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DVLA Petition- Action for Diabetic Drivers

Sorry, but after a years convoluted grief with this uncaring, unregulated, under resourced & wholly diabolical institution....never again.
As far as Im concerned never will I disclose anything to them, & never will I report a hypo to a UK GP.
If I were a mass murderer (no intended pun) and confessed to a priest HE would not disclose this to anyone. If I were a similar mass murderer and consulted a solicitor or barrister THEY would not disclose to anyone either.
A degree of professionalism sorely missing from the NHS
 
Hypoglycaemia:

Nocturnal hypoglycaemia is not a phenomenon that is easy to explain, and yes the context of the problem of hypoglycaemia itself needs to be considered before DVLA should make a judgement on the issue. I am a GP and my family suffer a condition called Reactive Hypoglycaemia, hence my interest on this topic. My family also have a strong history of diabetes, usually reverting to Type 1 following a diagnosis of Type 2.


It has been well established that intensive insulin therapy (lower HbA1c) can cause a progressive increase in hypoglycaemic episodes in Type 1 diabetics (DCCT: N Eng J Med 1993; 329:977).


Considering this premise, it should not be too difficult to understand the physiology of hypoglycaemia in the Type 1 diabetic or strategies to reduce the risk. This should form the context for DVLA decisions on fitness to drive in Type 1 diabetics.


Put simply, in laymen terms, insulin causes the potential for hypoglycaemia and therefore all Type 1 diabetics are at risk regardless of documented episodes requiring outside assistance as I will explain below. There is debate on the cut-off value to diagnose hypoglycaemia. I would assume, in the home at least, a blood glucose measurement will be possible, but that is not always the case.


Whilst Type 1 diabetics have been trained to identify the early warning signs of hypoglycaemia, nocturnal hypoglycaemia is in a different category altogether. You are asleep, therefore it becomes irrelevant as you are not awake to identify the early warning signs. This is why I have started off with the physiologic basis of hypoglycaemia. Recently the Somogyi hypothesis has been disputed and it has been suggested that the reverse is true in that nocturnal hypoglycaemia is associated with morning hypoglycaemia and vice versa. With nocturnal hyperglycaemia (and morning hyperglycaemia) this often forms the basis for Type 2s converting to Type 1s (known as Type 2s treated with Insulin) etc.


During night time, most people will be asleep. If they were awake and developed hypoglycaemia requiring outside assistance, then the situation changes. The DVLA must be concerned with people who ‘lose awareness to hypoglycaemia’ and not ‘hypoglycaemia’ per se. Most people sleep on a night time and sleep hypoglycaemia should not fall under this category as no one who is asleep can have ‘awareness’ of hypoglycaemia and therefore be deemed to have ‘lost’ this awareness that is so critical for driving. The danger is if they fell asleep due to hypoglycaemia, as opposed to going to bed normally and then suffering a hypoglycaemic episode during night time which required assistance, would also result in a call to the paramedics etc. If you have been aroused and requested glucose gel from your partner, that forms the ‘assistance’ or even requested glucagon (if you have it prescribed), this is NOT reportable because this still suggests you have awareness.


The danger on the roads comes from diabetics who are not aware of hypoglycaemia. It is assumed that they are awake, hence the conscious decision to drive, but have lost the awareness to hypoglycaemia and therefore deemed high risk were they to become unconscious and become a danger to themselves as well as others.


“DVLA:

What is a reportable hypoglycaemic episode?

Hypoglycaemia requiring assistance from another person at any time of day or night constitutes an episode for reporting purposes. The requirement of assistance would include:

- admission to Accident and Emergency,

- treatment from paramedics,

- assistance from a partner/friend who has to administer glucagon or glucose because the person cannot do so themselves (the important point is ‘cannot’)


It does not include another person offering or giving assistance, in circumstances where the person was aware of his/her hypoglycaemia and able to take appropriate action independently.


ABCD2 recommends that primary care teams should consider referral to the specialist team for patients who have suffered a single hypoglycaemic attack requiring assistance, especially where a second episode might result in loss of employment.


What about nocturnal hypoglycaemia?

A significant change in the assessment criteria for fitness to drive is the inclusion of episodes of severe nocturnal hypoglycaemia. If it is suspected that severe nocturnal hypoglycaemia is present, but not witnessed or treated, this would not necessarily constitute an episode for reporting. However, if the clinician had concerns it may be appropriate to advise the person to notify the DVLA. Similarly, data gathered while using continuous glucose monitoring devices or other evidence of hypoglycaemia may not constitute evidence to stop driving in the absence of symptoms unless the clinician has concerns”


The DVLA has provisions for reinstating licenses once it can be proved that the risk has been adequately treated (we can never say the risk has been removed).


The ADA (American Diabetes Association) defines Severe Hypoglycaemia as an event requiring the assistance of another person to actively administer carbohydrate, glucagon etc. Whilst plasma glucose measurements may not be available during such an event, neurologic recovery attributable to restoration of glucose to normal is considered sufficient evidence that the event was caused by low plasma glucose concentration.


On the other hand documented symptomatic hypoglycaemia is defined by the fact that the plasma glucose has been monitored and the levels coincide with the local or national guidance on the cut-off for diagnosing hypoglycaemia. Other forms of hypoglycaemia consist of asymptomatic, probable symptomatic and pseudo-hypoglycaemia.


The UK Hypoglycaemia Study Group (Diabetologia. 2007;50(6):1140) as well as other studies have documented the fact that hypoglycaemia occurs frequently in Type 1 diabetics. The average patient suffers countless numbers of episodes of asymptomatic hypoglycaemia, two episodes of symptomatic hypoglycaemia per week, and one episode of temporary disabling hypoglycaemia per year. The category in which ‘outside help’ is sought, i.e. severe hypoglycaemia, represents a small fraction of the total hypoglycaemic experience.


Nocturnal Hypoglycaemia:

Prevention of nocturnal hypoglycaemia can be through snacks containing protein (J Clin Endocrinol Metab. 1996;81(4):1508). I note you are on an insulin pump, however a Sensor-augmented CSII using an insulin pump that stops infusing insulin for up to two hours when the sensor detects a predetermined low glucose level has been shown to reduce nocturnal hypoglycaemia (N Eng J Med. 2013 Jul;369(3):224-32).


Exercise – interestingly – is linked to hypoglycaemia unawareness by reducing autonomic symptom responses. Post-exercise hypoglycaemia can occur hours after exercise. Simple monitoring of blood glucose post-exercise and using the approach of protein snacks can help.


For insulin-dependent diabetics having pure glucose and perhaps a glucagon kit is essential to recovery. In severe hypoglycaemia (that which requires assistance) an ambulance must always be called.


Finally:

The question you need to answer is: How was this assistance given during the night? (using the DVLA guidance above). If you had woken up and asked for assistance, that is not the same as what DVLA should be recommending. In my opinion people who are asleep may develop asymptomatic hypoglycaemia but not necessarily severe hypoglycaemia – how would anyone know in time to give the ‘sleeping’ person with severe hypoglycaemia, glucose? Unless that person was not rousable for some reason and assistance had to be given in the context of the affected person not asking for such assistance. If your context is not indicative of severe hypoglycaemia because you asked your partner, then you did not require the assistance that is associated with the definition of severe hypoglycaemia requiring your driving license to be revoked. Usually, in such circumstances it would be the clinician (see guideline above) that would advise you to inform DVLA based on the history you provided. It appears that the Consultant disagrees with DVLA, so it may be that you have not filled the form in correctly by assuming you had a reportable episode of hypoglycaemia, when it may be that you did not have such a reportable episode. In such an instance, DVLA will send you a form to advise you to make your case – or state the context. Again, I will refer to the DVLAs own guidance again: The requirement of assistance would include: admission to Accident and Emergency, treatment from paramedics, assistance from a partner/friend who has to administer glucagon or glucose because the person cannot do so themselves.


In treating such people, often it is misunderstood that oral food containing sugar can be given, there is a risk of aspiration and hence dextrose GEL or even cake frosting in the space between the teeth and buccal mucosa keeping the patient’s head tilted slightly to the side is the safest method of administering glucose to a Type 1 diabetic (or a Type 2 on Insulin) suffering from hypoglycaemia. However lack of a dextrose gel should not prevent use of any type of sugary product available.
 
I wish you all the good luck in the world to get this sorted out. I have read several letters regarding the DVLAs draconian approach to people with diabetes giving perhaps too much info to them and thus making it very easy for them to just take a persons licence away. This in turn means that people will not admit things to them which could be dangerous to everyone. It has been quoted that people with diabetes are very careful drivers because due to our condition we have to be more thoughtful than most in everything we do. I am in a local group and will ensure that this is passed on so that your petition gains even more signatures. Hope you have a speedy successful outcome.
 
Hi. Control can become erratic after such 'stress'. See my response.
 
My licence was revoked last October - I hadn't even suffered from any hypos requiring somebody else's assistance, however my GP misread a letter from my constant and advised DVLA that I suffered from recurrent bouts of severe hypoglycaemia...I was just about to begin a course of chemoradiotherapy and really needed my car to get to and from my local hospital. It took 3 months and several letters from my endocrinologist - as DVLA stated my GP (who I do not receive any assistance from regarding my diabetes -in fact I'm not sure Ive ever spoken to him other than to request prescriptions) had a better knowledge of my day to day control..DVLA seriously need to look into how they deal with this issue...it was extremely stressful at a time when I really did NOT need any more stress...
 
@gpwsi - Thank you for your useful comments. Unfortunately I did have two severe hypoglycaemic episodes due to heat and stress that I required help during the night time from my partner. I would not have been able to have dealt with this hypo by myself. This is most unusual for me and hasn't happened before. However, my consultant still felt knowing this information that I was safe to drive.
@Biker Jimbo - Thank you for your kind words but also for passing this around your local group. If you would like posters etc let me know and I can send you some.
@evianfan1985 I'm sorry to hear you had such awful trouble, at a time you really didn't need. I hope this has been resolved completely although I appreciate that this is besides the point. Hope your doing well with your treatment.
 
Hi Helen,
all done, signed, shared on face book and linked hopefully many more people will help. Either that or I will keep annoying them until they do!
 

Anyone being told that they are having their treatment (test strips or medication) changed for cost reasons is being lied to,
it is boneheaded decisions by CCG's and some GP practices strictly following their instructions. Another one size fits all argument.

The costs for all NHS prescriptions are publicly available and can be extracted from the monthly Drug Tariff and the monthly BNF documents (BNF used to be via BNF.ORG its now at https://www.medicinescomplete.com/mc/bnf/current/ ), the England and Wales version of the Drug Tariff is at http://www.ppa.org.uk/ppa/edt_intro.htm (Scotland and Northern Ireland have similar documents) its currently 818 pages (pdf) 3.2 MB. The drug tariff is published 3 working days before the 1st of each month

The December 2014 prices for test strips are in appendix IXR page 624…
and range from £6.99 … £31.90 per item equivalent to 14p … 33p per test

Hypodermic equipment is in appendix IXA page 290…,

Insulins range from £5.61…£30.68 for 10ml vials (for syringes and pumps), Cartridges from £17.50…£72.00, prefilled pens from £19.80…£86.40
(with one exception cartridge and prefilled pens are 1500unit prescription packages)

That gives a range from £5.61 to £48.00 per 1000 units of insulin with Tresiba® being £20 more expensive than any other Insulin

Correct treatment of diabetes is always cheaper than treating the complications and consequences. So CCG's should never be dictating prescribing practises to GPs. Sometimes the consequences mean potentially losing ones job and being unable to work in the area one trained in. This would be a violation of one's human rights..
 
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Hi there. You have a right to treatment but that doesn't mean you have a right to choose which insulin you have. The cost issue is more important for test strips and NICE recommends cost effective strips. There has to be a discussion between you and your GP but this seldom happens and patients dictate their test strips. Glargine and rapid acting are advisable and mixed perhaps not. But each person is different.
 
Perhaps you should be looking at it from other peoples views and the safety of other road users. How would you feel if you had an attack and ran yur car into a child crossing the road, or failed to stop at a juncion and took another driver out. The DVLA revoked your licence for areason, because they thought you were a hazard on the road and couldnt take the risk of having someones death on their conscience wheras you possibly could. What is more important you not having to catch a bus or a human life. The DVLA have standards they work to and I agree with them.


All these people above saying tick NO are encouraging your dishonesty and you would be committing a criminal offence by LYING on a form that is a legal government document.

I too am diabetic and I drive. If the DVLA took my licence I wuld be graetful they had seen fit to takeanother step to prevent accidents.
 
Dear SafetY TraiN, I would like to suggest that you read the petition properly before accusing people wrongly in a very rude manner. I do not appreciate you saying that I can deal with the death of a child on my conscience when that simply is not true. If you had read the information correctly you would see that I did inform the DVLA of my nocturnal hypos and would never lie about my medical condition. I am concerned that this directive has and will encourage other individuals to not inform their Consultant or the DVLA and this is something I would strongly discourage. Everyone is entitled to their opinion and I respect this, however please ensure that you have the correct facts before making assumptions. Many thanks.
 

I think you've completely missed the point of the petition. The starter of the petition clearly stated that her license has been removed due to her honesty.

The people agreeing to the petition are signing all due to a unfair judgement. I don't assume you read through the information and back story provided on the change.org site, because if you had and had done so correctly, you would have seen that the GP had approved themselves that she was safe to drive. If a medical professional is saying that it is again, safe to drive how can the DVLA, whom will have a much lesser knowledge of the medical history of the campaigner deem it acceptable and unsafe?

This petition isn't simply about one person, it is about many who have been treated in the same way, I do agree that bad management of diabetes is a risk, obviously but this is a case where it cannot be so. The campaigner has had to leave her job as a medical professional because of these circumstances, as she is a medical professional herself, I'm sure her diabetes will be managed extremely well and the two instances of hypo's were simply an odd occurrence.

SafetY TraiN, I hope you do your research for the work that you do, because you clearly haven't done it in this case.
 


Dear Helen,

I'm sorry to read about your situation. I have signed the petition.

Have you been in touch with your MP and your MEP? If not, contact and get them on your side and get them fighting both the DVLA and EU bureau-twits.

All the best,
Conrad
 
Thanks you Conrad,

I have been in touch with as many people as possible, people must be sick of me! I'm written to several MP's and MEP's and have also written to Downing Street who put me in touch with someone within the DVLA who informed me about how this issue has been ongoing for some time and that the EU was having a meeting with REFIT to review things in November which has been helpful. I'm hoping that my MP will continue to support my campaign an push for answers. Thank you for signing and sharing the campaign it's really appreciated.
 
nobody is sick of you at all Helen -- I am really proud of you.
Us D's need to fight our corner.
 
Sorry, but this is a very old problem.
Happened to me in 2011, DVLA applying the EU law, even before it was supposed to be actioned!!
There was a young lad on here a couple of years ago, with a similar petition. I signed his.
I contacted The British Diabetic Association 4 years ago. They got nowhere then. It appears they havent got much further now!

What are you seriously hoping to achieve?
Change EU laws? Get real!
 
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