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FAQs: neurological illness and driving

Driving is a privilege, not a right, and the onset of neurological illness may bring

limitations that make it impossible to drive safely, or may make it necessary to drive with adaptations or limitations. The rules are complex, but are easily accessed using the DVLA website. In particular there is a great deal more information in this website relating to the much rarer conditions. The neurological charities also offer a great deal of support and advice for their clients in the various disease groups.

Driving offers a degree of independence for patients who may become isolated and incapable of accessing community resources independently. This article summarises the rules for the major disease groups and indicates what the doctor is obliged to do if the rules are flouted.

Introduction

For many patients who develop neurological illness, driving represents one of the last links to a normal life. Driving to the shops, to see family members, visits to the hospital for outpatient appointments – all may be suddenly curtailed by the onset of an illness. Small wonder, then, that doctors do not relish the task of guiding patients through the quagmire of regulations that govern driving after stroke, epilepsy and the less common disabling neurological conditions.

Driving requires a high degree of concentration; good vision; hand, foot and eye co-ordination; and a capacity to think quite quickly and solve problems safely.

All of these abilities are likely to be affected by neurological illness. Many of the impairments that arise when a person develops an illness of this sort are invisible. The lack of insight that many patients exhibit with the gradual progression of the chronic neurological illnesses (multiple sclerosis, Parkinson's disease for example) makes the role of the doctor particularly important as a guardian of the public's safety, as well as the safety of the patient himself.

This article primarily addresses the rules for Group 1 drivers – basically cars and motorcycles. For Group 2 vehicles, which are essentially commercial vehicles carrying loads or passengers, much more stringent rules apply in most illness categories.

what are the rules regarding epilepsy and driving?

The DVLA regulations state that epileptic attacks are the most frequent cause of collapse at the wheel. Epilepsy is a relatively common condition. In Britain about 250,000 people take anticonvulsants and 2 per cent of the population have two or more seizures at some stage in their lives.

A person who has an epileptic seizure while awake must not drive for one year. The basic DVLA rule (for Group 1 drivers) is for a one-year break from driving followed by a medical review before reissuing the licence. This rule applies to all epileptic seizures regardless of type, including auras and warnings, myoclonic jerks, and is regardless of whether or not the person remains conscious.

To qualify for their licence to be returned the patient must comply with the advised treatment and check-ups for epilepsy, and the driving of a vehicle by the person ‘should not be likely to cause danger to the public'.

For seizures during sleep different rules apply: ‘a person who suffered an attack while asleep must refrain from driving for one year from the date of the attack, unless they have had an attack while asleep more than three years ago and have not had any awake attacks since that asleep attack'.

For Group 2 drivers the rules are much more stringent. A first, unprovoked seizure requires a ten-year period free of seizures, without medication. If a solitary seizure is associated with alcohol or substance misuse, or prescribed medication, a

five-year period free of further seizures is required, without medication. If there are further seizures the general epilepsy rules apply, requiring the ten-year

seizure-free period.

Provoked seizures are regarded separately, and may be dealt with on an individual basis by the DVLA. This might apply, for example, following head injury, a stroke, during or after intracranial surgery or with eclampsia. Seizures following the use of alcohol or recreational drugs, or after missing medication, are not considered to be provoked.

Following the requisite seizure-free period the licence is returned on application for a period of three years. Following a seizure-free period of seven years a full licence may be returned up to the age of 70.

Changing or stopping medication is a fraught issue for patients who have recovered their licences. The DVLA notes a 40 per cent increased associated risk of seizure in the first year of withdrawal of medication compared with those who continued on treatment in the MRC AntiEpileptic Drug Withdrawal Study Group.

The recommendation is that patients should be warned of the risk they run, both of seizures and of losing their licence. The DVLA advice is that the driver should not drive during the period of withdrawal and for six months afterwards.

The National Society for Epilepsy website www.epilepsynse.org.uk has a very useful summary of the regulations for epilepsy, and details of a helpline for the patient to use.

How soon can patients drive after a stroke?

Stroke is the single most common cause of disability in the UK, with over a quarter of a million people living with disability caused by stroke. Following a stroke or transient ischaemic attack (TIA), a driver is not permitted to drive for one month. If there are no residual neurological deficits at one month after the stroke, there is no need to notify the DVLA, otherwise the DVLA must be notified by the patient.

The DVLA exempts minor limb weakness from the need to notify, but makes specific note of the need to notify for visual field and cognitive defects, and impaired limb function. The distinction here is between minor limb weakness, which is not functionally relevant, and impaired function, which clearly is of importance. The patient should also notify his insurance company.

Multiple TIAs over a short period of time ‘may require three months freedom of further attacks' and notification of the DVLA. The guidance sounds loose in the DVLA documents, with no clear indication of what is meant by ‘a short period of time'. It is best to notify the DVLA and ask for guidance.

The Stroke Association has information on returning to driving after stroke – the spring 2005 edition of Stroke News was dedicated to the topic. It is available on the Association website www.stroke.org.uk and includes information for the patient on how to contact their helpline, the DVLA, mobility centres and Motability.

How do chronic neurological conditions affect driving ability?

In conditions such as multiple sclerosis, Parkinson's disease and motor neuron disease, the patient's decline is very gradual and idiosyncratic. These situations are much less predictable than for, say, epilepsy. The rule is that if medical assessment confirms that driving remains unimpaired, the driver can remain licensed. A short-period licence may be issued. If the driving controls have to be adapted this should be specified on the licence. If the condition is considered progressive or disabling a Group 2 licence is likely to be refused.

The Multiple Sclerosis Society's website www.mssociety.org.uk notes the anxiety that many sufferers have that they will automatically lose their licence, but advises notification of the DVLA and the insurance company on diagnosis, and notes the obligation to inform the DVLA of any worsening of the condition. It also points out that a licence can be applied for again if a relapse ends and symptoms improve.

What happens when a patient contacts the DVLA?

When a patient notifies the DVLA, it responds by sending a form for completion by the patient, and requests permission to contact the relevant GP. It then does one of three things:

• Asks the GP, or a consultant, to complete a medical report

• Asks a local appointed medical officer to examine the patient

• Asks the patient to undergo a driving assessment, eyesight examination or driving test.

According to the DVLA website dvla.gov.uk, if a decision can be made on the basis of the patient's own questionnaire answers, it should be made within 15 working days in 97.5 per cent of cases. In cases where more information is required, from a doctor or other source, a decision is made in 80 per cent of cases in 90 working days.

The decisions the DVLA can take include the following:

• The subject can retain his licence

• A driving licence may be issued for a limited period of one, two or three years followed by a reminder for a reassessment

• A driving licence indicating the need for special controls to be fitted may be issued

• The licence may be revoked. This outcome is sent with an explanation of the decision and information on how to appeal to a magistrate's court.

What if the patient ignores the DVLA or doctor's advice?

No GP likes this situation – if the illness precludes driving but the advice is being flouted, what is the doctor's duty? The answer is very straightforward, and is spelt out in the GMC booklet Confidentiality: Protecting and Providing Information. The GMC advice is that disclosure of personal information without consent may be justified where failure to do so may expose the patient or others to risk of death or serious harm. Such a situation ‘may arise... where a patient continues to drive, against medical advice, when unfit to do so'. In this situation ‘you should disclose relevant information to the medical adviser of the DVLA without delay' [author's italics].

Appendix 2 to the GMC confidentiality booklet provides the following advice:

• Make sure the patient understands that the condition may impair their ability to drive

• Ensure they understand that they have a legal duty to inform the DVLA

• If the patient is incapable of following this advice, for example due to dementia, the doctor should inform the DVLA immediately

• If the patient refuses to accept the diagnosis, or the effect of the condition on their ability to drive, suggest the patient seeks a second opinion, but advise that the patient must not drive until it is obtained

• If the patient continues to drive, make every reasonable effort to persuade them to stop; this may include informing their next of kin

• If this approach fails the doctor should inform the DVLA immediately. The patient should be informed that this is going to happen

• Once the DVLA has been informed, a letter should be sent to the patient informing him of the disclosure.

The Medical Defence Union has stated in a personal communication that many doctors phone the DVLA with the patient in the room to hear what is said, so they are left in no doubt as to the seriousness of the doctor's intentions. Many doctors speak to their defence union before taking this step to clarify the right action with an adviser.

USEFUL WEBSITE

DVLA dvla.gov.uk

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