Member dilemma
‘I am treating a patient for alcohol misuse. He has attended the surgery on a number of occasions under the influence of alcohol. The surgery is in a fairly rural location and I am concerned the patient may be driving himself to the surgery when over the legal limit for safe driving. I am concerned for the safety of the patient and others on the road, but I also do not want to betray the trust I have built up with the patient. Do I have an obligation to report the patient?’
This is a common query received by the Medical Protection advice line, but one which has clear guidance from the Medical Council and National Driver Licence Service (NDLS). NDLS is responsible for issuing, renewing, suspending, withdrawing, refusing or cancelling a person’s driving licence. Licensing decisions are based on a full consideration of relevant factors relating to the driver’s health and driving performance record. This means they will need to know if a driving licence holder has a condition that affects their safety as a driver.
National Driver Licence Service guidance
The NDLS has produced guidance entitled Medical Fitness to Drive Guidelines. The NDLS makes clear that a driver should advise the NDLS of any long-term or permanent injury or illness that may elevate risk of impairment while driving. Therefore, if you have informed a patient of their obligation to inform the NDLS, you do not have an absolute obligation to inform them yourself.
However, one of the responsibilities of the health professional is ‘to report to the NDLS regarding a person’s fitness to drive in the exceptional circumstances where there is a risk to the public and the driver cannot or will not cease driving.’
Medical Council’s guidance on confidentiality
As you are aware, you do have a duty of confidentiality towards your patients. However, there are instances where your duty of confidentiality can be overridden in the public interest.
In the Guide to Professional Conduct & Ethics, the Medical Council has published guidance relating to ‘disclosure without consent’ (paragraphs 31.1 to 31.3). The paragraph relating to public interest disclosures is particularly relevant:
Disclosure in the public interest may be made to protect the patient, other identifiable people, or the community more widely. Before making a disclosure in the public interest, you must satisfy yourself that the possible harm the disclosure may cause the patient is outweighed by the benefits that are likely to arise for the patient or for others. You should disclose the information to an appropriate person or authority, and include only the information needed to meet the purpose.
The Medical Council also advises that when you disclose information in the public interest, you should inform patients of the disclosure, unless this would cause them serious harm, or would undermine the purpose of the disclosure.
Advice
In the circumstances, the preferable option would be to clearly advise the patient of the risks, and advise the patient on medical fitness to drive in line with the relevant section within the NDLS guidance on alcohol misuse. In addition the patient should be advised that they should inform the NDLS of their condition.
If the patient continues driving despite appropriate advice and is likely to endanger the public, then the guideline’s section dealing with ‘Confidentiality, privacy and reporting to the NDLS’ outlines the factors to take into account when considering whether to report directly to the NDLS.
Before contacting the NDLS directly, you should try and obtain the patient’s consent to do so. The driver should be fully informed as to why the information needs to be disclosed to the NDLS, and be given the opportunity to consider this information. Failure to inform the driver could exacerbate mistrust in the patient–professional relationship. If the patient objects to the disclosure, you should consider any reasons they give for objecting.
If, following discussion with the patient, you decide not to inform the NDLS, then you must be able to justify the non-disclosure if called upon to do so. You should fully document your reasons as to why you are satisfied that the patient understands their obligations, and make a comprehensive note of your discussions.
If the patient withholds their consent, then you would need to decide whether or not your duty of confidentiality is outweighed by a public interest justification for disclosure. If you decide to contact the NDLS, you should tell the patient in writing once you have done so, and make a note on the patient’s record.
Irrespective of the outcome of the discussion, it is imperative to make comprehensive notes in the medical records to ensure you can justify the decisions made at a later date if required.