It is difficult to understand why there is such a huge discrepancy between the management of severe asthma recommended by evidence-based guidelines and that observed in clinical practice. The recommendations are relatively straightforward and have been widely promoted both in guidelines and reviews. Specialist physicians need to be more proactive in their implementation of such guidelines through the use of locally derived protocols and assessment sheets, reinforced by audit. The common occurrence of severe asthma and its considerable burden to the community would support such an approach.