Long before the financial meltdown, health officials and ministers had realised that one way to keep health costs down is to stop admitting people to hospital. What may seem a contradiction is a serious and worthwhile objective. People who don't need to be admitted to hospital generally recover better at home, at the same time reducing costs at expensive hospitals.
The critical issue is - who decides whether a patient should be taken to hospital?
Often the first person to an accident or acute illness, ambulance officers are treating patients at the scene every day and deciding whether patients require transport to hospital. Clinical care is complex and demands the best training, but good decisions produce better clinical outcomes for patients and could save the state health budget millions of dollars.
Developments in telemedicine may one day enable clinical advice to be exchanged, live, between the doctor in the hospital and the ambulance in the countryside. This would make the ambulance officer an ever more important player in the quest for greater health outcomes and efficiency.
Not surprisingly then, ambulance services are receiving plenty of attention from the Government.
Last year a new agency, the National Ambulance Sector Office (NASO), was established to better co-ordinate the complex contractual relationship between ambulance services, the Ministry of Health and Accident Compensation Corporation, as well as investigating whether efficiencies can be made to the existing services.
Recommendations from the office's review and resulting Government decisions are eagerly awaited by the sector.
At the centre of the issue is St John, a nationwide charitable organisation and by far the country's largest ambulance provider.
On account of its unique composition of volunteers and paid staff, New Zealanders pay considerably less in taxpayer funding than comparable emergency health services in countries like Australia and Britain.
A question no doubt exercising NASO is how the Government can maximise value from St John and other land and air ambulance providers, particularly as state health infrastructure shrinks in rural communities - and furthermore, how to do this without harming a charity that lays a very valuable golden egg for the community.
St John provides at no cost to the state most of its regional ambulance stations, facilities, ambulance fleet and equipment and an army of trained volunteers.
The organisation employs more than 800 paid ambulance officers who work alongside more than 2500 volunteer ambulance officers.
Across the whole organisation, St John has more than 7500 volunteers involved in ambulance services, first aid training, events and community services.
St John has established a 550-strong fleet of ambulances and operational vehicles, equipped with state-of-the-art communications and clinical apparatus, and operating from a network of more than 180 ambulance stations nationwide.
This infrastructure, worth hundreds of million dollars in replacement value, is provided to the community by St John from funds raised in partnership with the community.
Last year a new nationwide ambulance communications network was commissioned funded largely with capital from St John. The sophisticated system was completed efficiently and at significantly lower cost than recent communication upgrades for other emergency services.
If ambulance officers are to play a more important clinical role and reduce pressure on hospital admissions, the Government will need to significantly increase its investment in personnel, training and equipment.
In doing so it will need to move beyond the current short-term contract funding arrangement to a long-term strategic alliance with St John and other land and air ambulance services.
With its efficient organisational and clinical capacity St John and the Government could make the most of opportunities to further integrate with national health services - including expanding ambulance officers' roles in primary health. This would, among other benefits, supplement the lack of rural doctors.
To ensure St John continues to perform its growing role in delivering the Government's health objectives in the emergency care sector, we look forward to having a national plan soon for the whole ambulance sector and resources for further staff, training and equipment.
St John celebrates its 125th anniversary in New Zealand next year. The charity has successfully blended clinical and communications proficiency with a commitment to caring for the sick which dates back seamlessly to our origins in New Zealand in 1885.
Today St John is as ready as it ever was to maintain that legacy in communities all over New Zealand in a long-term partnership with the Government and the people.
* Rob Fenwick is retiring as Chancellor of the Order of St John at the end of this month.