Once, I believed my job could require of me no greater act of callousness than that of taking away a patient’s hope. I have observed the faces as other doctors do just that, how they fold and crumple beneath the blow of those words. And I have been that doctor myself, many times. You cannot be cured. You are going to die. He will never wake up. There is nothing more we can do.

Increasingly, though, I am unsure. It is misplaced hope, I suspect, that is the least kind thing we can give a patient. Yet almost as tenacious as hope itself is the doctor’s desire not to have to strip it away, to be the bearer of despair and hopelessness, even when we know the time for honesty is now.

Familiar as I am in my working life with both building and destroying the hopes of others, for myself – as perhaps for most of us – hope, like health, was something I largely took for granted. Its absence, however, was crushing. By the summer of 2016, there was so much I had lost faith in. My capacity to continue as the doctor I wished to be, the ability of the NHS to keep safe the patients entrusted to its care, the very survival of a health service so starved of funds and optimism. As my training post came to an end, a sense of hopelessness initially pervaded my newly emptied days.

On my stepping away from the NHS, life was by no means bad. To begin with, escaping the pressures of the hospital felt like liberation. I started to write. The daily rhythm of the writing and the school run, all my newfound time with Dave and the children, were exotic and unfamiliar. The time out – temporary respite from the burden of doing two doctors’ jobs or living with the fear that someone, inevitably, was going to slip through the net on my watch – was as restorative as any doctor’s prescription. I would stand on the sidelines of a school football match, watching my son and his friends being spattered in mud, feeling as though I could breathe again.

And then, in the space away from the hospital, something happened that was as uplifting as it was unexpected. I could not, it turned out, leave medicine. I missed my patients too much. Just as I had hung on the tales of medicine my father and grandfather told, I found that, whenever I ran into one of my doctor friends, I lived vicariously through their stories from work, relishing every detail. Sure enough, as the weeks went by, I hankered more and more after the hospital. I began to feel as though what mattered to me most, despite lying dormant and defeated, was still alive and capable of renewal. I remained, at heart, a doctor. I wanted to be back there, amid my friends and colleagues but, most of all, surrounded by patients. Hearing on the grapevine about a job in palliative care, the speciality I had been set on pursuing, I decided to apply.

Hospices are often understandably feared, seen as sinister citadels of death and dying behind whose doors lurk our most primal taboos. They are, for many, the embodiment of hopelessness. But, to me, the hospice is often filled with more of what matters in life than almost any other part of the hospital. Families who cherish their loved ones, whose shared grief is a testament to their love and longing. Patients who face what we all, at times, pretend not to know is coming, with such dignity and strength it can floor you. Staff who strive their utmost to give those at the end of their time the best possible life they can live. Humanity, compassion, complicated medicine, simple human touch or time – precious time spent listening and bearing witness. Even in an NHS at the end of its tether, the hospice, still, is a space in which you can be every bit as much of a healer you imagined all doctors to be, but which our overstretched, understaffed hospitals and general practices threaten to strip from the heart of the health service. On learning I had been given the job, it seemed so right, so natural, it felt like returning home.

On my first day back at work as an NHS doctor, the bike ride was a journey back in time. The wind lashed my face but the sky was blue. I freewheeled down the hill into the hospital grounds, as keen and eager as the house officer I had started out as eight years before. No one was more surprised than I was.

Tucked away on the most peaceful part of the site, the hospice sits within immaculate gardens, devotedly tended by volunteers. Inside, there is a calm rarely encountered in the frenetic activity of an acute hospital Trust in action. Artwork, natural light, discreet nooks and crannies containing semihidden armchairs, a merciful absence of hospital posters ordering people to wash their hands, eat more fruit, take part in the lunchtime Zumba.

We squeezed into a room slightly too small for purpose, ready to be briefed by the outgoing night team. I took my place among the other doctors, nurses, a child psychiatrist, social workers, occupational therapists, a music therapist, a psychologist and the hospice chaplain. The day’s ward list – each patient, their room number and their reason for admission – read like a litany of medical nightmares. Lung cancer, heart failure, breast cancer, sarcoma, motor neurone disease, glioblastoma, bowel cancer, ovarian cancer, endstage renal failure. But, as we focused in turn upon the needs of each patient, the diseases were scarcely mentioned. What could we do to help Grace feel sufficiently confident to spend a few hours at home with her husband this week? Had the new medications in the syringe driver successfully tackled Bob’s pain? Would it be OK for Jim’s old jazz band to join him and play in the hospice chapel? Was Simon’s daughter less distressed now? Had Anna’s wedding dress arrived and were we all aware the wedding was this Saturday? Life, as much as death, was everywhere and our job was to ensure it was the best life possible, no matter how fleeting.

One of the most humane aspects of the hospice are the sofas that double up as beds in each room, enabling a loved one, should they wish, to stay night and day beside a patient who is dying. When I started work, Sarah had already spent forty-eight hours at her husband’s side. They had made a pact, she told me, that, when the time was right, Stuart would like to come here, but only if she were there too. In the confines of their room, dimly lit, curtains half drawn, a collection of cards arranged at the bedside, it seemed that their fifty years of marriage – a lifetime entwined – had more weight and substance than Stuart himself, who by now was so diminished by cancer he seemed more spirit than man.

‘It’s as though I’ve already said goodbye,’ Sarah told me. ‘He has one foot here but one foot over there, and, although he knows I’m here, I think in his own mind he has already departed.’

She stroked her husband’s sunken cheek, knelt down and kissed his brow. In the lightest touch, the greatest intimacy. Even as life ebbed away, love had never seemed stronger. We had managed, through painstaking management of the drugs in his syringe driver, to successfully keep his symptoms at bay. I withdrew, satisfied both husband and wife were as comfortable as possible, humbled by the tenderness I had witnessed.

Death, of course, can be the farthest thing from peaceful, even in a hospice setting. Theresa, a patient in her forties with ovarian cancer, was tormented by the prospect of no longer being there for her teenage children. Though she worried terribly about the impact of their visiting their mother in a hospice, with her grossly swollen limbs and pain on manoeuvring, the prospect of attempting a visit back home filled her with even greater anxiety. It took coaxing, reassurance and meticulous attention to her symptoms to persuade her that a visit was possible. The whole team – nurses, doctors, occupational therapists – rallied all week to help build her confidence.

‘All I want is to lie on my bed with Jasmine like I used to and chat and hold her hand,’ said Theresa.

At the end of my first week at work, Theresa attempted her visit. I held her hand and calmed her nerves before she departed, and on her return I went to her room to find out how she had managed. Her face was unrecognisable. The drawn, grey, defeated mask had been replaced by exhausted radiance.

‘We lay on the bed together and we chatted, just like we used to,’ she said, tears brightening her eyes. ‘I didn’t think that was possible. I never believed I’d get home again.’

I smiled. How could I not? With the support of the entire team of staff at the hospice, a mother had shared at home with her daughter time she never thought she would have. The overarching frame of her cancer remained every bit as bleak and brutal, but within that we had enabled Theresa to experience more of what mattered than she knew was possible, and her joy at the realisation shone out of her.

In a parallel universe, the intensely personal care of the hospice would be everywhere in the NHS. Finite resources, of course, preclude that. Nor, in acute or emergency settings, would I wish too many of them to be diverted away from the fundamentals of addressing patients’ urgent, life-threatening needs. Nonetheless, it is perfectly clear that, as resources are squeezed ever tighter, compassion, kindness and attention to patients as individuals are being rationed as surely as the cataract surgeries, hip operations and the latest expensive cancer drugs. Staff may continue to remove themselves from brutalising conditions of work – as I did temporarily – or, with their compassion and commitment to the NHS fatally worn down, they may morph into burned-out clock-watchers. Either way, the health service is compromised, moving a step away from what it should – and still could – be.

Like the other great schisms in British politics in 2016 and 2017 – over Brexit, Nigel Farage, the price of Marmite, the shape of a Toblerone – the National Health Service is one of the great polarising forces of national life. In polls, the NHS consistently tops the list of things that make us most proud to be British, beating our history, the royal family, our system of democracy and our culture and arts. A cradle-to-grave health service, free to all in need, irrespective of their bank balance, clearly chimes with something deep within us, our sense of kinship, perhaps, with our fellow citizens – or a more basic human response to pain and suffering, a primal instinct to look after each other and be kind. Yet, though we love the NHS, we cannot escape the evidence that the health service is increasingly struggling to deliver good care.

In his final piece of writing, produced in the days before his death from inoperable lung cancer, the Times newspaper columnist A. A. Gill captured beautifully the strengths, ambitions, paradoxes and failings of our sacred, yet threadbare, NHS:

The lies, or at least exaggerations – that the NHS is uniquely brilliant, second to none, simply the best in the world – were painfully brought home to Gill when he discovered he was ineligible on the NHS for an expensive, novel cancer drug, which, though unable to cure him, might have given him more time with his loved ones. Had he lived in other European countries, the new agent nivolumab might have been available to him immediately, but in England, he explained, in order to access it without delay, he would have to pay for it himself. In the context of the NHS having such poor outcomes for cancer survival, one can only imagine Gill’s distress at being denied, as he saw it, the prospect of precious weeks’ and months’ more life on the grounds that nivolumab failed to offer the NHS sufficient value for taxpayers’ money.

In spite of this, Gill seemed to intuit precisely why so many of us cling so fiercely to the NHS – because of the story it tells us about ourselves. If we did not have the NHS to believe in, then how pinched and diminished might our collective self-image become? We want to convince ourselves we are decent, humane and generous, a society of individuals ever willing to reach out towards each other. But, if we are unwilling to pay sufficient tax for a system that ensures everyone receives the medical care they need, regardless of their ability to pay, then where does that leave us? Forced to confront the fact that we are too mean, ultimately, to fund the NHS’s future?

This is highly charged, emotive stuff. NHS detractors often dismiss these sentiments as nothing more than obfuscatory fluff. For them, the cold, hard, unpalatable truth is that the NHS is a monolithic dinosaur, a clunky, plodding relic of old that underperforms, overspends and should, by rights, have been extinct long ago were it not for the mawkishness of those who ignore the benefits of the free market’s invisible hand. As political strategist John McTernan claims, writing for the right-wing think tank the Institute of Economic Affairs,

This, of course, is a glib overstatement. It is perfectly possible to believe passionately in the political principles underpinning the NHS, while taking a cool, level-headed look at the evidence for how well and cost-effectively our health service is performing. Indeed, it would be odd for doctors, steeped as we are from university onwards in the science of practising evidence-based medicine, to exclude from our efforts a rational appraisal the overall efficacy of the NHS. Politically, I may cherish an equitable, income-taxfunded health service but, as a doctor, I want the best for my patients, so the NHS had better deliver.

Undeniably, some of the international data make grim reading. They show the NHS lagging behind other European and Western countries on many important performance indicators, with cancer being a striking example. For example, mortality data compiled by the OECD show the UK languishing in the bottom third of the thirty-five OECD countries for five-year survival for colorectal, breast and cervical cancer.81

Is this any surprise, however, given how little of our gross domestic product we choose to spend on health? At the time of writing – and despite Britain being the world’s sixth richest economy – the most recent OECD data show that in 2013 (the latest year for which full figures have been published) the UK spent only 8.5 per cent of its GDP on healthcare, placing the UK thirteenth out of the original fifteen countries of the EU.82 The EU average spend was 10.1 per cent of GDP. For health economists such as John Appleby, the chief economist of the independent health think tank the Nuffield Trust, the key question, therefore:

is increasingly not so much whether it is sustainable to spend more – after all, many countries already manage that and have done for decades. Rather, it is whether it is sustainable for our spending to remain so comparatively low, given the improvements in the quality of care and outcomes we want and expect from our health services.83

To put it another way, do we wish to cut NHS services to fit the current budget, or to provide the budget to fit the healthcare we want? Money, of course, is not the whole story. The NHS can still at times be infuriatingly lumbering. But, while there are, no doubt, ingenious ways of driving up NHS efficiency, merely shrinking the workforce and rationing the care the NHS provides is the opposite of clever. Less is not the new more. Shoestring budgets are not the route to international excellence. In health politics, just as in medicine, there is no place for false hope, disingenuousness or wishful thinking.

Transparency, if it means anything at all within the NHS, begins with candour about the costs of a world-class health service. If we want the best, we cannot avoid paying for it. Yet politicians’ fear of conducting this debate openly with the public ensures the continued denial, for political ends, of the facts about the crumbling state of the health service the government professes to cherish.

Discovering I was unable to walk away from caring for patients stirred in me a renewed sense of optimism. It suggested there was something stubborn and tenacious keeping the NHS afloat. At work, I see this everywhere. My nursing and doctor colleagues may be harried and exhausted but, for so many of them, as for me, the rewards of caring for others still outstrip the costs. And we cling, I suppose, to the glimmer of hope that one day things will change – a political sea change towards the NHS, new investment into services in terminal decline, another doctor or nurse on the rota.

The swiftest way to snuff out that hope is to deny the existence of the problems. This, at root, is the most corrosive consequence of the government’s weakness for spin because it takes away from NHS staff our right to speak, to be heard, to be believed, to have a voice. If no one listens when you try to say that patients are imperilled, if no one believes you when you say the NHS is at breaking point, if you are smeared and undermined by the government for trying to speak out, then in the end you cannot be blamed for hanging your head in mute despair. You have successfully been silenced.

Junior doctors screamed for a year about the dangers of overstretch and understaffing – and the misery of the 2016-17 winter crisis confirmed much of what we warned about – yet the Department of Health continues to maintain its elastic approach to evidence. You might therefore conclude, as I did temporarily, that junior doctors achieved nothing – our efforts were futile – and indeed that in today’s ‘post-truth’ era I am naïve to hope for more. After all, 2016 was the year in which a Cabinet minister claimed that the British people had ‘had enough of experts’ and, across the Atlantic, a proven serial liar went on to win the US presidential election. Facts and expertise have never looked more vulnerable.

For me, the lowest point in the junior doctor dispute came when, after a year of deploying contentious mortality statistics with devastating aplomb, Jeremy Hunt used his speech at the 2016 Conservative Party autumn conference to utter the extraordinary statement, ‘I say to the BMA and all junior doctors let’s not argue about statistics.’84 In almost the same breath, he used statistics – again contentiously – to add rhetorical ballast to his seven-day NHS policy. This time, he implied that weekend care was inadequate by claiming that, ‘when we checked’, only in one in ten hospitals were patients being reviewed by a consultant within fourteen hours of being admitted. In fact, independent statisticians had shown that at least 80 per cent of patients are reviewed within that timeframe.85 It was another statistical sleight of hand.

Statistics – facts – are the bedrock of good medicine. Doctors are scientists, not quacks, and health policy should be as evidence-based as our practice. It takes a special kind of chutzpah both to misuse statistics and to tell doctors to stop arguing about statistics all in the same twenty-minute speech. What could be more ‘alt-fact’ than that? Particularly when you have just positioned yourself – again – as the champion of NHS candour, avowing, as Hunt did in the very same speech, that patients ‘want to know that in our democracy no citizen will ever be rendered voiceless or powerless by a mighty state or a mighty bureaucracy, even one as loved as the NHS’.84

Throughout the year of bitter wrangling, if ever a phrase captured how junior doctors felt, it is that we were ‘rendered voiceless or powerless’ by the government. And, as patients and their families learned the hard way from Mid Staffs, when concerns are ignored for long enough, staff in the end give up trying to raise them. Their silence does not mean things are better, but that fatalistic resignation has taken root.

Yet it does not have to be this way. Giving up is a choice. As the American author and activist Rebecca Solnit writes:

Your opponents would love you to believe that it’s hopeless, that you have no power, that there’s no reason to act, that you can’t win. Hope is a gift you don’t have to surrender, a power you don’t have to throw away. And though hope can be an act of defiance, defiance isn’t enough reason to hope. But there are good reasons.86

Perhaps the best reason for maintaining hope is that, though Hunt achieved his desired ‘win’ over junior doctors, he inadvertently gave us both a voice and the confidence to use it. There is a pleasing irony to the fact that, for all the attempts to paint junior doctors as BMA-duped ‘militants’, no single individual has done more to inspire confidence, determination and the will to speak out among junior doctors than Jeremy Hunt himself.

Nor has anyone united so successfully a previously disparate bunch of doctors into one cohesive whole, 54,000 juniors with a shared sense of identity and a newfound taste for disruptive candour. We are, after all, our patients’ advocates every day at work – now we have extended that sense of advocacy into the political sphere, pushed by the disingenuousness of the current government’s stance towards facts and evidence in the NHS.

Once so subservient, heads tucked below the parapet, my generation of doctors has learned the hard way how to speak out and be heard. We are certainly not going to stop now. Whether the government likes it or not, there will be continued transparency and the facts will out, if not from the Department of Health or the powerbrokers of the medical establishment then from the grassroots up.

‘Rach! Can you believe it? Can you believe what’s happened to Sally? It’s a miracle!’

It was 8 a.m. I’d arrived early for my Sunday morning shift in the cancer centre, hoping quietly to nurse a double-strength latte while preparing for the morning ward round. Being immediately accosted by a nurse on arrival was far from usual, but then Sally Morley was no ordinary patient.

‘What? What’s happened?’ I asked, immediately concerned. ‘Is Sally OK?’

‘OK?’ the nurse laughed. ‘I told you, it’s a miracle. Just go and see for yourself.’

Some two months earlier, my first ever week as a junior doctor in the cancer centre, Sally had been the ward’s success story. A vivacious former care-home worker in her early sixties, she had been diagnosed with a particularly virulent form of leukaemia upon which standard chemotherapy had not landed a blow. Her last chance was a bone marrow transplant that had involved gruelling arsenals of drugs. The transplant had gone exceptionally well. She had weathered the side effects of her chemotherapy with remarkable robustness and unflagging good humour, and her donor bone marrow had engrafted beautifully. With normal blood counts that now showed no trace of leukaemia, she was poised at last to leave the hospital and renew life at home with her devoted husband.

Ron had barely left her side throughout her six-week stay in the cancer centre. When the drugs left her skin intolerably dry and itchy, he tenderly rubbed rose-scented lotion into her limbs to sooth them. When chemo put her off eating, he delivered lemon sorbet to her bedside, the only food she could contemplate. ‘Why can’t I meet a Ron?’ lamented the single nurses. ‘Why do I never date the good guys?’

On the Tuesday, I had carefully written her discharge summary, packed with information for her general practitioner. She had been set to go home the next day. But, on the Wednesday morning ward round, something had changed. Sally, ordinarily so irreverent and full of cheek, was subdued, almost vacant, when we arrived at her bedside. Nothing too alarming, only subtle alterations, but the Sally of old was not quite there. Blood tests revealed possible causes. Her sodium was too low; her heart rate, in addition, was far too high, rattling along at an inexplicably ferocious pace. By the Thursday, her deterioration was striking. She smiled only half-heartedly in response to our questions, unable even to vocalise a response. Worse, she seemed distressed at her confusion, picking in agitation at her hospital bedsheets, clawing at the cannula in her arm.

‘What’s happened?’ Ron begged my consultant. ‘What’s gone wrong? Why is she like this?’

The truth was, none of us knew.

‘Sally!’ he would say, gripping her hands. ‘Sally, it’s me, Ron. It’s Ron, your husband. Sally, are you there?’

She would turn blankly towards the sound of her husband’s pleas, gently touching his cheek with the back of her hand as though driven by innate compassion for her fellow man, despite no recognition of this one. Too often the effort would cause her to lapse into a twilight state of befuddled doziness, lost in a world of her own. Ron’s anguish was terrible to witness.

Weeks passed. Despite the endless bloods, brain scans and lumbar punctures, no cause of her decline could be found. Nevertheless, Ron insisted Sally would recover. ‘She’s a fighter,’ he would tell me. ‘I know she’s there, and she’s going to beat this.’ Gently at first, we tried to counsel caution, instil the idea that, with no diagnosis and no improvement in her function, the chances of recovery were slowly ebbing away. Ron would not hear a word of it. ‘Sally’s going to get better,’ he repeated, sitting doggedly at her bedside.

Eventually, one day, we made a diagnosis. The drops of cerebrospinal fluid I had eked from her spine in yet another painful diagnostic lumbar puncture were packed with a virus known as HHV-6. Ordinarily a mild and self-limiting infection, HHV-6 tends to colonise us all in early childhood, without our even noticing. Typically, it then lies dormant in the bloodstream, silently accompanying us into adulthood. But later in life, should someone require strong immunosuppression such as the chemotherapy drugs we had given Sally, the virus can sometimes reactivate, running rampant through the brain and occasionally causing severe disability or even death.

We treated Sally with the most aggressive antiviral drugs on the market, but all, apparently, to no avail. If anything, she continued to deteriorate, lurching between distressed, vacant and virtually comatose, sometimes all in the space of a day. The Sally we had come to love sank further and further away from us, leaving behind a husband who continued to dote upon her smallest need while refusing to mourn the loss of the wife who seemed submerged for ever.

‘There’s a chance she’ll get better, isn’t there, Rachel?’ Ron would ask me, eyes wide and beseeching. I ached to keep his hope alive, to give him reasons to believe, but in truth the wisest consultants in my team were by now profoundly pessimistic. ‘The longer she stays like this, the more likely the brain damage is permanent,’ my boss had said in the early days. Now we were many weeks down the line and none of us believed Sally would recover. Hope existed only in Ron, and even in him it was rapidly dwindling.

Then, early in the morning of my Sunday on-call shift, everything changed. When a healthcare assistant had arrived to check the patients’ observations, Sally had asked her with perfect lucidity what day of the week it was. Astonished, the nurses rushed straight to Sally’s bedside. She dumbfounded them all by asking, quite clearly, for breakfast. They hastily called Ron at home and urged him to come straight to the hospital.

And so it was that when I entered Sally’s room some hours later, feeling giddy myself with hope and intrigue, this quiet, unassuming, devoted husband almost fell into my arms, beaming and crying and scarcely making sense of the miracle of his wife being back.

‘Oh, Ron,’ chided his wife affectionately. ‘You are a silly one, aren’t you? Pull yourself together.’

‘Hello, Sally,’ I said, smiling incredulously. ‘How are you feeling this morning?’

‘Well, I’m all right,’ she said. ‘I just don’t know what’s wrong with this husband of mine.’ The virus had obliterated several months of memory. She had no recollection of being in hospital or even of receiving a diagnosis of leukaemia, but Sally the person was intact.

None of us could explain it. Medicine drew a blank. Every once in a while, a patient confounds all their doctors’ worst fears while fulfilling their loved ones’ greatest hopes. ‘It was like someone had switched on a light switch,’ Ron said to me later, still shaking his head in disbelief. ‘Flick and there she was again. It’s a miracle, just a miracle.’

Early on at medical school, I was taught to take a sceptical attitude towards misplaced certainty. ‘Never’ and ‘always’ are two words that doctors use at their peril. Exceptions, I swiftly learned, are everywhere, with patients and their diseases rarely conforming to the textbook descriptions I committed so carefully to memory. Yet, in the muddy, uncertain, imperfect, unpredictable world of my hospital, its activity revolves around certain fixed axes.

Pivotal to our health service are the instincts driving its staff. By and large, most of my colleagues have been propelled towards the NHS by a keenness to improve the lives of those of us unlucky enough to experience sickness. We try our best to help our patients through their journeys with illness, even if sometimes we do not get it right. Our primary motivation is helping others, not our own enrichment. Our patients inspire us every day. We have the privilege of routinely observing in those patients and their families more of what is good in people – strength, dignity, love, compassion – than I ever fully appreciated before becoming a doctor. We bear witness to the best and the worst of life, the cruellest blows, the unlikeliest recoveries. We do our bit to assist, if we possibly can. And there is always, even when medicine is exhausted, our touch or voice or smile. It can hurt. It can thrill. It can take your breath away. Painful, bittersweet, overwhelming, magnificent medicine. For me, no other job could come close.