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Appendix to the assessing fitness to drive guide for medical professionals.
The Secretary of State for Transport, acting through DVLA, has the responsibility of ensuring all licence holders are fit to drive.
The legal basis of fitness to drive in the UK lies in the following legislation:
According to Section 92 of the Road Traffic Act 1988:
Sections 92 and 94 of the Road Traffic Act 1988 also cover drivers with physical disabilities who require adaptations to their vehicles to ensure safe control. These adaptations must be coded and shown on the licence. See Appendix F, disabilities and vehicle adaptations and Appendix G, Mobility Centres and Driving Assessment Centres.
The law requires that driving licences shall not be issued to, nor renewed for, applicants with serious neurological disorders, unless supported by the applicant’s doctor.
A serious neurological disorder is defined for the purposes of driver licensing as any condition of the central or peripheral nervous system that has led, or may lead, to functional deficiency (sensory, including special senses, motor, and/or cognitive deficiency), and that could affect ability to drive.
When DVLA evaluates the licensing of these applicants, it will consider the functional status and risk of progression. A short-term licence for renewal after medical review is generally issued whenever there is a risk of progression.
Further information relating to specific functional criteria is found in the following chapters:
The following 2 boxes extract the paragraphs from regulations 72 and 73 of the Motor Vehicle (Driving Licences) Regulations 1999 (as amended) that govern the way in which epilepsy is ‘prescribed’ as a ‘relevant’ disability for Group 1 or Group 2 drivers (also see Appendix A, the legal basis for the medical standards).
(2) Epilepsy is prescribed for the purposes of section 92(2) of the Traffic Act 1988 as a relevant disability in relation to an applicant for, or a holder of, a Group 1 licence who has had 2 or more epileptic seizures during the previous 5 year period.
(2A) Epilepsy is prescribed for the purposes of section 92(4)(b) of the Traffic Act 1988 in relation to an applicant for a Group 1 licence who satisfies the conditions set out in paragraph (2F) below and who has either:
(a) been free from any unprovoked seizure during the period of one year immediately preceding the date when the licence is granted
(b) during that one year period has suffered no unprovoked seizure other than a permitted seizure.
(2B) A permitted seizure for the purposes of paragraph (2A)(b) is:
(a) a seizure – which can include a medication-adjustment seizure – falling within only one of the permitted patterns of seizure, or
(b) a medication-adjustment seizure, where:
(i) that medication-adjustment seizure does not fall within a permitted pattern of seizure
(ii) previously effective medication has been reinstated for at least 6 months immediately preceding the date when the licence is granted
(iii) that seizure occurred more than 6 months before the date when the licence is granted, and
(iv) there have been no other unprovoked seizures since that seizure
(c) a seizure occurring before a medication-adjustment seizure permitted under sub-paragraph (b) where:
(i) that earlier seizure has, to that point, formed part of only one permitted pattern of seizure and had occurred prior to any medication-adjustment seizure not falling within the same permitted pattern
(ii) it is a medication-adjustment seizure, which was not followed by any other type of unprovoked seizure, except for another medication-adjustment seizure.
(2C) A permitted pattern of seizure for the purposes of paragraph (2B) is a pattern of seizures:
(a) occurring during sleep, where:
(i) there has been a seizure while asleep more than one year before the date when the licence is granted
(ii) there have been seizures only while asleep between the date of that seizure while asleep and the date the licence is granted
(iii) there has never been an unprovoked seizure while awake
(b) occurring during sleep, where:
(i) there has been a seizure while asleep more than 3 years before the date when the licence is granted
(ii) there have been seizures only while asleep between the date of that seizure while asleep and the date the licence is granted
(iii) there is also a history of unprovoked seizure while awake, the last of which occurred more than 3 years before the date when the licence is granted
(c) without influence on consciousness or the ability to act, where:
(i) such a seizure has occurred more than one year before the date when the licence is granted
(ii) there have only been such seizures between the date of that seizure and the date when the licence is granted
(iii) there has never been any other type of unprovoked seizure.
(2D) An isolated seizure is prescribed for the purposes of section 92(2) of the Traffic Act 1988 as a relevant disability in relation to an applicant for, or a holder of, a Group 1 licence.
(a) in a case where there is an underlying causative factor that may increase future risk, where such a seizure has occurred during the previous one year period
(b) in any other case, where such a seizure has occurred during the previous 6 month period.
(2E) An isolated seizure is prescribed for the purposes of section 92(4)(b) of the Traffic Act 1988 in relation to an applicant for a Group 1 licence, who:
(i) in a case where there is an underlying causative factor that may increase future risk, has had such a seizure more than one year immediately before the date when the licence is granted
(ii) in any other case, has had such a seizure more than 6 months immediately before the date when the licence is granted
(b) has had no other unprovoked seizure since that seizure
(c) satisfies the condition set out in paragraph (2F).
(2F) The conditions are that:
(a) so far as is predictable, the applicant complies with the directions regarding treatment for epilepsy or isolated seizure, including directions as to regular medical check-ups made as part of that treatment, which may from time to time be given by a registered medical practitioner or one of the clinical team working under the supervision of that registered medical practitioner
(b) if required to do so by the Secretary of State, the applicant has provided a signed declaration agreeing to observe the condition in sub-paragraph (a)
(c) if required by the Secretary of State, there has been an appropriate medical assessment by a registered medical practitioner
(d) the Secretary of State is satisfied that the driving of a vehicle by the applicant in accordance with the licence is not likely to be a source of danger to the public.
(8) Epilepsy is prescribed for the purposes of section 92(2) of the Traffic Act as a relevant disability in relation to an applicant for, or a holder of, a Group 2 licence, where two or more epileptic seizures have occurred, or that person has been prescribed medication to treat epilepsy, during the previous ten year period.
(8A) Epilepsy is prescribed for the purposes of section 92(4)(b) of the Traffic Act 1988 in relation to an applicant for a group 2 licence who:
(a) in the case of a person whose last epileptic seizure was an isolated seizure satisfies the conditions in paragraph (8C) and (8D)
(b) in any other case, satisfies the conditions set out in paragraph (8D) and who, for a period of at least 10 years immediately preceding the date when the licence is granted has:
(i) been free from any epileptic seizure
(ii) has not been prescribed any medication to treat epilepsy.
(8B) An isolated seizure is prescribed for the purposes of section 92(2) of the Traffic Act 1988 as a relevant disability, in relation to an applicant for, or a holder of, a Group 2 licence, where during the previous 5 year period, such a seizure has occurred, or that person has been prescribed medication to treat epilepsy or a seizure.
(8C) An isolated seizure is prescribed for the purposes of section 92(4)(b) of the Traffic Act 1988 in relation to an applicant for a Group 2 licence who satisfies the conditions set out in paragraph (8D) and who, for a period of at least 5 years immediately preceding the date when the licence is granted:
(a) has been free from any unprovoked seizure
(b) has not been prescribed medication to treat epilepsy or a seizure.
(8D) The conditions are that:
(a) if required by the Secretary of State, there has been an appropriate medical assessment by a neurologist
(b) the Secretary of State is satisfied that the driving of a vehicle by the applicant, in accordance with the licence, is not likely to be a source of danger to the public.
This guidance relates only to epilepsy treatment.
During the therapeutic procedure of epilepsy medication being withdrawn by a medical practitioner, the risk of further epileptic seizures should be noted from a medicolegal point of view.
If an epileptic seizure does occur, the patient will need to meet the medical standards before resuming driving and will need to be counselled accordingly.
It is clearly recognised that withdrawal of epilepsy medication is associated with a risk of seizure recurrence. A number of studies have shown this, including a randomised study of withdrawal in patients in remission conducted by the Medical Research Council’s study group on epilepsy drug withdrawal. This study showed a 40% increased risk of seizure associated with the first year of withdrawal compared with continued treatment.
The Secretary of State for Transport’s Honorary Medical Advisory Panel on Driving and Disorders of the Nervous System states that patients should be warned of the risk they run, both of losing their driving licence and of having a seizure that could result in a road traffic accident.
The Advisory Panel states that drivers should usually be advised not to drive from the start of the withdrawal period and for 6 months after treatment cessation – it considers that a person remains as much at risk of seizure during the withdrawal as during the following 6 months.
This advice may not be appropriate in every case, however. One specific example is withdrawal of anticonvulsant medication when there is a well-established history of seizures only while asleep.
In such cases, any restriction on driving is best determined by the physicians concerned, after considering the history. It is the patient’s legal duty to comply with medical advice on driving.
It is important to remember that the driver licensing rules remain relevant in cases of medication being omitted as opposed to withdrawn, such as on admission to hospital.
For changes of medication, for example due to side effect profiles, the following general advice is applicable.
To be considered a provoked seizure, the seizure must be attributable solely to a recognisable provoking cause and that causative factor must be reliably avoidable. It should be clear that the seizure has been provoked by a stimulus that does not convey a risk of recurrence. Driving will usually need to cease for 6 months (group 1) or up to 5 years (group 2) following a provoked seizure. For Group 2 driving if evidence can be provided to show that an individual is at a less than 2% annual risk of having a further seizure before 5 years DVLA would be pleased to receive and consider this.
Doctors may wish to advise patients that the likely total period of time they will be required by DVLA not to drive will be extended if there is a previous history of unprovoked seizure or evidence of pre-existing cerebral pathology (e.g. longstanding cerebral lesion, epileptic activity on EEG or evidence of fixed neurological deficit), that increases the risk of further seizures.
In the absence of any previous seizure history or previous cerebral pathology, the following seizures may be treated as provoked:
The following provoked seizures are excepted and do not require driving to cease, although the relevant medical standards for the underlying condition will have to be met:
If drug treatment for any cardiovascular condition is required, any adverse effects likely to affect safe driving will necessitate the licence being refused or revoked.
A bus or lorry licence issued after cardiac assessment – usually for ischaemic or untreated heart valve disease – will usually be short-term, for a maximum licence duration of 3 years, and licence renewal will require satisfactory medical reports.
DVLA no longer requires regular anti-anginal medication (i.e. nitrates, beta blockers, calcium channel blockers, nicorandil, ivabradine and ranolazine) to be stopped prior to exercise tolerance testing. The requirements for exercise evaluation are:
DVLA will require exercise evaluation at regular intervals not to exceed 3 years if there is established coronary heart disease.
Exercise testing should be performed as outlined above.
Individuals with a locomotor or other disability who cannot undergo or comply with the exercise test requirements will require a gated myocardial perfusion scan or stress echo study accompanied when required by specialist cardiological opinion.
When DVLA requires these imaging tests, the relevant licensing standards are as follows.
LV ejection fraction is 40% or more:
Full DVLA protocol requirements for these tests are available on request (see contact details).
For licensing purposes, DVLA considers functional implication to be more predictive than anatomical findings in coronary artery disease. ‘Predictive’ refers to the risk of an infarct within 1 year. Grafts are considered as ‘coronary arteries’.
For this reason, exercise tolerance testing and, where necessary, myocardial perfusion imaging or stress echocardiography are the investigations of relevance (outlined above) with the standards as indicated to be applied.
Angiography is therefore not commissioned by DVLA.
If there is a conflict between the results of the functional test and a recent angiography, the case will be considered individually. Licensing will not normally be granted, however, unless the coronary arteries are unobstructed or the stenosis is not flow-limiting. The LV ejection fraction must also be at least 40%.
DVLA will refuse or revoke a Group 2 (bus or lorry) licence if there has been:
A bus or lorry licence for annual review may be issued after elective aortic root replacement surgery provided:
Group 2 licensing following elective external aortic support procedures will require individual consideration. Continued licensing thereafter will require regular clinical review, including MRI imaging one year after surgery and every 3 years thereafter.
‘Severe’ is defined (European Society of Cardiology guidelines) as:
This calculator is recommended by the European Society of Cardiology to assess Sudden Cardiac Death (SCD) risk in hypertrophic cardiomyopathy (HCM) patients and to assign patients into low, intermediate or high risk categories. The HCM risk categories for SCD have been defined as low risk (5 year risk of SCD less than 4%), intermediate risk (5 year risk of SCD 4 to 6%) and high risk (5 year risk of SCD equal to or greater than 6%).
Refer to table 4 for the classification of congenital heart disease complexity.
Information for drivers with diabetes, including the INF294 leaflet.
Any psychiatric condition that does not fit neatly into the classifications in Chapter 4 will need to be reported to DVLA if it is causing or is considered likely to cause symptoms that would affect driving.
Such symptoms include, for example:
The patient should be advised to declare both the condition and the symptoms of concern.
It is the relationship of symptoms to driving that is of importance.
The law sets out the minimum medical standards of fitness to drive and the requirements for mental health in broad terms state that:
Section 4 of the Road Traffic Act 1988 does not differentiate between illicit and prescribed drugs.
Any person driving or attempting to drive on a public highway or other public place while unfit due to any drug is liable for prosecution.
The likely severity of the underlying condition requiring electroconvulsive therapy (ECT) means the driver should be advised that they must notify DVLA.
Electroconvulsive therapy is usually employed in the context of an acute intervention for a severe depressive illness or, less commonly, as longer-term maintenance therapy.
In both courses, it is the severity of the underlying mental health condition that is of prime importance to the determination of whether driving may be permitted.
A seizure induced by ECT is regarded as provoked for the purposes of fitness to drive and is not a bar to licensing and driving – under both Group 1 car and motorcycle, and Group 2 bus and lorry.
The concerns for driving are:
Driving must stop during an acute course of treatment with ECT and is not permitted until the relevant medical standards and observation periods associated with underlying conditions have been met, as set out in Chapter 4 and with respect to any other mental health symptoms or psychiatric conditions that do not fit neatly into classifications.
Again, this guidance must stress that the underlying condition and response to treatment are what determine licensing and driving.
Where ECT is used as maintenance treatment with a single treatment sometimes given weeks apart there may be minimal or no symptoms. This would not affect driving or licensing providing there is no relapse of the underlying condition.
Driving must stop for 48 hours following the administration of an anaesthetic agent.
Driving often remains possible with certain adjustments for a disability, whether for a static and progressive disorder or a relapsing one. These vehicle modifications may be needed for:
Vehicle adaptations range from simple automatic transmission for many disorders, to sophisticated modifications such as joysticks and infrared controls for people with severe disabilities.
DVLA will need to know about a disability and whether any controls require modification, and will ask the patient to complete a simple questionnaire.
The driving licence is coded to reflect any vehicle modifications.
Assessment centres offer people advice about driving with a disability (these are listed in Appendix G).
Note that a person in receipt of the mobility component of Personal Independence Payment (PIP) can hold a driving licence from 16 years of age. (A person can’t apply for PIP until their 16th birthday.)
Some disabilities, if mild and non-progressive, may be compatible with driving large vehicles. DVLA needs to be notified and will require an individual assessment.
Users of Class 2 or 3 mobility vehicles – which are limited to 4 mph or 8 mph respectively – are not required to hold a driving licence, and they do not need to meet the medical standards for driving motor vehicles. DVLA recommends the following, however:
For more information, see Mobility scooters and powered wheelchairs: the rules.
Find a centre on the Driving Mobility website.
Hypertrophic cardiomyopathy – interpretation of ECG changes during exercise testing (Appendix C). Congenital heart disease – referencing of classification of complexity of congenital heart disease (Appendix C).
Changes to the style of the text.
Clarification regarding provoked seizures, including confirmation that eclamptic seizures do not require time from driving.
Appendix G: list of mobility centres and driving assessment centres replaced with new search tool on the Driving Mobility website.
Appendix B – Rewritten section on provoked seizures. Appendix C – Inclusion of the European Society of Cardiology Risk of Sudden Cardiac Death calculator.
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