In an NHS obsessed with adapting to a rapidly ageing population, GPs delivering primary care to students register as barely a blip on the radar of NHS policymakers.
University practices across the UK look after a student population of about 2.5m, nearly a fifth of whom are from overseas.
Many students are away from home for the first time, living unhealthy lifestyles with little money in their pockets.
High rates of mental ill health, risky sexual behaviour and drug and alcohol use mean the common perception that students are young, fit and need little support or NHS funding is deeply flawed, according to the GPs who treat them.
Practices looking after student populations have long felt underfunded - but after winding up on the wrong side of virtually every major change to GP contracts in the past decade, many are now on the brink of collapse.
Dr Dominique Thompson, a GP at the University of Bristol Health Service and executive committee member of the Student Health Association, says: 'We have all the similar pressures that other practices face, but are absolutely ignored by new government policies. Every time there is a new LES or CCG policy, it is aimed at the elderly.
'People are forgetting an entire generation of care. There is nothing about mental health or eating disorders, despite evidence of rising prevalence.'
GPs looking after students are well aware that an elderly patient with multiple long-term conditions is likely to need substantially more healthcare than your average 18- to 25-year-old at university.
But the Carr-Hill formula that determines how primary care funding is allocated means a practice serving predominantly students is likely to have a weighted list around half the size of its actual list at best.
The Student Health Association says this shows the weighting curve is too steep - it has called for an imminent review of the Carr-Hill formula to look at weighting students equally to deprived population groups.
Other sections of the GP workforce may also press claims for better recognition of their patient population via the funding formula. But few can claim to have suffered anything like the damaging series of cuts university practices have faced in recent years.
A major complaint for practices serving students has been that many funding streams available to the rest of general practice are simply beyond their grasp.
When a DES deal focused on elderly patients is rolled out with no alternative for practices that have unusual patient profiles, these practices have little choice but to shrug and accept they will be unable to earn a share of that income.
When the QOF started in 2005, some of its clinical domains were largely irrelevant to university practices.
To ensure all practices received at least a basic share of the funding, the original version of the QOF formula, which weights payment according to disease prevalence, rounded up payments for the 5% of practices with the lowest prevalence in each domain. But from 2009/10 this mechanism was scrapped.
Daniel Hammersley, business manager at the 40,000-patient University of Nottingham Health Service, says: 'We had a 40% cut in QOF income from the prevalence change.'
Most university practices suffered a similar loss, he adds. 'Our view was that the 5% cut-off was meant to reflect work regardless of prevalence. Losing that financially was against the spirit of the calculation in the first place.'
More recently, PMS reviews aimed at equalising funding with the GMS deal have threatened locally agreed funding settlements that have kept university practices going.
University practices have also been hit hard by the removal of MPIG top-ups to core funding.
Large correction factor payments, which have begun to be stripped away from this financial year, often reflected local funding top-ups agreed by university practices before the new GMS deal took effect in 2004.
In the rush to press ahead with the blanket removal of MPIG, the hardest-hit practices have been offered little support.
The dual-site Rowhedge and University of Essex Medical Practice is among the 98 'outlier' practices worst hit by MPIG cuts.
Senior partner Dr Michele Wall says that without extra funding, the practice will be forced to lay off two of its five GPs, as annual MPIG payments worth £250,000 a year are removed in the coming seven years.
Although the practice has been invited to apply for a two-year stay of execution on MPIG cuts, Dr Wall is convinced its bid will not satisfy NHS England's requirements. 'We don't meet the criteria,' she says. 'You have to be losing more than £3 per patient, you have to have a salary below a certain level and patients have to meet deprivation criteria.'
Although the practice satisfies the first two criteria, she says, its patients will be judged 'not deprived enough'. Tough decisions about the future viability of the practice are looming for Dr Wall and her partners.
'We have had to make significant cuts. We have lost one GP session and one nurse practitioner session per week. We have had to cut out bits we felt were necessary for a gold standard service - really pared it back to the bare bones.
'This year we will manage. Next year I'm not so sure. If staff leave, they won't be replaced. In year three of the MPIG losses, we're talking about losing staff. By year seven, we will have to lose two GPs out of five.
'Unless we take massive pay cuts and work much harder, there's no way to sustain five doctors. Why should we be having to do that?'
Large practices such as the University of Nottingham Health Service have been able to cope better than most with repeated erosion of income, by working hard to build other streams of income.
Dr Elaine Gibbs, a partner at the practice and Student Health Association president, says: 'We have not cut staff numbers. Because we are very big, we are able to look for other income streams.' The practice has expanded clinical research work and its travel clinic service, and bid for new service contracts.
Smaller practices have found the repeated hits on income far harder to take. Bedford GP Dr Alex Smallwood recently gave up an LMC role because pressure at his practice no longer left time for it.
'We have seen roughly an 8-9% fall in profits in the past year, and the year before that, a 4% fall. Cumulatively it's about 11% and that is with doing better on all sorts of things, such as QOF. It's hard work to keep losses down as low as possible,' he says.
'We have all had to reduce drawings by 15-20% in the past 18 months.'
Dr Smallwood cites cuts in PMS funding, increased pension contributions, prevalence losses and DESs that are 'uneconomical to chase' among contributing factors.
Small and large university practices alike say they have been hit by the transfer of responsibility for public health services to local authorities.
Many have had to bid in competitive tendering processes to retain services they already provide, such as sexual health clinics, on which their patients rely.
The move has left already stretched practices needing to maintain links and attend meetings with not just CCGs, area teams and universities to maintain funding, but now local councils too.
GPC chairman Dr Chaand Nagpaul says no national funding formula can reflect the needs of practices with unusual populations or working patterns, such as extremely rural practices, those in deprived areas, or university practices.
'It is wholly wrong that practices should suffer at the hands of a formula not designed to meet their needs,' he says. 'There is a need for a system to resource them - we need to look afresh at how the formula operates. For these practices, add-ons or special funding are more likely to work than a single national formula.'
NHS England has pledged to offer support to practices hit hard by funding cuts where they can show that their particular patient population justifies it, but few are expected to benefit.
In the meantime, university practices across the country will be hoping they will not have to wait until their patients grow old to receive funding that reflects their needs.
|Case studies Student health service under pressure|
University of Nottingham Health Service
The practice has 40,000 patients, about 80% of whom are students. Partners at the practice brought in business manager Daniel Hammersley five years ago because the need to look for new sources of income was becoming increasingly pressing.
Partner Dr Elaine Gibbs says the practice has had to work hard to maintain its income, but that its size has protected it.
'We have had to expand our private travel service, look for occupational health work and take on new AQP (any qualified provider) deals.'
The practice has also sought to expand clinical research work as a source of additional income. Part of its strategy has involved increasing staff hours to take on extra work.
The practice operates under a GMS contract and is facing MPIG losses.
Goldington Avenue Surgery
At this PMS practice in Bedford, about 15-20% of the patients are students. Partner Dr Alex Smallwood (pictured right) says underfunding of student patients dilutes funding the practice receives for the rest of its patient population.
Dr Smallwood says most students remain in the area outside term-time and the perception that they need limited support, or only part-time support, from their practice is wrong.
Erosion of funding for these patients in recent years has contributed heavily to an 11% drop in practice profits in the past two years.