Fitness to Drive –

Thorny Issues for GPs

Dr Iñigo Perez

Medical Adviser

DVLA

Nottingham 6 September 2014

Outline

• Drivers Medical Group• Case Scenarios• Q & A

Drivers Medical Group

• Section of DVLA• 20 Medical Advisers• 400 + Clerical Staff• Medical fitness to drive

• sudden and disabling events

• likely to impair safe handling of vehicle

Why do we do what we do ?

• Third European Union Directive

• Road Traffic Act 1988

• Motor Vehicles (Driving Licences) Regulations 1999

Standards of Fitness to Drive

Interpretation and application of the law by

Medical Advisory Panels

• Neurology

• Cardiology

• Diabetes

• Vision

• Alcohol/Substance Abuse

• Psychiatry

Case 1 Insulin treated diabetes

Mrs D had a small RTA two days ago after a hypo at the wheel (BM 1.8).

Her diabetes is normally well controlled but had a nocturnal hypo 5 months ago (husband woke her up and gave sugary drink). No other hypos in last 2 years.

She checks blood glucose twice a day, always first thing in the morning and at bedtime.

Is Mrs D fit to drive?

Case 1 Issues

1. Hypo at the wheel requires 3 months off driving

2. 2 hypos in 12 months

3. Inappropriate blood glucose monitoring

Insulin treated diabetes Group 1

Must satisfy the following criteria:

• adequate awareness of hypoglycaemia

• no more than one severe hypo in last 12 months

• appropriate blood glucose monitoring (within 2 hours of driving and every 2 hours while driving)

• not likely source of danger while driving

• visual acuity and field standards must be met

Insulin treated diabetes Group 2

Must satisfy the following criteria:

• no severe hypo in last 12 months

• full awareness of hypoglycaemia

• regularly monitors blood glucose at least twice daily and at times relevant to driving using a glucose meter with a memory function

• at annual examination by an independent Consultant Diabetologist, 3 months of blood glucose readings must be available

• demonstrate understanding of risks of hypo

Diabetes Group 2

Tablets with risk of hypoglycaemia

(e.g. sulphonylureas and glinides)

• regularly monitors blood glucose at least twice daily and at times relevant to driving

Case 2 Coronary Artery Disease

Mr C attends your practice for a taxi medical (Council applies Group 2 standards).

PMH includes CABG in 2010 (no problems since) and head injury (cerebral contusion) in 2008.

Complaints of knee pain since a fall 18 months ago. Rest of examination is normal.

Is Mrs D fit to drive?

Case 2 Issues

1. Coronary artery disease requires functional test (ETT, Myocardial Perfusion Scan, Stress Echo) every 3 years

2. Severe Head Injury in Group 2 drivers requires 2 to 4 years off driving

3. Delays with functional tests

Coronary Artery Disease Group 2

Angina

Acute Coronary Syndrome

Angioplasty ± stent

• off Group 2 driving for at least 6/52

• has to satisfy ETT or other functional test

CABG

• off Group 2 driving for at least 3/12

• LVEF is at least 40%

• has to satisfy ETT or other functional test

Case 3 EpilepsyMrs E had a tonic-clonic seizure 6 years ago. A

meningioma was diagnosed and almost completely

resected by surgery. Medication was stopped 3 years

ago and she started having simple partial seizures

(3-4 times a year) retaining consciousness and ability

to act. Mrs E does not want anticonvulsants as she is

trying to get pregnant and seizures do not bother her.

Neurologist suggests Epilepsy Regulations are

satisfied as history of seizures not affecting ability

to act or consciousness for more than 12 months.

Is Neurologist correct?

Epilepsy Regulations Group 1

Epilepsy defined as 2 or more seizures in 5 years

Qualifies for licence if:• free from any epileptic attack for 1 year

• sleep attacks only for 1 year (and never awake attacks)

• sleep attacks only for 3 years (and previous awake attack/attacks)

• epileptic attacks not affecting consciousness or ability to act for 12 months and no history of any other type of seizure

Epilepsy Regulations Group 2

Qualifies for licence if:

• free from any epileptic attack for last 10 years

• has not taken AED during these 10 years

Isolated Seizure

Group 1• 6 months off driving if normal EEG & brain scan

• 12 months off if abnormal EEG &/or brain scan

Group 2• 5 years off driving

• no AED during these 5 years

• recent assessment by Neurologist

• satisfactory results from investigations

Case 4 Visual Disorders

Mr V has got new prescription glasses. His

corrected visual acuities are R 6/24 and L 6/12-2.

He has been found to have a visual field defect

(incomplete R lower quadrantanopia). He had a

stroke 4 years ago but never informed DVLA.

However, he reports no problems driving, cycling

or playing badminton.

Is Mr V fit to drive?

Case 4 Issues

1. Poor corrected visual acuities

2. Visual field defect (VFD)

3. If significant, adaptation to VFD?

4. Notification to DVLA

Visual Disorders Group 1

Acuity• binocular visual acuity 6/12

• to read number plate at 20 m

Field of Vision• horizontal field of vision of at least 120°

• extension should be 50° left and right

• no significant defect encroaching in central 20° area

• Central 20° area of vision

• 120° width of field

Visual Disorders Group 2

Acuity• at least 6/7.5 in better eye and 6/60 in worse

eye (*Grandfather Rights – Contact DVLA)

• corrective power ≤ + 8 diopters

Field of Vision• horizontal field of vision of at least 160°

• extension 70° left & right and 30° up & down

• no defect within a radius of central 30°

VFD Exceptional Cases

If satisfies all the following (only Group 1):

• defect present for at least 12 months

• caused by an isolated event

• no other condition regarded as progressive and likely to affect the visual fields

• no monocularity or uncontrolled diplopia

• there is clinical confirmation of full functional adaptation

• practical driving assessment

Case 5 Notification to DVLA

Mrs N’s daughter attends the surgery. Her

mother was recently diagnosed with dementia

by the Memory Clinic. She was advised not

to drive and to inform DVLA. However, she

has done the opposite.

Mrs N’s daughter wants you to inform DVLA.

Who is responsible to notify DVLA?

• Drivers have a legal duty to inform DVLA of any

medical condition, which may affect safe driving

• Doctors can notify if disclosure is in the interest

of the individual or for safety of general public

• Anyone can inform DVLA

• Family notifications

Driver continues to drive against medical advice

Mrs I had insulin treated diabetes and was

having severe hypos. She had been advised

by her GP and Consultant to stop driving and

to inform the DVLA. However, she continued

to drive and did not inform the DVLA.

Her GP and Consultant were aware of this.

No one informed the DVLA.

Mrs I had a hypo and killed two people.

GMC Guidance To Doctors1. Dr to explain that their condition may affect safe driving and their

legal duty to inform DVLA . If patient is unable to understand advice

(eg dementia), Dr to inform DVLA asap.

2. If patient refuses to accept advice, arrange a second opinion and

inform patient not to drive until opinion is obtained.

3. If patient continues to drive when they may be unfit to do so, Dr

should make every reasonable effort to persuade them to stop. If

patient agrees, discuss concerns with relatives, friends or carers.

4. If unable to persuade patient to stop driving, or you discover that

they continue to drive against your advice, you should contact DVLA

asap and disclose relevant medical information to the Medical Adviser.

5. Before contacting DVLA, Dr should try to inform patient of decision to

disclose personal information. You should then also inform patient in

writing once you have done so.

Case 6 Dementia

Mr P has had Parkinson’s disease for 4 years and

is well controlled. He has now problems with

memory, concentration and occasional confusion.

Wife helps with ADLs. Mr P continues to drive. His

wife has no concerns about it, however, she

always goes in the car with him. His licence will be

due for renewal in 4 months. MMSE is 22/30.

Is Mr P fit to drive?

Case 6 Dementia

• Difficult to assess driving ability in dementia

• Poor short term memory, disorientation, lack of

judgement and insight, will almost certainly lead to

loss of driving entitlement

• In early dementia when sufficient skills are

retained and progression is slow, a licence may be

issued subject to annual review

• A decision regarding fitness to drive is usually

based on medical reports

• A formal driving assessment may be necessary

Driving Assessment

Forum of Mobility Centres – 16

1. Clinical assessment

2. Driving related functional assessment

3. Practical on-road driving assessment

Provisional Disability Assessment Licence (PDAL)

Case 7 D4 Medical Examination

It is 10 am. You are performing a D4 examination in a patient who is not from your practice. He smells of alcohol. When you ask him about it, he says he had a couple of drinks the night before

There is no past medical history of interest. However, he becomes defensive when you raise issues with regard to alcohol (sections 3 and 9), and admits to drinking no more than 2 pints 3 or 4 times a week .

Examination is normal.

D4 Medical Examination Report

First application for Group 2 and then at 45, 50, 55, 60, 65 (65+ every year)

Vision assessment to be filled by Dr or Optician

1. Nervous system 6. Further details

2. Diabetes 7. Consultants’ details

3. Psychiatric illness 8. Medication

4. Cardiac (7 subsections) 9. Additional information

5. General 10. Examining Dr’s details

D4 Medical Examination Report

• Dr to fully examine the patient and to take the

medical history

• Dr must fill in sections 1-10

• Section 11: patient & GP’s details, consent and

declaration

• Section 11 to be filled-in in the presence of the Dr

Red flags Alcohol

“The persistent misuse of drugs or alcohol,

whether or not such misuse amounts to

dependency, is a prescribed disability”.

Alcohol

Group 1• Persistent Misuse of alcohol requires 6 months of

control or abstinence

• Dependence on alcohol requires 12 months of control or abstinence

Group 2• Persistent Misuse of alcohol requires 12 months of

control or abstinence

• Dependence on alcohol requires 3 years of control or abstinence

Red flags Blackouts

At a glance has a table with 6 categories

Period off driving depends on diagnosis e.g. • reflex vasovagal syncope - no restrictions

• unexplained – 6 m for Group 1 & 12 m for Group 2

• cough syncope – 6 m for Group 1 & 5 y for Group 2

Unless clearly vasovagal, advise to stop driving

Take-home messages

1. When you are assessing patients with significant medical conditions, also consider their fitness to drive

2. If you are unclear about a patient’s fitness to drive, you could give the benefit of the doubt to a car driver but not to a vocational driver

3. If you support your patient’s fitness to drive, do it on good grounds; keep in mind the standards of fitness to drive and that the need for a car does not make a person fit to drive

Take-home messages4. Remember you can always contact the DVLA

Medical Advisers

• Telephone - 01792 782337 (10:30 am – 1 pm)

• Email: medadviser@dvla.gsi.gov.uk

Inigo.Perez-Celorrio@dvla.gsi.gov.uk

• Mail: Medical Adviser

Drivers Medical Group

Longview road

Swansea, SA99 1TU

“At a glance” Guide – available as pdf on www.gov.uk website