DVLA Guidelines Aims Objectives n n n General

DVLA Guidelines

Aims/Objectives n n n General Principles Legal Basis GMC Advice Seat Belts Conditions to consider Cases

General Principles www. dvla. gov. uk n At a Glance Guide to Current Medical Fitness to Drive n Panel meets 2 times/year n Each case considered individually n n ‘Those who suffer from a medical condition likely to cause a sudden disabling event at the wheel, or who are unable to safely control the vehicle for any other reason should not drive. ’

Legal Basis Road Traffic Act 1988 n Motor Vehicles Regulations 1999 n 2 nd EC Directive on Driving Licenses n n Section 92 Road Traffic Act 1988 ¨ Refers to prescribed, disability. relevent or prospective

GMC Advice n n n DVLA legally responsible for deciding if pt eligible to drive but doctors have responsibility to inform patient when to contact DVLA; or if patient unable e. g. dementia, to inform DVLA themselves. If patients want to continue to drive despite advice you should make every effort possible to encourage them to stop, including involving family but only with patient’s permission. If necessary you can offer 2 nd medical opinion. If you have evidence patient is still driving when not fit to do so you should inform DVLA immediately and let patient know you are doing this and confirm it in writing to patient.

Seat Belts n n n n Road Traffic Act 1988 – obliged all drivers/passengers front and back to wear seat belt at all times. Exemption if holding valid medical certificate. No conditions justify automatic exemption. Judge each case on own merit. Weigh up risk and benefit. Ask patient to demonstrate problem in car if possible. Consider belt adapters e. g. Drop links, Pulla Belts, Klunk Klips.

License Groups Group 1 – motor car and motor cycles n Group 2 – large lorries (category C) and buses (category D) n n Medical standards required for Group 2 higher

Post Surgery n n n No need to notify DVLA unless unable to drive for >3 months after surgery. No set time limit from DVLA Need to consider: ¨ ¨ ¨ n Type of surgery Anaesthesia Distraction due to pain Physical limitations Sedation from analgesia Co-morbidity Patient’s responsibility they are in control of vehicle.

? Faint –case 1 21 year old woman who is very slim presents following loss of consciousness for about 10 seconds during her night job shelf stacking in a supermarket. You think she has had a simple faint. What features do you consider? What do you advise on driving?

Case 1 n 1)Simple faint – 3 ps prodrome, postural, provoked – no affect on driving

Provoked seizure- case 2 1) 38 year old mother had a fit caused by eclampsia in pregnancy and she had an emergency C-section. She has just been discharged from hospital 3 weeks after giving birth but they forgot to advise her on driving. What do you say?

Case 2 n 2) – DVLA will deal with on individual basis as provoked seizure – contact DVLA. Also consider post surgery. Current advice post C-section

Case 3 1) Man had 2 syncopal episodes over last 3 months lasting 2 -3 minutes – sudden onset – no warning. Exact cause not yet known but ECG shows AF and awaiting Echo and 24 hour tape as an outpatient. He happens to drop into the conversation that he has driven to the surgery for his appointment today for a completely different problem.

Case 3 n 3)Consider it as syncope with high risk recurrence due to repeated event and ECG abnormality. Therefore no driving for 6/12. Man needs to stop driving and contact DVLA.

Case 4 4) 40 year old woman diagnosis of epilepsy stable on medication for several years and no fits in last 3 years. On Lamotrigine and decision made in OP clinic to halve the dose with view to stopping. She has forgotten what they advised her about driving in clinic.

Case 4 n 4)No driving during period of withdrawal and for 6 months after stopping or reducing dose.

Neurological Conditions n First Fit/Seizure n n n Group 1 CANNOT drive for 1 year after event and need medical review before returning to drive. Group 2 CANNOT drive for 10 years after event and must be seizure free without anticonvulsant for that time. Diagnosis of Epilepsy. n n Attack whilst awake or asleep no driving for 1 year (Gp 1) or 10 years (Gp 2). But if in Gp 1 and have attack asleep – if have had a previous attack while asleep more than 3 years previously (and no attacks awake since then) they may be able to continue to drive despite further attacks while asleep.

Neurological Conditions n Withdrawal of anti-convulsant ¨ Studies show 40% increased risk seizure after withdrawal of medication ¨ DVLA say refrain from driving during period of withdrawal and for 6 months after withdrawal. n Provoked seizure ¨ E. g. eclampsia, at time of head injury, 1 week after head injury but with normal CT head and no amnesia >30 mins, within 24 hours of stroke, within 24 hours of intracranial surgery – DVLA will deal with on individual basis

Neurological Conditions n Stroke/TIA Gp 1 – no driving 1 month and return subject to recovery. Consider any residual problems likely to affect driving. ¨ Multiple TIAs over short time no driving 3 months. ¨ Gp 2 – no driving 1 year then subject to medical report. ¨ n Loss of/altered conscious level Unexplained syncope with normal ECG and heart structure – Gp 1 one month and Gp 2 three months. ¨ Syncope with high risk recurrence e. g. ECG abnormality, structural heart defect, >1 event in 6 months, resulting in physical injury – Gp 1 6 months and Gp 2 one year. (But if abnormality identified and treated then Gp 1 one month and Gp 2 three months) ¨ n Also consider…. head injury, haemorrhage (SAH, extradural) tumours.

Case 5 5) You are GP – patient comes to you to say their neighbour (also registered at your practice) is driving despite having had a stroke leading to visual problems. She is concerned about her grandchildren playing by the house as the man in question keeps driving into the kerb. What do you do?

Case 5 considerations n n n 5)Look at details of man ? Allowed to drive or not. ? Visual field defect – has this been picked up post stroke? Has this been tested for? Has driving been d/w the patient? Call appt for patient to discuss driving or further testing. If transpires patient not meant to be driving – explain this again. If refuses to follow this then involve family with patients permission to perusade to stop driving. If all this fails – contact DVLA yourself and inform pt you are doing so.

Visual Problems n n Field Defect – must satisfy specific criteria. Needs field of at least 120 degrees on horizontal measure and no defect which encroaches within 20 degrees above or below horizontal meridian to drive. So homonymous or bitemporal defects NOT eligible to drive. (Binocular Esterman field test needed to satisfy DVLA. ) Acuity requirements Must be able to read in good light with use of visual aid if required. ¨ Must be able to read registration plate at distance of 20 metres, with aid if required. ¨ For Gp 2 license – must have acuity of 6/9 or better in good eye and no worse than 6/12 in worst eye with correction lenses. Uncorrected vision must be at least 3/60. ¨

Visual Problems n Monocular vision ¨ Gp 1 – can drive if clinically adapted to disability and remaining eye good. ¨ Gp 2 – cannot drive. n Colour blindness ¨ No driving limitations n Diplopia ¨ Gp 1 – must cease driving on diagnosis but can return if supported by consultant saying there is functional adaption to diagnosis/controlled using glasses or a patch. ¨ Gp 2 – cannot drive.

Chest Pain Case 5 Your 49 year old patient was admitted to the hospital with chest pain, he has a confirmed MI. No ongoing chest pain n What should you tell him about driving? n He is scheduled for a CABG n What do you need to tell him about driving after this. n

Case 5 After Mi no driving for 4 weeks group 1, 6 weeks, group 2. n After CABG no driving for 4 weeks group 2, 3 months. n

Cardiovascular Conditions n Angina Must cease driving when angina at rest or with emotion or while driving and can recommence when sx resolved. ¨ Gp 2 – need 6/52 free of angina and meet exercise and functional tests. ¨ n ACS/MI No driving 4/52 after MI or 1/52 after NSTEMI treated via angiplasty. ¨ Gp 2 – 6/52 after and must meet testing for relicensing. ¨ n PCI ¨ n 1/52 Gp 1 and 6/52 Gp 2 CABG ¨ ¨ 4/52 Gp 1 and 3/12 Gp 2 For Gp 2 must have ejection fraction >0. 4 and meet functional tests.

Cardiovascular Conditions n Arrhythmia ¨ n Pacemaker (and box change) ¨ n n n After insertion no driving for 1/52 or 6/52 if gp 2. AAA ¨ ¨ n If has caused or likely to cause incapacity should not drive until stable for 4/52 or if gp 2 3/12. Need to notify DVLA if > 6 cm and no driving if >6. 5 cm. For Gp 2 no driving if >5. 5 cm ICD permanently bars Gp 2 driving Gp 2 also requires exercise testing and other functional requirements prior to relicensing Left ventricular ejection fraction <0. 4 bar to all Gp 2 driving.

Psychiatric Conditions Severe Anxiety/Depression (impaired memory and concn and suicide risk) n Gp 1 – should cease driving until period of stability. Particular risk of suicide at wheel. ¨ Gp 2 – must be well and stable for 6 months and not on any medication which affects ability to drive. ¨ n Acute psychotic disorders Gp 1 – should be well for 3 months and compliant with and free from adverse effects of medication which may affect driving. ¨ Gp 2 – driving must cease pending medical enquiry. Normally need to be stable for 3 years and symptoms well controlled on medication and have good insight into their condition. Requires consultant report for DVLA. ¨

Psychiatric Conditions Hypomania/mania ¨ ¨ Gp 1 – well for 3 months, compliant with meds and good insight. Gp 2 – as for acute psychotic disorder. Chronic Schizophrenia Gp 1 – must be stable for 3 months, compliant with medication and free of adverse effects. ¨ Lack of insight does not rule out driving but beware high risk of delusions relating to other road users. ¨ Gp 2 – dependent on consultant report ¨ ¨ Dementia Gp 1 – no set rules. Subject to driving review at local centre and license issued on yearly basis. ¨ Gp 2 – driving disallowed. ¨

Binge drinking Case 6 A 42 year old buiding surveyor consults and asks you to help him cut down his frequent binge drinking. How would you approach the consultation? n What are some of the key issues to address? n

Risk? Case 6 n n n Risk on site Driving HGVs? Is he dependant, drunk in daytime, misusing? Misuse – state where alcohol causes disturbances in behaviour or results physical health damage and/or leads to consequences which are likely to cause patient and/or family harm Dependency – persistent use of alcohol with the features of misuse but also possibly features of withdrawal when not drinking and strong craving. Difficulty controlling drinking despite physical health consequences and evidence of increased tolerance.

Alcohol Use n Alcohol Misuse – defined by medical enquiry and/or abnormal blood results. Gp 1 – license revoked until had 6/12 period abstinence or controlled drinking ¨ Gp 2 – 1 year abstinence or period of controlled drinking ¨ n Alcohol Dependency – defined by medical enquiry and/or abnormal blood results. ¨ ¨ n Gp 1 – license revoked until 1 year of abstinence and normal blds Gp 2 – need 3 years abstinence Alcohol Related Seizure(s) Gp 1 – after one alcohol related seizure need 1 year after event before can drive and 1 yr abstinence and normal bloods. ¨ Gp 2 – need 5 years without seizure and need to have been off antiepileptic meds for 5 years. (+gp 1 rules) ¨

Drug Use n Cannabis/Amphetamines/Ecstacy (psychoactive drugs) Gp 1 – 6/12 free of use for license ¨ Gp 2 – 1 year off drugs ¨ n Heroin/Morphine/ Methadone/Cocaine Gp 1 – 1 year free of use required to drive. Those stable on methadone and/or buprenorphine may be considered separately. ¨ Gp 2 – 3 years off drugs ¨ n Benzodiazepines Gp 1 - need 1 year free of use. ¨ Gp 2 – 3 years off drugs. (All groups may be subject to DVLA urine tests and medical assessment from consultant prior to relicensing. ) ¨

Metabolic considerations Case 7 4) 25 year old school bus driver presents with urinary frequency and excessive thirst and has a BM of 25 on testing in your surgery. What do you do and what do you advise on driving?

Case 7 n 6)Type 1 DM – Gp 2 as bus driver. – would not be able to continue work. Inform pt need to tell DVLA. In some certain circumstances may be able to reapply for small lorries. In Gp 1 can carry on driving but be aware of hypos and follow advice leaflet

Diabetes Mellitus n n Patient information leaflets available to print from DVLA website. IDDM Gp 1 – patient must inform DVLA who will send information on driving precautions. OK to carry on driving so long as have no diabetic complications which may affect driving e. g. visual problems and so long as aware of hypoglycaemia and don’t suffer > 1 episode of disabling hypoglycaemia a year. ¨ Gp 2 – cannot have license. ¨ n Tablet/Diet controlled ¨ Gp 1 and 2 - need not inform DVLA unless have diabetic complications/ impaired awareness hypos/ frequent hypos.

Diabetes contd n Advice from DVLA on precautions – check BM before driving and every 2 hours on long journey. Keep sugar sweets in car. If get hypo symptoms pull over and get out drivers seat. If BM drops do not resume driving until 45 mins after BM has returned to normal (5 or more).

Miscellaneous n n Obstructive Sleep Apnoea – driving must cease until satisfactory control of symptoms obtained. For Gp 2 needs consultant opinion and annual review. Age – no upper age limit. DVLA requires confirmation at 70 yrs of no significant medical condition and will reissue 3 yr license. Disability – both limb/spinal disabilities and chronic neurological conditions (which may be static, relapsing or progressive) do not make driving impossible; but vehicle adaptions may be necessary and DVLA should be informed and adapt the license. Deafness – does not affect license for Gp 1. For Gp 2 must be able to communicate effectively in emergency situation.