Honour sick-leave system

No need for MC? No need to fear
Honour system for sick leave could benefit both employers and workers
By Janice Heng, The Straits Times, 10 May 2012

ONE fear has dominated the ongoing debate on whether workers should be able to take sick leave without a medical certificate (MC): If taking sick leave becomes easier, more people will do it.

It seems like common sense. But that fear rests on assumptions which can be questioned, and may also draw attention away from the potential benefits of switching to a no-MC system.

Under the Employment Act, which will be reviewed this year, workers are entitled to paid sick leave if it is certified by a doctor.

Last month, general practitioner David Tan Hsien Yung wrote to The Straits Times Forum Page to suggest removing the need for certification.

Instead, bosses can trust employees to be honest when calling in sick. In San Francisco, which Dr Tan had visited, giving uncertified sick leave is common.

In a Straits Times report last week, most bosses interviewed were not in favour of an honour system. The fear is that without the need for an MC, staff will malinger or feign illness to skip work.

Realistically, that already happens.

Doctors say they see more MC-seekers on Mondays and Fridays, when a day off means a long weekend.

Numbers also pick up during major sporting events such as the World Cup.

So the question is not whether workers will abuse medical leave. It seems some will, and already do.

The real question is whether allowing uncertified medical leave will cause more to do so. Will it?

Common sense would tell us that people who are wont to fake illness will continue to do so, with or without the need for an MC. The only difference is if an MC is done away with, they can call in sick without going through the charade of consulting a doctor.

That has the unintended benefit of reducing the load on the health-care system. Employees with genuine but minor ailments can also avoid a trip to the doctor, further easing the health-care crunch.

Doctors and health-care experts have noted that many patients are educated working adults who could buy medication from retail pharmacies - but go to the doctor because they need an MC.

'Imagine how many truly ill people I could have attended to instead,' former public health practitioner Irwin Clement Chung wrote in a Forum letter.

Subsidised polyclinics have long been put under stress by high patient volume, and the Government has been seeking ways to alleviate this.

National Healthcare Group said its polyclinics do not regularly collate data on MC numbers, nor do they track cases that only require home rest. But surely every little bit will help in lessening the load.

The cynic might ask: What about the borderline cases? Will more workers be tempted to skive by calling in sick without the need for an MC?

At first glance, it might appear that not having to spend time and money seeing a doctor should make it more attractive to fake illness and take sick leave.

But advanced economic theories suggest this might not be so. Some studies find that a penalty - or cost - can encourage behaviour it is meant to deter.

Israeli economists Uri Gneezy and Aldo Rustichini looked at day-care centres which fined parents for picking up their children late. After the fine began, more parents began turning up late.

Many other studies have shown that rewards or penalties can have the opposite effect from that intended, as they 'crowd out' intrinsic motivation. One found that volunteers put in less effort when paid, possibly because that makes them see the act as a transaction, not an altruistic gesture.

Similarly, the externally imposed cost of getting an MC may weaken the internal safeguards of conscience.

An employee might feel uncomfortable calling his boss and lying about sickness. But an official MC may make him feel he has 'paid for' the right to skive. He might think, 'I've seen a doctor and paid so much, what's wrong with taking MC?'

If borderline cases are already malingering, then allowing no-MC sick leave will not convince many new people to malinger. Absenteeism will not rise much.

Another Forum contributor's story bears this out. Ten years ago, Mr Amarjit S. Wasan's organisation started allowing uncertified sick leave of up to three days.

At first, there was a 'minor spike' in cases. But the rise was not sustained over time, and cases of abuse were few.

Bosses fearful of trying the honour system may be overestimating the potential increase in absenteeism.

Instead, a liberal sick leave regime can boost productivity, as ill workers stay home instead of spreading their germs around the office.

According to a 2009 report by the McGill University Institute of Health and Social Policy and the Harvard School of Public Health, companies incur higher costs from sick employees coming to work, compared to the costs of sick leave.

Secondly, even if absenteeism goes up, it can be mitigated. Supporters of uncertified sick leave have all noted the need for safeguards. These can include limiting the amount of uncertified sick leave, for example, to three consecutive days, and seven days a year. The total amount of sick leave can also continue to be capped at 14 days a year.

Some have suggested taking sick leave into account during performance appraisals, to discourage malingering and give employees an incentive to look after their health. But this would unfairly penalise the truly ill or spur them to turn up while sick, which benefits neither worker nor employer.

A hard look at this issue requires the weighing of potential danger of increased absenteeism against the direct and likely benefits.

Workers will save time and money, and can better recuperate at home.

Bosses will save on co-payments for their staff's medical bills, and might build better employee trust and morale.

The general public is less exposed to germs, as sick workers do not need to make the trek to clinics.

Polyclinics will have lighter loads.

And patients who do need a doctor's personal attention will receive it faster.

There is one group which has cause to fear: GPs, for whom MC-seekers may be a key clientele.

Yet it was a GP who first ignited the debate - a fact that should give naysayers pause.

Scrapping MCs 'would cut polyclinic queues'
Allowing uncertified paid sick leave has benefits: Some experts

By Janice Heng, The Straits Times, 10 May 2012

IF WORKERS could take sick leave without seeing a doctor, polyclinic queues might shrink by up to one-fifth, health experts have told The Straits Times.

Dr Loke Wai Chiong estimated that 30 to 40 per cent of patients at the clinics have conditions such as coughs and colds.

Of these, more than half are working adults who can get by on rest and medication from retail pharmacies. But they are at the polyclinics because they need a medical certificate (MC).

'We understood that that was a major reason they were there to see us,' said Dr Loke, a former director at both of Singapore's public health-care groups.

The need for MCs creates 'administrative demand, not clinical demand', said Fortis HealthCare Singapore chief executive Jeremy Lim, who is the former director of research at public health-care group SingHealth.

Under the Employment Act, which will be reviewed this year, workers are entitled to paid sick leave if certified.

In a letter to The Straits Times Forum last month, general practitioner David Tan Hsien Yung suggested removing the need for an MC for sick leave of less than three days. Workers could just call in sick, as is done in many other countries, he said.

'If uncertified sick leave is legally allowed, it would free up many unproductive doctor visits,' said Associate Professor Phua Kai Hong, a health economist at the Lee Kuan Yew School of Public Policy.

MP Lam Pin Min said it could minimise polyclinics' workloads and benefit patients.

'The time taken to visit the clinic can be quite long. This is actually counterproductive and it deprives the patient of the time to rest and recuperate,' added Dr Lam, who chairs the Government Parliamentary Committee for Health.

According to Ministry of Health (MOH) statistics, the longest polyclinic queues in March had over two hours' waiting time. Given the challenges that polyclinics face in reducing waiting times, employers should not create unnecessary demand by insisting on MCs, said Dr Lim.

Even if cases fall by a small percentage, the change in actual numbers would be substantial, he added: 'Even if we were able to reduce the volume by just 1 or 2 per cent, that's a heck of a lot of patients.'

And if sick workers stay out of polyclinics, it could minimise the spread of the flu bug, said Dr Lam.

Pharmacy chain Watsons said that over-the-counter medication makes up about half the sales for its pharmacy division. The proportion is growing due to higher medical literacy, said its marketing and development director Agatha Yap. Watsons also provides consultation for minor ailments such as coughs and colds.

The MOH said that over-the-counter medication can relieve mild symptoms, but those who continue to feel ill should seek medical attention.

Doctors also noted concerns that staff might take sick days when they are not ill. This could be prevented by measures such as public education, limiting the amount of uncertified sick leave, and rewarding healthy staff, they said.

Dr Loke added that some companies here use the honour system and have seen it work: 'It is worth other companies studying the model and considering it.'

But Singapore Medical Association president Chong Yeh Woei said the honour system may not be needed here. 'In countries where they have the honour system, it's expensive or difficult to see a doctor,' he added.

But seeing a doctor here is convenient, and the costs reasonable.

Long polyclinic queues are partly a result of some employers' policy of accepting only polyclinic MCs, he noted.

Changing the law might not be required, said Dr Lam. But the Government, as Singapore's largest employer, could set an example by not requiring MCs for civil servants, he added.

In response to queries, the MOH said that it notes 'the ongoing discussion on the issue' and understands that the Manpower Ministry is reviewing the Employment Act to ensure it remains relevant.

Both SingHealth's and the National Healthcare Group's polyclinics declined to comment.

More pros than cons in honour sick-leave system

AS A Singaporean who has lived and worked here for more than 30 years and in New Zealand for about 15 years, I am convinced that there are more advantages than disadvantages in introducing an honour system for sick leave ('Don't be put off by fear of abuse' by Mr Amarjit S. Wasan, and 'A responsible employee who is genuinely sick should be allowed to take some time off work without having to produce documentary evidence' by Mr Paul Heng; Monday).

In New Zealand, I have observed that the few recalcitrant workers who occasionally abused the system and reported sick irresponsibly, invariably drew the attention of their supervisors and became subject to closer scrutiny.

Such workers are few and are, in the normal process, weeded out from the vast majority of workers who, because of the trust, confidence and reliance placed on them by their employers, show high morale and dedication in reporting to work. Their self-esteem and sense of responsibility are enhanced and productivity improves considerably.

If such a system could work effectively in the West, I do not see why it cannot in a well-governed and sophisticated society like Singapore.

Surely, those few people who try to abuse the system in the workplace will invariably get spotted and disciplined if an honour system replaces medical certification for short bouts of routine illness.

Naturally, employers may experience a temporary and minor increase in workers reporting sick in the initial stages, but with proper reporting procedures, the instances of abuse will end.

Why not implement a system that can only have far-reaching benefits for employers, employees and society in general?

Dr V. Subramaniam
ST Forum, 9 May 2012

Don't be put off by fear of abuse

ALLOW me to offer a contrarian view to the article ('Honour system won't work, say bosses and HR experts'; last Tuesday). About 10 years ago, the international organisation I worked for, comprising 3,000 staff of 50 nationalities, discussed the issue of allowing employees to call in sick without requiring medical certificates.

As its director of compensation and benefits, and a Singaporean, I was initially sceptical but my more progressive colleagues persuaded us to proceed. We implemented a system of not requiring medical certificates for sick leave of three consecutive calendar days or less.

Concurrently, we introduced a system of providing biannual reports of staff using both certified and uncertified sick leave during the period, which supervisors factored into their staff performance management.

After three years, we evaluated the practice and concluded that introducing the honour-based system was a win-win result for all.

Initially, there was a minor spike in staff going on uncertified sick leave, but the rise was not sustained over a three-year period. Cases of abuse were few and confined to the poor performers, who could be taken aside for remedial action.

The requirement that staff, or their family members, call their supervisors to report when they were unwell also served to deter abuse of the system.

The organisation gained as its cost of co-payments for medical consultation and medication was reduced.

Staff convenience was enhanced as they did not have to visit doctors for minor ailments and incur their share of expenses. This mutual trust and confidence also lifted morale.

The implementation of such a scheme nationally will have other benefits, which have been highlighted by others.

The fear of occasional abuse by some should not hold up the implementation of a scheme that has widespread benefits.

Amarjit S. Wasan
ST Forum, 7 May 2012

'A responsible employee who is genuinely sick should be allowed to take some time off work without having to produce documentary evidence.'

MR PAUL HENG: 'When it comes to boss-employee relationships, there is a mutual lack of trust, and the belief that managers are more responsible and trustworthy compared to the rank and file ('Honour system won't work, say bosses and HR experts'; last Tuesday). The sooner we change this mindset, the better it will be for all. A responsible and trustworthy employee who is genuinely sick, or just feeling under the weather, should be allowed to take some time off work without having to produce documentary evidence. Bosses should also be discerning enough to request medical certificates from staff who have a habit of falling sick often.'

ST Forum, 7 May 2012 

Difficult to weed out those who feign illness

THE question of whether to require medical certificates or have an honour system for sick leave pivots on the balance between productivity and malingering ('Honour system won't work, say bosses and HR experts'; last Tuesday).

While workers who are genuinely sick should stay at home to recover, others may use the time to run errands or settle domestic chores.

It is difficult to weed out those who exploit the honour system, which is why a leave of absence sanctioned by a doctor is fairer to employers and the sick worker's colleagues.

The productivity of the company and the morale of staff who keep themselves fit can then be boosted.

Philip Sim
ST Forum, 7 May 2012 

Limited uncertified sick leave worth considering

DR DAVID Tan Hsien Yung is right to suggest replacing the current practice of requiring a medical certificate for sick leave with an honour system ('Replace MCs with honour system'; April 27).

Employees do not need medical certificates endorsed by doctors when they are too sick to work, especially for common minor ailments like diarrhoea, slight fever or flu, cough and headache.

Medicine for such minor ailments can be obtained at retail stores or pharmacies, and people usually stock them at home as well.

There should be an annual limit of, say, seven days of sick leave under the honour system. Employees should also be honest with their bosses and not abuse the system.

Where possible, employees should inform their bosses early when taking sick leave so as to avoid disrupting the work process.

As adults, employees should be given the discretion to decide whether their conditions require only self-medication and rest at home, or medical treatment.

The Ministry of Manpower and relevant agencies should consider Dr Tan's suggestion.

Muhammad Dzul Azhan Haji Sahban
ST Forum, 7 May 2012 

Let workers convert unused sick leave into cash bonus

ONE way to make the honour system work is to allow staff to convert any unused medical leave into a bonus at the end of the year ('Honour system won't work, say bosses and HR experts'; last Tuesday).

Having such a financial incentive in place will make workers think twice about abusing their medical leave. The company will also save money through reduced reimbursement of outpatient medical bills.

Removing the need for medical certificates will reduce the strain on health-care resources and allow patients needing urgent attention quicker access to doctors.

The Manpower Ministry and employers should explore ways to make such a system work.

Martin Lee
ST Forum, 7 May 2012

Honour system can work - within limits

I AM surprised by the reactions of employers, human resource personnel and even general practitioners ('Honour system won't work, say bosses and HR experts'; yesterday) to Dr David Tan Hsien Yung's proposal ('Replace MCs with honour system'; last Friday).

Of course, not all their concerns are unfounded, but they fail to see the merits of the honour system by making some fairly sweeping assumptions:

That employees will 'abuse' the system of trust: What this shows is management's distrust of employees. Should the work be decent, the environment conducive, the compensation and rewards commensurate, and employer-employee relations cordial, which level-headed worker would abuse the system by skiving?

That some conditions, albeit minor, ought to be attended to by qualified doctors: When I was working in the public health-care sector, I could attend to as many as 80 to 90 cases of 'coughs, colds, tummy aches and fevers' in a 41/2-hour morning session. I wonder what quality health care I was expected to deliver.

A good 80 per cent of those patients could well have told me their diagnoses outright, and a similar number would probably have enough medication, or were capable of buying some over the counter, for their ailments; they just needed the all-powerful medical certificate (MC). Imagine how many truly ill people I could have attended to instead.

However, the honour system for sick leave must not be applied unbridled. There must be checks and balances:

Absence of three consecutive days or more must be supported by a doctor's assessment and medical certification.

Total sick leave allowed in a year can still be capped at 14 days, beyond which additional certification requirements may be imposed.

Sick leave is factored into the worker's performance appraisal; this incentivises employees who take care of their health.

Declaration of sick leave must be made early, so that companies that are reliant on specially trained workers have reasonable time to arrange for workarounds or replacements.

Sick leave without MCs can be off limits to select groups of workers, such as contract or temporary staff.

Sick leave can be lumped together with annual leave (and other leave) as a complete paid leave benefits package.

Our manpower policies should evolve in tandem with a maturing and more discerning workforce. I urge the Manpower and Health ministries to study Dr Tan's proposal seriously.

Dr Irwin Clement Chung
ST Forum, 2 May 2012 

Untrustworthy society?
'This simply will not work. Every business will go bust.'

MR LAWRENCE SEOW: 'I am bemused by the good doctor's suggestion ('Replace MCs with honour system' by Dr David Tan Hsien Yung; last Friday). This simply will not work here. Other more mature cultures have virtues like trust, honour and honesty built into their systems. People can leave newspapers, flowers or food unattended, which anyone can take after paying. They function on the basis of trust. Try that here and every business will go bust.'

ST Forum, 2 May 2012 

Sick children
'Schools must be ready to accept letters from parents.'

MS SANDY LIM: 'As a registered nurse, I do not see the need to go to a doctor if I or my family members are suffering from general ailments ('Replace MCs with honour system' by Dr David Tan Hsien Yung; last Friday). Having to get medical certificates (MCs) for absence from work or school is a hassle, and increases the workload of doctors who may be needed to tend to truly ill patients. Schools must be ready to accept letters from parents if their children are too sick to attend class. Despite being very lethargic, my child insists that I take her to a doctor because her teachers want the children to produce MCs when they are absent. In future, they may view doctors as MC issuers whom they can go to when they do not feel like going to work.'

ST Forum, 2 May 2012 

Honour system won't work, say bosses and HR experts
MC from doctor still preferred; reasons cited include possible abuse
By Goh Shi Ting & Stacey Chia, The Straits Times, 1 May 2012

MORE patients requested a medical certificate (MC) yesterday, a check with general practitioners revealed. With today being a public holiday, that sick leave, if granted, would have led to a four-day weekend for some of them.

But while it is possible that workers may exaggerate the extent of their illnesses to get an MC, bosses said they would still prefer this doctor certification to an honour system where staff can call in sick and stay at home without seeing a doctor.

According to general practitioner David Tan Hsien Yung, this practice of giving 10 to 14 days of sick leave a year without an MC is common in San Francisco.

Dr Tan, who has just returned from an attachment there, wrote to The Straits Times Forum last week, calling on the Ministry of Manpower (MOM) to consider removing the need for sick leave to be certified by a doctor - as stated in the Employment Act.

'This will greatly reduce the strain on public resources, freeing up time in the doctors' consulting rooms for those patients who truly need the time, as well as empower employees to take better charge of their own health,' he said.

Asked for comments, an MOM spokesman said employers and unions will be closely consulted in an ongoing review of the Employment Act (EA). 'We will review all the pertinent EA provisions to ensure that they remain relevant in view of the changes in our workforce composition and employment practices.'

Most employers, such as Bigfoot Logistics' general manager Philip Moh, are not in favour of an honour system. 'We are not doctors. How would we know if they are really sick?' asked Mr Moh, whose firm has 330 operations staff.

Manufacturing firm Besley & Pike said it is best to have a professional confirm illness. 'It is probably okay for people in an office environment to call in sick without an MC, but in a large manufacturing industry, we cannot afford to have a shortage of workers,' said manager May Ang.

Human resource experts agree that the honour system is not likely to take off here. Mr David Ang, executive director of the Singapore Human Resource Institute, noted that while small outfits are generally more flexible, bigger organisations may want documented 'oversight' of who's working and who's not.

He added that it may be easier to implement the honour system among management but it could be 'messy and confusing' to extend it to rank-and-file staff.

Then, there are operational difficulties, making it hard for bosses to release staff without an MC. Mr Ang cited the example of a production line where employees have specific roles and it will be problematic to find a replacement.

General practitioners who spoke to The Straits Times said they do not share Dr Tan's sentiments either. 'I think the MC system is ingrained in Singapore culture, stemming from the British colonial period,' said Dr Lee Kwok Keng, a general practitioner at Sanitas Medical Practice. He also acknowledged the possibility of patients exploiting their employers if they do not have to produce an MC.

In his experience, he grants more MCs on Mondays and Fridays.

Others said it would be better to see a doctor even for something that can be treated with over-the-counter medication. Dr Jotham Lim, a family physician at Clinic @ The Sail, said the symptoms could indicate something more serious.

Despite the reservations from firms and doctors, HR experts said there are payoffs for firms that adopt the honour system. There could be cost savings from not picking up the tab for clinic visits, and less work in keeping track of MCs.

Some employers practise a variation of the honour system. Staff of a Swiss-based consulting company here are allowed to call in sick without an MC once a year. The managing director, who declined to be named, said: 'We trust our employees. Why make them see a doctor for medication that they probably already have at home?'

Mr Alan Low, 29, said more should consider implementing the system. 'It's troublesome and a waste of time to go down to the doctor when I can spend that time lying down and getting better,' said the engineer.

Replace MCs with honour system

I AM a doctor in a public primary health-care institution, and am currently on a six-week attachment at a hospital in San Francisco to learn some of their best practices. My hosts here have heard many good things about Singapore and its health-care system and are as keen to learn from me as I am from them.

One thing which I have found difficult to explain to them is the fact that many of our patients are those seeking medical certification for sick leave, adding to our already overloaded system ('Beefing up the Employment Act'; Wednesday).

It is ridiculous that people who are entrusted with carrying firearms, administering medication, making financial decisions on behalf of others or educating our young are not trusted to call in sick on their own without having to visit a doctor first.

Often, patients just need a day of rest with some medication which they can easily obtain from a pharmacy before going back to work reinvigorated.

In San Francisco, people are entitled to some 10 to 14 days of sick leave a year. If they take sick leave beyond a certain period, they are then required to produce a sick note. Otherwise, it is based on an honour system which seems to work well.

I wonder if the Ministry of Manpower will consider removing the need for sick leave to be certified by a doctor as is stated in the Employment Act. It could limit the need for a doctor's certification only for sick leave of three days or more.

This will greatly reduce the strain on public resources, freeing up time in the doctors' consulting rooms for those patients who truly need the time, as well as empower employees to take better charge of their own health.

I am sure the different organisations can come up with their own incentive programmes to ensure that employees stay healthy.

Dr David Tan Hsien Yung
ST Forum, 27 Apr 2012