Driving is a complex functional process requiring interaction of multiple sensory inputs, motor outputs and both cortical and sub-cortical brain function. Because of this, medical conditions affecting virtually every body system can potentially affect the ability to drive safely.
GPs, like all healthcare professionals, have a responsibility to take part in discussions about driving with patients and the GMC provides guidance on this.1
Yet the fact remains GPs, and other healthcare professionals, sometimes struggle to fit in the relevant discussions around fitness to drive with their patients. In busy pressurised consultations, it isn’t difficult to see why. However, this point of contact has major implications for the safety not only of the patient, but of all road users.
Having the discussion about driving
There are two key elements to the discussion: firstly, the impact of the patient’s condition on safe driving, and secondly whether any given condition requires DVLA notification.
These are not necessarily interlinked – many short duration, temporary conditions such as a TIA, surgical procedures, bone fractures or opiate prescriptions for pain that could clearly cause difficulty with safe driving would not require notification.
Other medical conditions require directly advising the patient to notify the DVLA. These are set out in the published UK standards ‘Assessing fitness to drive – a guide for medical professionals’.2
Keeping up to date
The UK standards are continuously reviewed and updated to reflect changes in medical practice and when necessary, legally prescribed standards for driving. No healthcare professional could reasonably be expected to retain and recall every one, and it is crucial to refer to current published standards. Aside from this, they are a detailed advice and guidance resource, available in pdf and HTML formats, with hyperlinked sections to quickly take users to the relevant sections and advice. The guidelines also serve as a useful information source to supplement, support and even facilitate the driving discussion itself.
Advising a patient to notify DVLA
During a driving discussion, consider the patient’s symptoms and assess whether they fall under one or both of these subgroups that would require notification:
1. Those that could cause sudden disabling events.
Examples include hypoglycaemia, cardiac arrhythmias, seizures or excessive sleepiness
2. Those that could cause difficulties with safe vehicle control
Examples here include neurological conditions, visual disorders and the effects of drugs and/or alcohol.
Having considered this, refer to the published standards to confirm where notification is required, and determine any likely periods where the patient may not be able to drive.
GB driving licences and fitness to drive standards
There are two types of driving licence in GB; Group 1 (car/related vehicle/ motorcycle) and Group 2 (lorry/ bus). Fitness to drive standards are invariably higher for Group 2 than Group 1 drivers. Decisions around medical fitness to hold a driving licence are taken by the Driver’s Medical section at the DVLA and applied against standards set either directly in legislation (for example vision or seizure conditions) or else set by the Secretary of State for Transport’s Advisory Medical Panels. DVLA deals with around 750,000 medical cases each year, with around 150,000 of these being notifications of new medical conditions.
The complexity of conditions requiring notification continues to rise as a consequence of progress in treating conditions previously considered incompatible with safe driving. Yet even allowing for this increase, the prospect of licence loss (revocation) or refusal is a small minority of all medical cases. There are a range of options open to DVLA in helping support continued licensing of drivers with medical conditions. These include short period review licences and permitting licensing to drive vehicles with an increasingly wide range of adaptations that can facilitate, support and assist safe driving. While DVLA’s principal role in medical driver licensing is to ensure road safety, we are always keen to facilitate licence issue where it is safe to do so, both for the driver and all other road users.
Below are some case scenarios to help illustrate how GPs should put this advice into action.
1. Retired female with Parkinson’s
Group 1 licence holder, retired school teacher, 67-year-old female with an 11-year history of Parkinson’s. Treated currently with dopamine agonists. She has had a recent deterioration in her symptoms with increasing tremor and rigidity affecting her left leg.
- Duration of Parkinson’s makes progression more likely
- Recent deterioration of symptoms suggests progression
- Limb difficulties indicate potential problems with safe vehicle control
- Should be advised to stop driving pending clinical review and notify DVLA
Comments: Licence action may not be required in these circumstances; short-term licensing may be a viable option as would assessment for suitable adaptations in the event that the left sided tremors affected vehicle control. For many patients with chronic medical conditions and the likelihood of deterioration with time, it is worthwhile initiating suitable discussions around alternative means of transport against the point where licence withdrawal inevitably becomes necessary.
2. Elderly male bus driver with heart disease
Group 2 licence holder, bus driver, 63-year-old male with ischaemic heart disease treated four years ago with two stents. Four months ago underwent successful elective minimal access CABG after onset of further angina. Now asymptomatic.
- Re-intervention for ischaemic heart disease
- Must be advised not to drive for three months post CABG and notify DVLA
- Will be required to demonstrate ejection fraction >40% and other cardiac functional test requirements are met before re-licensing. If not available at the time of enquiry, the DVLA will arrange/ fund these tests
Comments: Successful treatment for ischaemic heart disease does not equate to licence action and, in the case of professional drivers particularly, loss of employment. All Group 2 drivers with a wide range of cardiological conditions will be required to confirm that they are able to meet the functional test requirements before being re-licensed.
3. Late 30s female with depression
Group 1 licence holder, 39-year-old female single parent. Depression for last five years but significant recent deterioration in symptoms with agitation, poor concentration and suicidal intent requiring intensive community support from community mental health care crisis team. Her depression has improved and stabilised on sertraline in the last few weeks.
- Worsening of psychological state and threatened self harm
- Intervention of support team
- Should be advised not to drive and in view of self harm threat and current diagnosis of severe depression , must notify DVLA
Comments: Although the driver is now stable on revised medication, the self-harm threat and agitation requiring active intervention clearly indicates more severe depression certainly at the point that suicidal intent was high. Group 1 standards would usually require a period of at least three months of psychological stability before re-licensing. Longer term, and as long as stability was maintained, prolonged licensing would reasonably be anticipated.
4. Early 30s male with recently diagnosed type 1 diabetes
Group 1 licence holder, sales director for publishing company. 32-year-old male diagnosed with insulin dependent diabetes mellitus two years ago. Excellent diabetes control although has had two sudden onset hypoglycaemic episodes, both without warning though neither requiring assistance from anyone else. Subsequent assessments suggest he has very limited awareness of hypoglycaemia.
- Lack of awareness of hypoglycaemia developing is a major concern
- Should be advised to stop driving and must notify DVLA
Comments: Irrespective of seemingly good diabetes control, there have still been episodes of unheralded hypoglycaemia. While these hypoglycaemic events have not required assistance from another person (and so are not ‘severe’ as defined in law and so not themselves notifiable) the fact that there is no awareness of such events represents a major road safety concern. The driver would have to be advised to stop driving and may only resume this after confirmation that adequate awareness is regained. ‘Awareness’ means the ability to identify impending hypoglycaemia; symptoms might include a dry mouth, feeling weak, peri-oral or digital tingling amongst others. As a guide, the duration of symptoms experienced should be compatible with bringing a vehicle to a stop in a safe location.
5. Late 40s female HGV driver with sleep apnoea
Group 2 licence holder, HGV driver. 49-year-old female with obstructive sleep apnoea syndrome diagnosed three years ago. Fully compliant with CPAP therapy and previously good symptom control. Increasing episodes of tiredness during normal waking hours in the last two months, co-incident with changes in working patterns to twilight/night shifts. Epworth score 13.
- New onset tiredness during normal waking hours represents a road safety risk
- Irrespective of previously good symptom control or changes in work patterns, new onset symptoms require review
- Should be advised to stop driving and notify DVLA
Comments: Excessive or unexpected sleepiness is a significant road safety risk and always requires careful assessment. While a change in shift pattern may well result in temporary tiredness, two months of symptoms would be of concern. Long-term licensing is possible in many cases of excessive sleepiness and the key factor is that control of any causative condition(s) is established so that any excessive sleepiness is abolished.
6. Retired male with history of TIA
Group 1 licence holder, retired engineering worker. 67-year-old male with single TIA principally affecting speech this morning now attends afternoon surgery. No previous similar events, symptoms have completely resolved with no abnormal findings on examination.
- Should be advised to stop driving for one month
- No need to notify DVLA
Comments: As a first event TIA, the possibility of further episodes has to exist hence the restriction on driving both in the short (immediate) and intermediate (one month) periods. While recurrent events are unpredictable, a period off driving is required to allow time for any recurrent episodes to declare.
7. 82-year-old woman with a history of suspected dementia
This patient attends surgery with her daughter, who raises concerns regarding her mother’s failing memory. You carry out a brief cognitive assessment which reveals signs of cognitive impairment and possible dementia, and refer her to the local memory clinic. Her daughter subsequently writes to you, raising concerns regarding her mother’s driving, saying she ‘no longer feels safe in the car with her’.
You review the patient and advise her not to drive and to notify the DVLA of her condition. She refuses adamantly to stop driving or inform the DVLA and drives herself home from the surgery.
- Suspected dementia and relative’s concerns over unsafe driving
- Patient refusal to follow your advice to stop driving, highlighting a possible lack of insight
- Your professional responsibility to the patient and society.
Comments: When managing cases where cognitive impairment or dementia is suspected, the GP should consider the patient’s safety to drive. It is worth taking a history regarding driving from relatives, if available. If in doubt, the safest course of action will be to advise the driver that they should stop driving and to notify the DVLA whilst their assessment is ongoing. You can seek advice on an individual case with a DVLA doctor by phone or e-mail, without giving patient details.
Ideally the patient or relative will notify the DVLA themselves. If the patient, or relative, refuses to do so, then you should follow GMC guidance regarding breaching confidentiality to the DVLA; this process is also outlined on page 9-10 of the Government guidance for medical professionals.2,3
Always bear in mind the questions: Could this condition cause a sudden disabling event? Could this condition affect safe vehicle control? This should prompt you to initiate sympathetic but clear discussions about driving.
Review the ‘Assessing fitness to drive’ guidelines to inform yourself and the patient of next steps – whether to notify or not and, if any licensing action is necessary, what this action is likely to be
Notification to DVLA does not inevitably lead to licence loss. Short period licences with review or licenses for adapted vehicles are options that facilitate prolonged licence retention, as long as licence issue is safe
Reviewing the UK standards on medical fitness to drive can both inform and assist doctors and patients when discussing driving.
Doctors and all healthcare professionals are encouraged to contact the drivers’ medical section at DVLA if they would like advice on or discussion around a case, clarification of the UK guidelines or indeed to make a notification if they feel this is appropriate. DVLA has a dedicated telephone line where healthcare professionals can speak in confidence to one of DVLA’s doctors and also a dedicated email address.
Dr Alun Hemington-Gorse is a former GP, a DVLA doctor and diabetes panel secretary, DVLA
2. UK Government. Assessing fitness to drive: guide for medical professionals
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