You are a GP looking after a businessman with a history of alcohol misuse. He had been doing very well, but you know from his wife, also your patient, that he is going through a difficult time at work and that he has started drinking heavily again. He drives a lot for his work. How would you manage this, and should you involve the DVLA?
You can’t do much here, but his wife can
As the patient did not seek help himself, there is little you can do immediately. In order to diagnose alcohol misuse collateral information is helpful and often more objective, though not sufficient. To diagnose him, you would need to see him in clinic and he would be required to cooperate in an assessment – both unlikely to happen. Are you familiar with the diagnostic criteria for alcoholism, and levels of alcohol misuse? Have you got the time to learn about it now?
As his wife appears to be concerned about him, I would explain your specific concerns, especially regarding driving. This needs careful communication. She needs to understand the danger he his putting himself and others in.
As long as he keeps drinking he risks losing his licence, which may worry them both. It might help the patient’s wife if you explain that patients lose their driving licenses for a variety of reasons – strokes, heart attacks and epilepsy are common, and as long as problems are treated effectively, licenses are often granted again. Some people with alcohol problems lose their jobs, but quite a lot do keep them.
Remember also that anyone can report him to the DVLA directly and anonymously.
Signpost her to the local alcohol treatment service, and think about safeguarding too – do they have children?
If in doubt about your handling of an issue like this, speak to your medico-legal advisor and pursue training via a body such as the RCGP.
Dr Carsten Grimm is a GP and clinical lead at the alcohol misuse treatment service in Kirklees
Use discretion to try and get him to see you
The scenario indicates a common problem faced in general practice -information coming from a (presumably well intentioned) third party.
The first job is obviously to talk to the man about his drinking. How you do this depends on your relationship with both husband and wife to date. I would use my discretion from the detail behind what the wife has said t your and probably ask her what she thinks may be the best approach in getting him to come and see you, being careful not to cross over any lines of confidentiality.
In my experience, pretending that such conversations haven’t taken place never works well. Ideally his wife will persuade him to come in but, if necessary, and if that doesn’t succeed, I would not be averse to giving him a ring to express my concern and suggest a talk. It may sound rather obvious but any success in helping him to tackle his drinking lies in him wanting to do something about it.
Once face-to-face, he needs a full drinking history preferably with an AUDIT questionnaire which only takes a few minutes to do and can give some useful objective measure of his drinking, relative to previous occasions. When you are familiar with it you can mix it in with your conversation rather than sounding like an interrogation. If pushed for time the AUDIT c3 questions taking half a minute will flag up if there is a worrying departure from safe drinking levels but it is the other seven questions that will also give some idea (to the patient as well as you) of the implications of their drinking. To give a more immediate reflection of his drinking, it may be helpful to breathalyse him – every practice should have one.
In particular, it is obviously important to flag up the health risks of his heavy drinking, not only to his health but driving under the influence is like roaming with a lethal weapon. If further motivation is needed to tackle his drinking, it would be worth reminding him his job may well be at stake if he received a driving ban. However, I feel that the greatest chance of success lies with a therapeutic relationship with him and only as a last resort would I be contacting the DVLA. If he has driven to the surgery with a high breath alcohol, however, I may swipe his keys.
Dr Stephen Willot is a GP and clinical lead for drug and alcohol misuse services in Nottingham.
Dr Marika Davies: Form your own view about his fitness to drive
Having been made aware of this information about your patient, you need to form your own view about his health and fitness to drive. You may wish to invite him in for an appointment in order to explore the concerns and carry out a clinical assessment.
You should take care not to divulge the source of the information so as not to breach his wife’s confidentiality, unless you are able to obtain her consent for you to do so.
If it is your clinical opinion that the patient’s fitness to drive may be impaired by reasons of ill health, he should be advised of this and told that he has a legal duty to inform the DVLA. If he does not accept this you can suggest he seeks a second opinion and can help arrange this, but he should be advised not to drive in the meantime.
If he is continuing to drive despite your efforts to persuade him to stop, you should act in accordance with GMC guidance by contacting the DVLA immediately and disclosing any relevant information, in confidence, to the medical adviser. The patient should be informed of your decision to do so.
You should document carefully any discussions in the medical records and put your advice to the patient in writing. If you are unsure of the correct course of action you may wish to seek the advice of the DVLA’s medical adviser or your defence organisation.
Dr Marika Davies is medico-legal adviser at the Medical Protection Society