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There are some interesting points raised in Kearns's letter about the responsibilities of the occupational physician to the employer with the implication that, in the case of mental ill health, these are in conflict with and take precedence over responsibilities to the employee. In the much longer term this may be the case, but I would strongly maintain that it is in the interests of both the employer and the employee to try to ensure that the employee returns to work, and that severance should only be considered after other courses of action have been tried. The direct and indirect costs to the employer of getting rid of and replacing a skilled employee are huge and the motivational effects on the rest of the workforce can be very two edged.It is important that the employer should remain in touch with the employee from the beginning, using the advice of the occupational physician as required. Part of that advice in the first stage of absence should be that most people with common mental health problems will recover reasonably quickly. Employees will usually go to their general physician for treatment—to which most will respond and the main job of OH is to ensure that none of the parties concerned adopts attitudes or courses of action that will impair recovery or prevent return to work. Negativity about the prospects of recovery and return to work can become a self-fulfilling prophecy.
If the absence stretches beyond 
4 weeks and it is clear that the employee is not recovering as expected, further intervention of the kind I suggested in my original article may become necessary. I suspect that it is mainly here that I part company with Kearns, the tenor of whose letter suggests that it is the duty of the occupational physician to precipitate the employee into ‘retirement’ and ‘care’ if there is any doubt about recovery.
As Kearns implies, getting rid of someone because of mental illness is quite likely to lead to ‘retirement’ (i.e. lifelong unemployment) for that individual and further deterioration in their mental health. It could be argued that this is not the employer's concern since the burden will be borne mainly by the individual and his/her family and ultimately by the state through the National Health Service and the welfare benefits system; but I believe employers as citizens and taxpayers also have responsibilities.
Therefore I do not share Kearns's view of the role of the occupational physician as purveyor of medical advice to the employer which takes no account of the social consequences for the employee. I believe that it is in both the employer's and the employee's interests to take whatever steps are reasonably possible to enable the employee to return to work, including investing in CBT if it is clinically appropriate and affordable. The valency of the occupational physician should always be towards restoration of function and it is only when that route has been given a fair try that alternatives should be considered.
Director, Employment Programme, The Sainsbury Centre for Mental Health, 134–138 Borough High Street, London SE1 1LB, UK
e-mail: bob.grove{at}scmh.org.uk
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