The first 18 GP ear nose and throat specialists have graduated with a diploma from Middlesex University, validated by the Royal College of General Practitioners.The year-long distance-learning course was designed to improve diagnostic skills and allow GPs to carry out procedures otherwise done in an outpatient department.Ram Dhillon, consultant ENT surgeon at Northwick Park Hospital and programme leader, said: 'We can't take every Tom, Dick and Harry.We have got to achieve a threshold of expertise and have a mechanism for accrediting these GPs properly.We have created a framework.Now It is up to them how they work within their primary care trusts.'Referrals between practices will be encouraged and the GP specialists may conduct sessions at community hospitals.Courses for another ENT group and in cardiology will begin early next year.