Competition in the EMS market in the European Union

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Competition among pre-hospital emergency care
providers in the EMS market in the European Union
PUBLIC CONSULTATION – EFFECTIVE WAYS OF INVESTING IN HEALTH
April, 2015

2
Background
Introduction to the report
• On February 17, the European Commission's Expert Panel on Effective Ways of Investing in Health (EXPH) approved their preliminary
opinion on policy options regarding competition for public hearing. In this opinion, it was indicated that the preconditions for effective
competition in "pre-hospital emergency services" were not fulfilled, and therefore there is no propensity to develop effective competition in
the "pre-hospital emergency services" market
• The purpose of this report is to analyse the market for "pre-hospital emergency services" in the European Union and provide an
assessment as to
– the nature, structure and development of the "pre-hospital emergency services" market and to which extent competition exists in
the European national markets today
– which extent the preconditions for competition (as described by EXPH) are fulfilled for these markets
• The report concludes that there is competition among pre-hospital emergency care providers in the EU today, and that for mature
competitive markets the preconditions for competition are fulfilled (i.e. there is a high propensity towards fulfilling conditions for effective
competition)
• The Expert Panel on effective ways of investing in Health (EXPH) uses the term "pre-hospital emergency services" when assessing the
propensity to fulfil conditions for effective competition in different health markets. In this report, we will use the commonly used term
"Emergency Medical Services" (EMS) when we refer to these pre-hospital emergency services
The report is produced by Quartz+Co and is commissioned by Falck Emergency Europe

3
Structure of the report
Executive summary1
EMS market2
Competition in the European Union EMS market3
Country-level "Deep-Dive"4
Appendix5

4
The background for the report is that the EC Expert Panel has indicated in its preliminary opinion that
pre-hospital emergency services are unlikely to meet the preconditions for effective competition
* Expert Panel on Effective Ways of Investing in Health, preliminary opinion report, February 2015
Source: Quartz+Co analysis
1. EXECUTIVE SUMMARY
Good conditions Average conditions
Conditions unlikely to
be met
Pharmaceuticals Hospital care Emergency room
Pharmacy distribution Primary care Pre-hospital emergency
Patients' transportation Preventive care
Imaging Long-term nursing care
Laboratory tests Long-term home care
Medical specialists
Renal dialysis
Table 4. Propensity to fulfil conditions for effective competition in health
systems (Excerpt from the EC Expert Panel)*
• The EC Expert Panel indicated in its
preliminary opinion that pre-hospital
emergency services (EMS) were
unlikely to meet the preconditions for
competition
• The preconditions stated by the
Expert Panel were
– existence of multiple providers,
– easy entry and easy exit of
providers,
– enough information on prices and
qualities of providers,
– standardised product (or service)
Source: EC Expert Panel views.

5
• There is significant variation between EU countries concerning the EMS market characteristics with regards to number of providers,
commissioning of services, quality and performance monitoring and competence models (operating models)
• Large differences are seen in competitive market maturity on EMS in the EU today, spanning from low to high levels of market
maturity where all preconditions (existence of multiple providers, easy entry and exit, information on prices, quality as well as
standardised service) defined by the EC Expert Panel are met for the countries with high levels of maturity
• The existence of several mature competitive markets suggests that competition can be established in a broader EU context within
the foreseeable future
1. EXECUTIVE SUMMARY
During the last ten-year period there has been a strong trend towards developing more
competitive EMS markets across the EU-countries
– Multiple qualified service providers are already
present in many of the national markets
– Several companies have entered the market over the
last five years, indicating that there are favourable
conditions for market entry
– Information on prices, quality and performance
criteria is available and transparent to purchasers in
some countries
– Equipment and cars are standardised across the EU
and in a number of countries quality accreditations
are used
– Competence requirements and treatment guidelines
are not standardised across countries, but does not
constitute a barrier for cross border entry/competition
– The lead time for establishing functioning competitive
markets is observed to be ~10 years going from a
low to a medium level of market maturity
Our analysis show that well-functioning competitive EMS markets exist in several EU markets today
and that they can be developed relatively fast

6
Content
Executive summary1
EMS market2
Appendix5

7
The relevant pre-hospital emergency care sector in this report is referred to as the
"Emergency Medical Services (EMS) market"
2. EMS MARKET
Definitions and abbreviations
• WHO defines out-of-hospital EMS in a report on the Emergency Medical
Systems in the EU*, and includes "those components of the emergency
healthcare delivery system that occur outside the traditional setting (e.g. pre-
hospital care, transportation and others)"
• In this report, we define the Emergency Medical Services market as pre-
hospital emergency services with qualified personnel and blue-light vehicles.
The EMS market definition used here excludes Non Emergency Patient
Transportation Services (NEPTS, commonly referred to as PTS) from the
out-of-hospital EMS services definition from the WHO
• In this report, the term private service provider includes all non-public
service providers, including so-called private not-for-profit/NGOs, delivering
Emergency Medical Services
• Public service providers can be split into two categories; 1) public service
providers bidding for tenders, and 2) public service providers solely operating
their own EMS services
* Emergency Medical Services Systems in the European Union, WHO Regional Office for Europe (2008)

8
Service provision of EMS and PTS is often linked due to the current public tender practices;
throughout this report we focus on the market for EMS only
2. EMS MARKET
Emergency Medical Services (EMS):
− Prehospital emergency services
Mix of EMS and PTS:
− EMS and PTS in tenders
Patient Transportation Services (PTS):
− Non-emergency patient transport
Service provision overview
• Highly specialised service providers for EMS
• Number of private providers ranges from 2-25
per country, with high competence and
advanced equipment
• There are thousands of PTS providers across
the European Union
• These providers vary significantly, ranging
from taxi companies, small ambulance
services to large scale multinational providers
• Service providers span from the specialised
EMS providers, to PTS providers with limited
capabilities
Tenders/use of CPV codes*
• Some EU tenders include Emergency Medical
Services only
• Commonly used CPV codes for EMS:
85143000 – Ambulance services
85142000 – Paramedic services
75252000 – Rescue Services **
• Some tenders include non-emergency patient
transport only
• Commonly used CPV codes for PTS:
60140000 – Non-scheduled passenger transport
60130000 – Special-purpose road passenger
Transportation Service
• Some EU-tenders include provision of both
EMS services and Patient Transportation
Services
• Commonly used CPV codes:
85142000 – Paramedic services
75252000 – Rescue Services **
* Common Procurement Vocabulary (CPV) codes, established by the EU to pursue openness and transparency in public procurement; please
see appendix for examples of use of CPV codes in tenders
** Often wrongly used in German tenders due to the translation "Rescue Service" to "Rettungdienst" in German; which means Ambulance Services
Focus of this report

9
The total EU market for EMS is estimated to be approximately EUR 18-23 billion per year,
representing around 1-2% of the total health budget
195
228
378
446
2,683
3,200
* Assuming a 1.3%-1.7% share of health budgets across the EU, with total healthcare costs of EUR 1,350 billion for the EU based on 2012
data from Eurostat (estimated for Ireland, Italy, Latvia and Malta, no country-level data available)
** Based on estimated EMS costs for each country: the UK, the Netherlands, Denmark, Sweden, Finland and Germany (latest available data)
Source: Eurostat; UK Office for National Statistics; The World Bank; Quartz+Co analysis
EMS
market size
18-23
EMS cost per country
(selection)**
EUR million, estimate
Annual EMS costs in EU
(2012)*
EUR billion, estimate
EMS share of
health budget
(%)
Healthcare as
share of GDP
(%)
UK
DE
NL
SE
DK
FI
EMS cost per
inhabitant
EUR/capita
1.1%
0.9%
1.0%
0.6%
1.4%
1.1%
9.1%
11.0%
9.6%
12.1%
9.4%
11.3%
36.1
40.8
39.4
26.6
41.9
39.7
Population
density
person/km2
18
132
24
498
265
231
2. EMS MARKET

10
We see an underlying market growth for EMS in the EU
2. EMS MARKET
26
11
554
2
65-7445-64 75+25-4415-240-14
138
(27%)
25-44
46
(9%)
65-74 75+45-64
50
(10%)
140
(27%)
15-24
56
(11%)
0-14
79
(16%)
75+
60
(12%)
77
(15%) 55
(11%)
0-14 65-74
62
(12%)
139
(27%)
45-6425-44
119
(23%)
15-24
180.000
210.000
240.000
270.000
300.000
330.000
+19%
januar
2012
januar
2013
januar
2015
januar
2014
Transports per thousand citizens p.a. per age group
# of transports, US data
* Category A calls resulting in an ambulance arriving at the scene of the incident (NHS)
** Association of Ambulance Chief Executives, Journal of Paramedic Practice, June 2nd
Source: World Bank Databank: Health Nutrition and Population Statistics: Population estimates and projections; Annals of Emergency Medicine:
Analysis of ambulance transports and diversions among US emergency departments; NHS; Quartz+Co analysis
EU population by age group – development from 2015 to 2030
Million inhabitants
2015 2030
We see a strong underlying market growth for EMS in the
EU, driven by e.g. demographic shifts
• Across EU, industry observers see increasing demand
• In the UK for example, the use of ambulance services
has increased by 59% over a decade** and over the
past three years, the number of calls resulting in an
ambulance arriving at scene has increased with ~19%
• The share of citizens aged 65 and older is expected to
grow from 19% to 24% from 2015 to 2030 in the EU
• The number of transports is much higher for older
citizens
Calls resulting in an ambulance arriving at the scene of the incident, UK*
# of calls (Jan. 2012 – Jan. 2015)
INDICATIVE FOR EU

11
EL
There is significant variation between the EU countries in regard to number of providers, sourcing,
and quality & performance monitoring
Number of private providers*
The number of providers spans from only
1 public provider to around 20 private
companies competing in a single country
Sourcing of ambulance services
Sourcing in EU countries today is
provided by public organisations or
commissioned through concessions and
tenders
Public (no tenders)
Portugal and the Czech Republic
are examples of countries that
have public ambulance services
only
Concessions
In the Netherlands and in parts of
Germany the private provision of
ambulance services is sourced
through concessions
Tender process
In countries such as Denmark,
Sweden, Finland, Spain and in
parts of Germany, sourcing is
arranged through EU tenders
Quality and performance monitoring
Some countries have under-developed
systems with limited monitoring, others
have several indicators which are used
actively. There is a lack of cross-national
benchmarking
Limited
Many countries without private emergency
medical service provision have limited quality and
performance measures linked to sourcing or
management of sourced ambulance services
Extensive
• The UK has several measures for quality and
performance, including response time and
number of incidents treated
• Denmark has 4-22 measures per region
0 >1005
* Only dedicated EMS providers included in chart. The number of providers increases significantly when including mixed EMS/PTS providers
Source: Analysis of Emergency Medical Systems Across the World (Worcester Polytechnic Institute); Quartz+Co analysis
Characteristics Findings
10
UKNLDKSE FIDEESBEPT FRITATCZ PL
2. EMS MARKET
>20

12
Content
Executive summary1
EMS market2
Appendix5

13
There are large differences in market maturity in the EU on EMS - spanning from low to high levels of
competitive market maturity
Low
Competitive market maturity ranking of top 15 EU countries*
Rank: Low to high
Medium High
Characteristics of
levels of maturity for
competition
Use of private
providers
Easy entry and exit
Pure public provision of EMS Concession based commission
model, limited tendering
Tender based sourcing model
Standardisation Limited standardisation of
personnel, procedures and
equipment
1
2
4
Use of information and
transparency in sourcing
processes
3 Limited monitoring of
performance, concession-
based
Some tendering, limited use of
information in tenders and
contract management
Performance and quality
measures used in most tenders
and contract management
Some standardisation Standardisation of personnel,
procedures and equipment
ESIT PLPT BECZEL AT FI DEUK** SE DK
* Top-15 EU countries in terms of healthcare costs
** Private providers used for peak management
NLFR**
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET
No market entries in the past
decade
One market entry in the past
decade
One or more market entries
over the past decade

14
169
89
186445
More than half of the population in the top 15 EU countries live in countries with medium to high
levels of competitive market maturity
A large part of the population is based in medium to high maturity countries*
Million inhabitants
* Top 15 EU countries in terms of healthcare costs
Low Medium High
ESIT PLPT BECZEL AT FI DEUK SE DKNLFR
Medium and high
maturity countries:
62%

15
When considering the preconditions for competition defined by the EC Expert Panel, we see that
they are fulfilled for the EMS market in the countries with high levels of maturity
Precondition for
competition Assessment of the EMS market
1. Existence of
multiple
providers
• Competition in mature markets is characterised by having 2-20 competing providers
• Two providers or more (including the public provider) allow for competition on price and quality among suppliers
• A limited number of providers (up to 20, depending on size and structure of the country) gives economies of
scale and makes it easier for the government to manage the sourcing process, including tendering and
managing contracts
2. Easy entry
and easy exit
for providers
• Seven cases of cross-border entries have been observed where existing providers have entered new national
markets over the past five years
• Due to the complexity of the services provided in the EMS market, uncontrolled exits should be managed so that
negative consequences for the general population are minimised
3. Enough
information on
prices and
quality
• Information on prices is available and transparent to purchasers, and prices are quoted in a standardised manner,
e.g. per ambulance, per incident or per km
• Criteria for performance, such as response and mobilisation times, are included in tenders, and in some tenders
there is also demand for quality criteria, such as certain levels of survival rates and sufficient pain management etc.
• Performance measures are normally standardised across regions and in some cases wrongly used to assess the
quality of services delivered
4.
Standardised
product (or
service)
• There are standardised requirements for equipment and cars across the EU
• Competence requirements for personnel and procedures are not standardised across the EU, but competence
requirements do exist for regional/national markets
High maturity
level
DE
SE
ES
DK
FI
PL

16
Multiple qualified providers of EMS are already present in most of the national markets
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET – EXISTENCE OF MULTIPLE PROVIDERS
• There is a considerable private-
sector presence in the national
EMS markets
• This indicates that opportunities
exist for competition in the
markets, between private parties
or between private-public
providers
• The number of private providers
varies between countries – from
2-3 large providers to 30+
providers in some of the more
fragmented markets
30-40%
Only public
90%
85%
80%
Only public
32%
80%
25%
~7%
95%
38%
Only public
2%
70%
95%
90%
3%
EMS private provision
% of total market revenue
Private providers
#
* The overwhelming part of these providers are small operators with <10 employees primarily engaged in PTS
** Less than 10 players with a revenue of more than EUR 2 million
*** 3 players hold 26% of market share, the rest is fragmented
**** Private companies primarily used to relieve the emergency network during peak hours
***** Several operators are bidding but only four private providers currently have contracts
Source: Company homepages; National Health Authorities; Health Care Europe: Public Procurement; Falck; Quartz+Co Analysis
Not-for-profit/NGO
For profit
ESTIMATE
UK
NL
DK
SE
DE
ES
FR
FI
PL
CZ
BE
EL
3
15
30-40
Only public
~5
~4*****
~30
10****
~5,000*
20-25
>15***
~10**
Only public
Only public
<5
AT
PT
Country
IT

17
Several companies have entered new national markets over the past five years
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET – EASY ENTRY & EASY EXIT
Multinationals are entering the European countries
New entrants over the past 5 years
Dutch company ‘BIOS-groep’ created a Danish
subsidiary and successfully bid for an EMS
contract in Southern Denmark*
Falck acquired a German EMS provider in 2011
and made an additional major acquisition in 2013
* Bid won in August 2014; contract starting in September 2015
Source: Company websites; Orbis; Falck; Retriever; Quartz+Co Analysis
Falck entered the Spanish market by acquiring
an EMS provider in Northern Catalonia
• There is not necessarily a clear connection between
ensuring effective competition in the EMS markets, and
fulfilling the precondition of easy entry & easy exit put
forward by the EC Expert Panel
− Due to the complexity of the services provided in
the EMS market, uncontrolled exits should be
managed so that negative consequences for the
general population are minimised
− To reduce the risks accompanied with
uncontrolled exits, requirements should also be
made in advance to ensure financial and
operational robustness
− However, these necessary measures may also
imply hindrances for entrants
• Nonetheless, our analysis shows examples of providers
entering new EMS markets, thus indicating that the
precondition of possibility to enter new markets is met
Swedish private equity firm ‘Adelis’ acquired the
Finnish medical company ‘Med Group’
US based medical waste giant ‘Stericycle’
acquired ‘ERS Medical’
Italian private equity firm ‘InvestIndustrial’
acquired ‘Thames Ambulance’
Falck acquired 45% of ‘Medical Services Ltd’
2015201420132012

18
There is information on prices and costs available in some countries, indicating that the services are
measureable and that there is cost transparency for buyers and providers
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET – INFORMATION ON PRICES AND QUALITY
Country
Source: Rigsrevisionen: Beretning om regionernes præ-hospitale indsats; Akutudvalget; NHS: Transforming NHS ambulance services;
Västra Götalandsregionen: Verksamhetsdata; Stockholm Region: Healthcare Provider Guide
Type of information
available
Examples of
available data Examples of regularly published statistics
UK
Ambulance cost
index per county
Overall cost
index, share of
EMS costs used
for front-line
services, cost
per incident
SE Cost data available
on regional levels,
split on EMS and
PTS
Cost per hour,
per inhabitant,
per incident etc.
for some regions
DK Aggregated
ambulance costs
for EMS and PTS
Ambulance
spending (EMS,
PTS) per region

19
Some countries use performance metrics in tendering of ambulance services, while the use of quality
measures is less frequently observed
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET – INFORMATION ON PRICES AND QUALITY
* There is ongoing research on the different performance and quality metrics of pre-hospital care; please see reference overview in the appendix
Source: Rigsrevisionen; The Danish Healthcare Quality Programme; Region Nordjylland; Lippert (2013) Out-of-Hospital cardiac arrest data; NHS:
Transforming NHS ambulance services; Ambulancezorg Nederland; Socialstyrelsen Sverige: Healthcare comparisons; Region Västgötaland: New
tendering of ambulances gives shorter response times and higher quality; Beredskapsinfo (DK): Falck wins North Jutland ambulance tender;
Ambulancezorg Nederland: Key insights 2012
Country Performance metrics* Quality metrics* Use of metrics Examples of regularly published statistics
SE
Response and mobilisation
times for ambulances
Survival from out-
of-hospital cardiac
arrest and
infarctions
Used for defining
service levels in
some tenders
UK
Number of calls answered
within response and
mobilisation times,
incidents attended per
ambulance staff
Outcome from e.g.
cardiac arrest,
STEMI, stroke
Mainly for
broader
evaluation of
ambulance
services
DK
Response time for
ambulances
Cardiac arrest,
reports on adverse
events
Used for defining
service levels in
some tenders
NL
Response and mobilisation
times, call and dispatch
time per region and call
type, complaints statistics
n/a n/a

20
Equipment of Emergency Medical Services are standardised across the EU with clear guidelines for
equipment and vehicle standards
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET – STANDARDISED SERVICE
* Standards with the 1789:2007 name and alterations of the CEN part are national variants of the CEN 1789 standard
Source: CEN-1789 (European Committee on Standardization); National Standards Agencies; Quartz+Co Analysis
Ambulance types
A. Patient transport
ambulances (types
1 and 2)
Emphasis is on
transportation; limited
treatment or equipment
space
B. Emergency
ambulances
Increased treatment
space and the ability to
store significantly larger
amounts of medical
equipment than type A
C. Mobile intensive
care unit
Accommodates hospital
equipment such as
ventilators during
transport as well as
equipment equivalent to
type B
Description Compliance – current ambulance standard*
CEN 1789:2007 – Ambulance standard
Vehicle marking
Passive – pattern Active – sirens and lights
Type A2, B and C must
be equipped with sirens
and lights
UK
NL
DK
SE
SK
DE
ES
FR
FI
PL
RO
BE
EL
IT
PT
CZ
HU
AT
IE
HR
LT
SL
BG
EE
CY
LU
MT
LV
Main stretcher/undercarriage, carrying sheet/transfer
mattress, ventilation/respiration equipment, infusion
material, defibrillator, bandaging/nursing equipment,
personal protection, rescue material, communication
Type A equipment + pick-up stretcher, spinal
board, immobilisation equipment, diagnostic
equipment, pain relief, cardiac monitor, manual
resuscitator, helmet, personal infection protection
equipment, additional communication
Type B and A equipment + portable
advanced resuscitation system, thorax
draining kit, infusing device, central vein
catheters, PEEP-valve, capnometer
Required equipment















21
The existence of various training levels and competence models does not hinder the development of
competition across borders
3. COMPETITION IN THE EUROPEAN UNION EMS MARKET – STANDARDISED SERVICE
…still, EMS providers are competing across country
boarders with different competence models
• Bios-groep is competing in the
Netherlands, and has recently entered
Denmark
• Falck has operations in
regions/countries using several
different competence models, e.g.
Germany, Denmark and Sweden
• Italian private equity firm
Investindustrial has a portfolio with
EMS operation in Spain and has
entered the United Kingdom
There are many different competence models in the EU EMS markets…
• Ambulances in the UK are generally staffed with an EMT and a
paramedic
• EMTs train for 1 year before operating independently
• Paramedics start as EMTs and train for an additional 8 months
• German ambulances are dispatched with technicians and supported by
separate cars with doctors
• The doctor must have a specialisation in emergency medicine, and is
typically an anaesthetist
UK
DK
SE
DE
• In Sweden, ambulances are staffed with at least one registered nurse
(RN) in addition to a paramedic
• 8 of 21 counties require that the nurses should be specialised nurses
• Personnel can either treat on scene or bring patients quickly to the
hospital, depending on the conditions
• Ambulances in Denmark are required to have at least two persons on
board, at least one of them is a paramedic and/or EMT
• Basic EMT education takes 2 years and 3 months, intermediate EMT
requires 1.5 year of field training (>5 week course), and paramedic
education additional 3 year field training (>5 week course)
• The Netherlands employ a model where critical care nurses with
ambulance training can either treat on scene or bring patients quickly to
the hospital, depending on the conditions
• The Netherlands have a dedicated driver/nurse assistant
NL

22
10
5
0
2012200820041992 1996 2000
First year of introduction of EMS tenders by EU country*
There has been a major increase in the rate of development of competitive EMS markets within the
EU over the past ten years
PL
AT
FI
DE
SE
DK
ES
SK
SL
IT The number of
countries with EU-
wide tenders on
emergency medical
services has
increased rapidly
the past decade
* First EMS tender per country, either identified through official EU Ted entries (data available from 2010) or found through other sources
** Line indicates future development
Source: EU TED (tenders electronic daily; Falck; Quartz+Co analysis
Numberofcountries
Year
**

23
2005
During the last ten-year period there has been a strong trend towards developing more competitive
EMS markets across the EU-countries
Public only Concession-based Tender-based
Development in competition maturity per country, 2005-2015 comparison
UK*
NL
DK
SE
FI
DE
ES
PL
BE
PT
FR*
IT
AT
CZ
EL
2005 2015
2005 2015
2005 2015
2005 2015
2005 2015
2015
2015
2005 2015
2005 2015
2005 2015
2015**
2005 2015
2005 2015
2005 2015
2005 2015
* UK and France primarily applies public service delivery and peak load is provided by private sector
** For Belgium the 2005 status is not known
Source: Falck; Quartz+Co analysis
2005
Per 2005
Per 2015

24
Content
Executive summary1
EMS Market2
Appendix5

25
Denmark has a well-established private and competitive market for EMS
4. COUNTRY DEEP-DIVE
Key insights from Denmark Statements
• Denmark is unique in the EU due to the 100% outsourcing of
Emergency Medical Services
• The private sector presence in Denmark is significant in the
Emergency Medical Services market, with the large majority of
services provided by private providers. There is one large private
provider (Falck), and 3 other players (Responce, Ærø and Samsø
Redningskorps)* - in addition three public providers (the fire brigades
of Copenhagen, Roskilde and Frederiksberg) are participating in and
have won public tenders
• The Office of the Auditor General of Denmark assessed quality and
cost among pre-hospital services in 2014 stating that the Regions
should work towards reducing costs, e.g. through increasing
transparency and competitive tendering.
• The office also stated that most competition exists across Danish
regions where the most has been done to improve competition; i.e. it
is possible to stimulate to more competitive markets
* BIOS has won a tender, starting September 2015
Source: Rigsrevisionen: Beretning om regionernes præ-hospitale indsats (quotes are translations); Quartz+Co analysis
"The regions that have done the most to improve competition is also the regions
where most competition exists"
Auditor General, Jan. 14
"Capital Region, Region Zealand and Central Denmark Region is divided in
respectively 10, 6 and 8 smaller areas, and has respectively 3,2 and 3 providers
of ambulance services"
"[…] all regions henceforward should work towards increasing the transparency
and competitive tendering, e.g. by making control offers as Capital Region and
Region Zealand."
Key facts DK:
Population: 5.6 million
EMS cost: EUR 228 million
Private providers: 4
Private sector share: ~90%
Sourcing: Tendering
1990 2005 201520102000
2007: The
Regions get
responsibility for
EMS
2014: Auditor
General:
assessment
report
2015: 2nd
round of
Region
tenders
2008: 1st
round of
Region
tenders

26
Since the initial privatisation in 1993, the share of revenue for private providers has
increased to 30%
Key insights from Sweden Statements
• Since the initial privatisation of ambulance services in 1993, the share
of the private sector increased from 5% to more than 30% in the
2000s
• Today, the three private providers (Falck, Samariten and Premedic
Östergötland) operate approximately one third of the Swedish
EMS services whereas the rest is operated by the Swedish county
councils
• After the bankruptcy of the second largest private provider in 2012,
there has been a stronger focus on financial strength*
• The Swedish tenders are characterised by being of considerable
size (EUR 10-20 million**) and of 5-6 years' length
"We will deregulate and increase the potential for effective competition
throughout the economy and especially the public monopolies."
Per Westerberg – Minister of Industry and Commerce, 1992
1990 2005 201520102000Key facts SE:
EMS cost: EUR 378 million
Private providers: 3
Private sector share: 32%
Sourcing: Tendering
1993:
Introducing
public
tenders
2012: Bankruptcy
of the second
largest private
provider*
2005: Penalties for
non-compliance
introduced in most
tenders
* Sirius, the private operator in Skåne went bankrupt in 2012 – the services were taken over by Falck
** Landstingsrevisorna, "Prehospital vård – vårdkedjans första insats" (2013)
Source: Company homepages; Region Scania: Tendering of ambulance services; From Confusion Economics to a Market Economy; Quartz+Co analysis
"Estimated cost reductions by establishing competition of Scania's two
ambulance districts amount to 9% per year."
Scania Region, 2008

27
Germany has historically been heavily dominated by private not-for-profit/NGOs, but the
conditions for other private providers have improved after the EU decision in 2010
Key insights from Germany Statements
• The EMS service market in Germany is heavily dominated by
private not-for-profit/NGOs (DRK, ASB, Malteser and JUH), whereas
the rest of the private market is very fragmented (with Falck, MKT
Krankentransport Group and Aicher being the larger providers)
• In Germany, two outsourcing models are used: 1) the submission
model contracts providers to manage stations, 2) the concession
model grants licences to operate independent businesses in a defined
area
• In 2011, the EMS market became subject to public tenders (EU
decision**) which improved the conditions for competition among
private providers, and Falck entered the German market the following
year
"The judgement of the European Court has made it clear that rescue services do
not constitute the exercise of official authority. Thus, there is an obligation to
tender."*
Law firm Osborne Clarke, May 2010
Key facts DE:
EMS cost: EUR 3,200 million
Private providers: ~30
Private sector share: 80%
Sourcing: Submission or concession
model
1990 2005 201520102000
* English translation from interview in der Spiegel, May 1st 2010
** Judgement of the European Court of Justice, April 29, 2010
Source: Company homepages; World Bank; European Court of Justice; Falck; Quartz+Co analysis
2010: EU verdict
makes EMS subject
to public tenders
2010/11: Falck
enters Germany
"By failing to publish notices of the results of the procedure for the award of
contracts, the Federal Republic of Germany has failed to fulfil its obligations […]
on the coordination of procedures for the award of public work contracts, public
supply contracts and public service contracts […] thereof in relation to the award
in accordance with the tender model of contracts for public emergency
ambulance and qualified patient transport services."
Verdict by The European Court of Justice, April 29, 2010

28
The EMS service in the UK has historically been dominated by public providers, but recent
regulatory changes have led to three cross-border market entries in 2013
Key insights from the United Kingdom Key Regulators and Operators
• Both EMS and PTS services are dominated by the publicly
funded National Health Service ("NHS")
• The ambulance activities are divided into 10 local trusts
• The main market is currently based around PTS, but
increasingly EMS services are also tendered
• In the new "Health and Social Care Bill of 2012" local Clinical
Commissioning Groups (CCG) replace Primary Care Trusts
(PCT) as administrators of primary care and ambulance services
• CCGs will be responsible for healthcare quality and service,
giving them the freedom to choose their preferred providers
Key facts UK:
EMS cost: EUR 2,683 million
Private providers: 20-25
Private sector share: ~2%
Sourcing: Mainly tenders, but still
some concession based
1990 2005 201520102000
Source: Company homepages; World Bank; Falck; Quartz+Co analysis
2013: Falck,
Stericycle and
Investindustrial
enters market
• Responsible for authorising, controlling and
supporting CCGs going forward
• The Care Quality Commission (CQC) is an independent
regulator of healthcare services in the UK, and all providers
must meet standards
• Monitor will control both CCGs as well as service providers
• CCGs will be responsible for designing local health services,
including arranging emergency and urgent care services
• CCGs will be responsible for GBP 65 billion, out of the GBP
95 billion commissioned by the NHS
NHS
Commissioning
Board
Care Quality
Commission &
Monitor
Foundation trusts
Acute, Care &
Mental health
Ambulance
Operators
Tender (>GBP 100 000)
Direct (<GBP 100 000)
Clinical
Commissioning
Groups
2012: Health and
Social Care Bill

29
Content
Executive summary1
EMS Market2
Appendix5

30
Spain
• Tenders are used, and the trend is
towards larger contract size, which
might promote consolidation in the
fragmented market
• Standardisation on vehicles and
equipment implemented in Spanish
regulation (CEN 1789:2007)
Number of private providers
Easy entry and exit
Use of information/sourcing
Standardisation
• Large share of private providers in
the EMS market (~95%)
• Fragmented market situation, top-3
providers ~26% (of total market)
• Ongoing market consolidation
• Falck has entered the Spanish
market (2012)
• InvestIndustrial has entered the
Spanish market (2011)
Denmark
• 4 private EMS providers; ~90%
share of private actors in the
market
• Unique country due to 100%
outsourcing of EMS services
• Performance parameters are used
in tenders, whereas development of
quality parameters initiated in 2014
equipment implemented in Danish
• Standard requirements on
competence for personnel
Easy entry and exit
Standardisation
• BIOS is entering the Danish market
(September 2015)
Sweden
equipment implemented in Swedish
• Standard requirements on
competence for personnel
Easy entry and exit
Standardisation
• No recent entries
• Second largest private provider
went bankrupt in 2012
• 3 private EMS providers; in total
32% of the market
• Tenders are characterised by
having multiple objectives, (e.g.
performance and quality), and
counties are divided into smaller
areas to increase competition
Characteristics
Number of private providers1
Easy entry and exit2
processes
3
5. APPENDIX
Countries with a mature level of competition have a (limited) number of experienced private providers,
sophisticated tender processes, operationalised quality & performance criteria and are standardising
practices
Standardisation4
Source: Rigsrevisionen; Ambulancezorg Nederland: Ambulance Service in 2012 The Highlights; Ambulance Care in Europe; Falck; Quartz+Co Analysis
Easy entry and exit
Use of information
Low
Medium
High
Standardisation
APPENDIX

31
Poland
• There are less than five private
providers in Poland, representing
~7% of the EMS market
• There are high barriers to entry and
exit, as the provider needs to have
all necessary resources ready to
operate; ambulances, stations,
radio frequency etc.
• Each county measures
performance and is responsible to
organise a system that ensures
certain time limits for picking up
patients
• Ambulances are required to meet
EU standards (CEN 1789:2007)
Easy entry and exit
Standardisation
Germany
• Germany has ~30 EMS providers
• Large not-for-profit/NGOs
dominate, while the other private
providers are highly fragmented*
• After the EMS market became
subject to public tenders in 2011
(EU decision), the conditions for
competition among private
providers have improved*
• Ambulances and equipment are
CEN 1789:2007 compliant
• Ambulances with technicians are
supported by separate cars with
doctors**
Easy entry and exit
Standardisation
• Falck entered the German market
in 2010 and acquired a German
provider in 2011 and another in
2013
Finland
• Finland has approximately 30-40
private EMS providers
• The private provision of EMS is
estimated to be 25%
• Finland has switched back and
forth between insourcing and
tenders in recent years
• Reports indicate that response time
is being measured
Easy entry and exit
Standardisation
• Swedish private equity fund Adelis
Equity Partners acquired Med
Group in 2014
Characteristics
5. APPENDIX
Countries with a mature level of competition have a (limited) number of private providers,
sophisticated tender processes, operationalised quality & performance criteria and are standardising
practices
* See Germany Deep-Dive
** See competence overview
Source: Report Ambulance Care in Europe, Ambulancezorg Nederland; Tender Electronics Daily, EU; German Federal; Association of Emergency
Physicians: Curriculum, duration and qualification; Falck news release: Ambulances for Finland; Falck; Quartz+Co analysis
processes
3
Standardisation4
Easy entry and exit
Use of information
Low
Medium
High
Standardisation
APPENDIX

32
Italy
• The market is dominated by not-for-
profit/NGOs, but there are also a
number of private-for-profit
providers. Less than 10 of these
have > 2 EUR million in revenue
• No entries
• Tendering processes are likely to
be adopted gradually in most parts
of Italy, at varying adoption rates
• Compliant with CEN 1789:2007
• Overall approval and employee
qualification overseen by local
health authorities
• Large variation in training for
volunteers
Easy entry and exit
Standardisation
The Netherlands
• No entries
equipment implemented in Dutch
• Ambulance nurses and drivers
have standard requirements
Easy entry and exit
Standardisation
• A total of 15 private EMS providers;
38% share of private actors in the
market
• (National politics do not allow for
monopolists)
• The ambulance services market is
divided into concessions
• Established performance measures
like response time are presented by
Ambulancezorg Nederland
Characteristics
5. APPENDIX
Countries with medium levels of maturity have a (limited) number of private providers, immature
tender processes, some operationalised performance criteria, and they are standardising practices
Source: NHS: Transforming NHS ambulance services; United-Kingdom-Tenders.co.uk: Public tenders in the UK;
Ambulancezorg Nederland: Ambulance Care in Europe; Falck; Quartz+Co Analysis
United Kingdom
equipment implemented in British
processes
3
Standardisation4
Easy entry and exit
Standardisation
Easy entry and exit
Use of information
Low
Medium
High
Standardisation
• The UK has around 20-25 private
providers of EMS accounting for
approximately 2% of the total EMS
market
• Some tendering of EMS alongside
PTS during the past two years
• Performance is measured at
regional and national level and is
mostly used for evaluation
• After the passing of the Health and
Social Care Bill in 2012 there has
been at least three occurrences of
cross-border entry into the UK
market
APPENDIX

33
Austria
• Austria has several providers
(estimated ~5) and 95% of the EMS
market is private
• Most private providers are not-for-
profit/NGOs
• There are a few examples of
tenders the past three years
• The biggest provider, Red Cross,
has a required response time of 15
minutes in 95% of cases
• Personnel are trained as
ambulance crews and paramedics
and are supported by doctors*
Easy entry and exit
Standardisation
• No entries
Characteristics
5. APPENDIX
Countries with low levels of maturity of competition have few strong or no private providers, immature
tender processes, limited performance measurements and only some degree of standardisation
* See competence overview
** SAMU – Service d'Aide Medical Urgente (Emergency Medical Services)
Source: Health Care Europe: Public Procurement; Falck; Quartz+Co Analysis
processes
3
Standardisation4
Belgium
• Belgium has approximately 10
providers primarily used to relieve
the emergency network during
peak hours
• The sourcing is reported to differ
from region to region, with a large
share of private providers in
Antwerp, and mostly public in
Brussels
equipment implemented in Belgian
• Requirements for training and
conduct are reported to be less
stringent than rest of Europe
• Falck entered Belgium in 2006
(acquired Ambuce)
Easy entry and exit
Standardisation
France
• >5,000 (99% are very small
operators focused on PTS)
• Very limited private share (<3%) of
the EMS market, SAMU** uses
private providers in peak hours
• One entry
• France has limited quality and
performance measures linked to
sourcing or management of
sourced ambulance services
equipment implemented in French
Easy entry and exit
Standardisation
Easy entry and exit
Use of information
Low
Medium
High
Standardisation
APPENDIX

34
The Czech Republic
• Only public services for EMS (no
private sector presence)
• No central "Utstein-style" outcome-
based quality measures, but
example of quality measures exist
• Limited quality and performance
measures linked to sourcing
• Ambulances meet ALS standard in
accordance with EU regulation
• No entries
Easy entry and exit
Standardisation
Portugal
equipment implemented in
Portuguese regulation (CEN
1789:2007)
Easy entry and exit
Standardisation
• No entries
• NA
Greece
• No entries
• NA
• NA
Easy entry and exit
Standardisation
Characteristics
5. APPENDIX
Countries with low levels of maturity of competition have few or no private providers, immature
tender processes, limited performance measurements and only some degree of standardisation
Source: Ambulancezorg Nederland: Ambulance Care in Europe; Falck; Quartz+Co Analysis
processes
3
Standardisation4
Easy entry and exit
Use of information
Low
Medium
High
Standardisation
APPENDIX

35
List of references: Suggested reading on Emergency Medical Services
5. APPENDIX
List of references
APPENDIX
• Wilde, E. (2014). Ambulance and Patient Transport Service. Encyclopedia of Health Economics, Volume 1.
• Bradley P. (2011). Taking Healthcare to the Patient 2: A review of 6 years’ progress. Association of Ambulance Chief Executives UK.
• IKAS. (2011). The Danish Healthcare Quality Programme for the pre-hospital sector. Danish Institute for Quality and Accreditation in
Healthcare (IKAS).
• Turner J. (2010) What services and skills should be part of an Emergency Medical Service/pre-hospital care system that can manage high
demand and varied case mix? In Building the evidence base in pre-hospital emergency and urgent care. Department of Health UK.
• Turner J. (2009) The evidence for using response times as an ambulance service performance measure. Paper prepared for Department of
Health Ambulance Policy Team.
• Lethbridge, J. (2009). Privatisation of ambulance, emergency and firefighting services in Europe – A growing threat? Report Commissioned
by European Federation of Public Service Unions. Available at www.psiru.org.
• WHO. (2008). Emergency Medical Services Systems in the European Union, WHO Regional Office for Europe.
• Bevan, G and Hamblin, R. (2009). Hitting and missing targets by ambulance services for emergency calls. Effects of different systems of
performance measurements within the UK. Journal of the Royal Statistical Society. 172(1), 161-190.
• McConnel, C. E and Wilson, R. W. (1998). The demand for prehospital emergency services in an aging society. Social Science & Medicine
46(8), 1027-1031.

36
List of tenders: The varied use of CPV-codes for similar services negatively influences the
transparency in the market for EMS
5. APPENDIX
APPENDIX
Name of Service CPV-Code used Tender Authority Year
EMS- services & Patient Transport 75252000 Salzlandkreis in Saxony-Anhalt/Sachsen-Anhalt (Germany) 2015
EMS-services & Patient Transport 85000000 Kreis Bergstraße in Hessen (Germany) 2015
EMS-services & Patient Transport 75252000 Saalekreis Merseburg in Saxony-Anhalt/Sachsen-Anhalt (Germany) 2013
EMS-services & Patient Transport 85143000, 85141000 Heidekreis in Lower SaxonyNiedersachsen (Germany) 2013
EMS-services & Patient Transport 75252000, 80500000 North Rhine-Westphalia, Rhein-Sieg Kreis (Germany) 2014
EMS-services & Patient Transport 85143000, 85142000 North Rhine-Westphalia, Düsseldorf (Germany) 2014
EMS-services & Patient Transport 85143000, 60130000,
60140000
Capital Region (Denmark) 2014
EMS-Services None Hospital District of South-West Finland, Turku, (Finland) 2014
EMS-Services 85143000, 85110000 Gotland (Sweden) 2014
EMS-Services 85143000, 85142000 East Midlands Ambulance Service (UK) 2013
EMS-Services & Non-urgent Patient Transport 75252000 Land Tirol (Austria) 2009
EMS-Services and Medical Assistance at
public events
85111000, 85141000,
85142000, 85143000
Disputatión Provincial de Valencia (Spain) 2013
Urgent Care Transport Solution 85143000, 34114122,
60140000, 60170000,
85100000
NHS Shared Business Services, Salford (UK) 2013
Non-urgent Patient Transportation 85143000 Gobierno de Aragón (Spain) 2014
Non-urgent Patient Transport (transfers) 85143000 Raahe (Finland) 2014
Non-urgent Patient Transport 60130000, 60140000 Landstinget Östergötland (Sweden) 2015
Non-urgent Patient Transport 60130000 Shropshire CCG (UK) 2013
Non-urgent Patient Transport 85143000 Norwich (UK) 2013
Non-urgent Patient Transport 60130000, 60140000 Region North Denmark (Denmark) 2014
Non-urgent Patient Transport 85143000, 34114122 Chester Hospital NHS Foundation (UK) 2014
Examples of CPV-codes used for ambulance services in the TED database
Source: EU Ted database (Tenders Electronic Daily); Falck; Quartz+Co Analysis

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