The DVLA has recently updated its guidance for healthcare professionals on assessing patients' fitness to drive and how to report any concerns.
The MDU's Dr Catherine Wills spoke to Dr Wyn Parry, senior medical adviser at the DVLA, about what to do in situations where your responsibility to patient safety may be unclear.
My patient suffered unexplained syncope a week ago. I referred him for tests and advised him to stop driving and inform the DVLA. He was reluctant but, after discussion, I thought he had agreed.
Today he came back for the test results. He told me that he had chosen to wait and see if he had another episode of syncope before deciding whether to stop driving. So far he has not, and he has not informed the DVLA either. I couldn't persuade him to stop driving and he didn't accept my offer of a second opinion or allow me to speak with his wife, who I thought might help persuade him.
I told him that his insurance cover may be affected, and that I might need to tell the DVLA myself. He still refused, saying that if I did, he would lose his job and I would be to blame.
Was I right to advise him to stop driving and what should I do now?
Doctors have a crucial role in road safety and it is key to be aware of the UK standards on fitness to drive. You were entirely right to advise the patient to stop driving in this case, and unexplained syncope is one of the medical conditions that must be reported to the DVLA.
Doctors are responsible for advising patients about the impact of their condition on safe driving ability and are responsible for advising patients on their legal requirement to notify the DVLA of a relevant condition.
A list of relevant conditions can be found in the recently updated document, 'Assessing fitness to drive - a guide for medical professionals' (DVLA, June 2017).
Now you need to decide whether to inform the DVLA without patient consent. The GMC provides guidance in 'Confidentiality: patients' fitness to drive and reporting concerns to the DVLA or DVA' (2017). In the case of this patient a further syncopal episode while driving could well put others at a risk of death or serious harm. If he is continuing to drive against your advice, you should contact the DVLA promptly and disclose any relevant medical information, in confidence, to the medical adviser.
You should tell your patient in writing when you have contacted the DVLA and make a note, including an explanation of your reasons, in their records.
How should I contact DVLA?
You can call the DVLA to discuss the patient in confidence with a DVLA doctor (medical adviser) but DVLA require written confirmation, which is an acceptable alternative to the standard DVLA notification form.
As with any disclosure without consent, you should keep your disclosure to the minimum necessary for purpose. Under no circumstances does the DVLA reveal the source of any notification to the license holder. The medadviser email address (firstname.lastname@example.org) is secure but the DVLA will only accept emails from secure (nhsmail, nhs.uk) email addresses.
As with any disclosure without consent, you should keep your disclosure to the minimum necessary for purpose.
What is the timescale? Can the DVLA stop the patient driving immediately? I am worried that he poses a danger to the public.
It can take weeks or months for the DVLA to obtain all the necessary information to make a licencing decision. A patient who self-reports a medical condition to the DVLA but whose doctor has not advised them to stop driving is usually entitled to drive while waiting for a decision (so-called 'Section 88 cover', referring to Section 88 of the Road Traffic Act 1988).
But a patient should not drive while waiting for a decision if their doctor has advised them not to. Patients must be reminded that if they choose to ignore medical advice to stop driving, their insurance cover may be affected. Doctors should formally and clearly document the advice given.
If a doctor calls a DVLA medical adviser about a patient and the referring doctor has sufficient concerns about road safety consequent on any medical condition in that patient, then the DVLA medical adviser can revoke a licence effectively instantly (subject to written/ email confirmation as above).
If the patient continues to drive after I make the referral, putting themselves and the public at risk, what should I do?
The patient's licence might have been revoked immediately (as above). If however the doctor becomes aware that their patient continues to drive, your options are to contact DVLA again, at which point DVLA are able to involve the police, or to directly approach the police yourself.
So far as the driver licensing database is concerned (to which the police have access) only a licence revocation/restriction will be known; a driver under any DVLA medical enquiries will not have any licence database notes to this effect.
Will the DVLA keep me informed of their decision?
No. When the patient may lack the insight and/or memory to abide by the revocation of their licence the DVLA usually sends a decision letter to the GP. But in other cases where a notification has been sent without consent from the patient, the DVLA will acknowledge receipt but not send a copy of the decision.
My patient has type 2 diabetes and needs to start tablets. He is a lorry driver so I know he needs to inform the DVLA. How likely is it that his licence will be revoked?
It is impossible to give an accurate estimate without more clinical information. Overall, for all licence holders, between 5% and 7% of notifications of a medical condition lead to revocation of the licence.
The DVLA will need to know details about complications and, if the tablet carries a hypoglycaemia risk, details about the patient's understanding, awareness and self-monitoring etc.
I have been appointed by the DVLA to assess a patient. I am not the patient's usual GP. The patient has substance misuse problems and suffers arrhythmias. She has told me she drinks about 60 units of alcohol per week and I think this may be underlying her arrhythmias, but she has never before told a doctor about this.
I have asked her to tell her GP but I am not sure she will. Can I expect the DVLA to pass on a copy of the assessment questionnaire to the patient's GP?
You are one of a number of doctors who undertake independent medical assessments (usually for drug and/or alcohol misuse/dependence); the information you provide will be triangulated with all the other information held by DVLA on the patient, to help DVLA make a licencing decision.
The questionnaire you have completed to record your assessment will not be sent to the patient's GP. But if information emerges about other medical conditions then the DVLA will pursue these new points with the patient's GP and/or other relevant healthcare professionals.
We would advise you to annotate the assessment questionnaire to make clear what finding you would like DVLA to pursue. We would also recommend that you include a note of having advised the patient to tell her GP.
Dr Catherine Wills
MA(Oxon) MB BS LLM MRCP MFFLM
Catherine joined the MDU in 2004 and is deputy head of the advisory department. Previously, Catherine was a hospital consultant in general medicine, diabetes and endocrinology.
See more by Dr Catherine Wills