Comparing private and public ambulance services: a scoping review of quality outcomes

Emergency medical services (EMS) are vital for reducing death from time-sensitive conditions such as cardiac arrest and trauma. As health systems turn to private ambulance providers to meet rising demand and fiscal constraints, rigorous evaluation of their quality is essential.

We systematically searched PubMed, Embase, Medline, Web of Science, and Google Scholar for studies published from 2005 to 2025 that compared the quality of private and public ambulance services. Studies were included if they reported on service quality indicators, including response times, clinical outcomes, financial costs, and staffing. In addition, methodological quality was appraised using the Joanna Briggs Institute critical appraisal tools for peer-reviewed studies and the AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) checklist for grey literature, and study designs were further classified according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence framework.

Sixteen studies from 11 countries met the inclusion criteria. Fourteen studies assessed system-level indicators rather than clinical outcomes, including response time, prehospital interventions, transport characteristics, utilization, awareness, and satisfaction, costs and billing, and staff knowledge, and staff profiles. Only four studies examined differences in clinical outcomes. Private ambulance services are likely to incur higher patient charges, insurer payments, and out-of-pocket spending. Findings across other domains showed little consensus.

The evidence comparing private and public ambulance quality is limited, inconsistent, and highly context-dependent. More rigorous, multi-country studies using standardized metrics and transparent public reporting of quality indicators regardless of ownership status are urgently needed. Policymakers should exercise caution when integrating private providers into public EMS systems, with careful attention to contract design, terms of collaboration, and the establishment of minimum clinical governance standards to safeguard and improve quality of care.