A mixed system with EMS-based BLS first response along with BLS (EMT/EMT) and ALS (paramedic/AEMT) ambulances as well as Community/Advanced Practice Paramedics and supervisors in fly cars dispatched as requested by providers on scene or according to call type:
Omega: first response only
Alpha/Bravo: first response + BLS ambulance
Charlie: first response + ALS ambulance
Delta/Echo: first response, ALS ambulance, C/APP
C/APP's do Community Paramedic work between emergency calls, ALS ambulances hand over care to BLS units if the patient doesn't require ALS capabilities. Also have some trucks dedicated to BLS/"light" ALS transfers (AEMT/EMT), as well as some critical care capabilities (CCP x2 + EMT) for critical care inter-facility transfers.
Have an ALS:BLS ratio of about 4:10, target highly educated, highly trained paramedics and put them through an intense "on boarding" academy. Six months probationary period under an experienced paramedic.
For vehicles, my picks would be:
Chevrolet Suburban for BLS first response and C/APP's
Type II Sprinter for BLS and ALS ambulances
Type III Sprinter for critical care ambulances
All hi-vis yellow with green battenburg patterns. Blue lights. No bench seats, all should have forward-facing chairs instead with a "stand" in front with drawers and a monitor mount; keep the radio and the bulk of vital equipment on the provider side to avoid providers having to get up during transport.
Scrub tops (durable with a radio mic clip sewed on the front), EMS pants. No patches, just agency logo over left breast and name/cert over right. Make the uniforms ANSI compliant (a safety vest you can't forget to put on).
Alpha/bravo/charlie responses, no lights and sirens.
Delta/echo, lights and sirens as deemed safe to do so by crew.
Lights and sirens transport by clinical supervisor order only.
Entry level payscale
EMT: Valid certification. 3 month academy + 3 months probation/field training
AEMT: Valid certification. 3 month academy + 3 months probation/field training
Paramedic: Associate's degree minimum. 3 months academy + 6 months probation/field training.
C/APP/Critical-Care Paramedic: Bachelor's degree minimum and/or Associates + CP/CCP certification and/or Medic + RN. 3 months academy + 6 months probation/field training.
Supervisor: C/APP equivalent or relevant management/administrative education.
EMT: Same as state regs.
AEMT: Same as state regs.
Paramedic: Supraglottic airways only.
C/APP: ETI, (maybe) RSI, wound care (simple sutures), port/cath maintenance, limited dispensing, etc.
CCP: Vent management, IV drips, IABP monitoring/management, etc.
On-boarding academy be a mix of online and in person lectures as well as skills lab and would include:
Medical foundations (bio/A&P/patho review for both BLS and ALS)
Pharmacology review (not just EMS meds)
Operational guidelines and policies
EMS defensive tactics (something like DT4EMS, not guns and tasers and all that stuff)
EMT's and AEMT's operate under protocols or paramedic direction. Paramedics and up operate under guidelines with options for alternative care pathways available to them. C/APP follow-ups for high-risk refusals or patients targeted as "at-risk" by call review or internal/external providers.
12-hour shifts rotating between busy and slow stations every month.
An X-box and a copy of the original Star Wars trilogy in every station.