Category Archives: Stress Management

Family doctors working ‘beyond safe levels’, says GPs’ leader

As doctors describe dealing with up to 70 patients a day, college warns of risks to public health

Waiting room of GP practice


Patients face longer waits to see a GP, says the Patients Association. Photograph: Alamy


GPs across Britain are working above safe levels because of relentless and unmanageable workloads, leading doctors have warned.

Prof Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said that family doctors were “regularly working way beyond what could be considered safe for patients”, potentially jeopardising their own health and wellbeing.

Her comments were made in response to a survey by GP magazine Pulse. It heard from 900 GPs across the UK and found that each deals with 41 patients a day. The European Union of General Practitioners (UEMO), a leading forum of European family doctors, has said that seeing around 25 patients is safe.

The Pulse poll found that one in five family doctors (20%) deal with 50 daily patient contacts, which include face-to-face and telephone consultations, home visits and e-consultations. Some GPs told Pulse they have 70 contacts a day.

Prof Stokes-Lampard said: “GPs expect to be busy, and we are making more consultations than ever before as we strive to deliver the best possible care to all our patients who need it. But the workload at the moment is relentless and it’s taking its toll.”

One doctor, who reluctantly left a career carrying out 13- to 14-hour days as a partner for a more manageable workload as a salaried GP and 31 to 40 daily contacts, told Pulse: “I felt I was at a risk of making mistakes and causing potential harm to my patients and my career.”

Another spoke of one exceptional “horrendous” Monday where he had 71 contacts. Since then the practice has since increased the number of on-call doctors on Mondays to three.

Prof Stokes-Lampard said the survey backed up what the college has been saying for years – that many GPs are regularly working way beyond what could be considered safe for patients.

It was not necessarily the number of consultations, but the content of those consultations, she added. “Our patients are increasingly presenting with more complex, chronic conditions, many of which require much longer than the standard 10-minute appointment,” she said.

“Our workload needs to be addressed – it has risen at least 16% over the last seven years,” she added. “Yet the share of the overall NHS budget general practice receives is less than it was a decade ago, and our workforce has not risen at pace with demand.”

Dr Richard Vautrey, British Medical Association general practitioners committee chair, said: “We know that an unmanageable and unsafe workload is the primary reason behind doctors leaving general practice, which is leading to serious issues including practices closing to new patients and other surgeries closing entirely. This workload pressure also means GPs are increasingly suffering from burnout and patients are being put at risk of unsafe care.”

He urged the government to work with the BMA to come up with a longterm solution “to ensure the needs of a growing population with increasingly complex conditions can be met safely on the front line”.

Patients’ groups and MPs also expressed concern at the findings. Liz McAnulty, chair of the Patients Association, said: “We have gone past the point where efficiencies can be found, and firmly into territory where GPs’ workloads are unsustainable and where patients face growing waits to access GPs and greater risks to their safety.”

Shadow health secretary Jonathan Ashworth said the Royal College’s warning should serve as an urgent wake-up call to ministers. “The truth is, since 2010 years of severe underfunding of our NHS has left general practice squeezed with tired, overworked and overstretched GPs. We have lost 1,000 GPs in the past year.”

Obesity surgery ‘halves risk of death’ compared with lifestyle changes

Latest study lends support to experts who say more operations should be carried out in UK

Bariatric surgery reduces the size of the patient’s stomach. It is cost-effective and leads to substantial weight-loss as well as helping to tackle type 2 diabetes.


Bariatric surgery reduces the size of the patient’s stomach. It is cost-effective and leads to substantial weight-loss as well as helping to tackle type 2 diabetes. Photograph: Murdo Macleod for the Guardian

Obese patients undergoing stomach-shrinking surgery have half the risk of death in the years that follow compared with those tackling their weight through diet and behaviour alone, new research suggests.

Experts say obesity surgery is cost-effective, leads to substantial weight loss and can help tackle type 2 diabetes. But surgeons say not enough of the stomach-shrinking surgeries are carried out in the UK, with figures currently lagging behind other European countries, including France and Belgium – despite the latter having a smaller population.

“We don’t think this [new study] alone is sufficient to conclude that obese patients should push for bariatric surgery, but this additional information certainly seems to provide additional support,” said Philip Greenland, co-author of the latest study from Northwestern University.

Q&A

Share your experiences of obesity surgery

If you have had stomach-shrinking surgery we would like to hear from you. What was your experience like? Did you find the procedure helpful or not?

You can share your story using our encrypted form here. We will feature some of your contributions in our reporting.

In the new study, one of several on obesity surgery published in the Journal of the American Medical Association, researchers sought to explore whether stomach-shrinking operations, known as bariatric surgery, had a long-term impact on the risk of death among obese individuals, compared with non-surgical approaches to weight loss.

In total, more than 33,500 participants were involved in the study – 8,385 of whom had one of three types of bariatric surgery between 2005 and 2014. The majority of participants had a BMI greater than 35; obesity is defined as a BMI of 30 or higher.

The researchers followed up the participants over the years that followed their surgery until death, or the end of the follow-up period in December 2015, comparing the number of deaths and other metrics with those for obese patients who had not had surgery but were given dietary and behavioural help. Each surgery patient was compared to three who did not have surgery, but had similar characteristics such as age and sex, and were also followed until they too had surgery, died or the study ended.

The results reveal that the death rate during the study was 1.3% for those who had any form of bariatric surgery, while among those who had not had surgery it was 2.3%, although the length of follow-up period varied considerably from patient to patient.

Once other factors including age, sex and related diseases were taken into account, the team found those who did not have stomach-shrinking surgery had just over twice the risk of death compared to those who had, with all three types of surgery linked to lower mortality.

What’s more, the group which had surgery showed a greater reduction in BMI, lower rates of new diabetes diagnoses, improved blood pressure, and a greater proportion of diabetic individuals going into remission.

But the team add that a small proportion of surgery patients required further surgery, while they note the study was observational so cannot prove bariatric surgery itself reduced the risk of death since patients were not randomised, meaning it is possible that those who did not have surgery were in poorer health.

A second, smaller study in the same journal also highlighted benefits of bariatric surgery, comparing diabetes-related markers in obese adults who had lived with a diagnosis of type 2 diabetes for an average of nine years. Participants either received two years of intensive diet, exercise and medical management or, in addition, had bariatric surgery.

The results from 113 participants reveal that complications were more common among those who had had bariatric surgery, but that one year after the study began they had lost more weight on average, with a greater proportion having reached the combined targets for cholesterol, systolic blood pressure and a marker of glucose.

While this proportion fell for both groups after five years – at which point 98 patients were still providing data – those who had had bariatric surgery maintained the edge, with 23% reaching the combined targets, compared to just 4% of those offered lifestyle and medical interventions alone.

Francesco Rubino, professor of metabolic and bariatric surgery at King’s College London, who was not involved in the studies, said misunderstandings and stigma were holding back greater use of such operations in the UK. While Rubino noted that surgery is not for everyone, he added “This is a conversation GPs and doctors should have with patients more often.”

Obesity surgery ‘halves risk of death’ compared to lifestyle changes alone

Latest study of long-term impact of bariatric surgery lends support to experts who say more operations should be carried out in UK

Bariatric surgery reduces the size of the patient’s stomach. It is cost-effective and leads to substantial weight-loss as well as helping to tackle type 2 diabetes.


Bariatric surgery reduces the size of the patient’s stomach. It is cost-effective and leads to substantial weight-loss as well as helping to tackle type 2 diabetes. Photograph: Murdo Macleod for the Guardian

Obese patients undergoing stomach-shrinking surgery have half the risk of death in the years that follow compared with those tackling their weight through diet and behaviour alone, new research suggests.

Experts say obesity surgery is cost-effective, leads to substantial weight loss and can help tackle type 2 diabetes. But surgeons say not enough of the stomach-shrinking surgeries are carried out in the UK, with figures currently lagging behind other European countries, including France and Belgium – despite the latter having a smaller population.

“We don’t think this [new study] alone is sufficient to conclude that obese patients should push for bariatric surgery, but this additional information certainly seems to provide additional support,” said Philip Greenland, co-author of the latest study from Northwestern University.

Q&A

Share your experiences of obesity surgery

If you have had stomach-shrinking surgery we would like to hear from you. What was your experience like? Did you find the procedure helpful or not?

You can share your story using our encrypted form here. We will feature some of your contributions in our reporting.

In the new study, one of several on obesity surgery published in the Journal of the American Medical Association, researchers sought to explore whether stomach-shrinking operations, known as bariatric surgery, had a long-term impact on the risk of death among obese individuals, compared with non-surgical approaches to weight loss.

In total, more than 33,500 participants were involved in the study – 8,385 of whom had one of three types of bariatric surgery between 2005 and 2014. The majority of participants had a BMI greater than 35; obesity is defined as a BMI of 30 or higher.

The researchers followed up the participants over the years that followed their surgery until death, or the end of the follow-up period in December 2015, comparing the number of deaths and other metrics with those for obese patients who had not had surgery but were given dietary and behavioural help. Each surgery patient was compared to three who did not have surgery, but had similar characteristics such as age and sex, and were also followed until they too had surgery, died or the study ended.

The results reveal that the death rate during the study was 1.3% for those who had any form of bariatric surgery, while among those who had not had surgery it was 2.3%, although the length of follow-up period varied considerably from patient to patient.

Once other factors including age, sex and related diseases were taken into account, the team found those who did not have stomach-shrinking surgery had just over twice the risk of death compared to those who had, with all three types of surgery linked to lower mortality.

What’s more, the group which had surgery showed a greater reduction in BMI, lower rates of new diabetes diagnoses, improved blood pressure, and a greater proportion of diabetic individuals going into remission.

But the team add that a small proportion of surgery patients required further surgery, while they note the study was observational so cannot prove bariatric surgery itself reduced the risk of death since patients were not randomised, meaning it is possible that those who did not have surgery were in poorer health.

A second, smaller study in the same journal also highlighted benefits of bariatric surgery, comparing diabetes-related markers in obese adults who had lived with a diagnosis of type 2 diabetes for an average of nine years. Participants either received two years of intensive diet, exercise and medical management or, in addition, had bariatric surgery.

The results from 113 participants reveal that complications were more common among those who had had bariatric surgery, but that one year after the study began they had lost more weight on average, with a greater proportion having reached the combined targets for cholesterol, systolic blood pressure and a marker of glucose.

While this proportion fell for both groups after five years – at which point 98 patients were still providing data – those who had had bariatric surgery maintained the edge, with 23% reaching the combined targets, compared to just 4% of those offered lifestyle and medical interventions alone.

Francesco Rubino, professor of metabolic and bariatric surgery at King’s College London, who was not involved in the studies, said misunderstandings and stigma were holding back greater use of such operations in the UK. While Rubino noted that surgery is not for everyone, he added “This is a conversation GPs and doctors should have with patients more often.”

The new work and pensions secretary is an insult to disabled people

As backlashes go, the days following Esther McVey’s appointment as the new work and pensions secretary have seen intense criticism. Between 2012 and 2013, as minister for disabled people and later employment minister, McVey was famed for defending the indefensible, saying it was “right” that people were having to use food banks and claiming that benefit sanctions “teach” jobseekers to take looking for work seriously – going as far as comparing unemployed people to naughty schoolchildren being punished by a teacher – despite the destitution and death that sanctions have since caused. 

Yet this is about more than soundbites. From giving misleading information about the bedroom tax’s impact on disabled people to her decision to close the Independent Living Fund, McVey appeared to relish removing disability support, with campaigners accusing her of distorting the facts to help make that a reality. Worse, she was central in helping the rightwing press stoke up suspicion towards disabled people on benefits – most blatantly as David Cameron’s government began to abolish disability living allowance (DLA) and replace it with personal independence payments (PIP). As the Daily Mail put it at the time, McVey was on a mission to “pursue vast numbers of bogus disabled who carry on claiming the DLA long after they have ‘healed’.” That PIP is now wrongly withdrawing benefits from severely ill and disabled people – with 65% of decisions overturned on appeal – makes this all the more sickening.

The Department for Work and Pensions’ problems do not begin or end with McVey – she is the fifth person to hold the title since 2016 – but for Theresa May to (even reluctantly) promote someone with her track record is emblematic of the Conservatives’ disregard for disabled people.

I’ve spoken to many disabled people who are frightened by McVey’s appointment. That might be hard to understand if you are healthy or on a comfortable wage, but when you rely on social security to eat and pay rent, the DWP minister has power over you. For the families at the sharp end of austerity, McVey represents skipping dinner to pay the bedroom tax or becoming suicidal after losing benefits.

This year, the DWP will continue to oversee major social security changes, including more traumatic transfers from DLA to PIP and the ongoing rollout of the flawed universal credit, which is causing misery and hardship to thousands of families. In her previous ministerial roles, McVey showed herself to be a politician who never cared about the impact of such policies. But DWP decisions affect millions of people’s lives. Largely, for those who are already struggling with poverty and illness. That McVey is now in charge is an insult to them all.

As a GP, having my heart surgery cancelled gave me a new perspective on NHS underfunding

I am a GP partner in Oxford. I have worked in the NHS in Oxford for 20 years, barring two years in a post in rural Canada. In July 2017, we returned to the UK and a friend of mine, who’s a cardiothoracic anaesthetist, commented on my bounding neck pulses as we were chatting over a beer. A little later that day, I had a listen to my heart and even I, a GP, could hear a loud murmur. I asked one of my colleagues to have a listen, just to check I wasn’t being paranoid. I think he was trying to make me feel better and reassured me: “It’s probably just a flow murmur.”

Nevertheless, I saw my GP that day. With detached, mildly mounting alarm I registered the abnormal findings she discovered. High blood pressure, wide pulse pressure, mild tachycardia and, of course, The Murmur. Her worried expression made me more alarmed than the findings, and I found myself trying to reassure her that everything would be OK.


It’s quite difficult to describe the strangled sense of anger as I watched Jeremy Hunt on the news that night.

I saw the cardiologist in October and as soon as he mentioned he wanted to get the medical student, I knew I was in for some bad news. He told me I had severe aortic regurgitation, where blood flows in the reverse direction from where it’s supposed to as the heart pumps. He said he’d see me in six months and by that time I would have a new aortic valve. My reaction was silence, followed by expletive-laden surprise, not least as I had had no symptoms at all. Also, doctors never get sick.

It’s funny how that kind of news affects you – for a week or so, I was mentally crossing things off the list of things I could do with the rest of my life, and confronting the possibility that I might not see my daughter grow up.

In December, I was very relieved to get a date for my operation in January 2018 but my urgent surgery was cancelled when I called in at 10am on the day of admission. It’s difficult to describe the sense of loss that I felt. It came as a surprise, even for someone who works in the NHS every day. I really did not know what to do with myself.

As doctors in the NHS, we are trained from an early stage to soak up punishment, not to complain and to always carry on. But with my patient’s brain, I idly wondered how other people might be coping with similarly disorientating news all over the UK. About how they might be thinking how unfair this was, and what would they do now. Lives put on hold, terrible feelings of uncertainty, resignation and finally acceptance. After such news they must love, fear and hate the health service all at the same time. Nevertheless, the NHS is so beloved that it would never cross their minds that the government would have deliberately underfunded it for the last seven years. Some people might think it’s pretty decent of ministers to apologise for all the disruption, and that the government, to its credit, is forward-planning for a winter crisis.

The fact is, of course, that it is not, and that the crisis was entirely avoidable and is down to consistent underfunding. Doctors and the Kings Fund predicted it, even the head of NHS England predicted it. It’s quite difficult to describe the strangled sense of anger as I watched Jeremy Hunt on the news that night. I’m not sure how much more short-notice my surgery cancellation could have been, and yet here was my ultimate boss telling me that this was being done to avoid just such upheaval.

Q&A

Why is the NHS winter crisis so bad in 2017-18?

A combination of factors are at play. Hospitals have fewer beds than last year, so they are less able to deal with the recent, ongoing surge in illness. Last week, for example, the bed occupancy rate at 17 of England’s 153 acute hospital trusts was 98% or more, with the fullest – Walsall healthcare trust – 99.9% occupied.

NHS England admits that the service “has been under sustained pressure [recently because of] high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges, early indications of increasing flu prevalence and some reports suggesting a rise in the severity of illness among patients arriving at A&Es”.

Many NHS bosses and senior doctors say that the pressure the NHS is under now is the heaviest it has ever been. “We are seeing conditions that people have not experienced in their working lives,” says Dr Taj Hassan, the president of the Royal College of Emergency Medicine.

The unprecedented nature of the measures that NHS bosses have told hospitals to take – including cancelling tens of thousands of operations and outpatient appointments until at least the end of January – underlines the seriousness of the situation facing NHS services, including ambulance crews and GP surgeries.

Read a full Q&A on the NHS winter crisis

I was back to work the next day and I have my game face firmly back on, but I can’t deny it has been disruptive and upsetting. I’m determined not to let any of these developments compromise my patient care and commitment to the NHS. I am sanguine, but waiting hopefully for another appointment. I understand that this situation may well occur again. In that circumstance, I look forward to a time when the apology from my health secretary and prime minister will be replaced by sustained hard investment in the NHS. Platitudes and short-term measures will not save or improve it. And yet, as many commentators have already suggested, perhaps that is this government’s point.

How rhythms become a vital part of us | A neuroscientist explains

This column has run weekly for more than two years but, from a biological perspective, that is a bizarre rhythm. Cells and systems in the brain and body have built-in mechanisms to enforce a 24-hour sleep-wake cycle. And light-sensitive cells in the eye and elsewhere keep that synched to the earth’s rotation.

Animals and plants regulate their activities on an annual cycle, becoming frisky in spring and hibernating over the winter. Again, intrinsic mechanisms tend towards an annual cycle and sensors of various kinds nudge it to keep track of the earth’s rotation around the sun.

The physiology of women shows a monthly periodicity in almost all aspects, although it’s not known whether that has more than a coincidental relation to the orbiting of the moon.

But it is culture, particularly religious culture, that has lighted upon the seven-day cycle as an organising structure for our lives. Once something is in the external world, however, it starts to invade our biology, particularly our neurobiology. That’s why it’s so hard to wake up on Sunday morning even if you were silly enough to have set your alarm clock. In the end, science is part of culture.

Dr Daniel Glaser is director of Science Gallery at King’s College London

Surgeons don’t have to sign their names… in us | Barbara Ellen

Surgeon Simon Bramhall, who burned his initials on to the livers of two transplant patients while working at the Queen Elizabeth hospital, in Birmingham, has been fined £10,000 and given a 12-month community order.

Bramhall (now working for the NHS in Herefordshire) was fortunate not to have been struck off. It’s disturbing enough to think of your body being opened up for surgery, but to have somebody leave their mark there (“SB”) is grotesque; as the court found, it was “an abuse of power, and a betrayal of trust”. Bramhall’s defence argued that it was to lighten the mood in theatre. Really? In that case, put on some quiet background music – don’t sign a human organ, as if you’re some kind of rock star in scrubs being pestered for an autograph.

It seems that there was no lasting harm done – the marks wouldn’t have affected the performance of the liver and they would disappear in time. However, there’s always harm done; if nothing else, such incidents bolster the widespread public perception of surgeons being arrogant and superior.

Too many cases such as this and patient-surgeon trust would be in grave danger of breaking down.

A royal commission is not the way to solve the problems facing the NHS | Richard Vize

As patients die in corridors and A&E performance drops to its lowest ever level, calls are growing for a royal commission to address the mounting problems facing the NHS. This would be a big mistake.

This week the commission idea was raised in prime minister’s questions and the Centre for Policy Studies has published a remit for one. The attraction of a royal commission is that it offers a chance to cut through the party political noise to allow calm consideration of the issues. But the realities of setting one up far outweigh the potential benefits.

Virtually everything about a commission would harm the NHS. If it was announced on the health service’s 70th anniversary in July, by the time the members had been approved, the remit agreed, evidence gathered and the report written, even the most nimble commission would have taken at least three years. (The last one on the NHS, set up under Harold Wilson, took four years.)

That would put it within months of the 2022 general election. So legislation would have to wait until at least the first Queen’s speech of the next parliament, which means nothing would change before April 2024.

In the meantime, there would be six years of policy paralysis. Questions to ministers on every avoidable death, every missed target, every hospital deficit would be met with the words “we’ve set up a royal commission …”. The government could abdicate responsibility and accountability while hiding behind a mirage of activity.

Agreeing the terms of reference would be fraught and mission creep inevitable. While the heart of the issue would be sustainable funding, this would quickly suck in everything from operational efficiency to payment systems, drugs costs, buildings and procurement. Social care funding would have to be debated. Since the biggest cost is staffing, it would soon spill over into predicting future staffing needs, and therefore training requirements, capital investment in technology and more besides.


Any report would be out of date before it was published, and would sink under the weight of its own ambition.

Any attempt by a royal commission to offer wise words on the impact of technological advances such as gene therapy and artificial intelligence would be risible. The speed of change is so great that their words would be history, not policy.

A commission would inevitably tread on the landmine of NHS structure. The present evolving and rather chaotic setup has one big advantage – however imperfectly, it is allowing local areas to find a way of organising and operating that works for them, rather than having to meet the latest centrally imposed structure.

Greater Manchester, Surrey Heartlands and Cornwall are leading moves towards greater devolution in implementing national goals, including a stronger voice for local government. Eight areas are pioneering the development of integrated population health management under the “accountable care” banner. The rest of England is experimenting with the new care models established in the Five Year Forward View.

Together these represent seismic changes in the culture and operation of the NHS. Each one will have the best chance of success if it is allowed to develop at its own pace. We don’t need a grand plan.

A royal commission has superficial appeal, offering authority, wisdom and consensus. But it is wholly unsuited to tackling a fast-changing, technologically driven service desperate for financial security which needs answers quickly. Any report would be out of date before it was published, and would sink under the weight of its own ambition.

Whatever else the NHS lacks, it is not insight, evidence and analysis. The Nuffield Trust, King’s Fund and Health Foundation produce outstanding material daily on all aspects of care and management. The Institute for Fiscal Studies is piling in with a funding review. The NHS is awash with commission and thinktank reports, and the BMJ, health select committee and National Audit Office provide yet more evidence.

We don’t need a royal commission. The truth is already out there. We need a government with the courage to face up to tough choices and make some decisions – now, not in six years.

Richard Vize is a public policy commentator and analyst

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You don’t have to be poor to be hooked on drugs or alcohol but it helps

Dry January ought to be the season to talk about drunks. According to what passes for the public health debate, unfortunately, most of society thinks there’s little to say.

If you drink yourself to death, while taking care along the way to abuse your family, friends and unlucky strangers who cross your path, that’s your fault. You believed Ernest Hemingway when he said “a man does not exist until he is drunk”. No one has the right to be surprised that the drink has finished you – as it finished Hemingway – least of all your own pickled self. Stay too long at the bar, and you must expect to hear last orders called.

We have telethons and sponsored tests of endurance for every conceivable ailment. The charitable raise money to combat poverty in developing nations, cancer and heart disease. But I have yet to hear of a marathon run to save alcoholics from marathon binges or a public appeal on behalf of drying-out clinics. There’s no money in public health. Or votes either.

What applies to drink, applies to drug addiction, sexually transmitted diseases and obesity. In each instance, arguments you hear are filled with a mixture of denial and blame. The discourse is inherently conservative because it affirms that public intervention is pointless. People who cannot get through a week without a drink or a Saturday night without getting plastered are by any reasonable standard addicts. I speak from experience when I say that no heavy drinker agrees with this diagnosis. A line separates wild men on park benches from you and me having a good time. Britain’s tipsy culture won’t say where the line is for fear too many would find themselves on the wrong side. Never doubt that when you have crossed it, you alone will bear the blame.


I have yet to hear of a marathon run to save alcoholics from marathon binges or a public appeal on behalf of drying-out clinics

In this climate of punitive neglect, addiction and obesity are dismissed as diseases of choice, which to use that most class-bound of Tory insults, the “nanny state” cannot cure. It’s true that breaking free from heroin, alcohol or sugar requires an effort of individual will. It is equally true that it is easier to summon the strength to quit when others are on hand to help. These truths ought to be self-evident. But they are not evident in Britain. Virtually everyone who is running to fat has at one time or another denied the results of body-mass index tests that report they are obese. The index would find that Olympic sprinters are overweight, we say, in our defence. So it would. Yet how many of those who say it have the muscles of Usain Bolt?

To be fair, dieting is discussed to excess – unlike alcoholism and drug addiction. But the conversation is dominated by fad diets that always disappoint. When even the BBC, promotes obscurantist delusions about fasting, the favoured weight-loss strategy of medieval mystics, there is an urgent need for the state to foster public health.

The state is failing because the Conservatives have got away with a great, shining lie. Journalists who think themselves speakers of truth to power rarely notice the fabrication. Opposition politicians who bellow about the depth of their hatred of “the Tories” allow ministers to escape without criticism. The lie is that the government has ring-fenced health spending from cuts. The argument about health spending has thus been an argument about the government’s failure to allow the NHS to keep up with the costs of an ageing population and advances in medical technology.

Few spotted that, with a magician’s sleight of hand, the government removed public health from health spending in 2013, and – hey presto! – public health was no longer defined as health. This playing with names, these accounting tricks, have allowed ministers to pretend they are not cutting health spending at the very moment they cut it. The King’s Fund described how the con went down. There were good reasons for giving local authorities control of public health. Councils regulated pubs and fast-food restaurants. Of course they should be responsible for alcoholism and obesity. If Britain is ever to catch up with the rest of Europe and encourage people to walk, run and cycle, the bulk of the work would fall to local authorities. Once again it made sense for them to take the lead on fitness.

For a few years all went well. Then in June 2015, the Treasury clawed back £200m from the public health grant. Local authorities took on responsibility for childhood obesity. The money they received for the extra work hid the scale of the cuts. But not for long. The last spending review announced a reduced income in real terms of £600m a year until 2020-21. Services to help men, women and children stop smoking and to control the spread of sexually transmitted diseases including Aids are already a mess. Meanwhile, I’ve interviewed drug and alcohol workers with scores of clients on their books they cannot begin to help. Their one relief is the sight of rich junkies because they know that all they want is methadone and will get what counselling they need privately.

Speaking of the rich, one cannot overlook the class element in the government’s trickery. You don’t have to be poor to be drink or drug dependent. But it helps. Michael Marmot’s great work on inequality in health shows how it is determined by the wider inequalities of society that deny access to education and decent housing. This is another truth which ought to be self-evident, particularly in Britain where the poor and working class are twice as likely to be obese than their better-born peers.

Obesity costs Britain £20bn in NHS spending and lost working days, and that is before you count the human price of lives shortened by diabetes and heart disease. But as I started with booze let me finish with it. Public health is not separate from the national health. You can’t hide it in a corner and strangle it in the dark. Alcohol contributes to 60 illnesses from mouth cancer to depression. A man who abuses a woman is likely to be driven by drink. A driver who runs you down is likely to be drunk. Alcohol consumption accounts for more than one million hospital admissions a year and over half of all violent crimes.

That the government should lie when it says it has protected the health budget is bad enough. That it can get away with lying is astonishing. Alcoholics Anonymous describes alcohol as “cunning, baffling and powerful”. So it can seem. But it has nothing on the Conservative party.

High time: introducing the Guardian’s new cannabis column for grownups

Today, California becomes the world’s largest legal marijuana market. It’s not the first American state to go fully legal, but with its outsized cultural influence and economy larger than France, it’s about to do for cannabis what Hollywood did for celluloid and Silicon Valley did for the semi-conductor.

Already, 30 US states have legalized medical marijuana (Med). Next year, Canada is likely to become the first large industrialized nation to legalize recreational (Rec), with support from the prime minister, Justin Trudeau. Germany, Israel and Australia have the beginnings of Med industries. Legal marijuana is coming to your neighborhood, maybe a lot sooner than you think.

For decades the plant has been stigmatized, at best, as a time waster for malodorous and unproductive men, with the disapproval factor steepening after age 30. But here in Los Angeles, the world’s most important cannabis market, a rebranding is under way. Marketers are positioning marijuana as a mainstream “wellness” product, a calorie-free alternative to an after-work cocktail. In short, it’s on the brink of global conquest.


It will have profound consequences for how adults relax, but also how they date, parent and work

There’s much to celebrate in that. Among other things, cannabis can be fun, and in some patients it relieves certain kinds of suffering. In the US, legalization is an important victory for criminal justice reform, and racist “war on drugs” tactics which continue to ruin many lives.

For that reason and many more, marijuana needs to be taken seriously, even though it can make people act goofy.

With legalization, many more people will spend much more of their time high. It will have profound consequences for how adults relax, yes, but also how they date, parent and work. Already, seniors are the fastest growing group of users in the US.

Legalization supporters often say cannabis is safer than alcohol, and this view has gained mainstream credibility. As Barack Obama said, it was “no more dangerous than alcohol”.

A bag of cannabis seen in Toronto. Canada is likely to become the first large industrialized nation to legalize recreational use.


A bag of cannabis seen in Toronto. Canada is likely to become the first large industrialized nation to legalize recreational use. Photograph: Mark Blinch/Reuters

It’s true that you can’t fatally overdose on cannabis. And the drug is less likely than booze to presage a car accident, an assault or another life-shattering event. But legalization may give rise to unforeseen problems. (Some doctors have expressed concern about use during pregnancy.)

No one knows how mass-market weed will change how we live and relate to each other. It’s safe to guess it will alter daily life as irrevocably and intimately as landmark products like cars, smartphones and reliable birth control.

Society has embarked on these kinds of mass experiments before. More than a decade into the social media age we’re only beginning to appreciate the implications for our brains and for our world.

Cannabis, at least, is a familiar entity. The plant has been known as both a psychoactive and a medicine for millennia. But much of the existing information and superstition is anecdotal, since for a lifetime it’s been almost impossible to study this chemically complex plant.

Due to marijuana’s outlaw past, and its most famous property, a fog of misinformation and bullshit envelops the plant and everything it touches. As a reporter, I’ve been listening to it for three years.

Now that world-class marketers have arrived on the scene, the fog has, if anything, thickened. The shelves of California pot shops abound with products implying medical benefits. Several brands of cannabis lubes claim to heighten female orgasms. In stores, they sit alongside tempting gourmet chocolates and infused breath mints, discreet enough for work.

Marijuana bubble bath and body lotion for sale at a marijuana dispensary in Los Angeles, California.


Marijuana bubble bath and body lotion for sale at a marijuana dispensary in Los Angeles, California. Photograph: Robyn Beck/AFP/Getty Images

Some brands target young professionals and others, packaged to resemble pharmaceuticals, go after grandparents. Women of all ages are especially in demand; cannabis executives assume the men will follow along. This is all part of an industry-wide effort to reinvent marijuana as a cherished part of a functional life.

There’s some truth to this. But the organizations selling cannabis aren’t charities. While they talk constantly about “educating” the public about cannabis, it generally just means they’re talking up their product.

Cannabis has changed since you were in school. Upon entering a dispensary customers encounter dabs, rigs, concentrates, topicals, CBD and tinctures. Even the flower (that’s what it’s called now) comes in endless strains with unhelpful, sometimes threatening, names like Skywalker OG, Durban Poison and Blue Dream. The galaxy of websites dedicated to parsing them only makes it worse. My favorite write-up begins, “Pretty hard to write this on Dream Beaver.”

Now that the green genie is out of the bottle, let’s talk about it like adults.

High time is the Guardian’s new column about how cannabis legalization is changing modern life. Alex Halperin welcomes your thoughts, questions and concerns and will protect your anonymity. Get in touch: high.time@theguardian.com