NHS under the knife

Dave Kellaway reviews 'This is going to hurt', a BBC TV series starring Ben Wilshaw and Ambika Mod (2022) available on BBC iPlayer.


Based on Adam Kay’s bestselling book of the same name this drama presents an unsentimental but credible examination of the NHS. Kay was a junior doctor for six years and it is based on his own experiences working in maternity and obstetrics wards. Some of the scenes are not for the faint-hearted as some of the emergency procedures are shown in some detail.

Without giving away too much of the plot the series exposes a fundamental flaw at the heart of the NHS from its foundation. Nye Bevan said in 1948 ‘he had to stuff their mouths with gold’ in order get the doctors’ associations’ agreement to form the NHS. A great deal of power remained with the consultants and above all, their right to keep a lucrative side-line of private practice was maintained. Although technically the private practice was separate from NHS hospitals the doctors accepting referrals into their private practice are based in the NHS. All the doctors’ training costs are met by the state and whenever something goes wrong in the private sector it is the NHS that picks up the emergency.  Of course, private practice has grown enormously – I cannot remember TV adverts for it when I was younger. Today there is effectively a two-tier waiting list.

A whole episode shows how the luxurious private maternity clinic was woefully underprepared for a birth that went wrong. Private practice can cherry-pick the routine operations on knees or hips and leave all the chronic or more complicated issues to the NHS. We also see how the working conditions and stress levels for doctors are totally different in the private sector. When doing the locum shift in the private maternity hospital he can sit around most of the night and gets hotel level cuisine brought to him. Adam Kay did 97 hour weeks at times.

Some consultants are shown to lord it over the junior doctors. Their hours are protected and they can more or less choose their schedule. The crucial plot thread about an error is built up around the absence of the consultant from the hospital as the junior doctor is assigned to cover. A mistake about discharging a mother is made resulting in a very ill baby. The consultant had verbally agreed to that decision. Once there is an enquiry he completely drops the junior doctor who is forced to make a statement keeping the consultant out of it.

A friend of mine who worked in the bio-testing lab told me that research papers are often key to a consultant’s advancement on merit points. Quite often junior staff do a lot of the actual research work for papers with the consultant’s name on them. Senior doctors have a lot of control over career promotion so you can understand why junior doctors just go along with the system.

Ben Whishaw as Adam and Ambika Mod as Shruti in This is Going to Hurt (Credit: BBC/Sister/AMC/Anika Molnar)

At the same time, the junior doctors are important in training up interns. We see that Adam, played brilliantly by Ben Wilshaw, relays the bullying and domination he receives onto the young women of Asian heritage whom he has to mentor. Although this changes through the series he is flippantly sarcastic and not all that helpful for much of the earlier episodes. Another element of class is highlighted here since Adam comes from a medical family and an upper-middle-class background whereas Shruti interpreted by Ambika Mod – a breakthrough performance – is from a much poorer background. She has none of the assurance and perhaps entitlement of Adam as she struggles with her gruelling shifts and revision for medical exams. Certainly opening up access and support for working-class people to become doctors is still a major issue if we are going to improve the NHS.

Shruti’s story which becomes as important as Adam’s as the series develops also shows the lack of effective support and resources for staff experiencing stress in the NHS. Along with the ironic banter, there is a tacit acceptance of a sort of blitz spirit – we can tough it out, it is not going to get any easier so get used to it. Perhaps we need to tone down this idea we have of the heroic doctor.  I suppose too that those higher up have gone through this so feel it is a rite of passage and does not need changing.

The imbalance in power and salary between the nurses and the doctors comes over very well. We see that the more senior nurses often save as many lives as the doctors and can sometimes save the doctors from mistakes. For me, one of the best scenes in the whole drama is when Tracey (the ‘effective one’) admits to Adam that she had made the complaint he was stressing about. She correctly highlights how his sense of entitlement and arrogance could put patients’ health in danger. So the author and the series are admirably quite self-critical about the junior doctor’s performance. The series is all the more honest and accurate by showing the flaws in his character.

Through the story of Adam’s gay relationship, we see how the overwork and lack of support for NHS staff can take a heavy toll on one’s personal life. The tenderness and rawness of their relationship make the viewer care about these two people.

There has been some controversy from women who found the drama lacks respect for women and their bodies. Adam’s sardonic or dismissive comments do sometimes show a lack of respect. The natural childbirth movement also takes some stick from him as he is rather mocking of one woman making that choice. I think the show clearly intends to show Adam warts and all and to reflect the problems doctors do have in relating to women so I think viewers can get this. It is true that the need to make the drama visually dramatic meant that there was an exposure of women’s bodies that may not have been necessary for all circumstances. It is a difficult line to judge

Ambika Mod has responded to such criticisms:

A lot of viewers had been grateful that the drama “showed childbirth as it actually is – because it is brutal, it is messy, and it is gory. And that’s not something we’ve seen on television before,” she said.

Guardian article 18 Feb 2022

On the other hand, Milli Hill, author of the Positive Birth Book, said Kay’s book was “blatantly disrespectful towards women. It sums up the misogyny that’s baked into maternity care – the idea that any woman who thinks she can control labour or plan for labour is an idiot, basically.” (op cit)

It is true that the opinion of Adam does reflect the prejudices of some hospital doctors about a home or natural birth but I think we have to remember he is a flawed fictional character. The drama could have adapted the book in a way that reinserted the arguments made by Milli Hill, particularly by changing the scene where the woman is seen eating what she thinks is her placenta. That could have been presented differently. As for some women who have criticised it for triggering trauma I think the warnings for viewers about content were pretty clear.

Despite these criticisms, I think the drama worked well and built up to a great climax that was not overly telegraphed beforehand. Anyone who wants to know the day to day reality and some of the underlying factors of the NHS will find this show informative and engaging.

This is going to hurt can be seen on the BBC iPlayer. The book that the series is based on can be purchased here.

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Dave Kellaway is on the Editorial Board of Anti*Capitalist Resistance, a member of Socialist Resistance, and Hackney and Stoke Newington Labour Party, a contributor to International Viewpoint and Europe Solidaire Sans Frontieres.

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