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I work for one of the fire departments who make up the Seattle-King County EMS System (Medic One). As of 2012, our out of the hospital, witnessed cardiac arrest save rate it 51%. This is the highest in the nation. Now, I'm not trying to brag. My point is that this type of success didn't happen over night, and it didn't happen with a fragmented, uncoordinated EMS system. It's important to have a vision of what you want the EMS system to be, and regional and local government--along with all agencies--have to work together to impliment a REGIONAL system. Sound medical control, with a forward-thinking medical program director, who bases the system from a public health standpoint and who understands that EMS is better suited from a fire-based standpoint. Doesn't mean there is no room for privates, but the economies of scale and reduction in duplicity with fire agencies who already have stations strategically located makes the most sense.
Just my two cents....