Written evidence from the British Medical
Association (BMA) (DDD 32)
The British Medical Association (BMA) welcomes
the opportunity to submit evidence to the Committee's inquiry
into drink and drug driving law. As doctors, we witness first
hand the catastrophic impact of road traffic crashes. While considerable
progress has been made in reducing the number of deaths and serious
injuries on Britain's roads, the BMA believes that further measures
are necessary to reduce the levels of drink and drug driving.
The BMA's submission to the North Review of
Drink and Drug Driving Law has been used to inform our responses
to this inquiry and we welcome the opportunity to expand further
on our attached submission.
EXECUTIVE SUMMARY
— The BMA believes that lowering the prescribed
alcohol limit for driving should be given a high priority. There
is considerable evidence that driving impairment and crash risk
increase exponentially with increasing blood alcohol content (BAC)
levels, and that lowering the prescribed limit changes driver
behaviour and results in fewer serious and fatal crashes. A reduction
in the BAC limit to 50mg/100ml would bring the UK in line with
most other European countries, and would be in agreement with
the best available evidence on the effects of alcohol on driving
impairment. The use of a fixed penalty (namely 12 months mandatory
disqualification) at a BAC limit of 50/mg/100ml is appropriate.
— There are very limited scientific data
on the levels of drug driving. Front line experience of BMA members
attending patients indicates that it is an increasing problem
difficult to quantify because of the lack of simple reliable quantitative
field testing equipment. Enforcing the current legislation on
drug driving is complicated by the lack of distinction between
drink and drug driving in the Road Traffic Act 1988, and the difficulty
in detecting impairment resulting from drug use. In addressing
the problem of drug driving, as recommended in the North Review,
in the short-term, there should be a focus on developing preliminary
drug screening tests for use in police stations, capable of detecting
controlled drugs which are known to be commonly used by drivers.
In the longer term, a new offence should be introduced making
it unlawful to drive under the influence of specific drugs which
are deemed to impair driving ability.
— In relation to prescribed and over-the-counter
medications, where these are included in any new offence, there
are a number of important considerations. Individuals can respond
differently to certain prescribed drugs and there would need to
be a distinction between prescribed medications which may impair
driving ability on their own and where impairment results from
interactions with other drugs. The introduction of any new or
amended legislation would also need to be accompanied by clear
information for prescribers, pharmacists and patients on which
drugs are proscribed for driving, and with a programme to raise
awareness among the general public.
— Lowering the BAC limit and the introduction
of new measures to improve the process of detecting and deterring
drug driving would reduce the number of drink and drug driving-related
road traffic crashes, and associated mortality and morbidity.
The lowering of the BAC limit with a mandatory 12 months disqualification
for driving at or above that level is likely to provide a strong
deterrent effect, as has been found to occur at the higher BAC
limit.
— The BMA supports the recommendation in
the North Review to provide a general and unrestricted power to
require anyone who is driving a motor vehicle to cooperate with
a preliminary breath test.
— The BMA believes that forensic physicians
should be legally empowered to take blood samples for testing
for alcohol and drug levels without consent from a driver without
capacity after a road traffic accident, and that testing should
occur later only with the consent of the driver. Other than in
the strict circumstances laid down in the legislation, the BMA
is opposed to doctors (other than forensic physicians) being involved
in non-consensual testing of drivers involved in crashes for evidential
purposes.
ABOUT THE
BMA
1. The British Medical Association (BMA)
is an independent trade union and voluntary professional association
which represents doctors and medical students from all branches
of medicine throughout the UK. With a membership of over 140,000
worldwide, we promote the medical and allied sciences, seek to
maintain the honour and interests of the medical profession and
promote the achievement of high quality healthcare.
2. The BMA welcomes the opportunity to contribute
to this inquiry. As doctors, we witness first hand the catastrophic
impact of road traffic crashes. While considerable progress has
been made in reducing the number of deaths and serious injuries
on Britain's roads, the BMA believes that further measures are
necessary to reduce the levels of drink and drug driving.
3. The BMA's submission to the North Review
of Drink and Drug Driving Law has been used to inform our responses
to this inquiry, which are outlined below.
Should the permitted blood alcohol Limit be reduced
as proposed?
4. Yes. Lowering the prescribed alcohol
limit for driving should be given a high priority. The BMA has
a long history supporting a reduction in the legal alcohol limit
for drivers from 80mg/100ml to 50mg/100ml, and first called for
a lowering of the permitted blood alcohol content (BAC) level
in 1990. This was reaffirmed at the 2010 BMA Annual Representative
Meeting (ARM) where members unanimously supported Sir Peter North's
recommendation to lower the BAC limit to 50mg/100ml.
5. There is considerable evidence that driving
impairment and crash risk increase exponentially with increasing
BAC levels, and that lowering the prescribed limit changes driver
behaviour and results in fewer serious and fatal crashes. Driving
performance deteriorates significantly between a BAC of 50mg and
80mg/100ml, and crash risk increases.1,2 The relative crash risk
of drivers with a BAC of 50mg/100ml is double that for a person
with a zero BAC; the risk rises to 10 times for a BAC of 80mg/100ml.3,4,5
6. Modelling studies predict that lowering
the BAC limit to 50mg/100ml would reduce serious and fatal crashes,
and could expect to save 65 lives and prevent 250 serious injuries
per year in the UK.6 A 2010 review by the National Institute for
Health and Clinical Excellence (NICE) of effectiveness of drink
driving legislation estimated that lowering the BAC limit to 50mg/100ml
would reduce road fatalities by up to 13.8% and injuries by 1%
within six years of implementation. This would prevent 70 to 144
fatal, 139 to 323 serious and 1,121 to 2,606 minor injuries in
the first year of implementation, increasing to 158 to 303 fatal,
274 to 708 serious and 2,213 to 5,715 minor injuries prevented
annually by the sixth year of implementation.7
7. A reduction in the BAC limit to 50mg/100ml
would bring the UK in line with most other European countries,
and would be in agreement with the best available evidence on
the effects of alcohol on driving impairment.
8. There is widespread support from the
public and key stakeholders to reduce the BAC limit to 50mg/100ml.
In March 2008, the BMA Board of Science hosted a "stop drink-driving"
stakeholder event with representatives from the Medical Royal
Colleges, the police and the hospitality trade, and organisations
such as Alcohol Concern and the Institute of Alcohol Studies.
Following the event, letters of support from the various stakeholder
organisations were forwarded to the Department for Transport (DfT)
calling for the drink-drive limit to be lowered to 50mg/100ml.
9. In relation to a lower limit for certain
categories of driver, the BMA believes there should be consideration
for further reductions below 50mg/100ml for all newly qualified
drivers, and supports Sir Peter North's recommendation to review
the impact of a new prescribed limit of 50mg/100ml on young and
novice drivers over the five years following implementation and
consider further reductions at that stage.
If so, is the mandatory one year driving ban appropriate
for less severe offenders, at the new (lower) level?
10. Yes. The use of a fixed penalty (namely
12 months mandatory disqualification) at a BAC limit of 50/mg/100ml
is appropriate. As noted in the North Review, it would be a retrograde
step to lessen the deterrent effect of mandatory disqualification.
The 2010 NICE review found that driving licence suspension or
revocation is an effective deterrent for drink driving, influences
driver behaviour and results in fewer alcohol-related road crashes.8
The introduction of a graduated scale of penalties may also lead
to an increase in the acceptability of drink driving and create
a mixed road safety message.
How severe is the problem of drug driving and
what should be done to address it?
11. There are very limited scientific data
on the levels of drug driving. Front line experience of BMA members
attending patients indicates that it is an increasing problem
difficult to quantify because of the lack of simple reliable quantitative
field testing equipment. Evidence indicates that drug use and
the prevalence of drug driving have increased in recent years
in the UK.9 In a survey of club-goers in Scotland, 69% had taken
cannabis and 85% had at some time driven after using illegal drugs.10
The survey also identified common attitudes among drug users:
many were not aware of drug driving legislation, ignored anti-drug
campaigns, and did not believe that cannabis impairs driving ability.
12. The wider implications of this behaviour
are beginning to emerge. Research from 2000 indicates an increasing
incidence of road traffic crashes where individuals have tested
positive for drugs, and where drugs may have been a contributory
factor to the cause of the crash.11 A study by the Transport Research
Laboratory (TRL) of fatal collisions between 1985 and 1987, and
between 1996 and 1999 found that the incidence of medicinal drugs
and alcohol in road collisions casualties remained stable over
this period. Drug taking overall increased by a factor of three,
and the proportion of those testing positive for multiple drugs
increased dramatically, from 5% in 1985-87 to 26% in 1996-99.
Further research into the levels of drug driving, the dual use
of alcohol and drugs while driving, and the associated impact
on road safety is essential.
13. Enforcing the current legislation on
drug driving is complicated by the lack of distinction between
drink and drug driving in the Road Traffic Act 1988, and the difficulty
in detecting impairment resulting from drug use. Detection relies
on demonstrating impairment through physical examination in a
controlled environment, which can lead to delays in taking blood
samples. The procedure for testing at the police station is still
too variable, and is interpreted differently by individual forensic
physicians. In particular, the identification of a condition that
may be due to a drug is very broad-based and can lead to false
positives and false negative results. Thus, in cases where both
drugs and alcohol are suspected, it is therefore common practice
not to pursue enquiries about driver impairment as a result of
drug use. It is much simpler to prove the same offence with BAC
evidence linked to alcohol use.
14. The BMA does not support Sir Peter North's
recommendation to amend the Road Traffic Act 1988 to allow nurses
to also take on the role currently fulfilled by the forensic physician
in determining whether a drug driving suspect has a condition
which might be due to a drug. Nurses do not have the relevant
training, experience and expertise to undertake this role. Determining
whether a suspect has a condition which might be due to a drug
requires clinical judgement of an order only likely to be available
to someone trained from first principles in pathophysiology and
pharmacology, and who has an understanding of neurology and psychiatry.
15. In addressing the problem of drug driving,
as recommended in the North Review, in the short-term, there should
be a focus on developing preliminary drug screening tests for
use in police stations, capable of detecting controlled drugs
which are known to be commonly used by drivers. This would remove
the need for a forensic physician to investigate whether the suspect
has a condition which might be due to drug use. In the longer
term, a new offence should be introduced making it unlawful to
drive under the influence of specific drugs which are deemed to
impair driving ability. This requires research, and agreement
upon, levels at which controlled drugs which are prevalent among
drivers could be deemed to be impairing, and the establishment
of a list of which drugs, the presence of which was banned in
drivers at or above the specified levels.
16. In relation to prescribed and over-the-counter
medications, where these are included in any new offence, there
are a number of important considerations. Individuals can respond
differently to certain prescribed drugs and there would need to
be a distinction between prescribed medications which may impair
driving ability on their own and where impairment results from
interactions with other drugs (eg opiate derived analgesics and
sedative antihistamines). There are also conditions where drug
testing will be inherently complex such as hypoglycaemic reactions
that can be caused by prescribed drugs or other circumstances
such as nutritional status. Consideration would need to be given
to the fact that many currently prescribed medicines could become
unusable for drivers, and the impact this may have on prescribing
patterns and compliance with treatment regimes. In issuing penalties
for driving under the influence of a prescribed drug, consideration
would need to be given to ensuring any action is proportionate
in relation to the driver's medical condition.
17. The introduction of any new or amended
legislation would also need to be accompanied by clear information
for prescribers, pharmacists and patients on which drugs are proscribed
for driving, and with a programme to raise awareness among the
general public.
18. The existing offence of driving while
impaired by drugs in the Road Traffic Act 1988 should be maintained
to cover those drugs (including prescribed and over-the-counter
drugs) not listed in any new offence, as recommended in the North
Review.
What wider costs and benefits are likely to result
from changes to drink and drug driving law?
19. Lowering the BAC limit and the introduction
of new measures to improve the process of detecting and deterring
drug driving would reduce the number of drink and drug driving-related
road traffic crashes, and associated mortality and morbidity.
As noted previously, it has been estimated that reducing the BAC
limit from 80 to 50mg/100ml would save 65 lives and prevent 250
serious injuries per year in the UK.6 This would in turn reduce
the burden of drink-drive related mortality, morbidity and disability
on public healthcare services, and productivity and profitability
in the workplace (absenteeism and lost working days).
What would be the implications of such changes
for enforcement?
20. The lowering of the BAC limit with a
mandatory 12 months disqualification for driving at or above that
level is likely to provide a strong deterrent effect, as has been
found to occur at the higher BAC limit.8 It is unclear what effect
this would have on the number of offenders and resource demands
on the police services. As the North Review highlights, international
evidence indicates that drivers modify their drink driving behaviour
in response to a change in the legal BAC limit, where the percentage
of people driving at every BAC level, including in drivers who
drink heavily, decreases following a change in legislation. With
appropriate public awareness and communications, the number of
drink driving convictions would not be expected to increase substantially
if the BAC limit were lowered. The implementation of Sir Peter
North's recommendations to increase the policing priority for
drink and drug driving, as well as the development of roadside
and evidential screening devices should improve the ability of
the police to enforce the law and secure convictions in the longer
term.
21. The following provides information on
BMA policy in relation to a number of other areas considered in
the North Review.
Random and selective breath testing
22. The BMA supports the recommendation
in the North Review to provide a general and unrestricted power
to require anyone who is driving a motor vehicle to cooperate
with a preliminary breath test.
23. As highlighted in the 2008 BMA Board
of Science report Alcohol misuse: tackling the UK epidemic,
the BMA believes that the use of highly visible police enforcement
and non-selective random roadside breath testing measures (without
the need for prior suspicion of intoxification) are key components
of effective enforcement of drink-drive legislation.12
24. Under current regulations, enforcement
is operated through selective breath testing that requires police
to have judged that a motorist has consumed alcohol before implementing
the test. Non-selective random roadside breath testing is an advantageous
approach as motorists are unable to influence the likelihood of
being tested and there will be a perceived increased risk of detection.
Research from Northern Ireland, Scotland and England indicate
public support for these policies.13,14,15
25. With the exception of the UK, non-selective
breath testing is permitted throughout the European Union (EU).16
Research in Australia has found that highly visible, non-selective
testing can have a sustained and significant effect in reducing
levels of drink driving, alcohol-related road traffic crashes
and associated injuries and fatalities.17,18,19 One study found
non-selective testing to be twice as effective as selective testing,
with a reduction in fatal crashes of 35% and 15% respectively.19
Compulsory testing
26. The BMA believes that forensic physicians
should be legally empowered to take blood samples for testing
for alcohol and drug levels without consent from a driver without
capacity after a road traffic accident, and that testing should
occur later only with the consent of the driver. Other than in
the strict circumstances laid down in the legislation, the BMA
is opposed to doctors (other than forensic physicians) being involved
in non-consensual testing of drivers involved in crashes for evidential
purposes. The BMA publication Medical Ethics Today provides the
following guidance in relation to drivers who are temporarily
incapacitated either because of the crash or because of the effects
of drug or alcohol consumption:
"A blood specimen may be taken for future
testing for alcohol or other drugs from a person who has been
involved in an accident and is unable to give consent where:
— a police constable has assessed the person's
capacity and found the person to be incapable of giving valid
consent due to medical reasons; and
— the forensic physician taking the specimen
is satisfied, at the time the sample is requested, that the person
is not able to give valid consent (for whatever reason); and
— the person does not object to or resist
the specimen being taken and has not refused consent to the sample
being taken before losing competence; and
— in the view of the doctor in immediate
charge of the patient's care, taking the specimen would not be
prejudicial to the proper care and treatment of the patient.
The specimen is not tested until the person regains
competence and gives valid consent for it to be tested. If doctors
follow the advice in this summary they will fulfil both legal
and ethical requirements."
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JC, Voas RB (2006) The effectiveness of reducing illegal blood
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the limit to.05 BAC. Journal of Safety Research 37:233-43.
2 Compton R P, Blomberg R D, Moskowitz H et al
(2002) Crash risk of alcohol-impaired driving. Proceedings
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Safety, 4-9 August 2002, Montreal.
3 British Medical Association (2008) Alcohol
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Association.
4 World Health Organisation Regional Office for
Europe (2004) Transport, environment and health. Copenhagen:
World Health Organisation Regional Office for Europe.
5 Parliamentary Advisory Council for Transport
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Safety.
6 Allsop R E (2005) Some reasons for lowering
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for Public Health Excellence NICE.
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NICE.
9 European Monitoring Centre for Drugs and Drug
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The Incidence of drugs and alcohol in road traffic accident fatalities.
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14 Department of the Environment Northern Ireland
(2008) Northern Ireland road safety monitor. Belfast: Department
of the Environment Northern Ireland.
15 Scottish Executive Social Research (2008)
Transport research series. Drinking and driving 2007: prevalence,
decision making and attitudes. Edinburgh: Scottish Executive
Social Research.
16 Parliamentary Advisory Council for Transport
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and Transport Safety Bill. London: Parliamentary Advisory
Council for Transport Safety.
17 US Department of Health and Human Services
(2000) 10th Special Report to the US Congress on alcohol and
health. Washington: US Department of Health and Human Services.
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vehicle occupants. American Journal of Preventive Medicine
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19 Henstridge J, Homel R & Mackay P (1997)
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August 2010
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