Fitness to Drive –
Thorny Issues for GPs
Dr Iñigo Perez
Medical Adviser
DVLA
Nottingham 6 September 2014
Outline
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Drivers Medical Group
Case Scenarios
Q&A
Drivers Medical Group
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Section of DVLA
20 Medical Advisers
400 + Clerical Staff
Medical fitness to drive
sudden and disabling events
• likely to impair safe handling of vehicle
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Why do we do what we do ?
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Third European Union Directive
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Road Traffic Act 1988
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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
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CABG
off Group 2 driving for at least 3/12
• LVEF is at least 40%
• has to satisfy ETT or other functional test
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Case 3 Epilepsy
Mrs 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:
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free from any epileptic attack for last 10 years
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has not taken AED during these 10 years
Isolated Seizure
Group 1
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6 months off driving if normal EEG & brain scan
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12 months off if abnormal EEG &/or brain scan
Group 2
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5 years off driving
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no AED during these 5 years
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recent assessment by Neurologist
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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
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Central 20°
area of vision
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120° width of
field
Visual Disorders Group 2
Acuity
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at least 6/7.5 in better eye and 6/60 in worse
eye (*Grandfather Rights – Contact DVLA)
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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°
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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
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Doctors can notify if disclosure is in the interest
of the individual or for safety of general public
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• Anyone
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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 Doctors
1. 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
2. Diabetes
3. Psychiatric illness
4. Cardiac (7 subsections)
5. General
6. Further details
7. Consultants’ details
8. Medication
9. Additional information
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 messages
4. 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