Grace Ofori-Attah, creator and writer of World Productions’ ITV drama Malpractice, on the challenges of depicting mental illness with accuracy on the small screen.
In Series 2 of Malpractice, Dr Norma Callahan (Helen Behan) and Dr George Adjei (Jordan Kouamé) return to investigate Dr James Ford (Tom Hughes), after a patient dies during his on-call shift. The focus of this series was Psychiatry and Obstetrics, two seemingly polar specialties that overlap and intertwine in unpredictable and, at times, catastrophic ways.
Psychiatry and mental illness are difficult to depict accurately on TV, which is why they are rarely done with authenticity. Prior to becoming a scriptwriter, I worked as a doctor for over a decade, doing jobs in various specialties, eventually becoming a Consultant Psychiatrist. It’s an area of medicine I love because it’s still relatively unknown compared to other specialties, a complex mixture of biology, psychology and sociology, where the doctor is as much a part of the therapeutic process as any physical medication prescribed. It’s rare for a screenwriter to have years of firsthand experience working with acutely and chronically mentally unwell patients in inpatient, outpatient and A&E settings, which was a gift when creating this series as I didn’t need to do much research, but it also carried with it a professional responsibility to get things right. I was aided in this by an incredibly supportive team at World Productions, who have quickly picked up the medical jargon I frequently use, as well as an understanding of medical practice within the current NHS.
Depicting acute mental illness dramatically was challenging. In psychiatry, truth is often stranger than fiction. A seriously unwell patient with acute psychotic symptoms can easily feel like a cliché or an exaggeration of fact on the page, which can then be heightened further into the realms of melodrama or even comedy by a well-intentioned performance. This meant the script had to be carefully written with no room for dramatic interpretation of medical dialogue on set (sorry actors, but sometimes the experts are working in your favour!) It was tricky distilling the kind of detailed, gold standard psychiatric assessments that would be carried out in practice to the essential elements necessary to make enough sense to an unknowing audience, propel the story forward and maintain a sense of entertainment and drama. Some of these conversations were hard, with the bottom line from the most senior execs being ‘it’s got to be entertaining’ (i.e. get rid of the textbook level of detail, Grace!)
The other major challenge was truthfully depicting the current state of maternity care in the UK. When I was writing the series, I was aware of a number of high-profile maternity cases in the press, as well as the Ockenden Maternity Review. As a development team, it felt like every week we were sharing newspaper articles about horrific maternity stories, all with aspects relevant to the story we were trying to tell. These cases were always highly emotive and understandably, often highly critical of medical staff and hospital Trusts. However, in writing Malpractice, I didn’t want it to be black and white.
Every script was critically reviewed by two practising Psychiatric Consultants (Dr Abigail Smith and Dr William Shanahan) and an Obstetric Consultant (Dr Sophie Relph) to ensure that, once distilled, the medical content was still accurate. I was present on set most days, always for any medical scenes, with additional input from Dr Relph and our superb midwife advisor Zoe Meneilly. The prosthetics team went above and beyond to create frighteningly realistic pre- and post-term babies, functioning surgical abdomens, and numerous other medical pieces (special thanks to prosthetics masters Laurence Simmons and Davy Jones – without their expertise and creative problem-solving, the series wouldn’t exist). Obstetric scenes had real-life midwives, obstetricians and anaesthetists in supporting artist roles to add an extra layer of authenticity – it can take years to master how to hold and pull on a set of Anderson forceps correctly, unless you are Selin Hizli (Dr Sophia Hernandez, Obstetric registrar), who mastered this within a single training session!
It was crucial that the medical characters felt believable and that even when they were making decisions you didn’t agree with, you could understand why. We were blessed with the superb casting skills of Daniel Edwards once again (who cast series one so brilliantly), and through him we secured the sensational Tom Hughes to play Dr James Ford, the doctor under investigation. The part is complex, multilayered and emotionally challenging – Tom took to the part with enthusiasm and rigour. It was a joy to see him inhabit the role, playing the beats with nuance, sensitivity and a realism that at times took me right back to some of the more heart-pounding moments of my time as a junior doctor. Hannah McLean gave an incredible performance as Rosie Newman, a mother experiencing puerperal psychosis. We were incredibly fortunate to be able to film at Queen’s University Medical School, Belfast, during the students’ summer holiday, which added an extra layer of realism to the shoot. It was here that we filmed some of the most emotionally searing and tense scenes of the show – Rosie’s psychotic breakdown, restraint and eventual death, scenes Hannah enacted so realistically and with such delicacy, without it ever becoming sensationalised. We were also incredibly fortunate to cast Zoe Telford (Dr Kate McAllister, Consultant Psychiatrist) and the aforementioned Selin Hizli as brilliant supporting leads and antagonists to Dr Ford.
I’m often asked what I’d like viewers to take away from the series. I don’t think I started writing the series with one overarching message in mind but there is clearly something that comes through loud and clear. The doctors in Malpractice are real, as are the predicaments they face (chillingly so judging by the deluge of messages and emails I’ve received from doctors, nurses, and other medical staff working across the NHS, particularly following series 2 – one NHS Trust is now even using the show to teach consultants and midwives how to better communicate, something I’m overwhelmed by and extremely proud of). The doctors in the series make mistakes as everyone does in day-to-day life, except their mistakes come at a higher cost. When doctors are striking against doing more work for less pay, it’s easy for the work they do to be judged as vocational and, therefore, something that shouldn’t have a cost attached to it, something they have chosen to do and, therefore, have little right to protest against their working conditions. But I hope the series shows that nobody is choosing to work as an NHS doctor with a view to the money that can be made. As many viewers have said to me ‘I can’t believe the job is that awful’ – why would anyone do it? But in reality, the TV version is a scaled back version of the reality. The reality is more chaotic, more stressful, with fewer highs and many more lows. TV medical dramas are ten a penny but Malpractice is different. The series focuses not on heroic, life-saving doctors but doctors who are human, flawed and subsequently, under investigation. In choosing this type of doctor as my protagonist, I’m asking the audience to put themselves in the position of that doctor and judge whether the decisions they made were justifiable within the circumstances. I hope that it is more than a passive viewing experience, with audiences oscillating between supporting and disliking (or even hating) the choices the various doctors make. Ultimately, as a doctor, people’s lives are literally in your hands. Most doctors I know don’t take that lightly, but they continue to do their best to work within a system that is often unable to help them provide the gold standard of care they would choose for their patients. The weight of that responsibility takes its toll, which is something I hope viewers take away from the series and with any luck, it will make them a little more understanding of the doctor who gets round to seeing them after a ten-minute, ten-week, or even ten-month delay.
Grace Ofori-Attah – Creator, writer and executive producer of Malpractice. Grace is represented By Casarotto Ramsay
First picture: Grace Ofori-Attah (right) with Chrissy Skinns (left back to camera) on the set of Malpractice. Credit Peter Marley ITV
Malpractice Series 1 and 2 are both available to stream in full on ITVX
Jon Creamer
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