A common query received by Medical Protection is concern about the ability of a patient to drive safely and whether it would be appropriate to make a disclosure to the relevant authority. Dr Heidi Mounsey, Medicolegal Consultant at Medical Protection, looks at the guidance and an example case study.
Doctors and practice staff owe a duty of confidentiality to patients, but there is also a wider duty to protect others where this becomes necessary. This may mean disclosing information to the Driver and Vehicle Licensing Agency (DVLA) in England, Scotland and Wales, or Driver and Vehicle Agency (DVA) in Northern Ireland in the public interest. This is in the event a patient continues to drive when unsafe to do so or when a patient does not inform the DVLA or DVA about a medical condition when required.
The DVLA or DVA are legally responsible for deciding whether an individual is unfit to drive. In order to carry out that role, they need to know if a driving licence holder has a condition or is undergoing treatment that may affect, either now or in the future, their ability to safely drive.
It is the driver who is legally responsible for informing the DVLA or DVA about such a condition or treatment; however, doctors should alert patients to such issues that may impact on their ability to drive, including a reminder that it is the patient who has a duty to tell the appropriate agency. An individual who does not inform the DVLA about a condition that might affect their ability to drive safely could be fined up to £1,000 and may also be prosecuted in the event of an accident.
In a situation where a patient continues to drive but is unfit to do so the doctor or healthcare professional may need to disclose relevant information without consent to the DVLA or DVA.
The DVLA’s guidance sets out useful background information on licensing and licence groups, the medical enquiries procedure (which involves seeking information from the licence holder/applicant, and from relevant healthcare professionals), and the outcome of medical enquiries.
It is not routine for the DVLA to inform doctors of the outcome of a medical enquiry, except in cases where the driver may not have the insight or the ability to understand and abide by any refusal or revocation of their licence. In these circumstances the DVLA would usually send a decision letter to the patient’s GP.
In a situation where notification is provided to the DVLA by a doctor, the DVLA will acknowledge receipt of this, but would only send a decision letter in the circumstances outlined above.
The website listed at the end of the article also contains a link to the medical notification form for healthcare professionals to use, and also contact details for the DVA should a situation arise where a patient in Northern Ireland cannot or will not self-notify.
Further, the DVLA and DVA have the option for a healthcare professional to contact their own medical advisers and discuss concerns about a particular driver (identified by a unique reference number) or about fitness to drive in general, with contact details and hours of operation published on the website.
The GMC has also produced guidance entitled Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA.
This sets out that if a patient’s fitness to drive may be impaired, the doctor should:
- Explain to the patient that their fitness to drive may be impaired and that the patient is legally required to inform the DVLA or DVA.
- Inform the patient that it may be necessary to disclose relevant medical information about them to the DVLA or DVA if they drive when they are not fit to do so.
- Inform the DVLA or DVA as soon as is practicable if the patient is unable to understand the advice given, for example because of diagnosis of dementia.
- Suggest a second opinion if the patient refuses to accept that their driving may be impaired by their condition or treatment, and advise the patient not to drive in the meantime. If the patient consents, it is acceptable to discuss the situation with their relatives, friends or carers.
- Make every reasonable effort to persuade a patient to stop driving if they continue to do so despite advice to the contrary, and consider whether the refusal to stop driving puts others at risk of death or serious harm.
- Contact the DVLA or DVA promptly and disclose relevant information in the event it is considered such risks exist.
- Attempt to inform the patient of an intention to disclose information to the DVLA or DVA. If the patient objects, consideration should be given to their reasons for objecting. If disclosure is then made to the DVLA or DVA, the patient should be informed in writing.
- Document any advice given to the patient about their fitness to drive and any decision made with respect to disclosure of information to the DVLA or DVA.
The daughter of an elderly patient contacted the GP practice and spoke to Dr A to report that she was very concerned about her father’s deteriorating ability to drive safely, which she believed was an indication he had developed dementia. She described that at traffic lights in particular he seemed very uncertain and had driven through a red light on more than one occasion, or would stop at a green light for a period of time as if he was trying to work out what he should do next. He had also attempted to drive the wrong way around a roundabout, and had crashed into the gatepost at his house. She was worried he would be involved in an accident and asked whether he had been seen recently at the practice and whether he had a diagnosis of dementia. She asked that Dr A tell her father not to drive. She also requested that Dr A did not inform the patient that she had called the practice to discuss this as she believed he would see this as a betrayal of his trust.
Dr A was aware the practice had not seen the patient for some time, and that he did not have a diagnosis of dementia currently recorded on his records. There was no note on the file to suggest that the father had given consent for his medical history to be discussed with his daughter.
What should Dr A do?
It would be prudent for Dr A to explain to the daughter that she would take her concerns seriously but that in the absence of consent from the patient, she would not be able to discuss any aspect of his care, which would include whether or not he had recently been reviewed at the practice or the details of any diagnosis he may or may not have. It is important to remember that the patient’s confidentiality also extends to confirmation that there is an absence of a condition – it would still be breaching the patient’s confidentiality to confirm to his daughter that he did not have a diagnosis of dementia.
Dr A should confirm to the daughter that she will consider whether further action needs to be taken by the practice, but in the event she were to discuss this with the patient, she cannot guarantee the daughter’s confidentiality. Were the patient to directly ask, Dr A is not in a position to lie. However, she should ensure that any conversation with the patient is handled in a sensitive manner.
Following the call from the patient’s daughter, Dr A considered that a review of the patient was warranted in light of the information provided. It would be reasonable for Dr A to contact the patient and invite him for review to discuss concerns that had been raised by a third party, although Dr A should remember that she cannot lie to the patient about who has raised the concern if the patient were to ask.
The patient agreed to attend the practice. It was noted by a member of staff that he struggled to park his car in a bay, and eventually left the car in the middle of the car park, blocking another vehicle in.
During the consultation Dr A explained that someone had raised concerns about the patient’s driving and asked if he had noticed anything himself that he was worried about. The patient said that the only problem was that he seemed to get lost more frequently than he used to, but other than that he felt there were no difficulties either with his driving or at home generally. Dr A noticed, though, that the patient seemed quite unkempt and had only shaved one side of his face. He asked whether it was his daughter that had raised the concerns and Dr A confirmed that it was, and that she was worried about him. Dr A explained to him that although she had listened to the concerns raised by his daughter, she had not provided any confidential information but felt it necessary to follow up the concerns as they could potentially be serious. The patient became very cross when Dr A suggested undertaking a mini mental state examination and blood tests, and then even more angry when Dr A informed him that there may be a need for him to tell the DVLA depending on the outcome of tests.
The patient left the consultation shouting that no-one had any right to tell him what he should do. He was then observed getting into the car and driving away on the wrong side of the road.
Dr A made the decision to both call the police as she considered this was an immediate and serious risk to both the safety of the patient and the public.
The police contacted Dr A shortly afterwards to say that the patient was now at home and had not been seen driving by them, and therefore there was nothing further they could do on that occasion.
Dr A contacted the patient again to attempt a further discussion regarding his driving and to advise him to stop driving until further assessment had been made, but he hung up the phone.
Dr A therefore contacted the DVLA’s medical adviser to discuss the case in confidence, and ultimately a disclosure to them was made. Dr A subsequently wrote to the patient to set out that she had made such a disclosure and why, and to invite the patient to come back to the practice for a further consultation.
Dr A also thoroughly documented her decision making process in the patient’s medical records, along with the steps taken to engage and inform the patient.
Following disclosure by Dr A and subsequent consideration by the DVLA, the patient’s licence was revoked.