The series began as the brainchild of Jeremy Brock, a young BBC script editor, and Paul Unwin, a director at the Bristol Old Vic Theatre. A visit to a Bristol accident and emergency ward and conversation with one of the charge nurses prompted the idea of a series that would deal with the working lives of casualty staff but that would also have a campaigning edge at a time when the National Health Service in Britain was under increasing financial and political pressure. The proposal was taken up by the head of BBC drama, Jonathan Powell, who was convinced that a medical series was essential to a healthy schedule. The Bristol hospital became Holby General and the nurse, Peter Salt, one of the program’s medical advisers and a model for the longest-serving central character, charge nurse (later nursing manager) Charlie Fairhead.

The foregrounding of a male nurse was one of several ways in which Casualty set out to contest the traditional values of hospital drama. The gender stereotyping associated with sluice-room romances of popular medical fiction was inverted (if not always subverted) in storylines such as Charlie’s passionate involvement with a female house officer and the protracted consequences of nursing officer Duffin’s pregnancy by a feckless doctor. The series has also attempted to address racial underrepresentation by placing black characters at the center of the drama and has carried storylines on racial prejudice and abuse.

What Casualty sought to achieve in its first series was a gritty realism, bordering on documentary authenticity, capable of dealing with the day-to-day stresses of frontline emergency care, and the further difficulties of working in a system coming apart at the seams. Brock claimed to have been influenced by the high-octane style of MTM Entertainment Inc. shows, especially Hill Street Blues, with their overlapping narratives and dialogue, rapid cutting, and wry humor, though the series never went for the sort of élan found in its U.S. counterparts. It began on a modest budget and was shot exclusively on video, with lightweight cameras to give it pace and fluidity: the technique of following dialogue down corridors and picking up on several overlapping conversations within the same take was to become a hallmark of the emerging production style.

The central storyline for the first two series was the campaign to keep the night shift open at Holby in the teeth of funding cuts. The shift also provided the setting and time frame for each episode and, improbably, a justification for focusing on the same eight members of staff. By the end of the first series, although another was in production, there was talk of Casualty being axed. There had been criticism of the show’s stress-laden relentlessness and press coverage of protests from the medical professions about the disreputable image of staff conduct, though there was considerable support for the series’ representation of health-service conditions. The program also came under attack from the ruling Conservative Party for its stand against such key Thatcherite policies as funding cuts and the contracting out of services and, along with news coverage of the bombing of Tripoli and the drama The Monocled Mutineer, was held up as an example of alleged left-wing bias at the BBC.

However, as audience figures for the second series began to climb to 8 million, the BBC started to invest more in it. New characters were brought in, and a sharper style began to emerge, particularly in the cross-weaving of storylines and the more honed gallows humor. By 1991 Casualty had an audience of 12 to 13 million and the formula was securely established: a basic structure created by the ten main characters’ continuing stories, a major accident interwoven with six to eight further parallel storylines, and up to 80 short scenes per episode; a real-time feel based on the single-shift setting; sharp-cutting, mobile single-camera work; no background music; realistic lighting; an army of trauma-specific extras and models; and a range of 30 to 40 guest actors per series.

The casting of familiar, high-caliber performers in cameo roles was, for some time, one of the series’ main attractions, along with its growing reputation for graphic authenticity in the depiction of injuries and their treatment. The series also shed its regional identity: although still shot in and around Bristol, this was no longer its ostensible setting and the characters came to reflect a more general population mix. A proposal by Powell, by now controller of BBC 1, to go to a twice-weekly, early-evening slot was rejected, but by this time, many would argue, the show had already softened into a standardized predictability. By 1993 audiences were peaking at 15.47 million and the program was tent-poling the Saturday evening schedule. A ruling in that year by the Broadcasting Standards Council concerning the pre-watershed unsuitability of a story-line about rent boys and male rape and further controversy over an episode showing teenagers rioting and burning down the ward forced the new BBC 1 controller, Alan Yentob, into a promise of greater “responsibility” in the handling of topical material. A year later, audiences stood at 17 million. By 2001, however, they had dropped to around 8 million. In January 1999, a spin-off series, Holby Central, was launched, set in the hospital’s general wards and with some characters already established in Casualty.

Against the claim that Casualty had lost its earlier political abrasiveness, the producers would argue that public opinion had caught up with the program, that the once-controversial claims had become fact, and that the issues were more subtly woven into the fabric of the stories. By 1995, however, the series seemed to reach a final transformation into soap opera. It was the human-interest vignettes imported with each casualty case that now dominated, along with the lives and loves of the regular medical staff. Although the narratives have never fully lost their concern with the fabric of contemporary life, or with the social cohesion beyond the hospital doors, they have sometimes become more overtly theatrical. One later storyline followed two romantically involved characters to the Australian bush, while another dealt with a young, gay Asian male nurse whose HIV-positive status was leaked in the press and whose eventual departure was marked with a spirited gay wedding.

Casualty is a classic example of the intergeneric development of formula-based television fiction. All the attractions of hospital drama are there: life, death, and human vulnerability; institutional hierarchy; and personal and professional tensions. The show also chimes in with the ascendancy in the 1990s of a new genre of emergency service narrative on British television, from Carlton’s drama London’s Burning to such reconstruction programs as the BBC’s 999. Beneath the surface, however, the fictional structure rests on foundations tried and tested in the “cop-shop” police drama, and it is no coincidence that the background of founding producer Geraint Morris lay with series such as Softly Softly and Juliet Bravo. The accident and emergency ward, in particular the waiting area that provides the focal point of the production set, operates here as a classic frontline—a site of friction between the hospital community and life on the street, and a liminal space into which hundreds of individual cases are drawn, to be returned, in varying states of social and psychological repair, to the world beyond.