The observational documentary 24 Hours in the ER, currently airing on BBC America, is a compelling and intriguing series that offers unprecedented access to the emergency room at King’s College Hospital, one of London’s busiest, while capturing the daily life-or-death dramas that take place there. The most-watched unscripted series in the UK, the documentary follows the action of the medical staff, around the clock, over 28 days with 70 specially rigged remote cameras, all needed to authentically tell the emotional stories of the patients needing urgent medical attention, in a way that is more extraordinary than any American medical drama could ever hope for.
During a recent exclusive interview with Collider, series producer/director Amy Flanagan talked about the advantage of using this fixed camera technology for a documentary project, what a massive undertaking it was to coordinate things between the medical staff and production team, how surprised she was to see how American medical dramas have effected the way patients expect to be treated, that this series is the perfect example that real life is always stranger than fiction, and how she will also be involved with the second season that has already been ordered. Check out what she had to say after the jump:
Question: How did you get involved with this?
AMY FLANAGAN: Basically, (executive producers) Nick Curwin and Magnus Temple – two British producers – pioneered this way of filming documentaries, using this fixed camera technology. It uses the technology of Big Brother, but with a documentary sensibility. They first used it in a documentary series called The Family, where they rigged a family’s house with cameras a few years ago, and that was a big success in the UK. And then, they did it again by putting 40 remote cameras in a maternity ward for One Born Every Minute.
They realized that there’s something about using that technology that allows you to get incredibly intimate and very authentic footage, in a very different way than if you’re filming it with a handheld camera. So, they decided to try to do it in an emergency room, on a much bigger scaled. They approached me and Anthony Philipson – we made the series together. I was actually making another series, called The Hospital for UK television, at the time, and was already in King’s College Hospital, filming one of the episodes. I already knew the head of communications at the hospital, and they’d already met him and had begun to negotiate with him about us going there to film 24 Hours in the ER. That’s how it all came about.
How big of an undertaking was this show?
FLANAGAN: It was a massive undertaking. When I was first asked to come and make the series, I didn’t want to do it because it was too complicated. It’s the most complicated project I’ve ever done, just in terms of the ethics and the sheer number of contributors and the number of production personnel that we needed. We had nearly 150 people in our production team alone, and 70 cameras, 10,000 patients and many miles of camera cable. It was epic.
What sort of prep did you do, before you started shooting?
FLANAGAN: Me and an increasingly large number of producers and researchers spent two or three months in the hospital, meeting all of their staff and doing all of the normal things that you would do, with a normal observation documentary. It’s a very weird way of filmmaking. If you’re used to it just being you, or a couple of you, and a camera and the people you’re filming, you develop a very strong bond, over a period of months. This feels very remote and it feels like you’re not directing it because there are all these cameras and all these other people. You somehow feel not part of the process, in the same way. But, actually, you have to apply the same ethos as you would, with a normal documentary. So, I had to make sure that there were enough of our 150-strong team who knew, and had very good and strong relationships with enough of the nurses and doctors and porters and cleaners, who worked in the departments, so that when all these cameras were suddenly nailed to the wall, and we took the ceilings down in the departments and put 15 miles of camera cabling in, they didn’t totally freak out. They also trusted us and trusted that we were going to film what we said we were going to film, and that the tone would be a certain tone, and that it would be high-quality. I know King’s is delighted with the finished product.
Do you have a specific interest in the medical field, or was it just these specific projects that interested you?
FLANAGAN: The challenge of it definitely interested me. I don’t have a medical background. What really fascinates me about this is the casting pool you get in emergency rooms. By using these fixed cameras, what it allows you to do is film a young stabbing victim who’s rushed in and treated by the trauma team, at exactly the same time that a little old lady is being treated who has been widowed for 10 years and has slipped and had a fall, at exactly the same time that a young couple has come in because they’ve been in a car crash. You have all of these very different people, being treated in a very small place, all at the same time, and they all come in with a story. That’s what I was really interested in. It’s amazingly dramatic and there’s a lot of emotion. People are vulnerable when they come in, and no one expects to be there, but the staff always expects them. It’s a real equalizer. I can’t think of any other precinct, where you would have that mix of people, passing through constantly, with such high stakes. That was a very tempting proposition for a documentary maker.
Throughout the shoot, and also in the lead-up to the shoot, we saw these extraordinary things that were a privilege to see, with people going through life-threatening and life-changing experiences, and they allowed us to film it. It’s absolutely as dramatic as the dramas that we’re all used to watching, like E.R. and Grey’s Anatomy. We looked at a lot of American medical dramas when we were researching the series and deciding the kind of style we wanted it to take because we wanted it to be very character focused. Along with the dramatic storylines, you often come across characters who are in the waiting room. You might never see their treatment or ever really know why they’re there, but they’re either very funny or very moving, and you might go back to them, every now and then, while they’re sitting there waiting. Same with the medical staff. We weren’t just interested in the nurses and the doctors. We were also interested in the supporting cast, if you like, of the cleaners, the porters and the security guards, who you would see in a drama, but not in a documentary. It was a good excuse to watch lots of Nurse Jackie and E.R.
Were you surprised by how much the medical dramas have really affected the expectations of patients?
FLANAGAN: Absolutely! It’s the constant bane of the medical staff’s lives. People come in and they expect to be seen straight away, and they expect to be scanned the moment they walk through the doors because that’s what happens on TV. And, they want to be treated by George Clooney. Unfortunately, that’s not the case. Also, you do have to wait for hours and they’re not used to it. People complain. I was really shocked by the amount of hassle that the staff gets, particularly about waiting times. What was great about having this 24-hour framework was that we might have somebody complain about waiting with a splinter in their finger and then actually cut to someone who just had a stroke or is being treated because they’re obviously a priority. It was good to show why people don’t get scanned the moment they walk through the doors and aren’t seen, straight away. A lot of the time, there are more important people waiting to be seen before you. That’s a real sign of our society. They call it the McDonald’s treatment, in the hospital. That’s what they refer to it as. People want to come in, get treated and go again, like a drive-thru, and they can’t be, all the time. It’s a real consumer approach to medicine, which is very weird.
This series is being described as an observational documentary, instead of a reality series. Was that intentional, in order to distance it from the connotation given to reality programming?
FLANAGAN: Definitely! Our background is all in documentary, not in reality. It’s not a reality show. It is a documentary series. We’ve used reality technology, but the sensibility and the craft are very much documentary style. I think people feel that, when they watch it. All of our editors are top observational documentary editors, and the same with our composer. The interviews that we did, two or three months afterwards, were done by a team of documentary makers. People find it difficult to put into a documentary box because of the way it was filmed, but the sensibility and the values we have are absolutely that of documentary makers. It’s not a reality show and it’s not fictional entertainment. I’ve never worked in reality. That sounds very snobby of me, doesn’t it?
What was the process of setting up all of these cameras?
FLANAGAN: The pre-production period was about three months. Once we had official access from the chief executive, and also from the heads of communications and emergency, we needed grassroots access. We needed very good will from the staff on the ground because they were the ones we were filming. A team of about 30 or 40 assistant producers, producers and researchers went into the department, 24 hours a day, until we got to the shoot, so that they were used to having people there, all the time. They were used to having a member of the production team in each part of the department, for 24 hours a day, by the time we got to the shoot. And, they trusted us. We got to know who the key characters were, and who did and didn’t want to be filmed.
By the time the camera cabling began to go in, a lot of us had a pretty good relationship with a lot of them. And then, we had to meet with the hospital building managers, and all of the camera equipment had to go through inspection control. We eventually had to take the ceilings off of the department and thread in 15 miles of camera cabling, and was then connected to all of the camera screens, which we built into a mobile gallery in the car park of the hospital. About two or three days before the shoot started, we had a phone call from the head of communications, saying that part of the ceiling had fallen down. That was a really awful moment for all of us, but it was all fine, in the end.
Each of the cameras were connected to the cabling and nailed up onto the wall. That was a very tricky few days, and was very important for a lot of our team, to be in there reassuring staff. They’d agreed for the shoot to go ahead, but then 70 cameras went up and they got a bit nervous, right before the shoot started. We made sure that we were around all the time, until the shoot started. Once the shoot started, it was a brilliant way of filming in that kind of environment. They’re obviously incredibly busy, and they’ve had film crews in there quite a lot before, being an emergency department, but the staff really liked this way of filming because it’s incredibly unobtrusive. Although there was a member of my team in each area of the department, asking for consent and putting radio mics on and communicating information to the gallery, all the time, there weren’t 70 crews running around with 70 boom poles, and wires and cameras getting in the way. It’s a very discreet way of filming in that environment and, because of that, you get very, very intimate footage. Once someone had consented, we were right there, in these incredibly dramatic and intimate moments in people’s lives. There were moments as dramatic as someone being told they were about to die, which was extraordinary.
Was it difficult to get people who were willing to be on camera? Were you ever nervous that you wouldn’t get enough interesting stories to tell?
FLANAGAN: We were terrified, all the way through, that we wouldn’t get enough stories. We had a very detailed consent protocol that was 30 pages, which allowed for all sorts of different scenarios. You’re only ever asking for their consent to be filmed, there and then. You’re not asking for consent to broadcast, but they have to give their consent, at a later date. I was nervous that a lot of the more dramatic cases and serious trauma wouldn’t give their consent to be broadcast later on, but that didn’t happen. There was only one case that we had to drop, and that was because a boy who had been stabbed gave his consent, but then his mother was very worried afterwards that there would be a retaliation attack, if he went on television. That’s the only story that we didn’t use.
Those who did give their consent, everybody was really happy. Some patients died afterwards and, in that situation, we asked permission from the next of kin. I thought some families would not want us to use a lot of the material, and we tried to cut it very sensitively, but in every case, the families were really grateful that they had a record of their loved one, even if their loved one was in a degree of distress. They were very grateful that their last moments together had been recorded. That was something that I found surprising, actually. The exciting thing about an emergency department is that you never know who’s going to come in, and with what, and we had the added layer of whether they would consent. We knew there would be 10,000 patients when we were there, and there were, and about 20% gave their consent, which is about what we thought. We were terrified, all the way through the edit as well, that we wouldn’t have enough material, but we actually had a lot.
Do you think this series is the perfect example that real life is and always will be much stranger and more outrageous than fiction?
FLANAGAN: Absolutely! It is like the stuff of movies. If it was written in a drama, you just wouldn’t believe it. A wonderful, life-affirming thing for me, and the fascinating thing about that department, is that you have something so dramatic with such heightened emotion going on, and 10 meters away, you have something so ridiculous and utterly absurd happening. All of human life passes through that department, every day. It’s a brilliant mirror on how we behave, generally in society, but also particularly in British society. It was just absolutely fascinating and a total privilege to be there. Some of the stories the medical staff have are absolutely extraordinary. They are heroes. I really do think they are absolute heroes, those doctors and nurses. It was very life-affirming.
Being in such a high-stress environment must have had a personal effect on you. Were there times when you just needed to step away from everything that was going on?
FLANAGAN: Yes. The hardest job was for the people who were on the floor, actually in the department. It was the most stressful for them because they were face-to-face with often very serious injuries. We had a counselor, who was on-call, 24 hours a day, for any member of the production team that found it too difficult. What was interesting was that we all responded to very different cases. Just before I started the job, my father had a stroke, and King’s is a stroke center. He’s recovered now, but for me, the stroke patients that were around my father’s age were the ones I found the most moving and the most difficult. It really cut into all of our own personal experiences, as far as which cases we found quite hard to bare witness to, but we had a very supportive team.
For the team who worked in the gallery operating the cameras, they were one step back from what they were watching. The teams who worked in the hospital did find it very difficult sometimes, but we were all very aware of it and ready to support them, when needed. Everybody was very aware of the privilege. It was very privileged access. The other thing I really felt, that you don’t always see on camera, is that the atmosphere is very charged and there is very high emotion from the relatives and family that is quite stressful to be around, rather than the injuries themselves. It can feel very tense and emotional, for obvious reasons, and being around that is quite hard for the staff.
Looking back at this experience, what was the most rewarding thing for you, and what do you hope viewers take away from it?
FLANAGAN: Oh, gosh, that’s a hard question. There are so many things. I think the brilliant thing for me was that it really touched and captured the imagination of the British viewers. There was the universal sense that we’ve all been in the emergency room and we all have loved ones, and you can’t take those relationships for granted. You never expect to go there, and yet, you can be crossing the road or eat something funny or take the wrong step and suddenly you can be there and your life could change. It sounds so trite and cliche, but that’s what I felt.
It’s a visceral reminder of what your priorities in life are. I hope viewers take that away, and I also hope they find it entertaining. We tried to put lots of humor in, which is what the place is like. It’s not all grim. There’s a lot of humor, and it’s very life-affirming. I also hope people appreciate what the nurses and doctors do. This is about the universal stories of love, life, death and relationships. It’s not actually a medical series. It’s much more about relationships and who we are, as people. I hope people are grateful, the next time they go to an emergency room at 3 o’clock in the morning because they’ve drunk too much and hurt their knee, and don’t complain about waiting three hours.
Is this something you would like to do another season of, and are there things that you’ve learned that you can carry with you, for whatever you do next?
FLANAGAN: Definitely! There is a list of things that I’ve learned from this project that are unbelievable. Certainly, filming in a big, complicated institution like this was an amazing experience. Also, this way of filming is quite addictive. We’re talking about lots of future projects that we can use remote cameras in, where you might want to get more intimate footage than you could otherwise get. And, I will be helping with the second series, which has been commissioned by Channel 4 in the UK.