Introduction We admit around 2500 patients per year with neurological emergencies including stroke directly under our care. In 2006 we introduced an attending physician model for inpatient care. Since then, we have been studying and improving this system.

Methods A review of 600 consecutive inpatients stays using a standard tool to analyse why the patients were in hospital. Starting with these data, we tried new ways of working. During this time we have continually monitored bed utilisation, conducted audits of staff and patient satisfaction and tried several iterations of how we work.

Results Before the attending system, patients waited in hospital for senior clinical review or diagnostic tests. With daily consultant ward rounds and continuous senior availability in decision making, average bed occupancy fell from 33 to 19 beds and improved care for patients with short length of stay. This led us to incorporating stroke patients into the system. This was not successful, so we have now developed two parallel systems. This has significantly improved quality of care for stroke patients while reducing bed utilisation. To maintain sustainability a variety of operational changes have also needed to be introduced.

Conclusions The nature of the input and work pattern of consultants significantly affects the quality of care and bed requirements of our service. To achieve a high-quality efficient service requires genuine team working, accurate data and operational management support.