Brief interventions 2.0: a new agenda for alcohol policy, practice and research.

BACKGROUND: Alcohol problems are increasing across the world and becoming more complex. Limitations to international evidence and practice mean that the screening and brief intervention paradigm forged in the 1980s is no longer fit for the purpose of informing how conversations about alcohol should take place in healthcare and other services. A new paradigm for brief interventions has been called for. BRIEF INTERVENTIONS 2.0: We must start with a re-appraisal of the roles of alcohol in society now and the damage it does to individual and population health. Industry marketing and older unresolved ideas about alcohol continue to impede honest and thoughtful conversations and perpetuate stigma, stereotypes, and outright fictions. This makes it harder to think about and talk about how alcohol affects health, well-being, and other aspects of life, and how we as a society should respond. To progress, brief interventions should not be restricted only to the self-regulation of one's own drinking. Content can be orientated to the properties of the drug itself and the overlooked problems it causes, the policy issues and the politics of a powerful globalised industry. This entails challenging and reframing stigmatising notions of alcohol problems, and incorporating wider alcohol policy measures and issues that are relevant to how people think about their own and others' drinking. We draw on recent empirical work to examine the implications of this agenda for practitioners and for changing the public conversation on alcohol. CONCLUSION: Against a backdrop of continued financial pressures on health service delivery, this analysis provokes debate and invites new thinking on alcohol. We suggest that the case for advancing brief interventions version 2.0 is both compelling and urgent.

Young adults' change talk within brief motivational intervention in the emergency department and booster sessions is associated with a decrease in heavy drinking over 1 year.

OBJECTIVE: Investigate the effect of change talk (CT) within successive brief motivational interventions (BMIs) as a mechanism of change for alcohol use. METHOD: We conducted a secondary analysis of data from a randomized controlled trial in which 344 young adults (18-35 years old) admitted to a Swiss emergency department with alcohol intoxication received either BMI (N = 171) or brief advice (N = 173). Participants with a baseline audio-recorded BMI were included (N = 140; median age 23 [Q1-Q3: 20-27], 72.9% men). Up to three booster sessions by phone were offered at 1 week, 1 month, and 3 months. Percent CT and CT Average Strength were used as predictor variables. The outcome was the number of heavy drinking days (HDD) over the 30 days prior to research assessments at 1-, 3-, 6-, and 12-month follow-up. A latent growth curve modeling framework was first used to estimate predictor and outcome variable growth parameters (i.e., intercept and slope) over time, and then to regress HDD growth parameters on CT growth parameters. RESULTS: CT increased specifically from baseline to the 1-week booster session and thereafter remained stable. Higher baseline CT was associated with lower HDD at 1 month (Percent CT: b = -0.04, 95% confidence interval [-0.06, -0.01]; Average Strength: b = -0.99 [-1.67, -0.31]). An increase in CT from baseline to the 1-week booster session was related to a decrease in HDD from 1 month to 12 months (Percent CT: b = -0.08 [-0.14, -0.03]; Average Strength: b = -2.29 [-3.52, -1.07]). CONCLUSIONS: Both baseline CT and CT trajectory over the first week are meaningful predictors of HDD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Are we moving into a new era for alcohol policy globally? An analysis of the Global Alcohol Action Plan 2022-30.

The Global Alcohol Action Plan 2022-30 (GAAP) represents an important milestone in policy implementation at the global level on alcohol and health. There has, however, been little attention paid to the GAAP in the research literature. With a focus on the alcohol industry, this analysis examines the content of, and prospects for, the GAAP. It is clear why stronger action on alcohol and health is needed. The health harming nature of alcohol and policy interference by industry are now clearly understood. The alcohol industry is now thus regarded primarily as a key part of the problem. The GAAP calls for action in six areas with specific roles for public health actors, and invites powerful industry actors to desist from harmful activities, within each area. The broad outline of what is expected of the alcohol industry is now clear. It remains unclear, however, how far countries will continue to face formidable opposition from the major alcohol companies and their surrogates, in adopting and implementing evidence-based measures. Governments must now act at speed, and it is unclear if the targets set for 2030 will be met. If this long-running public health policy failure continues, this will have dire consequences for low and middle income countries where the alcohol market is expanding. Stronger actions may also be needed.

Randomized study of two different consent procedures on recall: a study within a digital alcohol intervention trial.

INTRODUCTION: Individuals' comprehension of the information provided in consent forms should fundamentally influence whether to participate initially in a study and later whether to remain a participant. Existing evidence, however, suggests that participants do not thoroughly read, comprehend, or recall the information in consent forms. This study aimed to better understand how well participants recalled trial procedure information in the consent materials they received prior to taking part in a trial of a digital alcohol intervention. METHOD: This study was nested within an online effectiveness trial. The study included a contrast between two layout approaches to present the trial procedure information: one where all materials were shown on the same page (One page) and one where participants had to click on links to get materials for certain parts of the study information (Active request). Recall of trial procedures was measured 2 months post-randomization with four questions. Participants were also asked to leave a comment after each question. RESULT: Of the 2437 individuals who registered interest in the parent trial, 1197 were randomized to One page and 1240 were randomized to Active request. Approximately 90% consented to participate and 53% of the participants responded to the recall questionnaire. Contrasting the consent layout showed no marked differences between groups in three out of the four questions on recall of trial procedures. There was, however, evidence that recall of aspects of how personal data would be handled during the trial did differ between the two groups, with the Active request group reporting less recall than the One page group. Free-text comments were used to give nuance to the quantitative analysis. CONCLUSION: Participants exposed to different layouts of trial procedure information exhibited varying levels of information recall 2 months after consenting. The findings highlight the influence of the presentation of consent forms, which should be given attention when designing trials. TRIAL REGISTRATION: ISRCTN ISRCTN48317451. Registered 6 December 2018, https://www.isrctn.com/ISRCTN48317451.

Mediational Analyses of the Effects of Social Behaviour and Network Therapy on Alcohol Use.

INTRODUCTION: Social behaviour and network therapy involves an active participation of the practitioner in recruiting a supportive network to change the client's alcohol use. Despite achieving beneficial effects on alcohol consumption, its possible mechanisms of change are a relatively under-studied topic compared to those of other alcohol treatment interventions. This study aimed to explore therapist skills through which social behaviour and network therapy may achieve effects on alcohol consumption in comparison with motivational enhancement therapy. METHODS: This study was secondary analysis of data from the UK Alcohol Treatment Trial, a multicentre, pragmatic, randomized controlled trial. The sample comprised 376 participants randomized to motivational enhancement therapy or social behaviour and network therapy. We used the UK Alcohol Treatment Trial Process Rating Scale to assess therapist skills. Outcomes drinks per drinking day and percentage of days abstinent were assessed 12 months after treatment initiation. Analyses were conducted in a simple mediation framework. RESULTS: Therapist skills score (combining frequency and quality) for involving others in behaviour change mediated social behaviour and network therapy effects on percentage of days abstinent (b = 0.06, 95% CI: 0.02; 0.10, p = 0.01). The frequency with which therapists acted as an active agent for change also mediated the effects of social behaviour and network therapy on percentage of days abstinent (b = 0.03, 95% CI: 0.003; 0.05, p = 0.03). The frequency with which the therapist stressed social support as a key factor in achieving change unexpectedly mediated an increase in drinks per drinking day (b = 0.10, 95% CI: 0.01; 0.18, p = 0.02). The two latter mediation effects were not sustained when quality was considered. All other indirect effects tested were non-significant. DISCUSSION/CONCLUSIONS: How social behaviour and network therapy exerts effects on alcohol outcomes is not yet well understood and in this study was not attributable to observed ratings of therapist treatment-specific skills. Therapist skill in planning the involvement of others during treatment, however, warrants further study. We suggest that the present findings should be regarded as hypothesis generating as it identifies specific targets for further investigation in alcohol treatment process studies.

Alcohol, cardiovascular disease and industry funding: A co-authorship network analysis of epidemiological studies.

INTRODUCTION: Alcohol's effects on cardiovascular disease (CVD) are controversial. Alcohol industry actors have shown particular interest in this subject, and been extensively involved through research funding, and in other ways, generating concerns about bias, particularly in reviews. MATERIAL & METHODS: We conducted a co-authorship network analysis of the primary studies included within a previous co-authorship study of 60 systematic reviews on the impact of alcohol on CVD. Additionally, we examined the relationships between declared alcohol industry funding and network structure. RESULTS: There were 713 unique primary studies with 2832 authors published between 1969 and 2019 located within 229 co-authorship subnetworks. There was industry funding across subnetworks and approximately 8% of all papers declared industry funding. The largest subnetwork dominated, comprising 43% of all authors, with sparse evidence of substantial industry funding. The second largest subnetwork contained approximately 4% of all authors, with largely different industry funders involved. Harvard affiliated authors who at the review level formed co-authorship subnetworks with industry funded authors were seen at the primary study level to belong to the largest epidemiological subnetwork. A small number of key authors make extensive alcohol industry funding declarations. CONCLUSIONS: There was no straightforward relationship between co-authorship network formation and alcohol industry funding of epidemiological studies on alcohol and CVD. More fine-grained attention to patterns of alcohol industry funding and to key nodes may shed further light on how far industry funding may be responsible for conflicting findings on alcohol and CVD.

Constructing public-private partnerships to undermine the public interest: critical discourse analysis of Working Together published by the International Alliance for Responsible Drinking.

BACKGROUND: The global burden of alcohol harm has increased and is forecast to grow further without effective policy implementation. Public-private partnerships aiming to address global health, and other societal challenges, are a burgeoning feature of neoliberal governance. Rhetorically distancing themselves from tobacco, the major alcohol companies are committed to tackling 'harmful drinking' and have created a distinct type of public relations organization for this purpose. The activities of such organizations are increasingly recognized as an impediment to the implementation of policies to reduce alcohol harm, including in low- and middle-income countries where markets are expanding. METHODS: The approach of critical discourse analysis is used to examine the discursive tactics and strategies used in Working Together; a 'toolkit' published by the key global level alcohol industry public relations organization, the International Alliance for Responsible Drinking (IARD). This study considers how it works discursively to set the terms of, and overcome skepticism about partnerships, to define aims and position various actors by constructing their roles. The construction of prospective partners provides insights into the alcohol industry itself. RESULTS: The toolkit operates as an ideological resource for forming public-private partnerships across the world based on the accumulated know-how of the major companies through IARD. This allows the largest alcohol companies to exercise leadership of the industry, while remaining off-stage. The toolkit relies on a form of rhetorical work which creates distance from obvious corporate interests and the harms caused to population health and society. This is accomplished by working against evidence-informed population level approaches, and thus avoiding policies that will make any significant difference to overall alcohol harm. Unspecific "complexity" affords opportunity for preferred types of "actions", and "partnership" provides opportunity to gain credibility by association, further minimizing the likelihood of any material harm being reduced. CONCLUSIONS: The toolkit is designed to not only legitimate the inclusion of alcohol industry actors as initiating 'partners', but also assigns them roles as managers of a set of carefully constructed relationships. This vision of public-private partnership reproduces the hegemonic narrative that has successfully blocked policy advances for decades and led to growing alcohol harm globally.

Exploratory mixed methods analysis of self-authored content from participants in a digital alcohol intervention trial.

BACKGROUND: Digital interventions readily permit data capture of participant engagement with them. If future interventions are intended to be more interactive, tailored, or a useful resource offered to users, it may be valuable to examine such data. One module available in a digital alcohol intervention recently tested in a randomised control trial offered participants the opportunity to self-author prompts that were sent to them by a text message at a time of their choosing. This study thus aimed to evaluate these self-authored prompts to increase knowledge on how individuals negotiate behaviour change and assess whether intervention content can be improved in the future. METHODS: The self-authored prompts were evaluated qualitatively using a combination of content and thematic analysis. The identified themes and subcategories are exemplified using anonymized quotes, and the frequency that each identified theme was coded for among the prompts was calculated. Associations between baseline characteristics and the odds of authoring a prompt at all, as well as a prompt within each theme, were investigated using logistic regression. RESULTS: Five themes were identified (Encouragement Style, Level of Awareness, Reminders of reasons to reduce/quit, Strategies to reduce/quit, and Timescale), all with several subcategories. The prompts module was more likely to be used by women and older individuals, as well as those for whom reducing alcohol consumption was perceived as important, or who felt they had the know-how to do so. Participants who had immediate access to the support tool (intervention group) were more than twice as likely to author a prompt (OR = 2.36; probability of association > 99%) compared to those with 4-month delayed access (control group). CONCLUSIONS: Individuals who engaged with the prompts module showed evidence of using the information provided in the support tool in an active way, with several showing goal setting and making plans to change their drinking behaviour. Individuals also used this opportunity to remind themselves of personal and specific reasons they wanted to change their drinking, as well as to encourage themselves to do so.

Mediators of effects of a digital alcohol intervention for online help-seekers: Findings from an effectiveness trial.

BACKGROUND: Digital alcohol interventions have been shown to exert effects in helping individuals reduce their drinking. However, little is known about the mechanisms which mediate such effects. The objective of this study was to estimate natural direct and indirect effects of a digital alcohol intervention. METHODS: This secondary analysis of mediated effects used data from a randomised controlled trial which included individuals with unhealthy alcohol use with access to a mobile phone aged 18 years or older in Sweden. The comparator was basic alcohol and health information. The digital intervention was centrally designed around weekly monitoring of consumption followed by feedback and tools to support behaviour change. Mediated effects were estimated using measures from 1-, 2-, and 4-months post-randomisation. Primary outcomes were total weekly consumption (TWC) and frequency of heavy episodic drinking (HED). A counterfactual framework was used to estimate three hypothesised mediators: importance, knowledge of how to change (know-how), and confidence. RESULTS: Between 25/04/2019 and 26/11/2020, 2129 participants were randomised. The intervention improved know-how and confidence, which in turn mediated the effects on TWC and HED at 2- and 4-months. Analyses with imputed data were not markedly different. CONCLUSIONS: A digital alcohol intervention was found to exert effects in reducing consumption by means of improving individuals' knowledge of how to reduce their consumption and confidence in their ability to reduce. The use of face-valid single item measures is a study limitation notwithstanding observed findings, as is attrition and lack of blinding of participants.

Alcohol policy framing in South Africa during the early stages of COVID-19: using extraordinary times to make an argument for a new normal.

INTRODUCTION: Public health and alcohol industry actors compete to frame alcohol policy problems and solutions. Little is known about how sudden shifts in the political context provide moments for policy actors to re-frame alcohol-related issues. South Africa's temporary bans on alcohol sales during the COVID-19 pandemic offered an opportunity to study this phenomenon. METHODS: We identified Professor Charles Parry from the South African Medical Research Council as a key policy actor. Parry uses a Twitter account primarily to comment on alcohol-related issues in South Africa. We harvested his tweets posted from March 18 to August 31, 2020, coinciding with the first two alcohol sales bans. We conducted a thematic analysis of the tweets to understand how Parry framed alcohol policy evidence and issues during these 'extraordinary times.' RESULTS: Parry underlined the extent of alcohol-related harm during 'normal times' with scientific evidence and contested industry actors' efforts to re-frame relevant evidence in a coherent and well-constructed argument. Parry used the temporary sales restrictions to highlight the magnitude of the health and social harms resulting from alcohol consumption, particularly trauma, rather than the COVID-19 transmission risks. Parry portrayed the sales ban as a policy learning opportunity (or 'experiment') for South Africa and beyond. CONCLUSIONS: Crisis conditions can provide new openings for public health (and industry) actors to make salient particular features of alcohol and alcohol policy evidence.

Managing Disruption: A Case Study of Boundary Work around Alcohol Industry Sponsored Scientific Interventions.

OBJECTIVES: Following recent work examining alcohol industry involvements in science, this is a case study that examines the ways in which the alcohol research community engages in 'boundary work' - in which scientists define and defend the demarcation between their community of knowledge makers and others, justifying their claim to legitimacy and authority - in response to alcohol industry-sponsored interventions. The case here involves an economist who disputes the research consensus positions and policy recommendations of the field, having been funded by the key global alcohol industry political organization. METHODS: We examine the 'functional' statements of both sides of this issue to show the ways in which the scientific and policy consensus of the field is disputed. Three examples of the responses of the alcohol research community, presenting different types of response, are interrogated. RESULTS: In late-career and retirement, this economist published extensively in alcohol and health economics journals within the peer-reviewed literature on two key topics in alcohol policy; pricing/taxation measures and advertising restrictions. These commentaries, reviews and correspondence propose alternative policies favored by the alcohol industry which are at odds with the alcohol public health evidence-base. The three examples examined of 'boundary work' performed by alcohol public health researchers illustrate the variety of ways in which the legitimacy of these interventions has been questioned; on technical grounds, on explicitly normative grounds, and as a body of work as a whole. DISCUSSION: Interventions in the scientific literature create important resources for alcohol industry actors to oppose alcohol policy measures globally. The alcohol research field may benefit from discussion about how to respond to these kinds of interventions.

The international center for alcohol policies (ICAP) book series: a key resource globally for alcohol industry political strategies.

This study examines the functions and purposes of the International Center for Alcohol Policies (ICAP) book series, published by Routledge between 1998 and 2010. The books were authored by invited academics, ICAP staffers, and alcohol industry representatives.The key data source for this paper was the framing material - forewords, introductions, conclusions - of the books. A thematic analysis positioned the contents with regard to ongoing alcohol research and public health policy issues.This was a project to 'shift the paradigm'. ICAP frames alcohol policy choices in ways which direct policy attention to sub-groups rather than the population level. Population-level approaches are caricatured as 'ideological'. The concept of 'balance' is prominent and is employed in multiple ways. Business interests are elided and industry involvement in policy making is promoted on scientific grounds. The intellectual programme is lent credibility by leading scientists and the imprimatur of an academic publisher.While this attempt to change the paradigm in alcohol science has failed, ineffective alcohol policies remain common, uninformed by scientific evidence on how harms at the societal level may be reduced. The ICAP book series continues to serve its function as a resource to support the status quo in respect of alcohol policy.

Who benefits from brief motivational intervention among young adults presenting to the emergency department with alcohol intoxication: A latent-class moderation analysis.

BACKGROUND: Research has not identified which patients optimally benefit from brief Motivational Interviewing (bMI) for heavy drinking when delivered to young adults in the Emergency Department (ED). METHODS: We conducted secondary analyses of data from a randomized controlled trial in which 344 young adults (18-35 years) presenting to the ED with alcohol intoxication received either bMI or Brief Advice (BA, control group). We used Latent Class Analysis to derive participants' profiles from baseline characteristics (i.e., sex, age, severity of alcohol use disorder, attribution of ED admission to alcohol use, importance, and confidence to change, cognitive discrepancy, anxiety, depression, and trait reactance). We then conducted a moderation analysis to assess the number of heavy drinking days at short-term (1-month) and long-term (12-month) follow-up using negative binomial regressions with interactions between the intervention and derived classes. RESULTS: Fit statistics indicated that a 4-class solution best fit the data. Class 3 (high severity, importance and discrepancy, and low confidence and anxiety) benefitted more from bMI than BA at short- and long-term follow-up than Class 1 (younger; lowest severity, importance, discrepancy, reactance, anxiety and depression, and highest confidence). Class 2 (older; highest severity, importance, discrepancy, reactance, anxiety and depression, and lowest confidence) also benefitted more from bMI than BA than did Class 1 at short-term follow-up. In these significant contrasts, Class 1 benefitted more from BA than bMI. There were no significant interactions involving Class 4 (more likely to be women; low severity; high levels of anxiety, depression, and reactance). CONCLUSIONS: This study identified the patient profiles that benefitted more from bMI than BA among nontreatment-seeking young adults who present intoxicated to the ED. The findings have implications for intervention design and argue for the importance of research aimed at developing intervention content tailored to patient profiles.

Evolution of the major alcohol companies key global policy vehicle through the prism of tax records 2011-19.

BACKGROUND: Important insights have been generated into the nature of the activities of the International Center for Alcohol Policies (ICAP). Its successor, the International Alliance for Responsible Drinking (IARD) is less well understood. This study aims to rectify evidence limitations on the political activities of the alcohol industry at the global level. METHODS: Internal Revenue Service filings were examined for ICAP and IARD each year between 2011 and 2019. Data were triangulated with other sources to establish what could be gleaned on the internal workings of these organisations. RESULTS: The stated purposes of ICAP and IARD are near identical. The main declared activities were similar for both organisations and comprised public affairs/policy, corporate social responsibility, science/research and communications. Both organisations work extensively with external actors and it has become possible more recently to identify the main contractors supplying services to IARD. DISCUSSION: This study sheds light on the political activities of the alcohol industry at the global level. It suggests that the evolution of ICAP into IARD has not been accompanied by shifts in the organisation and activities of the collaborative efforts of the major alcohol companies. CONCLUSION: Alcohol and global health research and policy agendas should give careful attention to the sophisticated nature of industry political activities.

Measurement of person-centred consultation skills among healthcare practitioners: a systematic review of reviews of validation studies.

BACKGROUND: Person-centred care is integral to high-quality health service provision, though concepts vary and the literature is complex. Validated instruments that measure person-centred practitioner skills, and behaviours within consultations, are needed for many reasons, including in training programmes. We aimed to provide a high-level synthesis of what was expected to be a large and diverse literature through a systematic review of existing reviews of validation studies a of instruments that measure person-centred practitioner skills and behaviours in consultations. The objectives were to undertake a critical appraisal of these reviews, and to summarise the available validated instruments and the evidence underpinning them. METHODS: A systematic search of Medline, EMBASE, PsycINFO and CINAHL was conducted in September 2020. Systematic reviews of validation studies of instruments measuring individual practitioner person-centred consultation skills or behaviours which report measurement properties were included. Review quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Details of the reviews, the included validation studies, and the instruments themselves are tabulated, including psychometric data, and a narrative overview of the reviews is provided. RESULTS: Four reviews were eligible for inclusion. These used different conceptualisations of person-centredness and targeted distinct, sometimes mutually exclusive, practitioners and settings. The four reviews included 68 unique validation studies examining 42 instruments, but with very few overlaps. The critical appraisal shows there is a need for improvements in the design of reviews in this area. The instruments included within these reviews have not been subject to extensive validation study. DISCUSSION: There are many instruments available which measure person-centred skills in healthcare practitioners and this study offers a guide to what is available to researchers and research users. The most relevant and promising instruments that have already been developed, or items within them, should be further studied rigorously. Validation study of existing material is needed, not the development of new measures.

Policy communities, devolution and policy transfer: The case of alcohol pricing in Wales.

This study investigates how processes of horizontal policy transfer can unfold in the context of devolution, examining the development of legislation on minimum unit pricing (MUP) in Wales, following on from Scotland's earlier policy decision. The study draws on a range of sources, including primary documents, media coverage, and interviews with policy participants. Our analysis identifies the importance of the specific character of Welsh political institutions, particularly the emphasis given to participation and consultation in policymaking. In the case of MUP, we document a process of policy-oriented learning, where policymakers made a concerted effort to draw on an assortment of expertise and experiences, including but not limited to the Scottish model. We also find that the Welsh public health policy community was well placed to support the framing of MUP and to address limitations in policy capacity. The findings hold implications for future studies of learning, devolution, and alcohol policy more generally.

Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic.

OBJECTIVE: The new structured medication review (SMR) service was introduced into the National Health Service in England during the COVID-19 pandemic, following a major expansion of clinical pharmacists within new formations known as primary care networks (PCNs). The aim of the SMR is to tackle problematic polypharmacy through comprehensive, personalised medication reviews involving shared decision-making. Investigation of clinical pharmacists' perceptions of training needs and skills acquisition issues for person-centred consultation practice will help better understand their readiness for these new roles. DESIGN: A longitudinal interview and observational study in general practice. SETTING AND PARTICIPANTS: A longitudinal study of 10 newly recruited clinical pharmacists interviewed three times, plus a single interview with 10 pharmacists recruited earlier and already established in general practice, across 20 newly forming PCNs in England. Observation of a compulsory 2-day history taking and consultation skills workshop. ANALYSIS: A modified framework method supported a constructionist thematic analysis. RESULTS: Remote working during the pandemic limited opportunities for patient-facing contact. Pharmacists new to their role in general practice were predominantly concerned with improving clinical knowledge and competence. Most said they already practiced person-centred care, using this terminology to describe transactional medicines-focused practice. Pharmacists rarely received direct feedback on consultation practice to calibrate perceptions of their own competence in person-centred communication, including shared decision-making skills. Training thus provided knowledge delivery with limited opportunities for actual skills acquisition. Pharmacists had difficulty translating abstract consultation principles into specific consultation practices. CONCLUSION: SMRs were introduced when the dedicated workforce was largely new and being trained. Addressing problematic polypharmacy requires structural and organisational interventions to enhance the communication skills of clinical pharmacists (and other health professionals), and their use in practice. The development of person-centred consultation skills requires much more substantial support than has so far been provided for clinical pharmacists.