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Correspondence problems and opportunities

Identifying benefits to support usage of Transfer of Care APIs.

Identification of benefits would be the responsibility of the project implementation team and personnel in affected business areas.  As such, benefits will be shaped by secondary care correspondence solutions currently in use and the flexibility of workflow arrangements at recipient GP Practices.  

The following problem areas are offered for consideration when determining benefits for patients, message initiators or message recipients.


Patient specific issues

Problem Opportunity

Delayed delivery of hospital correspondence could result in unnecessary re-admissions for patients or other less optimal care outcomes.

The NHS Standard Contract requires that discharges be delivered within 24-hours, and outpatient letters within 7-days.

Once the FHIR message is triggered for sending at the secondary care end, it should be delivered securely, reliably, and quickly over MESH and directly into the GP Foundation IT system.

With faster and accurate correspondence there is less pressure on a patient to remember their hospital care details.

Missed, inaccurate or incorrect content in hospital correspondence can result in patient harm.

Producing high quality clinical correspondence with full and accurate content aids optimum care for the patient and lessens the risk of clinical negligence litigation.

Vital correspondence is not sent by the hospital due to author or back office failures.  This has potential to cause harm to patient, for example because of the delayed or missed opportunity to provide new treatment or change existing treatment.

Linkage of correspondence systems to discharge and attendance events allows hospitals to track correspondence and note any intended and unintended correspondence exceptions.
GP practices failing to follow correct correspondence handling procedures, for example by failing to return any misdirected correspondence to the original sender may mean the correctly registered GP of the patient never receives the correspondence at the required time to optimise patient care.

Misdirected correspondence can be returned to the sender with less GP Practice dependency via ITK3 business level response codes.


GP practice specific issues

Problem Opportunity
Diversity in the medium (such as electronic or paper), message format (such as Kettering XML and CDA), any carried file type, document layout, and delivery mechanism (for example post, fax, email, proprietary interfaces, and MESH) can create unnecessary complexity in dealing with inbound correspondence at GP practices. The Transfer of Care APIs impose a set of standards that limit options so there is greater consistency in what is sent and how.  The expected result of adoption is a simplification and quickening of workflow activities within GP practices.
Incorrect addressing of correspondence creates activities that are time consuming for GP practice and hospital staff to deal with. It would also  delay the correspondence going to the actual registered GP practice of the patient.

Greater reliance on automated patient matching and automated feedback on this matching via ITK3 response codes, within the GP Foundation IT system, would allow the sending Hospital to take speedier corrective action. The patient matching within the GP Foundation IT system end can potentially occur without human intervention.

Hospitals have the option of not using static MESH Mailbox ID addressing (supported via a local address index), and instead use the MESH Demographic Composite Lookup capability to automatically route messages based on a Spine match of the patient’s NHS number, date of birth and family name, along with the relevant MESH workflow ID.

GPs can spend excessive time reviewing correspondence that may be best dealt with by another member of the team. Better support for categorising and filtering correspondence would allow GPs to focus on the correspondence that merits it.

Unique MESH workflow IDs have been created for each use case or message type. Distinguishing information also exists in the ITK3 message header that allows the recipient IT system to categorise Transfer of Care correspondence more easily into one of the four use cases.

GPs and other clinical and clerical staff may struggle to identify the important points in correspondence due to the different content and variation in layout within a use case.

Adoption of PRSB sections (clinical headings) and their associated elements in the message combined with a common process for rendering these elements within a GP Foundation IT system should facilitate more rapid comprehension of the contents and give clarity around further actions for GP Practice staff. 

The “Plan and requested action” section in the document serves this key requirement.

Missing content in correspondence may require GP practice staff to spend time chasing and querying hospital staff to get this information. Initially capturing the information electronically in a more structured manner at the hospital end reduces the likelihood that elements making up the message will be missed and increases the scope for validation during input.
Medicine reconciliation can be a time-consuming process at the GP practice end. Ability to carry encoded content opens the opportunity for some level of future automation of this activity.
Clinical coding can be a time-consuming process at the GP practice end. Ability to carry encoded content opens the opportunity for some level of future automation of this activity.

A hospital may amend correspondence after first sending it out for several reasons, including the correction of errors or addition of new information such as a pathology result. 

In addition, a hospital may send out, in error, actual duplicates rather than amended correspondence. GP practice staff need to be able to quickly determine which of the ‘duplicates’ contains the correct actions to follow or correct patient status to base future treatment on, and which to file and not action.

GP Foundation IT systems will provide visual warnings to end-users regarding the likelihood of duplicates to help ensure that only the latest correspondence for a particular hospital event is used for ongoing patient care.

Secondary care specific issues

Problem Opportunity
For each potential correspondence event, hospitals lack information on what action was taken, and its outcome. This would include an ability to identify correspondence not generated or not sent when there is a requirement to do so. Better correspondence tracking should contribute to hospitals identifying when correspondence has not been generated or has been generated but not sent.

Hospitals lack information on each individual correspondence document sent, such as whether it was appropriate, in a business sense, to the receiving GP practice.

Adopting FHIR structured messaging essentially introduces a tagging system on correspondence generation and delivery. 

An ability to handle returned ITK3 response codes at the hospital end completes the monitoring of correspondence activities and highlights data quality issues.

In addition to correspondence volumes and production turnaround times measured against NHS Standard Contract targets, hospitals may lack visibility on demographic data quality for accurate GP practice addressing and correct patient matching against information held at the GP practice end.

ITK3 response codes provide both positive and negative feedback, and link back to the identifier used for the initial message sent.

The hospital sending the message will therefore be informed whether a particular message has been delivered, processed correctly or not, and if processed correctly, whether the message is relevant or not to the GP practice from a business perspective (such as the patient is registered and active at GP Practice or patient is no longer at that GP practice). 

Work to enhance and potentially rationalise components of correspondence systems may deliver savings on overall production and delivery costs, in addition to providing reports on operational information, and driving up data quality.

Relevant correspondence content is not captured as discrete data items at source, making it difficult to validate and use this information for structured correspondence.

Capturing information via standardised/templated forms can ease and quicken correspondence production, in addition to improving data quality.  Standard templates across departments and different Trusts lessens familiarisation activities around correspondence production.

Using information electronically captured during patient interaction or shortly afterwards , which is not subject to rekeying, helps avoid errors in generating correspondence. 

Greater granularity in the capture of this clinical information would aid the building of FHIR messages.

Labour costs for paper handling and postal costs can be high for correspondence solutions. Switching to electronic processes can reduce costs and lead to better information security.

Last edited: 14 June 2021 1:58 pm