The announcement by the Driver and Vehicle Licensing Agency (DVLA) in the UK that it would be making changes to the regulations on people with diabetes driving heavy goods vehicles effective from October 2011 prompted a survey in our practice. We surveyed the number of patients in the practice who had a documented discussion on the implications of their medical condition on their fitness to drive, in particular patients with diabetes and epilepsy. 

European regulations

The European Council Directive 91/439/EEC on driving licences,¹ the so-called ‘Second Directive’, came into force on July 1, 1996. This contains details on minimum health criteria for fitness to drive. In July 2006 the Second European Working Group on Diabetes and Driving, working as advisor to the Driving Licence Committee of the EU, found that healthcare professionals are often unaware of the criteria used to evaluate the driving fitness of people with certain medical conditions.² It also noted a lack of clarity among patients and physicians on where the onus of responsibility lies in relation to notification of fitness to drive to licensing authorities and insurance bodies.²

The EU Diabetes Working Group² concluded that more emphasis should be placed on the responsibilities of licensing authorities, healthcare professionals and drivers themselves in relation to medical reporting and licensing. It suggested that licensing authorities should provide more information to physicians and drivers, and recommends that healthcare professionals should advise patients on the possible implications of their illness and its pharmacological treatment on their ability to drive safely. The working group also proposes that drivers should “honestly assess their driving capabilities with regard to their medical condition and treatments, and act appropriately”.² These recommendations should be applicable to all groups of patients regardless of their medical condition.

The legal obligations for drivers with epilepsy are made much clearer by the EU Epilepsy Working Group than those for drivers with diabetes. The Epilepsy Working Group⁶ places the onus of responsibility of reporting on drivers themselves. It does not place the healthcare professional under obligation to report the patient to the authorities. It recognises that forcing the physician to report the patient works adversely to road safety. It leads to an interference in the patient-doctor relationship, causing under-reporting of seizures and ultimately interferes with treatment. The group recommends legal protection for doctors in relation to reporting and non-reporting of patients. If these recommendations are initiated into EU and national law as suggested, it would be beneficial to extend them to include all medical conditions.

The situation in Ireland 

In Ireland, the Road Safety Authority’s Sláinte agus Tiomáint – Medical Fitness to Drive Guidelines (updated in February 2013) outline the conditions for driver licence issuing in relation to various illnesses.⁷ These conditions are summarised based on group 1 vehicles (cars, motorcycles, mopeds and tractors). Of interest to us were those conditions pertaining to diabetes and epilepsy. New guidelines are due early next year for group 2 vehicles (those with capacity for more than eight passengers and heavy goods vehicles). Until then the previous RSA guidelines Medical Aspects of Driver Licensing: A Guide for Registered Medical Practitioners 2010, should be used for group 2 drivers.

Diabetes

In the 2010 guidelines, the RSA states that drivers with diabetes as a group are at an increased risk of having a motor crash. It notes that hypoglycaemic episodes pose the most risk to drivers, although hypoglycaemia does not explain all of the increased risk.³ Many people with diabetes will be treated with oral hypoglycaemic drugs or insulin, which can provoke hypoglycaemia, resulting in temporary adverse effects on functional abilities, and in some cases can result in loss of consciousness. A study by Cox showed that starting at moderate hypoglycaemia (BG 2.6 +/- 0.28mmol/l), there was an impairment of driving capacity.⁴ About 44% of people with diabetes in this study did not react to these driving impairments and indicated they would drive in these circumstances. Graveling et al found that about 60% never tested blood glucose before driving and 38% never carried a blood glucose meter when driving. Most participants said they would stop driving to treat a hypo, but only 14% would wait more than 30 minutes to drive again.⁵

Epilepsy

Drivers with epilepsy are at increased risk for motor vehicle crashes because of a seizure, the underlying condition causing seizures or the side-effects of antiepileptic drugs. The RSA states: “Epileptic attacks are the most frequent cause of medical collapse at the wheel”.⁷ It explains that the odds of crashing are markedly reduced with long seizure-free intervals. Annual risk of seizure recurrence is less than 2% after eight years and less than 1% after 10 years. This latter figure is still 20 times greater than the general population seizure risks of 0.05% a year. Drivers of group 2 vehicles generally have longer driving times and distances;³ coupled with this, the heavier character of the vehicle and its passenger capacity, the severity of accidents and number of fatalities in group 2 is worse than for group 1. This is applicable to both diabetes and epilepsy.

Road Safety Authority guidelines

The updated RSA medical fitness to drive guidelines 2013 describe the conditions for issuing and reissuing of driving permits to drivers diagnosed with diabetes. These are largely taken from the EU guidelines which were implemented in September 2010. The RSA guidelines (see Table 1) place the emphasis on hypoglycaemia which, of course, applies to those patients who are on medications for their diabetes. In contrast to the 2010 guidelines which only briefly mention other complications of diabetes as having a prohibitive role in driving, the 2013 guidelines provide more guidance on other complications of diabetes such as retinopathy and renal disease. Perhaps, future revisions will give more prominence to further complications of diabetes, such as retinopathy and peripheral neuropathy. 

In relation to epilepsy, the RSA guidelines (see Table 2) recommend that fitness to drive shall be certified for a limited period only. It stresses the importance of identifying the person’s specific epilepsy syndrome and seizure type so that a proper evaluation of their driving safety can be undertaken. The proper implementation of these rules is of major importance. Ultimately, public safety is the primary goal; however individual mobility rights should not be violated if there is no special risk to public safety. There is a lot of variety in the groups of patients with diabetes and epilepsy (stability of the condition, type of treatment, presence of complications, level of patient education etc). Ideally, these are all factors which should be taken into account when assessing fitness to drive. 

It would appear that most drivers are not familiar with the legal issues concerning driving and the criteria used to evaluate the driving abilities of people with certain medical conditions. Many patients have never discussed the influence of their medical condition on their driving abilities with their doctors. Cox et al reported that half of the type 1 drivers and three quarters of the type 2 drivers had never discussed hypoglycaemia and driving with their physician.⁸ More attention should be given to the continuous education of healthcare professionals on the importance of discussing this. 

In the 2013 Medical Fitness to Drive guidelines, the RSA more clearly delineates the roles and responsibilities of the patient, healthcare professional and the licensing authority itself. Irish and EU law assigns patients with the responsibility of reporting any illness or injury which may affect their driving ability at the time that it arises. The guidelines also underline the importance of adherence to treatment and honesty within the patient-doctor relationship. The role of the healthcare professional is to assess a patient’s sensory, motor and cognitive ability to drive. It is also their role to advise the patient on the impact of their illness on their ability to drive. 

Of note, the guidelines state that it is the role of the healthcare professional to “advise the person of their responsibility to report their condition to the Driving Licensing Authority”.⁷ The healthcare professional should also report to the licensing authority any patient who poses a risk to the public, and the Irish Medical Council guidelines allow for such a breach of confidentiality. While the 2010 guidelines gave no directions on the recording of advice given to patients about driving ability, the 2013 guidelines recommend that there should be clear documentation in patient files, and provides a sample patient advisory form for this purpose. Whereas the 2010 guidelines expressed a preference for medical review to be made by an endocrinologist in the case of diabetes, and a neurologist in the case of epilepsy,³ the 2013 guidelines assert that assessments of driving ability can be carried out by GPs unless the circumstances of illness are not covered specifically by the standards.⁷

Drivers with a medical condition are often resistant to making a declaration to the authorities, because they fear that they may receive a driving ban. This misconception plays a major role in the under-reporting of relevant medical conditions. The guidelines state the licensing authority itself should inform members of the public of their responsibility to report any condition which may affect their driving ability, so an extensive media campaign may follow to advise the public of this fact. To date, in the case of both diabetes and epilepsy, as with many other conditions, a lot of patient education comes from general practice. This makes it important for GPs to be aware of the guidelines surrounding driving with a medical condition so that they can inform patients accordingly. The message which is probably of most importance to healthcare professionals is made in the opening pages of the 2013 guidelines, which states that healthcare professionals should keep informed of any changes in healthcare and law in order to fulfil their legal and ethical duties.

Practice survey

At the beginning of our practice survey, a list was compiled of all patients in the practice who had a diagnosis of diabetes or epilepsy. A list of 194 patients with diabetes attending Mercer’s Medical Centre was compiled based on a search for those who were coded on the database, and a search of the most commonly prescribed medications in this practice – insulin, metformin, gliclazide, liraglutide and sitagliptin. Several groups of patients were further excluded from this list; those who had been inaccurately listed due to family history or impaired glucose tolerance (12 patients), those not of legal driving age (four patients), and those who were either once-off visitors to the practice, or had not been seen in the practice for over one year due to relocation or long-term care (33 patients). This left a total of 145 active diabetes patients. Of these patients, 17 were diet-controlled but were left included due to the possibility of them commencing on medications in the future. Of these 145 patients, only five patients had been documented that either driving regulations were discussed or driving license applications were signed. 

The list of patients with epilepsy was recently updated by another audit in the practice. The total number of patients in the practice with epilepsy is 40. Several patients were further excluded from this list – those not of legal driving age (four patients) and those who were either once-off visitors to the practice, or had transferred to another practice (two patients). This left a total of 34 active patients with epilepsy. Of these patients, five had it documented in their charts that either driving regulations were discussed or that driving license applications were signed.

Letters were sent to all 179 patients informing them of the RSA guidelines and the obligation of all patients to report their medical status to the relevant licensing authorities and insurance providers. The correspondence advised all of these patients to discuss the guidelines further with their respective doctors if any clarification was required. 

This audit had two successful conclusions. It served to inform the medical staff in the practice of the exact guidelines pertaining to licensing of patients with diabetes and epilepsy. In addition, it resulted in informing all of the 179 relevant patients of the guidelines and their responsibilities in reporting in order to benefit their own personal safety and the safety of others.

Feedback

Feedback was low key with little direct comment from patients. It prompted a few patients (six) to make an appointment to specifically discuss the contents of the letter, but most patients chose to bring it up at their next routine appointment. The majority of patients were unaware of the exact regulations relating to their illness and driving, and overall feedback on the exercise was positive. 

Clinical staff in the practice also found this a worthwhile exercise, clarifying our role and reassuring us that best practice was being followed. 

Acknowledgement 

We would like to thank all the staff at Mercer’s Medical Centre, RCSI and the Mercer’s Foundation

References

1. Council Directive 91/439/EEC; July 1991;  http://eur-lex.europa.eu/LexUriServ/LexUriServ.o?uri=CELEX:31991L0439:en:NOT
2. Diabetes and Driving in Europe A Report of the Second European Working Group on Diabetes and Driving, an advisory board to the Driving Licence Committee of the European Union; July 2006
3. Medical Aspects Of Driver Licensing: A Guide for Registered Medical Practitioners 2010, Road Safety Authority; http://www.rsa.ie/RSA/Licensed-Drivers/Safe-driving/Medical-Issues/; retrieved 15th Dec 2011
4. Cox DJ, Gonder-Frederick LA, Clarke WL. Driving decrements in type 1 diabetes during moderate hypoglycaemia. Diabetes 1993; 42(2): 239
5. Graveling A, Warren R, Frier B. Hypoglycaemia and driving in people with insulin-treated diabetes: adherence to recommendations for avoidance. Diabetic Medicine 2004; 21, 1014-1019 
6. Epilepsy and Driving in Europe; A report of the Second European Working Group on Epilepsy and Driving, an advisory board to the Driving Licence Committee of the EuropeanUnion; April 2005
7. Sláinte agus Tiomáint: Medical Fitness to Drive Guidelines (Group 1 Drivers), National Programme Office for Traffic Medicine, Royal College of Physicians of Ireland/Road Safety Authority; February 2013
8. Cox DJ, Penberthy JK, Zrebiec J et al. Diabetes and driving mishaps: Frequency and correlations from a multinational survey. Diabetes Care 2003; 26: 2329–2334