My automated emails keep landing in patients' spam folders and I don't know why

Email deliverability is a technical and reputational problem that undermines the commercial value of any email communication programme. When emails land in spam, they are not seen, and the value of the content is lost entirely. For private healthcare providers, this affects appointment reminders, follow-up sequences, review requests, and patient recall campaigns.

steps: 7; steps
to start: 30 mins; to start

The short answer

Usually it is your domain setup, not your wording. Gmail requires every sender to use SPF or DKIM, and senders of more than 5,000 messages a day to use SPF, DKIM and DMARC. Many practice systems send from their own servers on your behalf without those records in place. Check your records, authenticate every system that sends as you, then watch your complaint and bounce rates.

7 steps

Do it yourself: step by step

0 of 7 done

Write down each tool that sends from your domain: Microsoft 365 or Google Workspace, practice management system, online booking, review requests, newsletter platform, website forms.
Time
30 mins
Typical cost
Free
Who does it
Practice manager
Done when: You have a complete list with the login for each

This problem is Solvable.

Copy this checklist

Email deliverability checklist for clinics

Free to copy, adapt and use. No sign-up.

Checklist

Email deliverability checklist

Domain: [yourclinic.co.uk] Checked by: [name] Date: [date]

1. Who sends as you

System	Purpose	Sends from address	SPF pass	DKIM pass
[Microsoft 365 / Google Workspace]	Staff email	[name]@[domain]	[ ]	[ ]
[Practice management system]	Reminders, invoices	[ ]	[ ]	[ ]
[Online booking]	Confirmations	[ ]	[ ]	[ ]
[Review platform]	Review requests	[ ]	[ ]	[ ]
[Newsletter tool]	Patient news	[ ]	[ ]	[ ]
[Website form]	Enquiry notifications	[ ]	[ ]	[ ]

2. DNS records

Exactly one SPF record, which includes every system above
DKIM enabled in each system and its records published
DMARC record published, for example: `v=DMARC1; p=none; rua=mailto:dmarc@[domain]`
After 4 clean weeks, DMARC moved to `p=quarantine`

3. Sending practice

Appointment reminders and marketing sent from different addresses, for example reminders@ and news@
Marketing emails have a one-click unsubscribe link
Only patients who consented, or who meet every soft opt-in condition and have not opted out, receive marketing
Bounced addresses removed after each send
Emails are mostly text, one or two links, no attachments in reminders
Subject lines are plain: "Your appointment on [date] at [time]"

4. Monitoring

Domain added to Google Postmaster Tools
Monthly check of spam complaint rate (Google target below 0.1%, limit 0.3%) and bounce rate (target under 2%)
DMARC reports reviewed for unknown senders

Message to send your IT supplier

"Please check SPF, DKIM and DMARC for [domain]. These systems send email as us: [list]. We need one SPF record covering all of them, DKIM switched on for each, and a DMARC record at p=none with reports to [address]. Please confirm when each passes a test."

Avoid these

Common mistakes

Adding a second SPF record for a new system instead of editing the first.
Assuming the practice management system handles authentication for you.
Sending marketing and appointment reminders from the same address.
Emailing patients who never agreed to marketing, which drives up complaints.
Rewriting subject lines when the real problem is DNS.

Free personal check

Done by Paul Robinson, not software

I'll check your domain's email setup and tell you why your messages are going to spam

What I need from you

Your website domain
The systems that send email as you (practice system, newsletter tool, email account)

What you get

Your SPF, DKIM and DMARC results in plain English
Which sending system is failing
The three changes to ask your IT support or supplier for

Within 2 working days

No sign-in, no sales call. I read every request myself and reply on WhatsApp.

Free tools

Check where you stand

Your illustrative estimate

£4,500

Solvable estimate. Rounded to the nearest £500. Updates as you type.

Emails sent per month

Starting figure 500. Change it to match your practice.

Share landing in spam

Starting figure 15%. Change it to match your practice.

Share that would have led to a booking

Starting figure 2% (from 2% (all Solvable estimates)). Change it to match your practice.

Initial consultation fee

Starting figure £250 (midpoint of £250 (Default: £250, a typical self-pay initial consultation fee (Solvable estimate). Change it to your own fee.)). Change it to match your practice.

Formula

Annual cost = emails sent per month x share landing in spam x share that would have led to a booking x initial consultation fee x 12

Variables and defaults

emails sent per month: 500
share landing in spam: 15%
share that would have led to a booking: 2% (all Solvable estimates)
initial consultation fee: £250 (Default: £250, a typical self-pay initial consultation fee (Solvable estimate). Change it to your own fee.)

Defaults only. Change them in the calculator to use your own numbers.

Assumptions and defaults

emails sent per month = 500
share landing in spam = 15%
share that would have led to a booking = 2% (all Solvable estimates)
initial consultation fee = £250 (Default: £250, a typical self-pay initial consultation fee (Solvable estimate). Change it to your own fee.)

Solvable estimate. 500 x 15% = 75 emails in spam, x 2% = 1.5 lost bookings a month, x £250 x 12 = £4,500 a year, counting the first consultation only. Authentication solutions most of this. Missed reminders also add to no-shows, which this does not count.

Benchmarks

Below 0.1 percent, never 0.3 percent
Gmail's spam rate target and limit in Postmaster Tools. All senders need SPF or DKIM; senders of more than 5,000 messages a day also need SPF, DKIM, DMARC and one-click unsubscribe on marketing
Source: Google Email sender guidelines
10 to 30 percent
Share of automated clinic email that can go to junk when the sending system is not authenticated on the clinic's domain. practice experience, not a published figure
Solvable estimate

Every supplier I know who solves this. No one pays to be listed. Where I've worked with them, I say so.

Granite PMS
Practice management software
Practice management software for private consultants and clinics.
Practice software for consultants with automated reminders. Ask whether it can send from your own domain.
Best for: Private consultants and small clinics
Price on request
Former client
Semble
Practice management software
Practice management and patient records software for private clinics and consultants, covering scheduling, notes, telehealth and payments.
Practice system with automated reminders. Ask them for the DKIM records to send from your own domain.
Best for: Private consultants, clinics and clinic groups
Price on request
No commercial relationship

Know a supplier I have missed? Tell me Suggest yourself

Email sending infrastructure is not correctly configured for deliverability Domain reputation has been damaged by previous sending behaviour or domain sharing Email content or subject lines trigger spam filters in common email clients

SPF, DKIM, and DMARC records are not correctly configured on the sending domain
The sending domain has a poor reputation score from previous high-bounce or complaint rates
Email content contains terms or formatting patterns that trigger spam classification
The clinic shares an IP address with other senders with poor sending practices
There is no deliverability monitoring in place to detect problems before they affect patients

If 25% of your emails are landing in spam across a 500-patient recall campaign, you are losing the response of up to 125 patients per campaign. At £420 per patient, that is over £52,000 per campaign in missed recall revenue.

Patient communication campaigns do not reach their intended recipients
Appointment reminders are missed because they land in junk folders
Follow-up and recall campaigns generate no response and are assumed to have failed
Review request campaigns do not generate reviews because patients never see them
Marketing investment in email content is wasted if the emails are not delivered

What it looks like in practice

A clinic whose emails achieve 72% inbox placement versus the achievable 96% is losing the potential response of 24 in every 100 emails sent before the patient even sees the message
Configuring SPF, DKIM, and DMARC records correctly takes approximately two hours with a technical email administrator and immediately improves deliverability on the next campaign send
Running a pre-campaign deliverability test using a tool such as Mail-Tester or GlockApps costs under £10 per test and identifies inbox placement issues before they affect patient communication

Paul Robinson

14 years in UK private healthcare

I solve this one for clinic and hospital teams

Want a hand? I'll look at your situation and tell you the three things I'd tackle first.

A few quick questions, about two minutes. I read every one myself and usually reply the same day.

No sales call unless you ask for one. Just a straight answer from me.

I reply personally, usually the same day.

Questions

Frequently asked questions

Why do some patients get our emails and others do not?

Each mailbox provider judges you differently. Gmail and Outlook are strictest about authentication, so failures show up there first.

Are appointment reminders marketing?

No. Service messages about a patient's care are not direct marketing, so they do not need marketing consent. Keep them free of promotional content to stay that way. Marketing emails need consent or the soft opt-in. This is general information, not legal advice. Speak to a data protection specialist about your own mailings.

Will changing DNS records break our normal email?

Not if done carefully. Changing SPF or DMARC wrongly can cause problems, so let your IT supplier do it and test straight after.

How quickly will it improve?

Authentication changes work on the next send. Reputation from past complaints can take several weeks to recover.

Should we use text messages instead?

Use both for reminders. Text is more reliable for time-critical messages. Email still matters for letters, forms and invoices.

Last reviewed: 30 October 2026

Sources

Google Email sender guidelines

The Solvable community

You're not the only one with this problem.

One problem solved every week, on WhatsApp.

Join the community

One message a week. No sales messages. Reply STOP any time.

The short answer

Do it yourself: step by step

1List every system that sends email as you30 mins · Free

2Test your current setup1 hour · Free to under £10 per test

3Publish a correct SPF record30 mins to 1 hour · Free, or IT supplier time

4Turn on DKIM for each system1 to 2 hours · Free, or IT supplier time

5Add a DMARC record30 mins plus a month of monitoring · Free, reporting tools from low monthly cost

6Clean your list and your content2 hours then monthly · Free

7Monitor monthly15 mins a month · Free