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Background Acute neurological presentations are common in emergency settings. These are managed with a high rate of misdiagnosis in about one-third of cases. This is the first description of a consultant-led model within an existing same day emergency care service.Methods As part of service evaluations, we prospectively collected data from 931 acute neurological presentations, over the first year since establishing the neurology same day emergency care (NeuroSDEC) embedded within the emergency department (ED) at University College London Hospital. The service was evaluated in terms of diagnostic accuracy, cost-saving and efficiency.Results 60.8% were female, mostly between 25 years and 40 years old. Most referrals were from ED, with the most common presenting symptom of headaches (343 cases, 36.8%).NeuroSDEC reduced lack of diagnosis in over 27% of cases, prevented admissions in over one-third of cases seen, saw same-day cases on average within 1 hour, reduced intended outpatient neurology referrals from 36.4% to 4.8%, cut stroke and transient ischaemic attack clinic referrals in half, completed the care of more than a third of cases (36.1%) exclusively in NeuroSDEC, aborted unnecessary acute brain imaging in 9.7% and cut intended lumbar punctures by 40% (49 reduced to 29).Conclusion Acute neurology presentations challenge acute physicians in distinguishing benign from serious neurological conditions in real time. Our NeuroSDEC model provides a successful example of a transformative healthcare model, safely reducing unnecessary investigations, outpatient referrals, admissions and misdiagnosis rates. A conservative estimate for potential cost savings was £660 000 in admission prevention alone, more than the excess staff cost of £363 000.