Presentation on theme: "Fitness to Drive – Thorny Issues for GPs Dr Iñigo Perez Medical Adviser DVLA Nottingham 6 September 2014."— Presentation transcript:
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 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 1Insulin 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 1Issues 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 diabetesGroup 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
DiabetesGroup 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 2Coronary 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 Complaints of knee pain since a fall 18 months ago. Rest of examination is normal. Is Mrs D fit to drive?
Case 2Issues 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 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: 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 4Issues 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°
VFDExceptional 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 5Notification 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 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 – Clinical assessment 2. Driving related functional assessment 3. Practical on-road driving assessment Provisional Disability Assessment Licence (PDAL)
Case 7D4 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 F irst 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 flagsAlcohol “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 flagsBlackouts 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 (10:30 am – 1 pm) Mail: Medical Adviser Drivers Medical Group Longview road Swansea, SA99 1TU “At a glance” Guide – available as pdf on website