Diabetes UK Position Statement
DRIVING AND DIABETES

Key points
Changes resulting from an EC directive have led to the introduction of stricter rules for drivers of cars and motorcycles (Group 1 vehicles) when people treated with insulin apply or reapply for licences.

In contrast, the ban on people treated with insulin driving lorries and passenger carrying vehicles (Group 2 vehicles) has been lifted. These drivers can now apply for a licence, but must have an annual independent medical assessment to prove their fitness to drive, which includes providing evidence of safe glycaemic control based on frequent and regular meter readings.

Diabetes UK generally welcomes the changes for Group 2 licences as we do not believe in blanket bans and have always campaigned for people to be individually assessed for their fitness to drive.
However, Diabetes UK has concerns about aspects of the changes to the rules for Group 1 licences and we are working with the DVLA to address these and ensure that people with diabetes are not unfairly discriminated against in the licence application process.

Introduction

Diabetes UK has always campaigned to ensure that people with diabetes are assessed fairly for their fitness to drive. We believe that all people with diabetes should be able to drive if they can prove their medical fitness. We maintain that people with diabetes pose no greater risk than other drivers and indeed there is no compelling evidence to suggest that they are more likely to have an accident than other drivers provided they take all necessary precautions. A review of the evidence for the European Working Group on Diabetes and Driving (1) found that any differences in risk were small compared with the differences in risk seen in the general population. A study in the UK (2) concluded that people using insulin did not pose a greater risk than the general driving population. There is some evidence, however, that recent severe hypoglycaemia or hypoglycaemic unawareness may be a predictor for future accidents (3).

Diabetes UK agrees that a person with diabetes should not be issued a licence if they cannot prove their medical fitness to drive. However, they should always be given the right to undergo assessment and the right to challenge a decision if their licence is revoked.

Diabetes UK advises people with diabetes on driving safely, in line with DVLA advice.

Current DVLA driving guidelines and restrictions for people with diabetes.

There are no restrictions for people who are on medications that do not cause hypoglycaemia.

People must inform the DVLA:

• If they use insulin or start to use insulin when they already have a licence 
• If their condition changes; for example, if they develop complications which can affect their ability to drive such as retinopathy resulting in visual problems, or peripheral neuropathy (loss of sensation in the feet due to nerve damage), or a stroke interfering with sight, muscle strength or balance or other serious medical condition – even if their diabetes is not treated with insulin . 
• If they require laser treatment for retinopathy in both eyes (or in the remaining eye if they have sight in only one eye) . 
• If they are experiencing recurrent severe hypoglycaemia (whether treated by medication or insulin) – see below. 

People who have group 1 licences and are using sulphonylureas which may cause hypoglycaemia are not expected to inform the DVLA that they are treated by these medications and are not issued with a restricted licence.

Group1 vehicles – cars and motorcycles

For insulin users licences for cars and motorcycles (Group 1) are issued for one, two or three years, depending on the individual person’s medical condition.

Driving licences can be revoked or not issued if a person has recurrent severe hypoglycaemia, which is defined by the DVLA as ‘more than one episode of hypoglycaemia during a period of 12 months that required assistance from another person’. (This means 2 or more episodes in a 12 month period).

Licences may also be revoked if someone has impaired awareness of hypoglycaemia and the DVLA require this if there is complete unawareness. Whilst the DVLA guidance does not define hypoglycaemia or hypoglycaemia unawareness, the Association of British Clinical Diabetologists (ABCD) has published guidance on this.

This states that as there is evidence for cognitive dysfunction around 3mmol/L, people who are asymptomatic when under this glucose concentration are at risk for impaired performance without awareness.

Given the inter-person variability for this and the margin for error in home glucose monitoring, a clinical assessment is advised (4).

Whilst people are not required to notify the DVLA if they are taking tablet medications that can cause hypoglycaemia (most commonly sulphonylureas see http://www.diabetes.org.uk/Guide-to-diabetes/Living_with_diabetes/Driving/Hypoglycaemia/), they must inform the DVLA if they have experienced more than one severe hypoglycaemic episode in 12 months due to these medications.

Group 2 vehicles (LGVs and PCVs)

From November 15th 2011 the blanket ban for insulin users for Group 2 vehicles – which includes lorries (large goods vehicles - LGVs) and passenger carrying vehicles (PCVs) was lifted. People being treated by insulin are now allowed to apply for a Group 2 licence providing they meet strict medical criteria and can demonstrate that they have adequate control of the condition with regular blood glucose monitoring. People with Group 2 vehicle licences who are treated with insulin will have to undergo annual independent medical assessments and show three month’s worth of blood glucose test results recorded on a memory blood glucose meter to demonstrate that their diabetes is adequately controlled.

People who start taking insulin to treat their diabetes (or who are newly diagnosed with Type 1) will need to take at least a three month break from driving Group 2 vehicles in order that they can show three months of blood glucose readings recorded on a memory meter to demonstrate that their diabetes is well controlled.

Concerns and implications

Group 1 licences

New standards for assessing fitness to drive for people with diabetes mean that people may have their licences revoked if they have recurrent severe hypoglycaemia. Recurrent means more than one episode in a 12 month period and severe is defined as “requiring assistance from another person”.
People can also have licences revoked if they have reduced awareness of the warning signs of hypoglycaemia.
 
Diabetes UK has concerns about the way that these new standards are being implemented. It is important that people recognise that most hypoglycaemia is not severe and can be easily treated by the person themselves. It is only if the assistance is actually needed, because the person is unable to manage themselves, that would count as a reportable episode.
If assistance is offered and received, but not
needed, this would not be reportable. People can also experience severe hypoglycaemia on a temporary basis due to illness or an underlying condition that is resolved.
We also have concerns about the inclusion of severe night-time hypoglycaemia in the reportable incidents as the evidence for the impact that night-time hypoglycaemia has on driving is not clear.

Diabetes UK is aware that some people are putting their health at risk in order that they do not risk losing their driving licence; for instance by keeping their blood glucose high to avoid hypoglycaemia.

Diabetes UK is also concerned about the impact that the changes in the regulations for Group 1 drivers are having on the relationship between people with diabetes and their health care professionals. There are concerns that people will not report severe hypoglycaemic events or reduced awareness of hypoglycaemia (both of which can often be addressed with medical advice) as this could put their licence at risk.
We are working with the DVLA to ensure that the standards are communicated clearly and interpreted correctly by people with diabetes and health professionals in order that people are not needlessly having licences revoked or experiencing delays in getting their licences re-issued.

We are also working with the DVLA to monitor the impact of the changes on people with diabetes and road safety. .
We are also working in the UK and Europe to monitor the impact of the changes on drivers with diabetes.

Group 2 licences.

Diabetes UK believes that insulin users should be subject to rigorous individual medical assessment to prove their medical fitness to drive lorries and buses and has welcomed the changes that remove a blanket ban for people on insulin driving these vehicles.

Diabetes UK is concerned that, under the new rules, people who are newly diagnosed with Type 1 or those with Type 2 who are moving to insulin will have to take a break of up to six months from driving Group 2 vehicles in order to go through the licensing procedure. This will be difficult for some vocational drivers.

Diabetes UK calls to action

DVLA / Department of Transport should monitor the implementation of the changes and regularly publish how many people with diabetes are having their licences revoked and the reasons why.

DVLA / Department of Transport should monitor the impact of the changes on road safety.
DVLA should improve the guidance given to people with diabetes and to healthcare professions about the driving licence application and renewal process in order that it is fair and transparent.

DVLA should publish data showing how they currently meet targets for issuing and renewing medically restricted driving licences and take steps to reduce the delays experienced by people with diabetes when applying and reapplying for driving licences.

Conclusion

Diabetes UK is working with the DVLA to improve the process for people with diabetes applying for driving licences and to monitor the impact of the changes. We will continue to work to ensure that the process is fair and transparent.
People with diabetes should be advised not to drive
• if they have just started to take insulin and their diabetes is not yet properly controlled
• if they have difficulty in recognising the early symptoms of hypoglycaemia
• if their blood glucose level is less than 4.0 mmol/l or they feel hypoglycaemic