In reply: We were pleased at the number of letters received exploring issues raised by our recent article.1

Jefford and colleagues question whether staff are aware of the Australian Pharmaceutical Advisory Council guidelines.2 We expect to answer this question during the consultancy that the NSW Therapeutic Assessment Group is conducting for the Commonwealth Department of Health and Ageing. In this consultancy, we are evaluating the implementation and effectiveness of these guidelines. After its completion in October this year, we will have an implementation map of activities being undertaken relevant to the guidelines in Australia. Recommendations formalised at a national workshop will be made to the Department of Health and Ageing regarding future implementation, including alternative models and workable solutions.

All three letters raise questions about the key stakeholders for continuity of care. We invited a range of clinical and administrative staff, including senior and junior medical staff, nurse clinicians, clinical pharmacists and general practitioners from the relevant Divisions. However, participation of junior medical staff was limited. As Jefford et al comment, consumers and community pharmacists warrant further consideration in strategies for improving information exchange between hospitals and GPs. We also agree that patients' knowledge of their medications is often deficient: with limited resources, we were only able to address this through the GPs who interviewed their patients following discharge.

Wilson rightly observes that continued improvement is dependent on organisations' developing clinical governance — accountability is a key driver for change. Change in practice is usually incremental, however, as we found in our study. Sustained change requires ongoing effort and support.

New comments on practical problems with faxing discharge summaries. In our study, GPs identified faxing as preferable because of problems experienced with summaries posted or delivered by patients. New also refers to the problem of patients having multiple GPs. It is up to the patient to advise the hospital appropriately, and this is a matter for consumer education. His suggestion of computerised hospital prescribing is an ideal we all hope will come to fruition sooner rather than later. In the meantime, we believe we have demonstrated the quality improvement process and its limitations and the value of GP audit in prompting that process.