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Background: Comparisons across trauma systems are key to identifying opportun ities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. Methods:We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortal ity, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. Results:The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medi cal teams (v. "scoop and run" in Quebec), helicopter transport (v. fixedwing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09-1.51) but lower for thora coabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries.