Mr. Barry O'Brien:

When I speak about the consultant I am referring to the medical manpower manager, the consultant and, I would even say, the hospital CEO. They are a major resource in the hospital and it is appropriate that they be managed and paid correctly and that the hours they work are approved in that way.

On the question of removing some of the tasks more appropriate to other grades, I draw the committee's attention to the public service agreement under which we are operating and, in particular, the commitments to skill mixes and having the right people with the right skills to the job. If the public sector unions approve Croke Park II we will have a significant increase in working hours by the various categories, including NCHDs, consultants, nurses and support staff. We will have capacity, therefore.

I do not think there is a debate over whether nurses are aware of this. We have invested heavily in medical and nursing education and we have significant numbers of advanced nurse practitioners who are ideally suited to be placed in emergency departments to work beside medical teams and act as decision makers at the same time. The committee will be interested to note that our emergency departments are the departments that are most compliant with the working time directive. We are almost completely compliant countrywide in emergency departments with all aspects of the directive. From that perspective, we are investing in enhancing people's skill sets and we are committed to making tasks more appropriate. However, one proposition continues to cost more money and more people, whereas the other proposition changes how people work by reforming what they do. System wide reforms are needed if we are to implement the directive. It is not simply a matter of telling the NCHD or the nurse to do something different. NCHDs are integral to these reforms, as is everybody else, but they will have to be led by senior management, clinicians and clinical directors.

I will ask Professor McGovern to address the question of retention because she is in a better position to comment.