To drive or not to drive: new guidelines in action

Drivers have nothing to fear from the new medical fitness to drive guidelines, Sláinte agus Tiomáint, the overall aim of which is to make driving safer for all road users. This message was stressed by Noel Brett, CEO of the Road Safety Authority (RSA), at the official launch of the guidelines in Dublin in February. Indeed, this message was repeated several times throughout the launch. 

The new guidelines were sent to all doctors in January, prior to the official launch. They provide better guidelines for medical professionals while also giving patients the best current advice on driving. 

It is important that doctors become familiar with the guidelines. I outlined the background to the new guidelines in a previous article (Forum, February 2013). Feedback at ICGP level indicates that some doctors feel the guidelines are very elaborate and laborious. I should point out that while they may be longer than previous guidelines, they are comprehensive and are a good source of reference. 

I would advise GP members to focus on chapter 1, which is a general chapter and covers a lot of relevant material. The chapter clearly outlines the roles and responsibilities of the various stakeholders involved – the drivers, the health professionals and the driving licensing authority. The whole area of confidentiality is also addressed in this chapter, as are the areas of second opinions and the role of consultants. There is also useful advice concerning temporary conditions and conditions which are initially undifferentiated. 

The examining doctor has some discretion in these situations and may well decide to advise the patient to limit driving or advise a shorter period of renewal than the standard 10 years licence renewal. This area is covered well. The guidelines also advise that doctors should generally certify fitness to drive in patients who are known to them, to avoid a situation where patients might ‘shop around’ in order to get a favourable medical opinion. The guidelines are available online at www.rsa.ie (licensed driver > medical issues) and in hard copy on request from the RSA. Doctors should have easy access to the guidelines and use them as a source of reference in more complex cases. 

Driving medical

I would like to emphasise the importance of the driving medical assessment in this process. Many patients have complicated medical histories and can be on a lot of medication. Because of this they need a comprehensive medical assessment. I have often been faced with a situation where a patient has a ‘shopping list’ of complaints and requests for medication, and then eventually presents me with the medical fitness to drive form. This is inappropriate. We GPs need to put aside dedicated time for the fitness to drive medical. We need to inform our staff to get this message across to patients. Where a patient presents a form at the end of a consultation, it would be wiser to arrange for them to return for a full medical examination. This should take about 15 minutes, or a little longer in exceptional cases. 

The forms 

The forms for the driving licence medical report have been redesigned. 

The main form is the D501, which is filled out partly by the patient and then completed by the examining doctor. This form is straightforward and we should make ourselves familiar with it. Driving licences for group 1 drivers can be issued for one year, three years or 10 years. There is a new line on form D501 requesting the patient to declare the date of their last epileptic seizure. This obviously only refers to patients with known epilepsy and it is felt that its inclusion is a good idea and fits in with European guidelines. 

There is also form D502, which is the driving licence eyesight report form. GPs usually fill this out for patients applying for their first provisional licence. The eyesight form is also used by optometrists, who carry out a lot of reports for provisional licences. 

The new patient advisory form is breaking new territory. This should be filled out by the examining doctor when a new medical condition emerges. This form can be used to bring patients’ attention to the fact that they have a medical condition that they themselves need to report to their licensing authority. The form also suggests that the patient should consider informing their insurers as well. From a medicolegal point of view, this form is important. Having completed the form, the doctor will give a copy of it to the patient and will retain a copy in the patient’s file. The media has raised concerns that doctors may use this form to report patients to the licensing authority. This is not the intention at all; the form is handed to the patient so they themselves can pass it on to the licensing authority where appropriate or where a relevant medical condition exists. 

Role of optometrists

There was a multidisciplinary team approach to the development of the new guidelines. Optometrists and ophthalmologists contributed greatly to this team. Optometrists are very much our colleagues in the community and have had an increasing role in recent years. Optometrists have an important role to play in the whole area of visual acuity and fitness to drive. It can be obvious when a patient does not have a visual problem. However, in cases where there is a possibility of visual problems, it might be wise to refer some patients for further assessment by an optometrist. Optometrists have a greater range of equipment and, in particular, are in a good position to measure visual fields. Patients who you might consider referring to an optometrist are those:

• With a history of TIA/stroke
• With glaucoma or a history of glaucoma in a first degree relative (aged over 40)
• With a history of ocular vascular incident
• With a history of retinal detachment
• With a history of severe head trauma, brain tumour, pituitary tumour
• Aged over 70 years of age.

For patients who are borderline following a GP examination, the optometrist has an important role in helping them to meet the requirements for driving. By going to the optometrist, patients may be able to increase their visual acuity by wearing glasses or contact lenses. 

Role of occupational therapist and driving assessments

Occupational therapists have become increasingly involved in the assessment and rehabilitation of drivers. This happens in the case of serious accidents, strokes and progressive neurological conditions in particular. However, many other conditions can benefit from occupational therapy and driving assessments. The level of service varies around the country but many OT departments in larger centres offer a service, particularly to their own patients. 

In addition, a number of companies provide driving helpful assessments both on-road and off-road. In many parts of the country this is available on a private basis and it is useful to know who will deliver the service in your area. The Irish Wheelchair Association also provides a service for driving assessment. 

As well as the conditions mentioned above, driving assessments may also be helpful in the case of early dementia when the dementia is mild to moderate. An on-road and off-road assessment in these situations can be helpful in deciding if the patient is fit to drive and also in showing the patient if they have some difficulty in the driving area. 

Alcohol and drug misuse and dependence 

The guidelines are clear on the areas of alcohol and drug misuse and also on dependency on these substances. A driver who is confirmed as having persistent alcohol or drug misuse must not drive for six months. The guidelines are clear on this. However, I can understand that doctors may have difficulty in implementing this area and in trying to convince patients that they must comply with these guidelines. This is an area that will be looked at again in the future by the National Programme Office for Traffic Medicine to ensure that the guidelines reflect clinical practice to the greatest extent possible. 

Significant medical disorders

Chapters 2 to 9 of the guidelines deal with the various medical and surgical disorders in detail. A lot of reference material is provided, which the doctor may need to refer to in more difficult situations. In particular, a person who has had an epileptic seizure should not drive for one year. The guidelines also spell out that drivers with insulin-dependent diabetes can only be given a one-year or three-year licence. 

With regard to psychiatric illness, it is emphasised that the most serious psychiatric illnesses may result in a patient not driving for a certain amount of time. Again, this is at the discretion of the examining doctor. In general, this would not apply to straightforward anxiety or depression but would refer to more serious psychotic conditions and perhaps severe depression and severe bipolar disorder. Doctors should use their discretion and their knowledge of the patient in these situations; advice from a psychiatrist may be helpful in some cases. Dementia is another significant area. It may be reasonable for the patient to drive with mild dementia, having been fully assessed. On-road and off-road assessments would be useful here and the licence could be issued for a reduced period such as one year. Liaison with relatives and carers may also be useful.

Fees and expenses

The issue of fees and payment for medical examinations in relation to fitness to drive was not a matter for this group. Traditionally, patients have paid for these examinations and the Irish Medical Organisation has always advised doctors that these examinations are not covered under the GMS contract for GPs. Most GPs charge a full surgery fee for these examinations while some may offer a reduced fee. This is the current situation and is likely to continue while we have our existing GMS contract. 

Assess your knowledge

The National Programme Office for Traffic Medicine (NPOTM), with the assistance of its expert working group, has developed an online course to allow doctors and other health professionals to assess their knowledge of the guidelines. To register for this opportunity to collect three CPD credits, visit the NPOTM online registration at www.rcpi.ie (courses and events calendar > medical fitness to drive guidelines).

Feedback on the guidelines

In summary, I feel that the new guidelines are a helpful and a good source of reference. The forms are straightforward to use and will be modified in the future depending on feedback to the RSA and the NPOTM. Work is in progress on new guidelines for group 2 drivers, which are expected to be launched early in 2014, along with revised group 1 guidelines. The guidelines will be revised on an annual basis as new evidence emerges and also in terms of feedback on their use. In the meantime the RSA, the NPOTM and the ICGP would value any feedback from GPs on the guidelines.