The responsibility for making the decision about whether or not a person should continue to drive is that of the Driver and Vehicle Licensing Agency (DVLA), with the doctor acting only as a source of information and advice. Drivers have a duty to keep the DVLA informed of any condition that may impair their ability to drive. Doctors have a responsibility to advise their patients to inform the DVLA of any condition likely to make driving dangerous.

If a patient fails to take this advice, their doctor may then contact the DVLA directly. In such circumstances, the General Medical Council (GMC) has issued clear guidelines for doctors, which involve ensuring that the patient understands that their condition may affect driving ability, explaining to patients that they have a legal duty to inform the DVLA and facilitating a second opinion as necessary (Box 1). If patients continue to drive when not fit to do so, the doctor should make every reasonable effort to persuade them to stop. This may include telling their next of kin. If this fails, or there is evidence that the patient continues to drive, the doctor should disclose relevant medical information immediately, in confidence, to the medical adviser at the DVLA. Prior to this, the doctor should inform the patient of their decision to do so and confirm this in writing.

Following the DVLA regulations for alcohol problems, Group 1 entitlement to drive is affected if a diagnosis of alcohol misuse or alcohol dependency is confirmed by medical enquiry (and by otherwise unexplained blood markers in the case of alcohol misuse). Alcohol dependency requires a recommended 12-month period of licence revocation or refusal, to attain abstinence or controlled drinking and with normalisation of blood parameters if relevant (see Table 1).

Table 1. Summary of the Driver and Vehicle Licensing Agency (DVLA) regulations for alcohol problems (Taken from DVLA, 2003)

Alcohol problem	Group 1 entitlement	Group 2 entitlement
Alcohol misuse	Licence revocation or refusal until a minimum 6-month period of controlled drinking or abstinence has been attained, with normalisation of blood parameters	Licence revocation or refusal until at least a 1-year period of abstinence or controlled drinking has been obtained with normalisation of blood parameters
Alcohol dependency	Licence revocation or refusal until a 1-year period free from alcohol problems has been attained. Abstinence will normally be required, with normalisation of blood parameters, if relevant. Additional restrictions if seizures occur	Vocational licensing will not be granted where there is a history of alcohol dependency within the past 3 years. Additional restrictions if seizures occur

Licence restoration requires satisfactory independent medical examination, arranged by the DVLA, with satisfactory blood results and medical reports from the patient's doctor. The patient is recommended to seek advice from medical or other sources during the period off the road.

As doctors working in a busy alcohol problems clinic, we were interested to find out how many of the patients referred to us were following DVLA regulations and indeed how many who held driving licences were aware of the regulations. We knew of a lack of awareness of the guidelines in this patient group, but to what extent was it a problem? We also considered that the health professionals that these patients were attending might not be actively discussing DVLA regulations with them. This may, in part, be related to the concern that patients will fail to engage in treatment with those whom they perceive as being responsible for their licence being revoked. In cases of patients who continue to drive despite advice to the contrary, doctors may feel particularly uncomfortable informing the DVLA due to issues of confidentiality and the preservation of an effective doctor-patient relationship. To this end we devised the following study.

Aims and method

An anonymous survey of patients who had a diagnosis of alcohol dependence was carried out. The survey aimed to ascertain the following:

1. 1. How much knowledge patients with alcohol dependence had of DVLA regulations.

2. 2. To what extent they followed such regulations.

3. 3. What information they had been given by health professionals.

4. 4. Most importantly, whether there are implications for the doctor-patient relationship if the patient knows that doctors have a duty to notify the DVLA in certain circumstances.

The participants in the study consisted of the next 58 patients from the starting date of the study who attended an alcohol problems clinic in Glasgow and who fulfilled the following criteria:

1. 1. a diagnosis of alcohol dependence

2. 2. insight into their diagnosis

3. 3. possession of a current driving licence

4. 4. capacity and willingness to provide consent for participation in the study.

Participants were asked to complete a brief, anonymous questionnaire (unsupervised) about their driving habits and knowledge of DVLA regulations (Box 2). The last question specifically referred to whether patients would continue to seek treatment if the doctor might be informing the DVLA of their diagnosis.

Results

The following results from each question shown in Box 2 are described below.

From questions 1 and 2 we found that all the responders (n=58) had a full UK driving licence (one had a heavy goods vehicle (HGV) licence) but two were currently banned from driving. Neither of these said why they were banned but it may have been due to alcohol-related offences; they were excluded from the remainder of the survey, leaving 56 patients with a current driving licence.

A total of 89% of responders to question 3 (n=50) had driven in the last year. All were driving cars or vans and one person was driving a taxi. The person with the HGV licence was driving a car only.

Box 3 shows that 55% of responders were driving daily (n=31). Only 11% were not driving (n=6).

Box 3. Frequency of driving (answers to question 5)

Daily	31
Weekly	9
Monthly	1
Less than monthly	7
Unclear	2
Not driving	6
Total	56

For questions 6 and 7 regarding the DVLA regulations for driving in individuals with a diagnosis of alcohol dependence (see Box 2), 57% (n=32) did not answer the question or responded by saying that they did not know. Of those that did answer, 83% (n=20) gave an answer that was incorrect. The vast majority of answers (90%, n=18) made reference to driving under the influence of alcohol and this appeared to reveal that at best many had only a limited understanding of the regulations. Of the 4 responders (or 7%) who appeared to give correct answers to the question, 2 then undermined their answers by saying they were still driving, i.e. implying that they were not actually aware of the regulations.

Responses to question 7 indicated that 7 people or 13% did not think they were following the regulations, regardless of what they thought the regulations were. There were 4 correct (but incomplete) responses to question 6 as follows:

1. • ‘Don't’

2. • ‘Don't drive’

3. • ‘Must inform DVLA of your condition’

4. • ‘Revoke your licence’

Of the 20 incorrect responses, examples are as follows:

1. • ‘I believe they would prefer you don't drink and drive.’

2. • ‘Not aware of any specific regulations. I do know the limit, the rate of metabolism and can therefore calculate any morning-after effect.’

3. • ‘Suspension and fine – don't drink and drive.’

4. • ‘Same as those without, 80 mg/l.’

5. • ‘Don't drink and drive.’

6. • ‘Do not drive while drinking.’

7. • ‘Do not drive for at least 12 h.’

8. • ‘Not sure, under 68 mg in blood.’

9. • ‘1 unit, i.e. one glass of table wine.’

10. • ‘Half a pint per day if driving daily.’

11. • ‘You have to undergo a medical if you have been convicted of drink driving with 200 mg/100 ml blood alcohol.’

One answer was partially correct:

1. • ‘Obliged to inform the DVLA (but not compulsory).’

From questions 8 and 9 it was found that only 14% of responders (n=8) said a health professional had discussed DVLA regulations with them. Some circled more than one type of health professional. Of the health professionals mentioned, 4 were GPs, 1 was a nurse and only 1 person said a psychiatrist had discussed DVLA regulations with them.

Of the 8 people who said they had been spoken to by a health professional, 5 people answered question 10. No one said that they had been spoken to about the regulations regarding alcohol dependence. The 5 answers given were as follows:

1. • ‘Not to drive for several weeks due to health.’

2. • ‘Do not drink any alcohol whilst driving.’

3. • ‘To remember you will be risking the lives of others as well as your own and your concentration dulls under the influence of alcohol.’

4. • ‘Take special care.’

5. • ‘Unable to drive due to epilepsy.’

Responses to question 11 showed that 48% of responders (n=27) said the DVLA regulations would not have an effect on them seeking treatment but 39% (n=22) said they would be less likely to attend or stop attending for treatment.

Discussion

We believe that the results of this study highlight a number of difficulties involved in managing patients with alcohol dependence who drive.

First, 89% of the patients with this diagnosis (n=50) had driven a vehicle in the 12 months prior to filling in the questionnaire. This suggests that most heavy drinkers who possess a valid driving licence continue to drive, and 55% of the patients in this study (n=31) were in fact driving on a daily basis. Second, in terms of knowledge and awareness of DVLA regulations, it is clear that nearly all participants were not so much unsure as completely unaware that there were any restrictions for those drivers with significant alcohol problems. Many appeared to think that any restrictions were to do with driving under the influence of alcohol only, rather than there being any longer-term implications for their drinking behaviour. As a result, it is hardly to be expected that these individuals will be actively seeking to inform the DVLA of their condition if they are unaware of the regulations.

Eighty-six percent of patients (n=48) claimed that no health professional had ever discussed DVLA regulations with them, which is a disappointing statistic, even allowing for some cases where patients may have forgotten or misinterpreted such advice. We believe that this is likely to reflect an avoidance on the part of health professionals to discuss such matters since once a patient reveals that he continues to drive and has not informed the DVLA, the onus is on the doctor to ensure that the DVLA are informed. This can of course lead to difficult interactions with some patients who perceive the doctor as being intrusive or breaching confidentiality. The responses to the final question in the survey appear to confirm that this particular issue has major implications for the doctor-patient relationship. Of the patients who answered this question, 45% (n=22) indicated that they would be less likely to seek treatment, or would not seek treatment at all, in the knowledge that doctors had a legal duty to inform the DVLA.

In cases of patients with some form of impairment affecting their driving ability, the issues of confidentiality and the doctor-patient relationship are not, of course, limited to psychiatric or substance misuse settings. Similar difficulties can occur in primary care, general hospital wards and accident and emergency units.

Interms of our own results, it could be argued that even if the doctor-patient relationship is being adversely affected in just a single case, this in itself is a significant finding which illustrates that the issue merits further investigation.

We propose that further useful research in this area might involve a survey of health professionals regarding their knowledge of DVLA regulations and GMC advice, and their current attitudes and practice.

Declaration of interest

None.