Providing an individualised written asthma "action plan" is a particularly high-profile part of Step 6 of the Australian Asthma Management Plan: "Educate and review regularly". The idea of a written action plan is that the patient is given a set of rules by which to alter therapy, dependent on either peak expiratory flow monitoring or symptom levels. The implication is that an appropriate, early response to deterioration will prevent dangerous exacerbations and will generally improve health-related quality of life. Written action plans for asthma are perceived to be so important that they became one of the two Australian Council on Healthcare Standards Performance Indicators for quality assessment of acute respiratory medicine in Australian hospitals.

However, the evidence — whether from research or from clinical practice — that written action plans, in themselves, are effective is equivocal. There are now a number of Cochrane Collaboration Airway Group systematic reviews that examine this area, but the outcomes are inconsistent. Gibson et al analysed up to 36 studies comparing self-management, education plus regular practitioner review against usual care.1,2 They found that active intervention significantly reduced hospitalisation, emergency room visits, unscheduled visits to the GP, days off work or school, nocturnal attacks of asthma, and quality of life, but that lung function was not altered. Self-management programs that involved a written action plan were more effective than those that did not, but regular doctor review seemed to be most important. Indeed, a review by Toelle et al failed to find consistent evidence that written plans, of themselves, have any effect on asthma control.3 Powell and Gibson found that optimising asthma control through adjustment of inhaled corticosteroid dose could be as well achieved by written guidelines for the patient as by seeing their doctor to adjust the dose.4 Somewhat paradoxically, there was evidence that removing regular doctor visits from a management plan was deleterious. Verbal and written instructions to patients seemed equally valuable: the intensity of education seemed to be more important than the format of the advice.

But is the proof of the pudding in the eating? If so, ownership of written action plans seems to be falling in Australia although it was never particularly popular in the asthma community. A community sample in South Australia showed a fall from 42.3% in self-reported ownership of written plans in 1995 to 22.2% in 2001, as reported in this issue of the Journal (page 483).5 Furthermore, a large epidemiological study conducted recently in Melbourne also indicated a fall in written action plan use, albeit from an even lower base: in 1999 just 13.3% of Victorians with self-reported asthma had ever been given such a plan, compared with 19.9% in 1993.6 The current situation and available facts therefore raise more questions than they answer.7 Why is uptake of written action plans so disappointing? If written action plans work, why are they not more popular? What is their main purpose — is it to prevent exacerbations or to control day-to-day levels of disease activity?

Studies have shown that written action plans are viewed positively by patients, but in practice, they modify their plans according to their own perceptions and experience of asthma.8 It is important that doctors realise this and give patients time to explore such issues and then incorporate them into an agreed plan. Indeed, the role of doctors is very important — their degree of empathy with patients and the amount of time they give to management issues have significant outcome effects in asthma.9 Presumably this "doctor effect" will extend to the uptake and usefulness of asthma action plans. What seems certain is that action plans cannot be used as a substitute for regular detailed review and comprehensive education of patients with asthma. Developing long-term relationships with their doctors, accompanied by being involved in discussion and decision making is important.9,10 Data suggest it is the "process" not the written action plan per se that is currently at fault.

Complicating the delivery of asthma care is the poor training of doctors in creating or delivering care packages involving negotiated action plans. Indeed, the main reason for patients not having a written asthma action plan is that they are not given one by their doctor!8 Longitudinal studies are needed to evaluate the effects of enhancing physicians' "participatory decision making" style9 on outcomes of patients with asthma, especially in general practice, where most such patients are managed. This is particularly so in light of the year-old Commonwealth Government-funded national initiative for asthma management in the community, in which a 3+ visit plan in general practice11 provides a framework for optimising treatment and education. This plan includes a written action plan for patients with moderate-to-severe asthma. This needs to be rigorously assessed in routine clinical practice, as even the best ideas and most worthy initiatives from professional "enthusiasts" can be confounded through lack of sufficient time and commitment. Evidence shows that patients will not cooperate with any intervention that is less than fully backed by the time and authentic personal commitment of their doctors. Yet, in a pressurised fee-for-service system, it can be difficult to sustain interest and enthusiasm in the long term.

In conclusion, the uptake of asthma action plans in Australia is disappointing, especially as we know they can be useful as part of the right package. Perhaps the management of chronic diseases like asthma needs different sorts of practitioners in a different professional and funding milieu. Yet another challenge for our beleaguered healthcare system?