Interview with Prasanna Puwanarajah – Writer and Executive Producer of Breathtaking

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What is your medical background?

I trained as a hospital doctor between 1999 and 2005 and worked in the NHS between 2005 and 2009. In that time I worked all over the south of England. Predominantly in Oxford and then in a number of London hospitals, south coast hospitals and I spent some time at the children’s hospital in Bristol and at St Michael’s Hospital there. And in places like Frimley Park Hospital. So I was a doctor living out of their car for a time. Looking back, I was running from the dread of hospital medicine that I felt in the first two years. I just felt less and less familiar to myself over that time.

And so when I took some time away, in the third and fourth years of those four years, I had little periods of doing other things. Sleeping on my sister’s sofa in London and going to see fringe plays and things like that. I recognised more the person I was in those times and just allowed that drift to happen. So here I am, almost 15 years later, on that different road.

In the last few years I’ve worked as a writer in television and in the past I’ve written plays. My first play was performed at the National Theatre about 10 years ago. I’ve written a couple of screenplays that for various reasons are unmakeable. I also work as an actor in TV and theatre and I direct in theatre and films.

What was your own pandemic experience?

I volunteered early on to go back into the NHS and had my General Medical Council registration reactivated. So, I went through the re-joining process but in the end wasn’t redeployed.

You had worked with co-writer Jed Mercurio before?

We met at an audition for his TV medical drama series Critical which was screened in 2015. We shot it all in a studio outside of London so we were all kettled there for nine months with lots of conversations off camera. We also ended up working together on a science fiction TV show that became a graphic novel.

Breathtaking is based, in part, on third co-writer Rachel Clarke’s book of the same name. How did this screen production originate?

I have known Rachel Clarke for nearly 20 years. She was a medical student of mine when I was a junior doctor in Oxford. She was brilliant even back then. Rachel was a graduate entry medic having previously worked as a documentary maker for 10 years. We stayed in touch infrequently over the years. And when she started writing her books, which I read, we talked about those. At that time I was considering material, possibly in the medical space, for television. It was a thing I wanted to try and explore. We were talking about other books of hers and then the pandemic happened.

She wrote her book Breathtaking early on in the pandemic. I read it in manuscript form and it was clear that was the piece of work that was pressing in terms of its need to be out in the world. I got in touch with Jed and said I thought we had something here that we could really collaborate on. Jed, along with a lot of medical people who work in writing, the creative sector, documentary and in journalism, were already thinking about the representation of those times and Jed was interested in Breathtaking too.

We worked almost like a team of people in the health service. There were specific roles. Rachel and I broke the story down into three episodes and we were taking to Jed about the particular details within that. Then Rachel and I wrote a 40-page outline of how things were going to go. Really drawing on Rachel’s experiences and experiences I had come across in terms of testimony. It’s very important that all of the medical events presented on screen were things that had actually happened to the people we had spoken to. Then we took it to ITV who were immediately brilliant at provoking in all of the right directions of what we were doing and encouraging us to depict all of the fears and horrors and strange moments of beauty.

So then it was just a case of laying down the script. For me that’s not the most challenging bit. It’s the bit that is most like performing, in a way. So that happened quite quickly. Rachel and I laid down passes of the script and Rachel would work into them with specific medical detailing. And then Jed would look at it at the end and we would put it all together. We then passed the script on to a group of 20 or so medical advisors. A mixture of health care professionals of all denominations and got them to give it not only a sense check but a sense of how much it felt like the NHS to them. So we incorporated those thoughts and then moved into production.

Breathtaking is a story about life...as well as death?

It’s a story about survival. And it’s about how people get through and how they get each other through. That’s incredibly realistic, I think, to a lot of people’s experiences in the health service. Even though it depicts desperate times and tragic occurrences the hope is that the drama is fundamentally a powerful voice for the positivity of that time. And the cherishing of the memory of the people who lost their lives looking after us. As well as the people who lost their lives despite that care. All of which is something I think we can try and take the first steps towards honouring. We did absolutely want this to feel like a drama that looked at the ways in which people tried to survive.

Is everything in Breathtaking based on fact?

The medicine depicted in the show is based on experiences of health care professionals as reported to us or as experienced by us. We have been very careful. Wanting to depict it in its reality but also wanting to depict it in its honesty and its candour. We’ve tried to portray the most tragic occurrences in the series with precision, care and unsensationalism. Mainly because the material demands that respect and it needs very little inflection because it is so horrendous. We’ve worked very carefully on the medicine to make sure it is as carefully and realistically depicted as possible. We’ve taken great pains to ensure those scenes reflect a kind of reality. But after that it’s the actors in the room who depict those scenes, the emotional truth of those scenes and they do that incredibly potently. It’s a combination of different things. But it’s mainly care and precision and a desire to be clear and honest and to let the material be its own truth.

The knowledge that people did this for real is the main thing that just gets the heads down on set to get the job done. There is a big unexpressed traumatic legacy in a lot of us around the pandemic. That’s been something to hold on set and make sure that people are able to work safely.

Abbey and the hospital staff are faced with impossible choices?

The depiction of that sense of the air being sucked out of the room, literally, is the image at the heart of Rachel’s book. Medics are very particular about measurement and understanding things that are happening in front of them. But there was a huge unknown with Coronavirus when it first arrived because people just didn’t know what its behaviour was. And it didn’t behave like things that rank and file NHS workers had seen before. So the processes were being made on the fly by people doing their best. Some of the things they were seeing in patients felt like an alien physiology at work.

You ended up in situations where hospitals were suddenly questioning whether they were able to deliver oxygen to patients at adequate flow rates. There were these quite existential questions coming in that you would never think hospital management or staff would ever have to concern themselves with. So you were outside of the realms of a known universe in a way. Plus your colleagues are getting sick and some of them are dying.

Before the pandemic wave hit the UK, medical staff here were talking to their colleagues in Italy where patients were being treated in corridors and they were giving explicit warnings about what to expect. I was speaking to friends who were consultants who were going, ‘If this really hits the fan, just jump in the car and come down because we’re definitely going to need an extra pair of hands.’ Which is a bewilderingly frightening thing for an NHS consultant to say on the phone. That’s the kind of thing we were trying to bottle in episode one.

In the hospitals that had relatively small intensive care units the scaling up orders were not about adding a few beds but multiplying the number of beds they had by 10 or whatever. Hospitals were turning operating theatres into ventilation spaces. They were procuring ventilators. There was all that stuff early on about a national project to produce ventilators. And due to lack of resources, doctors also had to ration care and, essentially, make decisions about who would live and who would die. The drama will speak for itself on that.

Breathtaking contrasts the words spoken at No 10 press conferences with the reality of what was actually happening inside hospitals at the exact same time?

Early on there were statements being made by the government about the amount of PPE available to hospital staff that really did diverge from the clinical reality. And that divergence continued in a number of areas as the pandemic developed. That felt like a very important thing for the drama to address. It’s a choice to finesse the truth whenever that choice is made. There is a difference between the response and the presentation of that response. That’s what the drama is interested in. In the timeline specific to the medical reality alongside the timeline specific to the political reality. We have taken great pains to match those two things together forensically to the day. So that the drama depicts how occasionally divergent those two things were. Those things are important for people to understand and to learn. The audience will make its own mind up. All we want to do is make sure we have been as robust as possible in our processes of depiction.

We are just presenting things that happened to people. It’s clear from looking at the observable timeline of the two streams of narratives that there is divergence. I think that is going to be clear to viewers. That there was a reality that was not being spoken about in the pandemic. And that really does need to come to light. The Covid Inquiry is now delving into these things in a much more systemic way as we look at it through the eyes of a Abbey and her team.

Breathtaking has a positive energy around it. That is around handing a truth back to the people who didn’t get a chance to say it. In general there is overwhelming support for the NHS and for its staff. There has been an amplification of negative energy towards the NHS, which is a tough thing for staff members to experience, especially with what they’ve been through. But by and large I think we all feel incredibly fortunate to live in a country where we have this extraordinary instrument of health care free at the point of delivery. I think it’s going to be a really positive thing for us to all come together and share in these kinds of experiences so that we can work out a way to cherish the NHS better.

Where did you film?

We filmed at the former University of Ulster Jordanstown campus in Belfast. In a now unused early 1970s’ building that is a dead ringer for a large NHS hospital. We gutted out three floors and installed an Emergency Department, a ward and an intensive care unit with Ashleigh Jeffers, our brilliant production designer, and Thom Petty, our amazing lead medical advisor. Working together to get all of those layers of authenticity into the set. From ventilators through to old bits of Blu-Tack that haven’t been removed from the walls. Our director Craig Viveiros has been forensic about those details physically being present.

This is the clearest and most realistic depiction of the NHS that I have ever seen. I’ve worked on medical shows before where the aims of those shows have been really quite different. Working on those didn’t come with quite the same internal, visceral, triggery reaction. Walking on to our set I was immediately feeling a sensory dissonance; that somewhere in my sense memory the temperature should be 10 degrees higher and all of the smells of the NHS should be there. There was an internal thing happening with me that felt like the visual stimulus I was receiving was not being matched by the other things. So my body didn’t know where it was.

Breathtaking depicts the reality of Covid, including filming some medical procedures as they would be done in real time?

A lot of CPR (Cardiopulmonary Resuscitation) shown in TV dramas is a surface level thing. That actually doesn’t involve what CPR should involve which is the compression of the chest to squeeze blood out of the top of the heart and round the body. Also to generate a bit of gas exchange through the lungs which physically pushes air in and out. And the truth is it’s a fairly brutal process. To participate in, to watch and certainly to have done to you. There’s often the breaking of ribs and so on. So it’s a very different thing to how it is usually depicted on screen. We have worked out ways to make sure the way we do it is how it would be if you witnessed it on a ward. We’ve gone to particular lengths to get those practical aspects of the medicine right.

You also depict what overstretched hospital intensive care units looked like?

The scenes of what essentially looks like a warehouse of patients on ventilators is a very powerful image. We have been very particular about building spaces that feel like they have been overpopulated in this moment. To depict the reality of intensive care units being essentially asked to take a number of patients they would never be asked to take normally. It’s very moving, actually. It feels intense and it feels busy. It is its own kind of tragedy. Hopefully that will give people a real insight into how those things felt in those units.

What was also important to us was to depict what was happening just on regular wards that were not as well prepared or well stocked with PPE and so on and were a different type of front line. In some ways those are things are just as harrowing. And differently harrowing.

Plus we show how hospital staff had to treat patients in a store room cupboard even before the pandemic arrived. That was a pre-pandemic reality for the NHS. A service stretched to breaking point even prior to the pandemic. After many years of cuts, under investment, staff leaving and so on. The NHS had already had a tough 10 years financially in terms of investment. For a pandemic to happen at the end of that was particularly savage. Because the NHS was pushed into this space of operation fraility. That is even more of a testament to the efforts by the people working within the NHS to get the nation through.

We’ve written the show to feel fluidic. Scenes flow into each other. You follow characters in and out of spaces. So the world happens to them in quite a seamless way. Our director Craig Viveiros has taken that and run with it. We worked with production designer Ashleigh Jeffers to build environments that allowed that fluidity. We wanted it to feel like a living, breathing hospital that cameras had just got into to witness events unfolding. Craig found a way to do that and has executed it amazingly. This story required no embellishment. What we were doing was fine tuning things to make sure there was clarity around what was happening. So the audience has the clearest window into it. Because there are a lot of technical things going on in the hospital. It should feel like your local hospital in a way.

The drama shows the abuse NHS faced from Covid deniers who claimed the pandemic was a hoax. Both via social media and in confrontations when they were going to work?

There was a lot of fear at that time and there still is. Fear and misinformation are close companions in a way. They don’t reflect people necessarily. They reflect responses. Fundamentally people were frightened. They were frightened for themselves and their families. There are ways to manipulate and cash in on that fear, which is deeply venal. But I don’t think that’s about the people who experience the fear. That’s about the people who set up a turnstile beside it. NHS staff dealing with a large number of patients dying from Covid felt anger, frustration, bewilderment and fear in the face of all of that. There is video footage online of those sorts of things happening. You can also see the kind of things that people have said and say on social media. NHS staff had to navigate these kinds of things coming into work in the stresses that were already present in the pandemic.

The impact of the pandemic on NHS staff is still being felt today?

There’s enormous emotional, psychological injury that has happened in the health service. It’s devastating that what we’ve subsequently had to deal with is health care professionals having to strike in order to make that point. There is a lot of work to be done to tell this story properly and honestly and add it to the national narrative around the NHS. The long term support of health care professionals post-pandemic is going to be vital. Many NHS staff have also seen their lives profoundly changed because of Long Covid. So it’s important for us to depict as many kind of realities as possible to bring them all to bear in this drama.

Health care professionals did not have a choice. They ran into the burning building. And they did it at huge personal cost and sacrifice. I spoke to people who couldn’t see their families for months on end. Who couldn’t physically contact their young children who were shielding and vulnerable for various reasons. They made the choice to care for their patients. Which is just what health care professionals do. And they do it every day. Even in the absence of a pandemic. It’s a choice to be there and to serve it that way. Many viewers will also probably not know about the extra lengths hospital staff went in their care for patients. A lot of those things pre-date the pandemic and we include them in this drama.

On a personal level, what does it mean to you to have been involved in bringing Breathtaking to the screen?

It’s an absolute honour and a privilege for me to work on Breathtaking. There is such a need for the story of the pandemic to be told through the eyes of the health care professionals. It makes me feel quite emotional to think that a lot of suffering happened in silence. And that that continues now as people struggle to be paid adequately for doing these incredibly important jobs. It’s extremely important to hold the real story up to the light.

About

Breathtaking airs at 9pm on Monday 19th, Tuesday 20th, Wednesday 21st February on ITV1 and ITVX as well as STV and STV player.

February 20, 2024 2:00am ET by ITV Press Centre  

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