Mark Statton, head of public sector strategy at Quadient, writes that digital-first will stall unless the NHS tackles its unstructured mail problem. 

NHS England’s decision in June 2025 to make the NHS App the “default digital communication channel” marked a clear turning point in how the health service intends to communicate with the public. The move, expected to save up to £200 million over three years, reflects a long-term ambition to shift away from printed letters and embrace faster, more timely and accessible digital communication.

Momentum is certainly building. NHS App usage reached a record 45 million registered users by September, according to official NHS statistics. More patients than ever are accessing test results, appointment details and clinical correspondence digitally.

Initial progress has been made by digitising structured documents such as appointment reminders and standardised clinic letters, which are well-suited to templates and automation. But the NHS’s communication ecosystem is far more complex. Unstructured mail – the typed clinic summaries, discharge notes, follow-up instructions and administrative documents produced daily across departments – remains a major barrier. Unless this part of the system is modernised, the full benefits of digital-first communication will remain out of reach.

The hidden majority of NHS correspondence 

The exact number of letters the NHS sends each year is not centrally published, but the service issues millions of documents annually across trusts, community services and primary care. Even at a local level, volumes are substantial. Last year, Royal Devon NHS Trust confirmed that it alone sends around two million letters a year. Scaled across more than 200 trusts, the national volume is enormous.

A significant proportion of these letters is unstructured. Findings from more than 200 FOI requests issued to NHS organisations indicate that between 45-60% of outgoing communication is unstructured.

Unlike appointment reminders generated from a patient administration system or EPR system, unstructured documents vary widely in format. Address blocks appear in different corners. Page layout and spacing differ between departments. Files are merged, edited or annotated manually. The result is a collection of communication that cannot reliably pass through automated digital workflows.

This variation is more than an irritation. It directly limits the NHS’s ability to route communication consistently through the NHS App, email or SMS. While structured communication has become easier to digitise, unstructured communication still takes the long route: printed in-house, corrected by administrative staff, or sent to external print rooms. For patients, this means receiving some updates instantly through the NHS App and others days later by post – depending solely on where the communication originated.

Nurse using a smartphone

When communication breaks down, patients notice

Patients increasingly rely on digital channels to stay informed. But when different parts of the NHS send information using inconsistent methods and timings, the patient experience suffers. A recent article argued that communication is the basis of 17% of all formal complaints about hospital and community health services. When digital updates and paper letters conflict, confusion follows – for example, when a digital notification suggests an appointment is confirmed, only for a letter to arrive later with different details.

Communication inconsistencies create operational pressures too. Staff must reformat documents so they can be sent, correct demographic details, produce accessible formats and reissue letters when content is unclear. Each task is small in isolation, but across thousands of communications every week, the administrative load becomes significant.

Postal delays compound the issue. With variability in second-class delivery performance noted in recent Ofcom monitoring, printed letters regularly take several days to reach patients. Missed appointments, repeated contacts and re-bookings all add avoidable strain to clinical services.

Why unstructured mail must become a digital-first priority

Digitising unstructured communication is not as simple as introducing more templates. It requires the ability to recognise, interpret and standardise a wide variety of documents – many of them created manually and without consistent formatting.

Addressing this challenge can unlock several benefits. Once unstructured letters follow predictable patterns, they can move cleanly through digital channels, giving patients communication that arrives reliably and in the right place. It also strengthens accessibility. The NHS’s duties under the Accessible Information Standard require information to be clear and usable for every patient, yet unstructured documents are the most likely to need layout, formatting or language adjustments. Standardisation makes accessible formats faster and easier to produce.

There are operational gains too. When documents arrive in a consistent, digital-ready state, staff spend less time performing manual checks or reworking content and more time supporting patient care. And for patients, the experience becomes noticeably more coherent. Mixed messages and conflicting updates diminish when every communication, regardless of where it originates, travels through the same modern, consistent system.

A more complete future for NHS communication

The NHS’s commitment to digital-first is the right one. Real-time updates, clearer communication and a reduced environmental footprint all contribute to a more modern, responsive service. But the next stage of progress depends on addressing the complex, often unnoticed half of the communication ecosystem.

Structured documents have led the way. Now the strategic opportunity lies in bringing the unstructured majority into the same digital framework. Trusts that take steps to understand, standardise and modernise these documents will be well positioned to deliver truly consistent, efficient and patient-centred communication.

Digital-first is within reach – but only when the whole communication pathway is brought along with it.