Appendix to the assessing fitness to drive guide for medical professionals.
Appendix A: The legal basis for the medical standards
The Secretary of State for Transport, acting through the 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:
- European Commission’s Third Directive on driving licences (2006/126/EC) – which came into effect here on 19 January 2013
- Road Traffic Act 1988
- Motor Vehicles (Driving Licences) Regulations 1999 (as amended).
According to Section 92 of the Road Traffic Act 1988:
- A relevant disability is any condition which is either prescribed (by Regulations) or any other disability where driving is likely to be a source of danger to the public. A driver who is suffering from a relevant disability must not be licensed, but there are some prescribed disabilities where licensing is permitted provided certain conditions are met.
- Prospective disabilities are any medical conditions that, because of their progressive or intermittent nature, may develop into relevant disabilities in time. Examples are Parkinson’s disease and early dementia. A driver with a prospective disability may be granted a driving licence for up to 5 years, after which renewal requires further medical review.
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.
‘Serious neurological disorders’
Changes to Annex III of the EC Directive 2006/126/EC require 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 the 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:
- Chapter 1, neurological disorders
- Chapter 4, psychiatric disorders
- Chapter 6, visual disorders
- Chapter 8, miscellaneous conditions – excessive sleepiness
Appendix B: Epilepsy regulations and further guidance
The legislation governing drivers with epilepsy
The following two boxes extract the paragraphs 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).
Group 1 car and motorcycle
(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) 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 1 year immediately preceding the date when the licence is granted
b) during that 1 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 seizure – which can include a medication-adjustment seizure – falling within only one of the:
a) permitted patterns of seizure
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
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) immediately above, where:
i. that earlier seizure has, to that point, formed part of only one permitted pattern of seizure and has 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 1 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 1 year before the date when the licence is granted ii. here 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 1 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:
a) who: i. in a case where there is an underlying causative factor that may increase future risk, has had such a seizure more than 1 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) who has had no other unprovoked seizure since that seizure
c) who satisfies the condition set out in paragraph (2F).
(2F) The conditions mentioned immediately above 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) immediately above
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.
Group 2 bus and lorry
(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 mentioned immediately above 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.
Withdrawal of epilepsy medication
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 satisfy driving licence regulations 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 epilepsy regulations 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:
- When changing from one medication to another and both would be reasonably expected to be equally efficacious, then no period of time off driving is recommended.
- When the new medication is felt to be less efficacious than the previous medication, the 6 months off driving period is recommended. This time period would start from the end of the change over period.
For Group 1 car motorcycle, and possibly Group 2 bus and lorry categories, provoked or acute symptomatic seizures may be dealt with on an individual basis by the DVLA if there is no previous unprovoked seizure history.
Unprovoked seizures associated with alcohol or drug misuse, sleep deprivation or a structural abnormality are not considered provoked for licensing purposes. Similarly, reports of seizure as a side-effect of prescribed medication will not be considered as provoked and will require 6 months off driving for Group 1 driving and 5 years for Group 2 licensing. Multiple medication-induced seizures would not normally be classified as epilepsy for the purposes of driver licensing.
For seizure with alcohol or illicit drugs, see Drug or alcohol misuse or dependence.
Doctors may wish to advise patients that the likely total period of time they will be required by the DVLA not to drive will be influenced by, among other things:
- whether it is clear that the seizure has been provoked by a stimulus that does not convey any risk of recurrence and does not represent an unmasking of an underlying liability
- whether the stimulus has been appropriately managed or is unlikely to occur at the wheel.
In the absence of any previous seizure history or previous cerebral pathology, the following seizures may also be treated as provoked:
- eclamptic seizures
- reflex anoxic seizures
- seizure in the first week following a head injury
- at the time of a stroke, TIA, or spontaneous acute subdural haematoma or within the ensuing 24 hours
- during intracranial surgery or the ensuing 24 hours
- associated with severe electrolyte disturbance.
Appendix C: Cardiovascular considerations
Group 1 car and motorcycle and Group 2 bus and lorry entitlements
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.
Group 2 bus and lorry entitlement only
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.
Exercise tolerance testing
The DVLA no longer requires regular anti-anginal medication (i.e. nitrates, bete blockers, calcium channel blockers, nicorandil, ivabradine and ranolazine) to be stopped prior to exercise tolerance testing. The requirements for exercise evaluation are:
- The test must be on a bicycle (cycling for 10 minutes with 20 W per minute increments, to a total of 200 W) or treadmill.
- The patient should be able to complete 3 stages of the standard Bruce protocol or equivalent safely, while remaining free of signs of cardiovascular dysfunction, viz:
- angina pectoris
- sustained ventricular tachycardia
- There must be no electrocardiographic ST segment shift (usually of not more than 2 mm horizontal or down-sloping) that is interpreted by a cardiologist as indicative of myocardial ischaemia, either during exercise or the recovery period.
Should atrial fibrillation develop de novo during exercise testing, the licensing requirements will be the same as for individuals with pre-existing atrial fibrillation – that is, provided all the DVLA exercise tolerance test criteria above are met, licensing will be subject to echocardiogram and confirmation of left ventricular ejection fraction of at least 40%.
The DVLA will require exercise evaluation at regular intervals not to exceed 3 years if there is established coronary heart disease.
Chest pain of uncertain cause (angina not yet excluded)
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.
Stress myocardial perfusion scan or stress echocardiography
When the DVLA requires these imaging tests, the relevant licensing standards are as follows, provided the LV ejection fraction is 40% or more:
- no more than 10% of the myocardium is affected by reversible ischaemic change on myocardial perfusion imaging
- no more than one segment is affected by reversible ischaemic change on stress echocardiography
Full DVLA protocol requirements for these tests are available on request (see contact details).
For licensing purposes, the 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 the 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%.
Hypertrophic cardiomyopathy and exercise tolerance testing
For the purpose of assessing hypertrophic cardiomyopathy, the DVLA would consider an exercise tolerance test (see above) falling short of 9 minutes acceptable provided:
- there is no obvious cardiac cause for stopping the test in under 9 minutes
- there is a rise of at least 25 mm Hg in systolic blood pressure during exercise testing
- all other requirements are met as outlined under hypertrophic cardiomyopathy.
Marfan syndrome: aortic root replacement
The DVLA will refuse or revoke a licence if there has been:
- emergency aortic root surgery
- elective aortic root surgery associated with complications or high risk factors – for example, aortic root, valve and arch (including de-branching) surgery, external aortic support operation
A bus or lorry licence for annual review may be issued in elective aortic root replacement surgery provided:
- surgery is successful without complications
- there is satisfactory regular specialist follow-up
- no evidence of suture-line aneurysm postoperatively and on 2-yearly MRI or CT surveillance following valve-sparing surgery for root replacement plus valve replacement.
Severe aortic stenosis (to include sub-aortic and supravalvular stenosis, any RVOT obstruction)
‘Severe’ is defined (European Society of Cardiology guidelines) as:
|aortic valve area||– less than 1cm²
– less than 0.6 cm²/m² body surface area (BSA)
|mean aortic pressure gradient||– greater than 40 mmHg|
|maximum jet velocity||– greater than 4 metres/second.|
Introduction of the ESC HCM Risk-SCD Calculator
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%).
Appendix D: INF188/2 leaflet
Appendix E: Important notes concerning psychiatric disorders
All mental health symptoms must be considered
Any psychiatric condition that does not fit neatly into the classifications in Chapter 4 will need to be reported to the DVLA if it is causing or is considered likely to cause symptoms that would affect driving.
Such symptoms include, for example:
- any impairment of consciousness or awareness
- any increased liability to distraction
- or any other symptoms affecting the safe operation of the vehicle
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 Third Driving Licence Directive 2006/126/EC requires member states to set minimum medical standards of fitness to drive and sets out the requirements for mental health in broad terms:
- the laws make a clear distinction between the standards for Group 1 car and motorcycle, and Group 2 bus and lorry licensing. The standards for the latter are more stringent because of the size of the vehicles and the greater amounts of time spent at the wheel by occupational drivers
- severe mental disorder is a prescribed disability for the purposes of section 92 of the Road Traffic Act 1988. Regulations define “severe mental disorder” as including mental illness, arrested or incomplete development of the mind, psychopathic disorder, and severe impairment of intelligence or social functioning
- the laws require that standards of fitness to drive must reflect, not only the need for an improvement in the mental state, but also a period of stability, such that the risk of relapse can be assessed should the patient fail to recognise any deterioration
- misuse of or dependence on alcohol or drugs are cases that require consideration of the standards in Chapter 5 in addition to those for psychiatric disorders in Chapter 4.
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.
- All drugs with an action on the central nervous system can impair alertness, concentration and driving performance
- This is of particular relevance at the initiation of treatment, or soon after, and also when dosage is being increased. Anyone who is adversely affected must not drive.
- It should be taken into account when planning the treatment of a patient who is a professional driver that the older tricyclic antidepressants can have pronounced anticholinergic and antihistaminic effects, which may impair driving, whereas the more recently developed antidepressants may have fewer such effects
- Antipsychotic drugs, including depot preparations, can cause motor or extrapyramidal effects as well as sedation or poor concentration. These effects, either alone or in combination, may be sufficient to impair driving, and careful clinical assessment is required.
- The epileptogenic potential of psychotropic medication should be given particular consideration in patients who are professional drivers.
- Benzodiazepines are the psychotropic medications most likely to impair driving performance – the long-acting compounds in particular – and alcohol will potentiate effects
- Doctors have a duty of care to advise their patients of the potential dangers of adverse effects from medications and their interactions with other substances, especially alcohol
The likely severity of the underlying condition requiring electroconvulsive therapy (ECT) means the driver should be advised that they must notify the 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:
- severity of the underlying illness requiring ECT treatment
- potential cognitive or memory disturbances associated with both the underlying depression and the ECT therapy
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.
Appendix F: Disabilities and vehicle adaptations
Group 1 car and motorcycle
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:
- permanent limb and spinal disabilities – for example, amputation, hemiplegia, cerebral palsy, ankylosing spondylitis, or severe arthritis (especially with pain)
- chronic neurological disorders – for example, multiple sclerosis, Parkinson’s disease, motor neurone disease, or peripheral neuropathy
Vehicle adaptations range from simple automatic transmission for many disorders, to sophisticated modifications such as joysticks and infrared controls for people with severe disabilities.
The 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 can hold a driving licence from 16 years of age. (A person can’t apply for PIP until their 16th birthday.)
Group 2 bus and lorry
Some disabilities, if mild and non-progressive, may be compatible with driving large vehicles. The DVLA needs to be notified and will require an individual assessment.
Mobility scooters and powered wheelchairs
Users of Class 2 or 3 mobility vehicles – which are limited on the road to 4 mph or 8 mph – are not required to hold a driving licence, and they do not need to meet the medical standards for driving motor vehicles. The DVLA recommends the following, however:
- individuals with a medical condition that may affect their ability to drive these mobility vehicles should consult their GP first
- users should be able to read a car number plate from a distance of 12.3 metres
For more information, see Mobility scooters and powered wheelchairs: the rules.