Acting in the public interest: driving a clear message

The link between driving and vision has been in the news again. How do you balance their duty of acting in the public interest with that of ensuring patient confidentiality? Our Clinical Adviser examines the issues.

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Author: Daniel Hardiman-McCartney MCOptom, Clinical Adviser 
Date: 20 December 2017

Driving and vision has been in the news again. The ‘Don’t swerve a sight test’ campaign by the AOP was a call to action for drivers, and the recent publication of the driving and vision report by the GOC explored stakeholders’ views of the current system and how well the public is protected. Both revealed that practitioners are reluctant to act in the public interest to disclose to the DVLA patients who continue to drive and who did not, or who were highly likely not to meet the required vision standards for driving. 

Why might this be? Is it that practitioners don’t know they can breach confidentiality, is it that on balance their professional judgment is that a breach of confidentiality is unjustified, or is it some other reason entirely? I have spoken to some to some practitioners who say they are unsure as to their responsibility and others who feel for the devastating consequences on their patient’s independence, and look for any reason possible to justify a non-disclosure, be that doubt as to the repeatability of tests or ambiguity about whether the patient is driving.

Driving is not an absolute right, and it is subject to various safeguards in order to keep the roads safe.

The utility of car travel and the freedom it brings is essential to many people and, beyond the necessity, driving is often considered symbolic of a person’s independence. However, driving is not an absolute right, and it is subject to various safeguards in order to keep the roads safe. One, in particular a person’s fitness to drive, has particular relevance to optometrists. Optometrists in the UK have never been asked or designated to be the gate keepers of vision standards for standard car drivers; in fact they still are not. You can gain a driving licence and drive your entire life without ever setting foot into an opticians’ practice. The UK has, and still adopts, the simple test of reading a number plate when you take your driving test, and then an ongoing process of self-declaration; this applies not just for vision but for all fitness and health impairments. Yet, over the last five years, there has been increasing pressure on optometrists to protect the public from those drivers whose vision falls below the required standard and the DVLA has recently indicated to the GOC that a statement from the regulator would provide clarity for all registrants and a consistent approach with other medical regulators, and recent minutes from the GOC indicate that it will produce guidance in due course. In the meantime, the College’s Guidance for professional practice has been cited by the DVLA along with the GMC’s guidance on this subject as offering clear guidance to medical professionals.

Visual acuity
The visual acuity standards can be found on page 94 of the DVLA fitness to drive guide.

Visual fields
The visual field standards can be found on page 95 of the DVLA fitness to drive guide.

The visual field requirements relate to the binocular Esterman visual fields test, which is beyond the scope of a routine sight test and most eye examinations.  If there is a declared history of injury or a medical condition which may affect a binocular field of vision, such as glaucoma, you should inform your patient that they must inform the DVLA who will arrange a suitable field of vision test. If you do offer the binocular Esterman test, you should be aware of the specific DVLA requirements. Due to the subjective nature of the test, borderline findings may not be duplicated on appeal.

What I should do in practice?

Our guidance (A223) states that if you conclude a patient is unfit to drive, you should:

  • first tell the patient that they are unfit to drive and give the reasons. You may wish to discuss your concerns with a relative or carer, if the patient consents to this
  • tell the patient that they have a legal duty to inform the DVLA or DVA about their condition
  • put your advice in writing to the patient
  • record your advice and keep a copy of any correspondence to the patient on the patient record, and 
  • notify the patient’s GP, if appropriate, with the patient’s consent.

Fortunately, most people would not want to drive if they did not meet the required standard and are not legal to do so, and so informing them helps them to avoid committing an offence and possibly having their insurance invalidated.

If a patient declares to you that they will continue to drive, or you discover they are continuing to drive against your advice, it is absolutely appropriate to break a patient’s confidentiality in order to act in the public interest (A223). And I would argue it is also a practitioner’s moral obligation to both our patients and the communities we serve. If you conclude acting in the public interest outweighs the duty of confidentiality, you should:

  • notify the appropriate authority in writing (DVLA in England)
  • notify the patient’s GP of the action being taken, and
  • notify the patient, if appropriate. 

(Read this in our guidance A225, A226 and C85)

Secondly, disclosing to the DVLA that a person is borderline and may not meet the required visual standard is not the same as taking away a person’s ability to drive. It is activating a process when the DVLA will make the assessment as to whether a person’s vision meets the required standard.

Finally, it is for the patient to assure themselves that they are fit to drive. Optometrists should put their findings in writing following a discussion with the patient during the sight test. When asked for an opinion about a patient’s fitness to drive, an optometrist should explain the likely outcome of a DVLA assessment, referring to the current standards found in the DVLA assessing fitness to drive document.  

When drivers continue to drive contrary to advice and are therefore a threat to the safety of others, or you have reasonable grounds to believe they have not informed the DVLA, you may breach your duty for confidentiality and disclose your findings to the DVLA using their telephone advice line or in writing. You may do this as the break in confidentiality is to protect the safety of other road users and you are acting ‘in the public interest’, potentially preventing your patient from causing a car accident and injury because of their defective eyesight. To complicate matters, the accuracy of the test chart and visual acuity test should be considered. A recent paper found that drivers with a VA of 6/7.5 or better could be advised they meet the required standard, but those with vision 6/9 to 6/12 may or may not be able to read a number plate at the required distance. So, the test itself has limitations and this may influence your judgement.

Knowing the visual standards is the easy bit. However, applying them to clinical practice is more challenging. Understanding that there is no absolute right to confidentiality just as there is no absolute right to a driving licence means that practitioners should consider their duty of confidentiality alongside the need to act in the public interest. In such cases, there is plenty of guidance and support available from the both the College and representative bodies such as the AOP to ensure you follow the correct procedure.  Making the right decision in these cases may be a tough call, and result in some significant consequences for your patient. This is why it is always a good idea to discuss such cases with your colleagues and, if you would find it helpful, to phone the clinical advice line to talk through a case with an impartial colleague.    

Watch our ethical scenario video on confidentiality and driving.   

 

DVLA contact information
Notification can be provided by healthcare professionals in the above circumstances, in confidence:
E: medadviser@dvla.gsi.gov.uk
T: 01792 782337
Medical Business Support, D7, West DVLA, Swansea, SA6 7JL

 

FURTHER READING:

College Guidance for professional practice

Examining patients who drive (A218-A226)

Disclosing information about adults without their consent (C85)

DVLA

Assessing fitness to drive – a guide for medical professionals

AOP

Don’t swerve

GOC Vision and Driving

Final report C36(17)

Box E,. Gandolfi, J. (2010) Maintaining safe mobility for the ageing population RAC Foundation

Latham, K,. Rae, S. (2014) Advising patients on visual fitness to drive: implications of revised DVLA regulations British Journal of Ophthalmology

Daniel Hardiman-McCartney MCOptom
Clinical Adviser, College of Optometrists

Daniel graduated from Anglia Ruskin University, where he won the Haag Strait prize for best dissertation. Before joining the College, he was Managing Director of an independent practice in Cambridge and a visiting clinician at Anglia Ruskin University. He has also worked as a senior glaucoma optometrist with Addenbrooke’s Hospital in Cambridge and as a diabetic retinopathy screening optometrist. Daniel was a member of Cambridgeshire LOC from 2007 to 2015 and a member of the College of Optometrists Council, representing its Eastern region, from 2009 to 2014.  

Daniel has an interest in the effects of vision in art and is known throughout the industry as a passionate advocate of iconic and artisan eyewear. He currently practises part time in independent practice, is a locum, a glaucoma specialist optometrist across East Anglia with Newmedica and is clinical adviser to the College of Optometrists.

 

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