This week I spoke in the media on the vexed question of when doctors should tell the driving authorities - the DVLA - if a patient has a medical condition which means they should be banned from driving. To me, this wasn't really a major change - doctors had been given pretty similar guidance just 18 months ago. But suddenly, my twitter account lit up with strong views on both sides of the debate.
The doctor and the public
'It's a no-brainer!' people protested, citing tragedies like the deaths of 16-year-old Cassie McCord in 2011 and three-year-old Poppy-Arabella Clarke in 2016. Cassie was killed by an 87-year- old who had failed a police driving test, but refused to give up his licence. The driver in this case had his eyesight tested by police just three days earlier, after he missed the entrance to a petrol station and drove into a tree - but the police had no power to seize his car, as they would have done if he was driving without insurance.
Poppy-Arabella was killed by a 72-year-old who had been advised to stop driving because of his eyesight, but had refused to inform the DVLA. At the time of the crash, he was not wearing his glasses and drove straight through a red light.
Of course these stories are heart-wrenching. Of course we all want to protect families from having to go through a similar tragedy. But…
The doctor and the patient
Comments in the opposite camp ranged from 'It's more complicated than it seems' to 'I would be impressed if doctors had direct experience of someone's driving?! Can't report otherwise! #NannyState'. Another of my followers, a GP, pointed out you didn't need to see someone driving if you know they have epilepsy to know they shouldn't be on the road.
But actually, the nanny state isn't my biggest concern. I'm more worried about our patients losing trust in us - because that could also lead to lives being lost.
Doctor-patient confidentiality means that a vulnerable 17-year-old can trust that I will never, ever tell her parents she's pregnant unless she allows me to. It means a man with HIV doesn't need to live in fear that he won't get a job because I let slip to a potential employer. It means, quite simply, that they can trust me. If they didn't, that girl might take herself off to a backstreet clinic rather than confiding in me and working through all the options open to her. The man might soldier on without any support until he sank into depression, couldn't cope anymore and took his own life. Alternatively, he might not get counselling about how to avoid infecting others, or treatment that could reduce his risk of giving the virus to others to almost zero, and pass on HIV through unprotected sex. Doctor-patient confidentiality saves lives.
What the guidance actually says
In fact, the guidance from the DVLA isn't really new - it's giving doctors greater clarity for the difficult balancing act they have in situations like these.
Even before today, a doctor had a duty to inform the relevant authorities if they thought the risk to the public and/or the person of not breaching confidentiality was greater than the risk of not informing. But they had to make really exhaustive efforts to get the patient to inform the DVLA themselves - the legal obligation has always lain with the patient.
The updated guidance says that doctors still need to "make every reasonable effort" to persuade the patient to self-report. However, they do now give some circumstances where, even if the patient does not consent, they should let the DVLA know themselves. And they now make it clear that they should do that, in a few situations, even when they haven't told the patient they're going to.
The guidance states:
"If you become aware that a patient is continuing to drive when they may not be fit to do so, you should make every reasonable effort to persuade them to stop. If you do not manage to persuade the patient to stop driving, or you discover that they are continuing to drive against your advice, you should consider whether the patient's refusal to stop driving leaves others exposed to a risk of death or serious harm. If you believe that it does, you should contact the DVLA or DVA promptly and disclose any relevant medical information, in confidence, to the medical adviser.
"Before contacting the DVLA or DVA, you should try to inform the patient of your intention to disclose personal information. If the patient objects to the disclosure, you should consider any reasons they give for objecting. If you decide to contact the DVLA or DVA, you should tell your patient in writing once you have done so, and make a note on the patient's record."
A slippery slope?
This is not the end of the doctor-patient relationship as we know it. It doesn't mean doctors have carte blanche to hand out information about their patients on a whim. No doctor wants to breach their patient's trust; it's fundamental to the long-term, tailored healthcare and advice a GP provides day in, day out. But it's also our duty as doctors to advise our patients and always make a decision based on clinical grounds, even if at times we reach a decision the patient may disagree with.
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