1. DRIVING AND DIABETES

2. Key points
In November 2011 changes, due to an EC directive, led to stricter licensing rules for drivers of cars and motorcycles (Group 1 vehicles) for people treated with insulin
In contrast, the ban on people treated with insulin from driving lorries and passenger carrying vehicles (Group 2 vehicles) has been lifted
Diabetes UK regularly talks with DVLA to ensure that application process is fair and to work to resolve issues raised by people with diabetes

3. What are the rules for drivers with diabetes?

4. What do drivers with diabetes have to report?
There are no restrictions for people who are on medications that do not cause hypoglycaemia.
People must inform the DVLA:
If they use insulin or start to use insulin when they already have a licence
If their condition changes; for example, if they develop complications which can affect their ability to drive
Q. What are the complications that should be reported?
Retinopathy resulting in visual problems, or peripheral neuropathy (loss of sensation in the feet due to nerve damage), or a stroke interfering with sight, muscle strength or balance or other serious medical condition – even if their diabetes is not treated with insulin. Also if people have retinopathy in both eyes (or in the remaining eye if they have sight in only one eye). Also recurrent severe hypoglycaemia or lack of awareness of hypoglycaemia - see slide 6
Q. Do you have to report to the DVLA that you are using medication that can cause hypos?
No, and you do not have a restricted (one or three year licence) like people treated with insulin, but you do have to report frequent severe hypoglycaemia (this is explained next).

5. What happens when you report a move to insulin treatment (for people with Type 2)?
You will be asked to surrender your licence (until 70 years licence) and you will be issued with a restricted period licence for one, two or three years.
If you had an entitlement on your licence to drive a large camper van (over 3.5 tonnes) you will lose this and have to reapply for a Group 2 licence (one year renewable)
When someone goes onto insulin they would need to report this to the DVLA and they would lose their “til 70” licence.  It would be replaced with a restricted licence (1 or 3 years) that they would have to then renew every three years.  They would also lose their entitlement to drive vehicles over 3.5 tonnes (3,500kg) and so would have to get a Group 2 licence for these – some large camper vans / motor homes are over 3.5 tonnes. It is the weight of the vehicle that defines the licence required.  (If people have not had to surrender their licence because of the insulin treated diabetes they would have been able to carry on driving vehicles between 3.5 and 7.5 tonnes on their normal car licence).  The Group 2 licence is subject to an annual independent medical assessment.

6. What are the new rules relating to hypos?
People will not be issued licences – or will have them revoked (taken away) if they have recurrent severe hypoglycaemia
This is defined as more than one episode of hypoglycaemia (two or more) during a period of 12 months that required assistance from another person
Q. What is hypoglycaemia?
A. Hypoglycaemia, or hypo, is the medical term for low blood glucose levels – that is a blood glucose level of less than 4 mmol/l. This is too low to provide enough energy for your body’s activities.
Q. What if the severe hypos were caused by an illness or other problem that is now resolved?
People are expected to tell the DVLA about any recurrent severe hypoglycaemia even if there was a good explanation and there is no on-going issue (for instance if someone was adjusting to a new treatment pattern or a pump). When people apply for a renewal of their licence they will be asked about severe recurrent hypoglycaemia on the form (DIAB1).
Q. What about hypos that happen when someone is asleep?
If a severe hypo occurs during sleep and the person requires assistance – that is they actually need the help because they are unable to help themselves – this should be reported if there is more than one such event in a 12 month period.
Q. What if someone helped me but I did not really need it?
A. It is important that people recognise that most hypoglycaemia is not severe and can be easily treated by the person themselves. It is only if the assistance is actually needed, because the person is unable to manage themselves, that would count as a reportable episode. If assistance is offered and received, but not needed, this would not be reportable.

7. Awareness of hypoglycemia
People will also not be issued licences – or will have them revoked (taken away) if they have lack of awareness of hypoglycaemia
This is defined by the DVLA (for car drivers) as total lack of awareness – meaning you do not get any warning symptoms of the onset of hypoglycaemia
Q. What are the warning signs of hypoglycaemia?
A. These vary from person to person, but the symptoms of hypoglycaemia may include feeling hungry, sweating, shakiness, palpitations, feeling faint, dizziness, nausea or a headache. Sometimes you may notice blurred vision or tingling of the lips.
Q. What if I am worried I may be losing awareness of hypoglycaemia?
A. You should talk to your doctor or specialist nurse – it is quite possible to regain awareness through a managed programme of treatment – if you have lost all awareness you should stop driving and tell the DVLA (and then seek help from a healthcare professional).

8. Testing blood glucose for driving
The legislation passed in November 2011 also states that drivers with diabetes treated with insulin have to undertake “appropriate blood glucose monitoring”
People are now asked to sign a declaration on the application form to apply for, or renew, a licence to say that they understand the need to test their blood glucose at times relevant to driving.
Q. When should you test your blood glucose when driving?
The DVLA (and Diabetes UK) guidance is that you should test at times relevant to driving (not more than 2 hours before the start of the first journey and every 2 hours while driving - they don’t expect you test each time you get in the car if you are in and out).  Note – this is only for people treated with insulin. 
Q. If a person is on sulphonylureas (which can cause hypos) they are not required to test by law if they are driving an ordinary car (they would be if driving a passenger vehicle or HGV)
Q. Does someone have to sign this declaration?
Yes, or the DVLA will not issue a licence
Q. What are the legal implications of this declaration?
This is difficult to know – the DVLA says the declaration is there to serve as a reminder to people to test. (A previous version of the declaration asked people to sign to say they would test, which many people were very concerned about. Diabetes UK has worked with the DVLA to change this to the current wording on the new form which has been in use since May 2012).
Q. Does this mean that people have to prescribed enough test strips if they drive regularly?
A. A person’s self monitoring of blood glucose and their requirement for test strips should be agreed on an individual basis between them and their doctor. If someone needs to test for driving this should definitely be taken into account. Best practice guidelines already make this clear and many PCTs / clusters are amending their guidelines on self monitoring and access to test strips to take these new DVLA rules into account. Diabetes UK is also producing revised position statements on self monitoring of blood glucose.

9. Getting a revoked licence back / querying a decision to revoke
If someone feels that the decision is wrong they can go back to DVLA medical division – the person who sent the letter - and ask them to reconsider.
If relevant, medical evidence - or a letter from the doctor - would be useful.
Q. Is there a legal appeal?
A. Yes, people can appeal through the courts, but this is costly and time-consuming

10. Getting a revoked licence back
As soon as you have not had more than one episode of severe hypoglycaemia – that is 12 months after the last but one episode – you can reapply for your licence – you may only get a one year licence at this point
If someone loses their licence due total lack of awareness of hypoglycaemia they can reapply as soon as they have regained their awareness (if they are able to get back some awareness)

11. WHAT is diabetes uk doing about this?

12. Diabetes UK’s position
Diabetes UK has always campaigned to ensure people with diabetes are assessed fairly for their fitness to drive
We believe everyone with diabetes should be able to drive if they can demonstrate their medical fitness – we oppose blanket bans
We maintain that people with diabetes pose no greater risk than other drivers if they take all necessary precautions and provided they do not have complications (such as lack of awareness of hypoglycaemia)
Q. What is the evidence about diabetes and driving
A. A review of the evidence for the European Working Group on Diabetes and Driving (1) found that any differences in risk were small compared with the differences in risk seen in the general population. A study in the UK (2) concluded that people using insulin did not pose a greater risk than the general driving population. There is some evidence, however, that recent severe hypoglycaemia or hypoglycaemic unawareness may be a predictor for future accidents (3) – see position statement for references
Q. What are the precautions that people should take?
Avoid long or stressful journeys if tired. If treated with insulin, test your blood glucose level before driving and regularly during a long drive – preferably every two hours. Do not drive if:
they have just started to take insulin and their diabetes is not yet properly controlled
• they have difficulty in recognising the early symptoms of hypoglycaemia
• their blood glucose level is less than 4.0 mmol/l or they feel hypoglycaemic
• they have any problems with their eyesight that cannot be corrected by glasses / contact lenses.

13. Highlighting concerns
Diabetes UK had concerns about the way that the new standards were being implemented and we have worked with the DVLA to address these
Diabetes UK is also concerned about the impact that the changes are having on the relationship between people with diabetes and their health care professionals and that people will not report severe hypoglycaemic events or reduced awareness of hypoglycaemia (both of which can often be addressed with medical advice)

14. Working with the DVLA
Diabetes UK has worked with the DVLA to ensure that the standards are communicated clearly so that that people are not needlessly having licences revoked or experiencing delays in getting their licences re-issued. 
We have worked with the DVLA to draft a new form and guidance for people completing it
We have also worked with the DVLA to improve the letters that they send to people with diabetes
We have involved people with diabetes in this work
Q. Why did we need guidance?
A. There was no guidance for completing the form previously. People sought clarification from Diabetes UK Careline or tried to get through to DVLA which often led to delays
Q. When will the new form and guidance be in use?
These went live in May and June 2012 (and have been slightly updated due to feedback from people with diabetes since. The guidance and the new form are available here
Who was involved?
A. Diabetes Voices – in meetings and by . Involvement Network. Also included views from Facebook and Careline feedback.

15. What has changed on the form?
Many changes were agreed before the form was finalised in May For example:
The form now clearly states what is meant by severe hypoglycaemia (and the guidance emphasises this)
The declaration that people are asked to sign has been modified
The form now stresses that the definition for severe hypoglycaemia “requiring assistance from another person” means only where you really needed help and not where help was given, but you could have treated yourself.
The declaration introduced after Nov 2011 originally asked people to sign to say that they agreed “to test my blood glucose before driving and at times relevant to driving”. Many people were very concerned about this and were nervous about signing it and the legal implications. It has now been changed to “I understand the need to test . .” As we pointed out that this is more in line with the legislation and the intention of the declaration.

16. What has changed – cont. . .
The reference to other named clinics attending has been removed – people with diabetes objected to this as they felt it was discriminatory and insensitive
The contact (and other) details requested on the form better reflect what is actually required to process the application and the reality of who can provide information about someone’s diabetes management (both Type 1 and 2)
Q. Why did people object to the “other clinics” section?
A. A frequently heard complaint from people with diabetes is that they feel discriminated against unfairly compared to, for example, people who drink and drive or those who have previously lost their licence for drink driving. They are then presented with a form to complete every three years which asks them – on the first page - to state whether they have attended various clinics including alcohol, drugs, psychiatry. As they pointed out – they would not be asked about these issues (which bear no relation to the fact they have diabetes) if they did not have diabetes and therefore have to reapply for their licence every three years. The form now just asks for details of “any other clinics attending”.

17. Working with the DVLA
We are continuing to work with the DVLA on proposals to make the application process fairer and less time consuming for people with diabetes
For instance we have recently met to discuss the work they are doing to put the application process on line which is leading to a streamlining of the questions and the information required and should make the process more efficient
Q. How many people are losing their licences because of the changes?
Recent data from the DVLA shows that last year (2012) 1217 people in the UK lost their licence due to the new standards on hypoglycaemia, this compares with 526 the year before. The rise now appears to be falling. In 2013 so far every month there have been fewer licences revoked than in the same month last year (e.g. In August 2012 there were 98 licences revoked for severe hypoglycaemia and in August 2013 there were 66).

18. Working with the DVLA: visual tests
Some people will be asked to have visual field test when they reapply for their licence
DVLA now have a contract with Specsavers to deliver these – since mid 2014
We have been working with DVLA to sort out some problems with this contract and to clarify what people with diabetes can expect from the service
Q. Why would I be asked to undergo a visual field test?
A. If you have had treatment for diabetic retinopathy in both eyes
Q. What can you do if you are not happy with the visual field test conducted by Specsavers?
If you feel that their first test wasn’t conducted properly then you should speak to the tester and ask for another attempt. If, for example, Specsavers then return 2-3 accurate charts the DVLA would usually accept the best result. You should not have to pay for this.
Q. How far will I have to travel for my test at Specsavers?
A. Specsavers must provide an Optometrist within a 25 mile radius of each customer for Group 1, and a 50 mile radius for Group 2. Early analysis indicates that, on average, people now have to travel nearly 7 miles to stores.

19. Work in Europe
Diabetes UK are working in the UK and Europe to monitor the impact of the changes on drivers with diabetes
We have worked with the DVLA Medical Panel and Dept for Transport to successfully challenge the rules on night-time hypos – these should change next year (2017)
Q. Could the Directive be reviewed and the law be changed again?
It is possible, the EU have indicated that they may review the Directive
Q. How are we challenging night-time hypos?
A . This has now been reviewed in the EU - whether severe night-time hypoglycaemia should be excluded from those incidents that are reported to DVLA (as in the past) and they have recently published an amendment on the Commission website. We are now working with the DVLA to ensure that this is implemented in the UK as quickly as possible.

20. Further information
Diabetes UK website:
If you want get involved in campaigning about driving issues please contact Diabetes Voices

21. Call Careline: 0345 123 2399 Monday–Friday 9am–7pm
Help and advice
Call Careline:
Monday–Friday 9am–7pm

22. ANY QUESTIONS?
(Please can you feed back to if there are questions you found difficult to answer or which come up frequently and are not answered in the presentation. Thank you.