Lazarus, relevance and the NZMA

When word of the New Zealand Medical Association’s intention to fold and liquidate hit the media, the most common reaction was one of sadness.

Despite having been critical of the NZMA and not being a doctor, I felt sad too. For me, it represented the loss of the only pan-professional medical association in Aotearoa New Zealand for all doctors, regardless of their branch of medicine or form of employment.

What compounded this sadness was the absence of any strategic plan to reboot a new pan-professional body. This was an error of the outgoing NZMA board leadership although it was not responsible for the crisis that led to the collapse. Then I thought of an ancient bloke called Lazarus.

Jesus raising Lazarus from the dead

According to the Gospel of John in the New Testament, Jesus raised Lazarus from the dead four days after his entombment. Not a bad achievement. The event is said to have taken place at Bethany, which today is the Palestinian town of Al-Eizariya. In science and popular culture today, the name ‘Lazarus’ is frequently used in reference to apparent restoration to life.

The sudden and dramatic demise of the NZMA was both surprising and unsurprising. NZMA was the only medical body that was truly pan-professional at least in form. But, in substance, it increasingly was not.

In its first year, following its formation in 1989, the Association of Salaried Medical Specialists (ASMS) had a membership density of around two-thirds of its potential, with over half its members also NZMA members. By the time of the NZMA collapse, perhaps 5% were also NZMA members.

Of the many ASMS 10-person national executives I served over the years as Executive Director, at best one or two individuals were also NZMA members (often none). And yet, they were all natural joiners of medical and related organisations.

When I left ASMS in December 2019, ASMS had around three times more working medical practitioner members than the NZMA – whereas the latter should have twice the number.

Relevance and membership

The issue was relevance. In the early to mid-1990s, the NZMA had two strong chairs, Drs Alister Scott (respiratory physician) and Dennis Pezaro (general practitioner), who were prepared to voice the medical profession’s concerns at the challenges of that ideologically driven era.

For me this was the highpoint of NZMA’s effectiveness. But the subsequent chair triggered a departure by taking an explicit pro-government position. This left an impression of lack of independence from government.

There was an inability by NZMA’s elected leadership to project its tangible relevance to the medical profession. This was despite it having some quality chairs speaking out on various issues over the years.

Lesley Clarke had worked for the NZMA in the mid-1990s. In 2011, she returned, this time as chief executive. Clarke may have thought that the loss of a lucrative contract with the Medical Protection Society a few years earlier – due to MPS’ loss of confidence in NZMA’s leadership – was her biggest financial challenge.

However, her study of the membership data revealed a precarious situation that then NZMA board appeared unaware of. But, after reporting this in some detail as a good chief executive should, she was subsequently verbally told off by a senior board member for doing so. This highlighted the fact that it was not just declining membership that was mortally wounding NZMA; it was also a consciousness of denial.

Former Chief Executive Lesley Clarke warned NZMA of precariousness of membership numbers but was confronted by a denial consciousness

This didn’t stop Clarke continuing to report this precariousness. There was some increasing appreciation within the board, but it was insufficient to break the denial bubble.

There was a misplaced belief that the NZMA was protected by the status of its name, the building it owned, the medical journal and, perhaps, the profession’s code of ethics, for which it was responsible. This obscured the reality of declining membership due to declining relevance.

Much has been said of other factors that led to the collapse. In particular, soon after Clarke’s appointment, the building was declared an earthquake risk. This was no one’s fault; it was simply bad luck. Being an official historic place further restricted options.

NZMA building; horrendous cost burden but not cause of Association’s collapse

NZMA building; horrendous cost burden but not cause of Association’s collapse

It was a horrendous, unanticipated cost burden that hit the NZMA hard. But it was not the cause of the collapse. If the association had a strong membership level, it could have worked through the crisis, just as ASMS would have done in a similar situation.

Contributing to the elected leadership being in denial was its antiquated structure, modelled to a large extent on the British Medical Association. But in the UK there are over 328,000 registered doctors; New Zealand has some 18,000.

NZMA needed a nimbler structure suitable for a much smaller medical profession, which would require a completely new NZMA starting with a clean sheet of paper. The denial bubble prevented this.

Declining influence

The absence of a united medical voice diminishes the profession’s influence at the political and other decision-making level. Representation on issues affecting the profession as a whole is more fragmented and inconsistent as a result.

While the NZMA lost relevance and therefore members over the years, it was not a dormant body. It was prolific in producing quality submissions on a range of relevant issues. Chief Executive Clarke had high credibility within the various medical bodies and wider health sector.

In my early years with ASMS, I witnessed two outstanding examples of the potential of an effective pan-professional organisation. One was the withering critique by Dr Scott of the attempt to run the health system as competing businesses. This included describing it as designed by the sort of people who sought to make a profit out of a soup kitchen.

The second, under the leadership of Dr Pezaro, was the NZMA’s support for a successful campaign to overturn a ridiculously low threshold for medical manslaughter. This required overcoming the opposition of the then justice minister. At the time, I thought the campaign was destined to fail; I was wrong.

A later chair, Pippa MacKay, proved to be a superb and thoughtful spokesperson in responding to the conviction of a high-profile doctor for rape. Dr MacKay helped the public appreciate that the credibility of the profession should not be tarred because of a rapist who happened to be a doctor.

In subsequent years, the NZMA, more than any other large medical organisation, championed with some effect the need to address inequities in the health system. It also played an important role in warning of the risk of trade agreements compromising the sovereignty of New Zealand’s health policy, including pharmaceutical purchasing.

Time for a Lazarus moment

There are compelling reasons for a pan-professional medical association. A profession is a disciplined group of individuals who adhere to ethical standards and, through a “social contract”, are accepted by the public as possessing special knowledge and skills in a body of learning. The professionals fulfil their social contract by applying this knowledge and exercising these skills in the interest of others.

The medical profession needs a pan-professional body to represent it, both on issues common to the whole profession and in support of parts of the profession where there is sufficient consensus. But it can’t be resurrected along the same lines as the NZMA.

Beginning with at least the ASMS, Resident Doctors Association and the Royal New Zealand College of General Practitioners (perhaps also the Council of Medical Colleges), there is a need to start with a clean sheet of paper focusing on relevance and achieving a credible membership density. This might involve shifting away from individual subscriptions. But it would be dependent on developing a strong membership base.

Medical associations in countries of similar size to New Zealand, such as Denmark and the Netherlands, have achieved relevance and membership density through strong informal and formal arrangements. The World Medical Association is well placed to assist with this and would be willing to do so.

How about Medical Association of Aotearoa as a starter?

Learn from William Tell

As a child I used to watch a television programme about Switzerland’s William Tell. My enduring recollection is not Tell shooting an arrow through an apple on his son’s head. Rather, it was demonstrating how easy it was to break a single twig with his hands but how difficult it was to do the same with a bunch of bound twigs.

[This post is an abridged version of my column published in NZ Doctor, 6 July 2022]

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