Staff are working under pressure, there aren't enough volunteers and the service faces a funding shake-up. But its chief executive inspires enthusiasm.
The arrival of chief executive Peter Bradley has been balm to the often-troubled souls who work for St John.
They knew they were in trouble - that's clear when you've worked 13 hours without a break for lunch or dinner and you know that the next day will be the same.
But staff the Herald spoke to have a great enthusiasm for Mr Bradley - mainly because he keeps talking about finding ways to serve patients better.
Mr Bradley's focus on the clinical side of St John has led to an upswing in support among a beleaguered staff.
It's not because he has "fixed" any problems - but because they believe he may.
"They've got some hope we're trying to sort things out," says Mr Bradley. "We've got morale issues - we've got issues - no doubt about that."
The former St John ambulance officer and manager left for Britain in 1995. He came back 18 months ago after running the London Ambulance Service.
It is the busiest ambulance service in Britain, with 4500 staff serving 7 million people. It receives 1.5 million calls for help each year.
St John in New Zealand, by contrast, serves about 4 million people, has 2400 staff (and 8000 volunteers) and each year receives 380,000 calls for help.
Mr Bradley's focus is making sure ambulance staff aren't sent to jobs they don't need to attend. The 111 caller who summoned an ambulance after four days of constipation comes to mind.
He also wants more staff - 438 to be exact - and more funding.
When it comes to the money, he says taxpayers will get a better, sharper service and the Government will see the benefit of increasing funds to the "biggest primary healthcare organisation in the country".
In the time since he came back, Mr Bradley says, he has found things "we can do better".
"But for me, the biggest thing is putting the focus on patients."
St John is about to receive a significant boost to funding and a change to how it is funded.
The Ministry of Health is expected to provide about $3 million, which will be used to hire more staff.
Officers the Herald spoke to believe "emergency medical technicians" - a training level below paramedic - will form a large part of the new staff pool.
Mr Bradley says he also hopes the Accident Compensation Corporation's funding scheme will change. St John is currently paid for deliveries to hospital - which is perverse, given that the ambulance service is under pressure to reduce hospital admissions.
One ambulance officer says it's bizarre to get funded for delivering a football player with a sprain from the fields next to a hospital when a three-hour callout will attract no funding if the patient dies.
Money is important to St John, which the Government funds for just 80 per cent of its work. Health Minister Tony Ryall says the "model" is working and will not be changed.
The rest of the money comes from donations and grants. Patient transport and event management (see below) cost the organisation money.
St John runs a scheme which involves people becoming "supporters" for $45. The benefit is supporters don't need to pay when calling an ambulance. Those who don't become "supporters" pay for the ambulance service they use, with the exception of accident callouts.
Last year, St John received $233 million, $205 million from taxpayers and the rest from donations and investments.
St John also lends money to those involved with the organisation - but doesn't declare who gets it.
The loans, which previously have been recorded as interest-free, are currently about $1.1 million.
St John ambulance stations were built in the wealthier parts of New Zealand, which historically put emergency help closest to the rich.
Mr Bradley confirms the historical skew but says the stations now mainly serve as bases where ambulances are picked up or dropped off.
"We're doing a review about where our stations should be in Auckland. We will say, 'Where best do we need our resources to be dispatched from?"'
The skew arose when money was raised by 150 local area committees for services in their areas.
It meant St John's expressions of need through fundraising campaigns often jarred with those who studied the balance sheet to find $80 million tucked away in accounts around the country.
But communities that worked to save the money were eager to keep it for the benefit of the immediate community.
Mr Bradley says he's been told St John has the seventh-highest amount of cash reserves of any charity.
But accounts show most if it is locked away where the central organisation can't touch it.
"That's changing. We'll be consulting on how we use our funds internally that we raise to get best use of it across the country. That's changing and I think the Government recognises that as well."
The changing profile of St John makes that less realistic and the challenge is to convince the local area committees of the benefit of parting with their wealth - about $80 million worth locked away from the national body.
Mr Bradley cites the Whangarei area committee, which is working towards improving services in other parts of Northland.
Health officials have been told St John needs hundreds more staff to fully crew the emergency service.
The service has been using single ambulance officers to work alone - even through night shifts - sparking concerns over safety for staff and how they are meant to treat patients while driving.
St John has told officials it is 430 fulltime staff short of being able to fully staff ambulances. The organisation describes "challenges maintaining a volunteer workforce to use as a second crew position".
It also says there is a "reliance on volunteers in busy urban areas ... maintaining efficient volunteers for these purposes is rapidly becoming problematic". St John says it needs 126 fulltime staff for this.
The draft ambulance strategy, released in 2008 under Labour, aimed to have all ambulances in urban areas double-crewed in four years - by 2012.
The final strategy released under the new National Government made no mention of fully crewing ambulances.
Mr Ryall concedes "rare occasions" on which extra staff brought in to double-crew ambulances were instead used to staff another vehicle, but says it is not routine.
He says new techniques are aimed at reducing the workload on ambulances. Single-crew staff in standard vehicles are treating people at home, removing the need for ambulance transport.
Mr Bradley says the organisation is putting a greater focus on volunteers, with $500,000 put into support and dedicated staff to build and better manage the base.
"We can do more to support our volunteers. It won't solve all the issues because in some places there just are no people to work on vehicles and join St John."
Overtime payments made to ambulance staff show the pressure on those working for St John.
The payments are contained in documents obtained by the Herald and show staff costs in some regions are 20 per cent higher because of the demands on those working for St John.
It means staff in some areas will work another entire day across a normal 40-hour week - not that St John staff work a normal day.
In Auckland, where overtime and missed meal payments boost costs by 8 per cent, a normal day could begin at 6am and finish at 6pm.
St John pays its workers $19,000 a month to cover missed meals, giving truth to talk among staff of a routine of coming in, getting in the ambulance and not stopping until it is time to go home.
"They burn out in three years. A lot of them go overseas," says one advanced paramedic of his colleagues in Auckland.
Another advanced paramedic says the organisation is susceptible to raids from overseas ambulance companies.
Mr Bradley: "The biggest issue in London Ambulance Service - I've come 12,000 miles - is not finishing on time and not getting a break.
"The biggest issue in Auckland: not finishing on time, not getting a break."
About a year ago, an Australian organisation swooped into Auckland and hired almost 20 paramedics.
"It wasn't uncommon there would be only two [advanced paramedics] in all of Auckland."
AUT provides about 80 paramedics a year.
Volunteer firefighters have been told by St John that if they don't want to help they shouldn't have to.
That came after the NZ Professional Firefighters Union expressed concerns about response levels and training. It also follows concerns from volunteer fire chiefs over the number of calls they are having to attend.
The Fire Service and St John signed an agreement in December that was intended to have firefighters backing up ambulance staff.
Now St John is looking at visiting individual fire chiefs to see if they want to continue being back-up for the ambulance service.
"Where we know there are concerns, we will meet with each individual fire chief and get some confirmation they want to continue," says Mr Bradley.
"We do this on the basis they want to do it, not on the basis we are asking."
He says the level of work they are being asked to respond to isn't appreciated.
"At times the level of volume of calls that may fall into their area has not been fully appreciated."
There are four areas - one in the North Island - where joint fire and ambulance vehicles are being trialled.
Another plan is to develop "community first responders" in small communities.
"Members of the local community carry a pager, carry a vest, go in their own cars, with a little bit of training in life-saving", says Mr Bradley.
"That would reduce the burden on people."
Health officials have been told "areas of significant population have notably reduced service", according to a St John briefing note. The December briefing to health officials at the Ministry of Health and ACC also refers to a "reliance on volunteers in busy urban areas", saying it is "rapidly becoming problematic".
The Ministry of Health has identified those areas as Auckland, Christchurch, Waihi, Temuka, Hamilton, Whangarei, Alexandra, Picton, Rotorua and Feilding
There are also parts of the country where St John says there is "no coverage" and "we are totally reliant on volunteer crewing and at times there are no volunteer crews available".
The note states the situation is not uncommon in neighbouring areas. The result is "large geographic areas uncovered".
The ministry says those areas are: the West Coast of the South Island, the Far North, parts of rural Southland, rural Canterbury and part of Taranaki.
The ministry and ACC's national ambulance support office (Naso) also contradicted St John.
Despite receiving a briefing paper from St John saying it has no coverage in "large geographic areas", Naso states: "St John has assured Naso that there are no areas without any cover."
Not just emergencies
Patient transport roles and event management have clashed with St John's primary role as an emergency ambulance service, the Herald has found.
Paid ambulance staff have told of being sent to events - races, rowing, and rugby - only to be called away for emergency tasks.
The departure has cost St John contracts - even when replacement volunteers are drafted in but don't meet the level of expertise spelled out in the contract with event organisers.
Mr Bradley confirms event contracts have been lost after St John has failed to fulfil promises to provide paid staff, when those workers are called away for emergencies.
"There's been some overlap in providing a frontline ambulance service and events. I've been very clear on that - we're not here to have events impacting on frontline services."
He says there is a recognition of the need as a charity to support community events but a better focus is needed on charging events which can afford it.
"We need to be better at deciding which events we can resource and support."
Patient transport contracted by district health boards is also interfering with frontline duties.
Mr Bradley says emergency response has been stretched thin when ambulances are committed to transporting patients.
And doing that work doesn't make money.
"We lose money [on the patient transfer service]. Our [district health board] partners understand some of that and we have successfully negotiated increases in contracts in many parts of New Zealand."
Before the ambulance arrives, 111 calls can also go wrong and have tragic consequences. Read more: tinyurl.com/111woes