J Occup Rehabil (2011) 21:S28–S34 DOI 10.1007/s10926-011-9286-4
Occupational Rehabilitation in Hong Kong: Current Status and Future Needs H. K. H. Kwok • G. P. Y. Szeto • A. S. K. Cheng H. Siu • C. C. H. Chan
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Published online: 28 January 2011 Ó Springer Science+Business Media, LLC 2011
Abstract Introduction: This paper reviews the development of occupational rehabilitation in Hong Kong, both in terms of the science as well as the service for injured workers. Besides, it also reviews the existing Employees’ Compensation Ordinance for work injury to illustrate how the policy could influence the success and development of the discipline. Methods: Five experienced occupational rehabilitation providers, including 1 occupational medicine specialist, 3 occupational therapists, and 1 physiotherapist critically reviewed the past and current development of occupational rehabilitation in Hong Kong as well as the local contextual factors, which could influence its future development. Results: Since the enactment of the Employees’ Compensation Ordinance in the 1950s, there have been progressive improvements in the field of occupational rehabilitation in Hong Kong. Services in the early years were mostly based on the biomedical model, where doctors and patients tended to focus on clinical symptoms and physical pathology when making clinical decisions. Since then, remarkable academic achievements have been made in the field locally, from the validation of clinical instruments for assessment of work capacity, assessment of employment readiness to the evaluation of efficacy of interventional programs for injured
H. K. H. Kwok (&) Occupational Medicine Service, Queen Mary Hospital, Hong Kong, China e-mail:
[email protected] G. P. Y. Szeto A. S. K. Cheng H. Siu C. C. H. Chan Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China A. S. K. Cheng C. C. H. Chan Ergonomics and Human Performance Laboratory, The Hong Kong Polytechnic University, Hong Kong, China
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workers focusing on work related outcomes. However, there has been a relatively lack of progress in the development of related policies and implementation of related programs for occupational rehabilitation. There is no built in linkage between rehabilitation, compensation and prevention in the current system in Hong Kong, and there is no rehabilitation policy specific to those workers with occupational diseases and injuries. Conclusions: There are still deficiencies in the development and provision of occupational rehabilitation services in Hong Kong. Incorporation of requirements for occupational rehabilitation at the legislation and policy levels should be seriously considered in the future. Besides, the development of the Occupational Medicine subspecialty in the public hospital system in Hong Kong is considered a facilitator to the future development of occupational rehabilitation in Hong Kong. Keywords Rehabilitation Occupational therapy Occupational medicine Workers’ compensation
Introduction Internationally, the problem of work injury and rehabilitation remains a significant burden to society, both in financial terms as well as impact on population health and social issues [1]. Hong Kong faces the same problems and the current system does not provide a favourable environment for comprehensive occupational rehabilitation services, due to constraints in the labour and healthcare legislature. In previous decades various sectors in Hong Kong have tried to tackle this problem through enactment of legislation and policies, research initiatives in the discipline, medical services developments, and the collaboration of the stakeholders (including the government,
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insurance companies, medical professions and labour forces) through different settings. Yet, occupational rehabilitation services remain relatively underdeveloped and underfunded, and the need for more service provision remains more challenging than ever in order to cater for more than 44,000 work injury cases every year. In fact, Hong Kong has very high accident rate on sites across different Asian countries than Japan, South Korea, Taiwan and Singapore [2]. Many challenges remain to be solved in the development of the science and services of occupational rehabilitation. Therefore, the purpose of this paper is to review the development of occupational rehabilitation in Hong Kong, both in terms of the science as well as the service for injured workers. Besides, this paper also reviews the existing Employees’ Compensation Ordinance for work injury to illustrate how the policy could influence the success and development of the discipline.
Hong Kong Workers’ Compensation System The Employees’ Compensation Ordinance in Hong Kong has been enacted since 1953 as a no-fault, non-contributory employee compensation system for work injuries. It lays down the rights and obligations of employers and employees in respect of injuries or death caused by accidents arising out of and in the course of employment, or by prescribed occupational diseases under the Ordinance. In effect it shifts the liability of workplace accidents from negligence liability to a form of shared strict liability. It covers all full-time or part-time employees who are employed under contracts of service or apprenticeship. It also applies to workers employed by local employers in Hong Kong injured while working outside Hong Kong. If an employee sustains an injury or dies as a result of an accident arising out of and in the course of his employment, his employer is in general liable to pay compensation under this Ordinance even if the employee might have committed acts of faults or negligence when the accident occurred. In addition, an employer must be in possession of a valid insurance policy to cover his liabilities both under the Employees’ Compensation Ordinance and at common law for the work injuries for his employees. In the event of a work accident resulting in injury to a worker, the employer will be liable to pay for medical expenses, compensation for permanent total incapacity suffered by the worker, and periodic payments during the period of temporary incapacity up to 24 months. Assessment of the necessary period of absence and the loss of earning capacity is provided for by the Employees’ Compensation Boards of the Hong Kong Labour Department [3]. There have been several important criticisms regarding the employees’ compensation system in Hong Kong. Of the
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most important one is the lack of specification for rehabilitation under the Ordinance [4]. The linkage between rehabilitation and compensation is not established. Without a systematic specification, many cases are not referred for occupational rehabilitation resulting in a less than satisfactory return to work outcome. The referral of workers for receiving occupational rehabilitation relies on a clinical rather than protocol driven decision. Without a standardized protocol, occupational rehabilitation has been made to compete with compensation which seems to emphasize in the existing Employees’ Compensation Ordinance. Another important feature of the Hong Kong Employees’ Compensation Ordinance is that injured workers is eligible to pursue common law claims for the incident, even after the employees’ compensation case is settled. Under the Employees’ Compensation Ordinance, the maximum compensation payable for any injury or death is capped. In some cases, the compensation received may not fully account for the loss suffered by the injured worker. In other occasions, the amount of the compensation may not meet the worker’s expectation. With these, individual injured worker might decide to proceed to common law litigations for making a negligence claim against the employer. In fact, Hong Kong is one of the few places which offer injured workers unrestricted common law access after the provision of statutory benefits [5]. Such practice is in contrast to other places such as Singapore where injured worker is provided with a once-and-for-all election between statutory compensation and common law access. In Australia, the system sets a threshold-based restriction (only cases with certain degree of resulting impairment would be eligible for common law litigations) on the injured workers for accessing to common law. The Hong Kong system also stipulates a one-off payment compensation scheme, which frees up the employer’s responsibility on providing continuing care to the injured employees. This arrangement is conducive to workers to maximize their claims after the injury rather than receiving rehabilitation for increasing the chance for returning to work. These will compromise the effectiveness of the occupational rehabilitation services delivered in Hong Kong.
Highlights of Occupational Rehabilitation Services in Hong Kong Earlier Systems (Till 2002) The first White Paper on Rehabilitation entitled ‘‘Integrating the Disabled into the Community: A United Effort’’ has been introduced in 1977. The second White Paper on Rehabilitation entitled ‘‘Equal Opportunities and Full
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Participation: A Better Tomorrow for all’’ has been published in 1995. These papers set out the goals and directions of the rehabilitation policies and programs into the 21st century [6]. Nevertheless, the contents gear towards management of acute phase of the injury or the disease with very little emphasis placed on rehabilitation services for injured workers, let alone their return to work. In the 1990s’, injured workers received mostly medical rehabilitation services in public hospitals. The services offered by these settings were designed based on the conventional biomedical model. Medical doctors tended to focus on clinical symptoms and physical pathology when making clinical referrals for diagnosis and treatment. Referrals for work rehabilitation which included functional capacity evaluation, work reconditioning and hardening were relatively common for patients who had been staying in the medical system for an extended period of time (i.e. chronic case) [7]. Work rehabilitation was regarded as one of the medical rehabilitation interventions for facilitating patients to leave the medical system. According to the Hong Kong Hospital Authority statistics, 50% of the ‘‘second priority patients’’ referrals would have to wait for 5 weeks or more for a specialist outpatient appointment [8]. The injured workers received the services in the public system which inevitably shared the resources and service pattern with the general population. Despite a highly competent and comprehensive medical system, the services which injured workers tended to receive were not specialized for returning to work and coordinated for achieving the work-related outcomes [9]. Voluntary Rehabilitation Program Initiative (in 2003) In March 2003, the Labour Department of the Government of Hong Kong SAR and the Hong Kong Federation of Insurers (HKFI) launched the Voluntary Rehabilitation Program (VRP). This initiative was developed to meet the needs for a more coordinated occupational rehabilitation practice for injured workers in Hong Kong. At the same time, this program was meant to involve the insurance company such that the timely services received by the workers could be covered by the insurance as stipulated by the Ordinance. By now, 14 insurance companies in the territory have joined the scheme. Construction industry workers have been the initial target for joining the program. Subsequently, workers in catering, transportation, manufacturing and all other industries have been covered in this program. One major aim of VRP is to provide injured workers with timely rehabilitation services paid for by the insurance company. This is believed to tackle the problems associated with the fact that, as the majority of the occupational rehabilitation services are provided by the public medical
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and health system, injured workers would need to compete the resources with other diagnostic groups such as in neurology and oncology. The anticipated outcomes are to facilitate better and faster recovery of the workers from injuries for safe and early return to work. When an injured worker is identified, the insurance company will refer the worker to one of the company’s panel doctors for management on a voluntary basis. The insurer will be responsible for all the medical expenses incurred for the treatment of the injured worker. From March 2004 to October 2005, 876 injured workers were referred to the program and 801 accepted the referral [10]. The high take-up rate however, did not seem to lead to effective return to work outcomes as only a handful of cases subsequently were offered a work trial through the program (N = 53 from November 2004 to October 2005)[11]. These figures only accounted for less than 2% of all work injury cases in Hong Kong in 2004 and 2005 [12]. Different sources of evidence suggest that the VRP has not been as optimistic as originally envisaged in offering a solution for return to work of injured workers. The major criticism has been on the voluntary referral process and the insurance companies bear the medical expenses whenever the bills for services go beyond the statutory reimbursable amount. According to the information gathered by Hong Kong Federation of Insurers in 2008, the average costs per medical consultation per worker was found to range from HK$226 for general practitioner to HK$511 for medical specialist. The costs for radiology, physiotherapy and occupational therapy services ranged from HK$316 to HK$632 per visit [13]. The data also indicated that those who had been referred to VRP tended to suffer from more severe injuries to the body. The consequence was that the insurance companies were likely to pay for the expenses which exceeded the statutory provisions and in return might not have substantially hastened the return to work process. Practitioners in the field found that the documentation procedures stipulated by the VRP program were cumbersome. The development of VRP also did not cover the specialization process of occupational rehabilitation services. In particularly, the link between the rehabilitation services that the injured workers received and the return to work process was not emphasized. In fact, the VRP stressed on work trial especially light work duties but not other return to work processes and options. Elsewhere in many developed countries, rehabilitation of injured worker is closely linked with the workplace, and the process needs to have a smooth transition from the clinical management to workplace rehabilitation and return to work [14–16]. The development of return to work processes is of utmost importance to the success of VRP because as most employers in Hong Kong operates small enterprises (\20 employees) for which providing suitable duties for injured
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workers would be less feasible [17]. The common problems which they would encounter are to the lack of knowledge on modifying jobs and flexibility to offer alternative placements for injured workers. The VRP does not seem to address the problems which have been encountered by the industries, insurance companies and occupational rehabilitation practitioners in Hong Kong. Inhouse Occupational Rehabilitation Services in the Hospital Authority—A Model for Future Practice In Hong Kong, injured workers can receive occupational rehabilitation services through private or public sectors. The public services are offered in hospitals or rehabilitation centres which are operated exclusively by the Hong Kong Hospital Authority (HA). The HA is a statutory body responsible for managing all public hospitals in Hong Kong and the funding comes from the Government of the Hong Kong Special Administrative Region, China. As occupational rehabilitation services are part of the public medical and health services offered to the entire population in the territory, injured workers will need to be put on a waiting list for receiving the necessary occupational rehabilitation services similar to other patients within the system. This has resulted in a long delayed of rehabilitation services to be received by the injured workers. In 2005, the HA set up the Occupational Medicine Services, which aims to provide a fast and coordinated service for employees who injure at work. The initial target has been limited to the employees of the HA, with a view to expand the services to workers outside of HA in the later phase. The reason for targeting at HA employees as a start is that HA has a rather high inhouse injury rate. The injuries among its 57,000 employees account for about 10% of the total number of reported cases in Hong Kong. As of the year 2009, seven clinics have been established in the territory with a few of them providing limited services to the general public.
Summary of Research Studies Related to Occupational Rehabilitation in Hong Kong Occupational rehabilitation has been implemented in local healthcare service for many years. There are also a number of research studies conducted and published. These studies have contributed to the evidence-based occupational rehabilitation practice in Hong Kong. They include validation of assessment instruments, design of physical and/or psychosocial interventions, and implementation of case management for effective return to work. Validation of clinical instruments for assessing workers’ work capacity was one of the first initiatives among the researchers in Hong Kong. Evidence was collected on
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common instruments which were developed in other countries. Lee and Chan (2003) investigated the applicability of the Dictionary of Occupational Titles (DOT) and used formwork carpenters as an example. The results indicated that the DOT was largely relevant despite there were a few discrepancies attributable to the specificity of job natures of the formwork carpentry between the US and Hong Kong [18]. Lee et al. (2001) [19] also collected evidence on the test–retest reliability of common functional capacity evaluation (FCE) instruments such as VAPAR CWS and BTE work simulators. In addition, the predictive validity of job-specific FCE on the employment status of patients with specific and non-specific injury was examined. The results showed that job-specific FCE demonstrated a higher level of predictive validity when compared with generic FCE [20]. Besides, job-specific FCE showed a better predictive validity in relation to the return to work of patients with a specific injury, such as a distal radius fracture, than patients with a nonspecific injury, such as nonspecific low back pain. However, a longer time period from injury to FCE, compensable injury, and job difficulty would reduce the predictive ability of job-specific FCE [20, 21]. Self-reported assessments were also validated by different teams of researchers. These included Chinese versions of the Oswestry Disability Index (CODI) [22], the Lam Assessment of Employment Readiness (C-LASER) [23], and the Fear-Avoidance Beliefs Questionnaire [24]. These validated instruments enable researchers and clinicians to identify the problems with the workers, capture the changes and return to work readiness of the workers, and make possible assessment of loss of earning capacity and estimation of loss of income of workers. Although the more integrated multidisciplinary approach developed over the past two decades by many in the west has generated improvement in our understanding of mechanisms and management of work disability [25, 26], there is need for consideration by local rehabilitation professionals in Hong Kong the context in which both understanding and implementation of work disability and occupational rehabilitation is applied in local culture. To develop evidence-based practice in occupational rehabilitation in Hong Kong, studies have been conducted to evaluate the efficacy of interventional programs designed for injured workers. The first few studies focused more on the physical aspects of specific diagnostic groups. For instance, Chan et al. (2000) [27] designed a six-weeks standardized program for reducing the pain and increase functional capacity of female workers suffered from lateral epicondylitis. The program was conceptualized based on a dose-and-response model and subjects were prescribed with progressive work-hardening training, home exercise and educational sessions. Throughout the sessions, subjects’ pain level and functional capacity were monitored.
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Outcome measures used were physical-related such as pain intensity, isometric strength and endurance, and psychosocial-related such as self-perceived performance competence and satisfaction. Szeto and her colleagues conducted indepth studies trying to understand the physical components related to work injuries. For instance, Szeto et al. (2002) revealed that in office workers with work-related neck and upper limb musculoskeletal symptoms, neck and shoulder postures were found to have more head tilting, neck flexion and greater acromion protraction than those without symptoms [28, 29]. Other studies also found that monotonous keyboard work was related to more intense activities in the right upper trapezius suggesting that altered muscle recruitment patterns could precede the onset of discomfort among office workers with work-related neck and upper limb disorders [29, 30]. Nevertheless, the return to work rate, earning capacity and costs related to intervention and loss of income were not used as the outcome of the intervention. There are two main lines of randomized controlled trials which were conducted by researchers in Hong Kong. Common to these two trials, emphases were placed on work-related outcomes. Li et al. (2006) conducted a program to facilitate the work readiness on RTW of injured workers with prolonged sick leave and difficulties in resuming their work roles. This study designed a threeweeks intensive work-readiness training program combined with three-weeks job placement program. The results indicated that the workers in the training group showed significantly higher return to work rate (by 20%), higher work readiness, lower level of anxiety and better self-perceived health status; and thus were motivated and ready to resume employment than the waiting list group [31, 32]. The second trial was led by Cheng and Hung (2007) who designed a workplace-based work hardening program for individuals suffering from work-related rotator cuff disorders. The results suggested that workers in the workplacebased program were found to have better functional capacity, and perceived health condition and to consequently improve return to work rate than the traditional clinic-based work hardening program. The study further explained that the benefits were brought about by addressing the psychosocial issues related to peers and employer and preventing re-injury of the workers [33]. These findings concur with those revealed in other studies conducted out of Asia that workers’ adjustment of disability throughout the return to work process was the most crucial element of successful rehabilitation of injured workers [34, 35]. Alongside with the controlled trial, a few in-depth studies were conducted on the psychosocial or socio-demographic factors associated with returning to work. The results showed that older age, high physical work demands, and high wage replacement during sick leave period were significant determinants on delayed return to work [36].
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Furthermore, among all work- and health-related factors, the readiness of return to work measured by the level of precontemplation (i.e. hesitation) was the strongest predictor of long-term return to work outcome. This study also revealed the usefulness of workers’ need-specific intervention (such as individual counseling was prescribed when workers were identified in the pre-contemplation stage) for facilitating effective return to work [37]. More recent studies explored the usefulness of case management regime for enhancing return to work of injured workers. Besides, much emphasis had been put on exploring other benefits such as shortening of sick leave days and lowering of costs to insurers. Lai and Chan (2007) [38] used a cohort comparison group design on injured workers who were with or without case management. The results indicated that case management processes provided for injured workers was able to reduce number of sick leave days and compensation costs. Chong and Cheng (2010) [39] reviewed the case management model in Hong Kong and found that most of the local systems possessed features similar to those revealed in other studies. They included processes which evaluate, plan, coordinate and monitor the options and services required to meet the needs of injured employees [40–42]. Besides the research work carried out by researchers in Department of Rehabilitation Sciences, the Hong Kong Polytechnic University in Hong Kong, other institutions had developed pilot programs for further enhancing the development of occupational rehabilitation. For instance, the Department of Orthopaedics and Traumatology of Chinese University of Hong Kong set up the Occupational Orthopedics Rehabilitation Centre to develop more dedicated occupational rehabilitation services to patients with work injuries. More recently the Orthopaedics Rehabilitation Subspecialty under the Hong Kong College of Orthopaedics Surgeons highlighted occupational rehabilitation as a key theme. The main theme of the Hong Kong Orthopaedics Association 30th Annual Congress held in November 2010, was on Occupational Orthopaedics. It is hoped that through such awareness in occupational rehabilitation injured workers could benefit more from the services in the coming months and years.
Future Needs in Occupational Rehabilitation The provision of rehabilitation services for work injuries very often depends on the availability of the service and the approach adopted by the attending medical practitioners. Traditionally, medical practitioners have been trained to focus on symptoms, physical and emotional well-being, as the primary measures of treatment success [43]. Treating or preventing work disability, which are the focus work of
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occupational medicine specialists, are not viewed as central to the training of most clinical specialties, other than for those working in the specialties of rehabilitation and occupational medicine [44].These result in the relative lack of participation in occupational rehabilitation by medical practitioners. There are currently very few occupational medicine specialists involved in occupational rehabilitation services in Hong Kong. According to the Medical Council of Hong Kong, in 2010 only 11 medical practitioners are registered specialists in occupational medicine [45], although it has been estimated in 2005 by the Hong Kong Academy of Medicine that 52 occupational medicine specialists would be needed for the whole territory [46]. There is still a long way for Hong Kong to have adequate clinical service provision in occupational medicine and occupational rehabilitation. The specialization process of rehabilitation practitioners such as occupational therapists and physiotherapists are in its infancy. Occupational rehabilitation has been regarded as a sub-specialty of these disciplines. It is desirable for the disciplines in the field to formulate a cross-discipline training program leading to specialization in occupational rehabilitation in Hong Kong.
Conclusions While Hong Kong has contributed significantly to the science for practice in occupational rehabilitation, there are obvious deficiencies in the development and provision of such services in the field. In the academic aspects, the case management approach in the handling of work injury cases should be further explored, and a systematic case management protocol which is suitable to the local medical and health system is worth to be developed. At the policy level, the requirements for occupational rehabilitation and return to work processes to be incorporated into the legislation should be seriously considered. Whether public funding is continued to be used for providing occupational rehabilitation services for injured workers should be discussed at the administration level. Such discussion should become part of the agenda under the current Healthcare Financing Reform initiative in Hong Kong. At the service provision level, the public medical and health system can place more emphasis and resources in the development of occupational rehabilitation services for injured workers. Training opportunities for surgeons and physicians as well as health professionals should be of high priority given the relatively lack of manpower dedicated to these services. All these proposals will not be easily accomplished, but it is hoped that through closer cooperation between different stakeholders that further improvements of the discipline be realized in the coming future.
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