry: Locally Commissioned Service is offered to all practices in Suffolk, hub model offered in addition by Suffolk GP Federation as a sub-contract to the LES – CYP + Adult North East Essex (NEE) – Community service GPPC and direct practice level delivery. Suffolk/NEE - a pathway is in place across Suffolk to manage demand based on population need and weighted population data. However, demand for spirometry services continues to increase, placing ongoing pressure on existing capacity.
FeNO: FeNO testing is available in some areas at Primary Care Network (PCN) level.
CYP Respiratory Clinical Lead response is for Norfolk and Suffolk ICS.
Spirometry: Also access via Community Diagnostic Centre.
FeNO: Some access via a local change to the GP contract.
Spirometry: Also access via Community Diagnostic Centre.
FeNO: FeNO is not currently commissioned. Conversations taking place with primary care to review Locally Commissioned Service within new ICS footprint.
Established CYP Asthma Team continue to provide updates and teaching for primary and secondary care, improving communication between primary and secondary care, developing discharge pathways to improve a safer discharge process, promoting asthma friendly schools.
Spirometry: Spirometry commissioning is not consistent across the entire ICS footprint. Commissioning and delivery of spirometry services varies significantly by Place (Leeds, Bradford District and Craven, Calderdale and Kirklees, and Wakefield). In many areas services are commissioned through Place-level enhanced services or delivered through Community Diagnostic Centres or secondary care pathways.
FeNO: FeNO commissioning varies by Place. Some provision at Community Diagnostic Centres.
A safe place to breathe - tackling the impact of housing on childhood asthma in West Yorkshire.
Respiratory Review survey methodology
The Respiratory Review presents key metrics from publicly available data for all ICSs in England, combined with information provided by ICSs through a survey or Freedom of Information (FOI) request.
A survey was sent to all 42 ICSs and conducted between January and March 2026. In April 2026, Asthma + Lung UK sent a Freedom of Information request to ICSs who had not completed the survey. This consisted of a subset of survey questions. Where ICSs had merged, we asked for data on the former ICS footprint. We received 38 responses - 19 ICSs answered our original survey and 19 ICSs responded to our FOI request.
We would like to thank clinical and non-clinical leaders across England’s ICSs for working with us to create the Review, either through completing a survey or by providing answers to the subsequent FOI request.
Please contact us with any questions or comments about the Respiratory Review. We are also happy to help make connections between Integrated Care Systems. Contact us at policy@asthmaandlung.org.uk.