To disclose or not to disclose to the DVLA

Driver and vehicle licensing agency (DVLA) standards are used to inform decision-making on fitness to drive at work in occupational health (OH) practice [1]. The standards can also be used as a benchmarking tool for the risk of sudden incapacitation in other safety-critical duties. While DVLA reporting and the ethical challenges of this are covered in undergraduate and postgraduate medical training, clarity on how this applies in OH contexts is lacking. What is the role of the occupational physician in reporting workers to the DVLA if drivers do not notify the DVLA when required to by law?

The legal requirement of DVLA notification lies in the identification of a notifiable condition, even if the driver currently meets the required medical standards for fitness to drive. Notification should not be delayed by investigations. When the precise cause of an episode affecting fitness to drive cannot be determined, the DVLA will apply the medical standard according to the most likely cause. The legal duty to notify the DVLA lies with the driver. Clinicians have a professional obligation to ensure the driver is aware of the need to declare their medical condition. Failing to provide this advice would carry the potential for criticism from both the professional regulator and from coroner’s or fatal accident inquiries. While the General Medical Council (GMC) and General Optical Council explicitly document these professional expectations, other healthcare professionals often refer to GMC guidance as good practice.

The functional nature of an OH assessment can reveal information pertinent to safety of driving that may be unknown to the worker’s general practitioner (GP) or other treating clinicians. Therefore, it may be that the occupational physician is the first healthcare worker to recognize and raise the issue of DVLA notification. This dilemma can present when an OH assessment reveals that a worker must notify the DVLA and/ or stop driving, but they do not notify the DVLA and continue to drive to work or outside work, even if not permitted to drive at work. The usual remit of OH being bound by the work context is superseded by risk to others in the public. The clinician–worker relationship is different for physicians than treating clinicians and confidentiality takes on a different angle as employers are also involved. The OHP is not always able to fulfil all fiduciary obligations as in a typical therapeutic relationship, but most characteristics and duties of the doctor–patient relationship translate across settings [2]. OH teams can feel siloed when navigating this as there is generally less dialogue between occupational physicians and the worker’s treating teams than between a worker’s GP and specialist teams. Unless considering breaching confidentiality, communication from OH teams to the worker’s treating clinicians can only take place with their explicit consent [3].

The Faculty of Occupational Medicine (FOM) ethics guidance emphasizes that the duty not to disclose confidential information without consent is not absolute when disclosure is required by law or in the public interest [3]. Though risk to others from driving may be outside the workplace, it remains a risk, and OH physicians (OHPs) should refer to the GMC’s guidance on doctors’ responsibilities for fitness to drive [4]. The first step is referring to DVLA standards to determine fitness to drive and whether notification is required by law [1]. This is the legal responsibility of the driver under the Road Traffic Act 1988. If they do not notify the DVLA, the clinician can help arrange a second opinion and should make every reasonable effort to persuade them to stop driving if concerned they are not fit to drive. Doctors should tell the patient that they may be obliged to disclose relevant medical information about them to the DVLA if they continue driving when they are not fit to. If the patient continues to drive, the doctor must assess whether this presents risk of death or serious harm to others and decide on whether to contact the DVLA to inform them of any relevant medical information or concerns about fitness to drive without the patient’s consent. This is a breach of patient confidentiality in the public interest, and while it may be an ethical and professional duty for a clinician to breach confidentiality to notify the DVLA, it is not a legal duty. There are some statutes that require disclosure of confidential information where this would otherwise be a breach [5], and while some have suggested making breaching confidentiality for DVLA disclosure mandatory [6], this is not currently the case. Good practice is to inform the patient of the upcoming disclosure, consider any reasons for objecting they may have, and if proceeding with disclosure disclose to the DVLA, they should inform the patient of this in writing. Breaching confidentiality to the employer about fitness to drive may be necessary in the public interest depending on the worker’s role.

All four ethical principles are involved. Autonomy, in the doctor’s duty to respect the patient’s choices and their confidentiality. Beneficence and non-maleficence in weighing up what is the overall best and least harmful outcome for the patients and the public. Finally, justice, in the duty for doctors to practice consistently safely and fairly and promote a just and healthy society for all. The GMC encourages doctors to weigh the potential harm to the patient and others of non-disclosure against the potential harm to the patient and others in breaching confidentiality. This includes any potential risk the patient will disengage with healthcare. In an occupational context, driving may be a worker’s only means of transport to work. Stopping them from driving could have negative psychosocial consequences and a wider financial impact [7]. The GMC suggests potential harm to the public could include a negative impact on trust in doctors more widely. In the occupational context, the social and financial consequences to society in general if the worker can no longer get to work and do their job are another consideration.

The GMC states that if a patient’s refusal to stop driving leaves others exposed to risk of death or serious harm, the doctor should contact the DVLA to disclose relevant medical information. Given an OHP is not the treating clinician (in most settings) they must usually accept that another clinician or team has clinical responsibility for the worker. Yet, FOM Ethics guidance emphasizes that once clinical responsibility is assumed by an OHP, it is not relinquished until it is handed over to an appropriate colleague [8]. It may be that an OHP is the only medical professional who has recognized that an individual continues to drive while unfit and must lead in addressing this. If a worker reports they have previously discussed driving with their treating team, and the OHP is still concerned guidelines are not being followed, they cannot exonerate themselves of this clinical and ethical responsibility until satisfied the issue of driving has been appropriately addressed.

Maintaining boundaries between the OHP role and a treating role can be achieved if the worker can be signposted to their treating team or GP for support with navigating DVLA notification outside of the work context. Given public safety is a concern, it is likely to be appropriate to seek permission from the worker to communicate with their treating specialist team or GP, or to ask the worker to share correspondence from the DVLA to ensure the issue is adequately addressed. This would satisfy the FOM guidance around secure handover of clinical responsibility and could also serve as a second opinion recommended by the GMC.

If a worker does not consent to the concerns around their fitness to drive to be shared and handed over to with their treating team, the OHP retains clinical responsibility and must refer to the GMC guidance for doctors to disclose relevant information without consent to the DVLA. Prior to breaching confidentiality doctors can seek advice from a senior colleague, the DVLA’s medical advisor and their indemnity provider. Indemnity providers may not always be familiar with how OH roles differ from therapeutic roles. Education on this is necessary for consistency of support for OH clinicians navigating these ethical dilemmas. Clinicians can find it challenging to get the support they need from medical indemnity providers. Similarly, clinicians can be more personally and professionally exposed to scrutiny than the DVLA as the regulator. Drivers who have had their confidentiality breached in the public interest may raise concerns with the GMC, which can put the clinician into multiple jeopardy around the potential professional, legal and financial implications of this.

Once notified, the DVLA will commence medical enquiry. If a clinician considers a driver unfit, this should be explicit in communication with the DVLA for their license to be revoked or refused immediately. Otherwise, they will retain legal driving entitlement during the enquiry. Most notifications result in drivers retaining their license, even if restrictions are added. Only 10% of notifications result in revocation of a license or refusal of license application. If the worker’s only means of transport to work is driving, OH clinicians should recommend ways to reduce the impact of being unable to drive on the worker and those around them. This can include signposting the worker and their manager to Access to Work to apply for funding to pay for alternative transport to work, adaptations such as options for remote working and redeployment on medical grounds [9].

The challenges of navigating fitness to drive illustrate the interface between health, function and risk. The impact of this on work and health for the individual and those around them is an example of the value of OH services to society and the disadvantage faced by workers that cannot access this support.

Acknowledgments

The authors would like to thank Nick Jenkins, Driver and Vehicle Licensing Agency.

Funding

Imperial College London is grateful for support from the NIHR Applied Research Collaboration NW London. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.