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GPs may have to prove their fitness to practise through knowledge tests, observation of their work and detailed clinical audits every five years, under plans set out last week by the CMO.

Revalidation will be split into two parts under the plans, both of which will operate on a five-year cycle (see box).

GPs will be relicensed if their basic competence, measured in toughened-up annual appraisals, is satisfactory.

They will also be recertified as suitable to remain registered as GPs if they pass a 'comprehensive assessment' of their specialist skills, set by the RCGP.

GPs who fail to meet the required level in either strand of revalidation will be suspended or forced to work under supervision while a 'tailored plan of remediation and rehabilitation' is drawn up. The GMC and the National Clinical Assessment Service would receive details of why they failed.

Recertification will be based on data from 'clinical audit, simulator tests, knowledge tests, continuing professional development or observation of practice'. The RCGP will ask the GMC to recertify a GP once they meet required standards in these tests.

Appraisals will no longer be purely formative, with appraisers asked to include explicit judgments about whether appraisees meet a list of standards.

Relicensing will depend on appraisal, along with submissions detailing any concerns about the GP's work by practising clinicians working as local GMC watchdogs, or 'affiliates'. These affiliates are expected to be in post in all major hospitals and at primary care organisation (PCO) level.

Once this information has been compiled, the PCO where the GP works will send a report to the GMC recommending them for relicensing.

The plans aim to create an environment in which GPs have to prove their competence.

CMO Sir Liam Donaldson said it was standard in many high-risk industries to consider professionals not competent until proven otherwise, and this was the approach the NHS should adopt.

Doctors, he said, may not be tested at all over a 35-year career: 'A commercial pilot over the same period would be subject to about 100 assessments of their ability to fly safely.'

The RCGP will consult with members to determine how certification tests will work, and the results will go into a DoH consultation which runs until 10 November.

- Opinion, page 21.