§ Mr. George Howarth (Knowsley, North)
I should first like to express my gratitude for the opportunity to have this debate today. The Minister will be aware that, on 12 July 1994, I introduced the Unfitness to Drive on Medical Grounds Bill under the ten-minute rule. The purpose of the Bill was to place a statutory obligation on medical practitioners to report cases to the Driver and Vehicle Licensing Agency when they considered a patient to be medically unfit to drive. As is usually the case with ten-minute Bills, mine did not receive a Second Reading.
My reasons for introducing the Bill arose from the tragic death of a young constituent, Paul Scarisbrick, in a road traffic accident on the M62 in Liverpool. The circumstances of Paul's death illustrate my argument. The accident occurred because a 73-year-old man, Mr. Abrams, who was suffering from Alzheimer's disease, took the wrong turn and ended up driving the wrong way along the M62. The outcome was that his vehicle collided with Paul's vehicle, and Paul was killed.
It emerged at the coroner's inquest that Mr. Abrams and members of his family had previously been advised by a consultant at Mossley Hill hospital that, given his condition, it was unsafe for him to continue driving. Unfortunately, that advice was ignored. Equally unfortunate was the fact that the medical practitioners concerned took the decision—the consequences of which were appallingly visited on Paul and his family—not to inform the Driver and Vehicle Licensing Agency of their concern.
It was the practitioners' view—it is a view held by many medical practitioners—that their greater responsibility was to preserve the doctor-patient confidentiality aspect of their relationship. It logically followed that public safety considerations were of subsidiary importance.
I received a letter from the corner who conducted the inquest—Mr. S. R. Barter MBE, a respected Liverpool district coroner—who said:I am in no doubt in my own mind that the existing law should be changed by statute. Once a doctor has made a clinical judgment, following full investigation, that a patient is suffering from a disease which makes him a danger to himself and the public if he continues to drive, then he should be under a statutory obligation to inform the DVLA of his opinion.That point of view should be taken heavily into account.
There have been further developments since I first raised the issue in the House two years ago. I have received a great deal of encouragement from members of the public and from a wide variety of organisations to continue pressing this issue, and I have been encouraged greatly by Mr. and Mrs. Scarisbrick, Paul's mother and father, to continue the campaign.
I received a letter from a person in Crewe. I do not have her permission to use her name, and so she shall remain anonymous. She said that she had heard about my Bill on BBC news, and went on to say:My father suffered a stroke four years ago and lost the use of his left hand, and movement in his left leg was severely restricted. He applied to have to his licence renewed stating that he had been ill. A new licence was sent to him and no further checks were made. My father was 74 at that time and extremely anxious to drive. As he is a widower and I am the only child I felt responsible and 848 consequently wrote to DVLA to explain his condition, they then cancelled his licence that they had just issued. This action by me made the relationship between my father and I very awkward as he still thinks he would be all right to drive.That letter is an example of the dilemma faced by family members who feel that an elderly parent who is in some way infirm should not be driving, and who take action. The decision clearly creates difficulties for their relationship with their parents or elderly relations.
On 29 July 1994 I received a letter from a solicitor, Mr. Bernie Rowe, of Lyons Davidson solicitors, in Bristol. He said:My firm deals with several thousand road traffic accident claims each year, and each year produces its 'crop' of cases, nearly always involving relatively serious road accidents, where serious injury or death has resulted from drivers who have continued to drive despite health problems which would suggest they should not be behind the wheel.As an immediate past chairman of the Motor Accident Solicitors Society, I know of many other solicitors throughout the country who will have a similar experience to my own. I had not been aware of your initiative on this matter until today, but as a result of reading the article in The Post, I have asked the Motor Accident Solicitors Society administrator to add to the next management committee's agenda details of your initiative.He went on to mention my Bill, which he supported.
That is some of the evidence. I have files full of evidence, but selected only those two examples because I think that they make useful and significant points.
Some 12 months ago, with Mr. and Mrs. Scarisbrick, I met the Minister, who was kind enough to arrange a meeting in his office. We all felt that it was a constructive and useful meeting. I thank the Minister for the helpful and sympathetic approach he has taken to this case and to the issues that it raises.
The Minister's position then was that, while he sympathises with the aims of my Bill, he has been advised by the lawyers concerned that it would be difficult to introduce an acceptable procedure for policing statutory obligations on medical practitioners. I think that that is still his position.
In a letter to Mrs. and Mrs. Scarisbrick, dated 13 May 1996, the Minister said:I would be sorry if you had the impression that progress had not been made in responding to the problem. When I wrote to George Howarth on 8 June, I included a copy of extracts from the document which the General Medical Council had recently agreed, advising doctors that they should be prepared to notify DVLA of cases of this sort, in certain specified conditions. This guidance has since been officially promulgated, publicised in national press and circulated to every doctor in the United Kingdom. Our Chief Medical Adviser has recently discussed the matter again with the GMC, and they will be undertaking some fresh publicity.I am grateful for the action that has been taken.
So far, so good, but I remain unconvinced that those new arrangements, although very much an improvement over the previous system, provide any sanctions against medical practitioners who choose to ignore them, whether from misguided ethical considerations or from sheer negligence. Ideally, I should still like the arrangements to be put on a statutory basis. However, I realise that that is not a likely probability, at least in the short term.
I propose that the Minister enters into a consultation exercise with the General Medical Council, and with other interested parties, to discover whether it would be possible to develop a voluntary scheme that will be policed professionally rather than statutorily.
849 If the idea is to succeed, it must have three vital components. The first and most important criterion is that there must be a clear commitment to the reporting of such cases to the DVLA as a matter of routine, not as an exception. If a medical practitioner feels that somebody is unfit to drive, he must immediately report that fact to the DVLA. A separate set of procedures, which are extremely fair and do not make any prejudgments, is then pursued. The decision is subject to an independent medical examination.
Secondly, a clear sanction should be applied to medical practitioners who neglect to carry out that responsibility. If it could be made to work, I should have no objection if that were to be a professional sanction rather than a legal sanction under the criminal or civil law. If, when the Minister consults the General Medical Council, it can come up with such a way of dealing with the problem, I would be happy to see that go ahead, and to see whether it could be worked out without the need for statutory regulation.
Thirdly, Mr. Scarisbrick is keen, especially with progressive diseases such as Alzheimer's disease, that we should take into account the need for clear thought about how to determine at what point, in a general sense, a patient is liable to become unfit to drive for medical reasons. I know that that is a difficult concept to pinpoint, and that doctors are wary of applying generalised arguments to specific cases.
However, Mr. Scarisbrick has a point, because it is predictable that someone suffering from a degenerative disease is likely to become unfit to drive at some point. If the prospects cannot be easily determined, cases must be monitored and patients re-examined on a regular basis, to establish when they have reached the point at which they should no longer be driving.
Mr. Scarisbrick also asked me to raise four points, and I shall do so briefly. If the Minister wants to take more time to consider them, that is fine by me. I am sure that he will write either to me or to Mr. Scarisbrick about them. First, Mr. Scarisbrick feels that some progress has already been made, and he is grateful for that. Secondly, his main aim is to ensure that, once a person has been discovered to be suffering from an illness such as Alzheimer's disease, that person should not be allowed to drive. I covered that point in a slightly different way earlier.
Thirdly, Mr. Scarisbrick has noted that there are more and more reports of accidents involving older people, especially in cases involving motorway driving, in which the risks are often far greater—I believe that the Minister mentioned another such case in his letter of 13 May. Fourthly, Mr. Scarisbrick feels that, perhaps for a limited number of cases, there should be some process of medical certification when people apply for the renewal of insurance policies.
I know that the Minister is sympathetic, and equally that he is aware that, on behalf of Mr. and Mrs. Scarisbrick, I have a fixed commitment to making further progress, so that the chances of another accident as horrific as that involving Paul are drastically reduced. I urge the hon. Gentleman to respond positively to my suggestion; if he wants to take it away and think about it, that is perfectly understandable. I believe that there is more progress to be made, so I hope that he will join me in that endeavour, so that we can try to reduce the possibility of any such thing ever happening again.
§ Mr. Edward O'Hara (Knowsley, South)
I shall speak briefly in support of my hon. Friend the Member for Knowsley, North (Mr. Howarth). I feel a strong sense of involvement with the case, for several reasons. First, the M62 motorway passes through my constituency at the point where the tragic accident happened. Secondly, although Mr. Scarisbrick and his family are now my hon. Friend's constituents, after the boundary changes they will become my constituents. Most importantly, their late son was a close friend of my children and their friends; they all went to school together, and I know how devastated that small community of decent young people was by the accident.
I endorse all that my hon. Friend has said, especially the three points that he raised at the end of his speech. People in my constituency, especially those closely involved with the tragic accident, cannot understand why the medical profession does not already have a statutory duty enforceable by sanctions. They certainly cannot understand why medical opinion cannot be brought closely to bear on the problem. I hope that the Minister will be able to respond positively to what my hon. Friend has said.
§ The Parliamentary Under-Secretary of State for Transport (Mr. Steve Norris)
I am grateful to the hon. Member for Knowsley, North (Mr. Howarth) for raising this important subject. As he said, I met Mr. and Mrs. Scarisbrick when they came with him to see me last year, and we had a meeting at which useful progress was made. I welcome the further opportunity given by today's debate, because this is a problem to which at least part of the answer lies in publicity, whereby doctors and the public at large will become aware of the issues and be able to act more appropriately.
There are two things to say at the outset. First, my right hon. Friend the Secretary of State and I very much sympathise with the Scarisbricks in the sad loss of their son in an accident caused by a driver suffering from Alzheimer's disease travelling in the wrong direction on a motorway. That is a dreadful human tragedy that no words of ours can mend. Secondly, we greatly appreciate the way in which the Scarisbricks have pressed us to take measures to reduce the likelihood that further blameless drivers will suffer in a similar way in future. If they feel that, in some way, some good may come out of the terrible tragedy that befell them, I entirely share that sentiment.
Let us examine the legal position and consider recent developments, and then I shall say a word about the hon. Gentleman's proposition about doctors being liable—a suggestion endorsed by the hon. Member for Knowsley, South (Mr. O'Hara). All drivers are under a statutory obligation, when applying for a licence, to declare whether they are suffering from relevant or prospective disabilities. They must also notify the licensing authority if they subsequently become aware that they are suffering from such a disability.
The licensing authority has the power to refuse an application or revoke a licence, and can require a person to give consent to the provision of such medical reports as are necessary. Ultimately, it is the licensing authority's decision, not that of a patient's doctor, whether an 851 individual is fit to drive. Problems of the sort that we are talking about today arise when a driver is not aware of his incapacity and does not accept advice from his doctor, or indeed, from his family and friends, that he should notify the DVLA, but continues to drive.
Last year, the Medical Commission on Accident Prevention issued a revised guide entitled "Medical Aspects of Fitness to Drive", edited by the former chief medical adviser at the Department of Transport, Dr. John Taylor. That guide, which is available to all doctors, addresses those issues, and I have sent the hon. Member for Knowsley, North a copy.
It is important to underline the fact that, in his introduction, Dr. Taylor picks out for specific attention the problem that we are discussing, and refers to the unhappy case of Paul Scarisbrick. He advises doctors:where a patient's disorder makes him manifestly dangerous as a driver and his condition renders him incapable of taking advice that he must inform DVLA, or where he refuses to do so, practitioners have a civil law duty to immediately inform DVLA medical staff.That is a statement of the law as it stands today. The doctor is under a civil law duty to inform DVLA.
Confidentiality is a fundamental principle on which patient-doctor relationships rest, but the guide recognises that there are circumstances in which it is right that doctors should breach that confidentiality in the public interest if the result of not doing so would be to place someone else, or, indeed, patients themselves, at risk of serious harm or death. Such circumstances do not arise often, but cases involving patients with Alzheimer's disease might well be among them.
Since the issue of the guide, the General Medical Council has amplified its guidance to doctors, emphasising that, where patients continue to drive against advice when medically unfit to do so, doctors should pass information to medical advisers at DVLA without delay. The guidelines set out in some detail the steps that a doctor should take. Where the patient cannot understand the doctor's advice—for example, because of dementia—the doctor should inform DVLA immediately.
Where a patient understands the advice but refuses to accept it. doctors should suggest a second opinion, and if that does not do the trick, approach the patient's next of kin. If those efforts of persuasion fail, the doctor should pass the information in confidence to DVLA. Those guidelines, which were approved by the General Medical Council about a year ago, give doctors clear guidance on their responsibilities—both to their patients and the public at large—when faced with such circumstances, which are often very worrying.
The hon. Member for Knowsley, North made an extremely important point when he mentioned the family who were upset because they had to advise an elderly member of the family that he should not drive. There is no doubt that that is precisely the sort of circumstances in which relatives are extraordinarily diffident. Friends, too, are diffident about insisting that someone—perhaps with whom they live—should give up a facility from which they derive great practical benefit, which represents a final sign of aging or of suffering from a particular ailment that is unlikely to improve. That is a traumatic and difficult time.
There is clear advice from the GMC that, if relatives' efforts of persuasion and second opinions fail or advice is understood but simply not taken, the doctor personally 852 should pass the information in confidence to the DVLA. It has been put to me very clearly by a doctor with whom I recently discussed the matter that, bluntly, that is what doctors are there for. In such circumstances, they have to be clear where their duty lies.
The hon. Member for Knowsley, North has suggested—his private Member's Bill incorporated the suggestion—that there should be a specific statutory obligation on doctors to refer cases to the DVLA when they believe that a patient is unfit to drive, which would go beyond the principles that I have described and, in a sense, apply a sanction to a doctor who was deemed not to have made a suitable notification. I understand that there is such legislation in north America, but our research suggests that, in practice, it has not been effective. The reason is fairly straightforward.
It would certainly be very difficult to frame legislation that avoids a potential effect on the confidential doctor-patient relationship, but, more importantly, there is a risk that such a statutory provision would discourage patients from taking their problems to doctors. It is entirely predictable that patients whose condition varied would, if they did not feel particularly well on the day that they were due to be examined by their doctor, find some reason for cancelling the appointment and present themselves only when they felt that they were at their best. Doctors would rapidly develop a risk aversion, which would not be helpful either to them or to their patients.
I know of at least one case of a patient being examined by a doctor who came to the conclusion that, on balance, the patient ought to be allowed to drive. That patient subsequently caused a death due to dementia or psychosis that rendered him incapable of driving, yet the doctor had exercised his judgment and there was no suggestion that he did it with other than total responsibility and professionalism.
My Department and I have taken the view that, in such circumstances, it is intolerable to expose doctors to the risk of penalty or litigation when, in effect, the law is exercising that marvellous commodity known as 20:20 vision hindsight. On that basis, and bearing in mind the strong advice that I have described, we have so far remained unpersuaded that legislation such as that suggested by the hon. Members for Knowsley, North and for Knowsley, South is desirable.
§ Mr. George Howarth
The difficulty that I have with that concept is that, for whatever reason, some doctors will take what I consider a misguided ethical position on doctor-patient confidentiality. Although that is one problem, I must be honest and say that some doctors are so hard-pressed that they take the line of least resistance. There must be some compulsion on doctors in such circumstances so that they feel that, on balance, it is better to take the decision than, on balance, leave it on one side.
§ Mr. Norris
I entirely understand that point. I do not think that the hon. Gentleman and I are at odds on what we want the outcome to be. We want doctors clearly to understand their duty. The hon. Gentleman would introduce a legal constraint on them. I have said that, although I quite understand the merit of that argument, there would be a prospect of some serious disbenefit to doctors who are simply trying to do their best. As I have 853 said, there is very clear guidance, which, if I may paraphrase, says to doctors: "Be under no illusion. Your confidential relationship with your patient is extremely important but it cannot be more important than the life of an innocent bystander or another driver such as Paul Scarisbrick, or, indeed, patients themselves. In those circumstances, your duty, general practitioner, is entirely clear."
I will not, of course, close my mind or say that the Department's mind is closed on the matter, and I shall look at the idea of incorporating declarations on medical insurance forms, which may have some merit. Without any prejudice, I am happy that we should do so.
854 The main message should go out very clearly to doctors, and I am extremely grateful to the hon. Member for Knowsley, North for giving us the opportunity to send it. It is very simple: if in doubt about the ethics of disclosure, rather than whether the patient is fit to drive, be in no doubt. In fact, there is no doubt that there is a very distinct obligation to report. The judgment on suitability is of course a matter for doctors themselves.
§ It being Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o'clock.