<p>Paramedic training has evolved into higher education, raising concerns about initial assessment and ongoing competence in airway management and intubation. Advanced paramedics have demonstrated high intubation success rates, comparable to pre-hospital physicians. Further, paramedics are increasingly involved in delivering pre-hospital emergency anaesthesia, prompting debate in the United Kingdom about expanding their role. Thames Valley Air Ambulance have developed a novel pathway enabling a consultant paramedic to independently deliver pre-hospital emergency anaesthesia. We describe this novel pathway development, including attainment and maintenance of competence in anaesthesia, airway management and intubation. This pathway is intended for a small, highly skilled subset of paramedics. It highlights the need for national curricula and competency frameworks. Future work will focus on evaluating the safety and effectiveness of consultant paramedic-led anaesthesia, ensuring high-quality care, regardless of provider.</p>