Ambulance services will be cut without extra government funding, says the country's largest provider. St John warns it "cannot survive in the future" without more cash from taxpayers.
And ambulance providers have secured powerful support, with New Zealand First leader Winston Peters backing the funding boost - and promising to make it an election issue.
St John chief executive Peter Bradley says St John cannot continue providing the services it does now on the basis of charitable funding.
Cuts would include slower responses to non-urgent calls, reducing staff numbers by not replacing those who left, a reduction in training and fewer people answering calls from the public.
Bradley said: "It really would be about reducing the level of service but focusing crucially on those lifesaving patients because we want to preserve that at all costs."
Bradley's outspoken demand for funding comes as Cabinet considers a report showing St John ambulance services are cost-effective and provide better value for money than similar services in other countries.
Health Minister David Clark's office has refused to provide a copy of the report. Clark said he would not comment on funding for ambulances while work was under way on the issue.
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St John isn't a government agency but a contracted service provided to the Ministry of Health. It gets 72 per cent of its funding through the government contract and needs to fundraise to get the rest.
It costs about $330 million to run St John a year - it got extra funding this year with a $25m top-up over two years after it sounded an alarm with the Government, adding to a Budget increase of $17m over four years.
Deputy Prime Minister Peters - speaking as the NZ First leader - said the ambulance service was "seriously in trouble". He said NZ First had been instrumental in securing extra funding this year and was now looking to a sustainable future.
"My personal view, and my party's view, is we need to look at funding St John at 90 per cent." He said he would be campaigning on that for the 2020 election. Peters said Clark - as Minister of Health - faced funding needs in "so many areas of health ... run down in so many ways" but "we both know we have to get things on to a better footing" for the ambulance service.
"We must be able to afford it. We are putting people's lives at risk."
Bradley and Wellington Free Ambulance chief executive Mike Grant told the Herald it was currently impossible to plan further than 12 months ahead.
Bradley said increasing demand and St John's increased response had led it to the point where "the ability to keep pace financially with that demand has become more difficult".
He said money pulled in by fundraising had increased 25 per cent in the past five years. "Asking more and more of the public to fundraise is becoming more and more difficult."
He said there was a need to "completely restructure the financial arrangements for St John".
It comes at a time when demand increased due to population growth, an ageing population and increasingly congested roads while carrying rising costs of adopting improved knowledge and technology.
Bradley said St John finished with an $18m hole when the 2019 financial year ended in June. The organisation's annual returns have also shown a steady erosion of its financial reserves, eating into capital built up over decades.
Extra cash from a one-off government payment "means we can survive well this year" but the year following would be difficult, he said.
Bradley said St John was already constrained and fielded fewer ambulances and paramedics than it wanted.
Strained resources meant St John wasn't meeting targets set by the Government. Figures in the charity's latest annual report confirm the statement - rapid response times fell in every part of the country except Canterbury.
Bradley said a mix of government funding and public support could work but the balance was wrong.
"Currently it's 70 per cent government funding. It needs to be at 90 per cent". At that level, ambulance services would have "'a long-term sustainable future as an emergency ambulance service".
"In the past 18 months, it's become absolutely apparent to me as chief executive that we cannot survive in the future without the funding model changed and like I say, it's historical. It's not this Government's fault. It's a history."
Bradley said it was difficult to speak out. "You want the public to be confident with the service you're providing and not to scaremonger to undermine the confidence in our service. It's a really fine balance to strike."
Efforts to engage with officials at the Ministry of Health and ACC had led to being told to wait until the current contract expired in 2021 and renegotiate then.
Bradley said relationships between St John and government agencies - the Ministry of Health and ACC - were strong and he considered Clark to be a "big supporter of St John".
"It's about the health priorities and where St John fits. I think the challenge we've got is that we're not seen to actually have too much wrong with us."
Last year, St John told the Government it needed $100m extra per year. The same budget bid had gone in this year, starting with $40m a year and building up over four years.
Ambulance services cost about $50 per head of population at the moment - a bargain, said Bradley, compared with $100 per person in Australia. Increasing funding would shift the funding to around $70 per person.
He said St John had previously managed funding shortfalls but wouldn't be able to continue doing so.
"I don't think that can continue much longer, in which case we will need to work with MOH and ACC to reconfigure the service to run a smaller service."
It could mean telling the public: "We'll come to you if you're dying or we'll get there but you'll a wait longer."
Ministry of Health deputy director-general Keriana Brooking said reviews had found St John to be cost-efficient - "this partly reflects the benefit of St John's community model to leverage its volunteers".
She said the ministry was working with ambulance providers "to better understand the services being delivered and associated cost of delivery".
"No decisions have been made to stop delivery of any current service offering."
St John's position has the support of one of the two unions for ambulance staff, the NZ Ambulance Association.
Chairman Mark Quin said the ambulance provider had always "tried to do everything" but realised "if they continue … they will go broke".
He said that included providing services for which it was not directly funded but considered a critical part of its role. An example was a St John pilot scheme to identify heart attacks faster in people outside urban centres and organising rapid airborne transport.
It had showed such good results, the pilot had been rolled out across the country and was saving lives, levelling the quality of provincial-versus-urban treatment for cardiac patients.
"The Ministry of Health would say at the moment St John is over-delivering on its contract."
Quin said he believed cuts to services would happen without a funding increase. "Everyone is putting their hand out but we are an essential service. We literally are the ambulance at the bottom of the cliff."
First Union's national co-ordinator for ambulance staff, Sarah Stone, wasn't willing to throw the organisation behind Bradley, saying St John's first priority should be to pay its paramedics better.
"It's a broken service. People are so tired."
She said she had told MPs: "I don't believe it's safe out there for the New Zealand public. This service is not running the way it's meant to run."
The National Party's health spokesman, Michael Woodhouse, said there remained a lack of clarity in St John accounts over its contracted emergency responses and other activities, such as patient transfers and paramedic cover for events.
"If they want 100 per cent funding for emergency services when they are a private charity, the price for that has to be a greater level of scrutiny."