By: Angelica Burlaza

As the NHS navigates a post-Brexit landscape, a growing consensus among healthcare leaders suggests that the current structural model of the NHS requires a strategic “re-balancing.” Dr. Eric Balki, an NHS leader, partner at TCG Medical, Concord Partnership, and a veteran of primary care, argues that the key to a sustainable NHS lies in combining frontline efficiency with internationally recognized governance standards.

The Current Landscape: ICBs and the PCN Paradox

The current NHS architecture relies heavily on Integrated Care Boards (ICBs) and Primary Care Networks (PCNs). ICBs were originally formed to solve the historic “silo” problem in British healthcare. The vision was to establish a unified body to oversee and integrate hospitals, community services, and mental health care within a defined region, thereby theoretically improving overall population health through shared oversight and accountability.

Alongside this, PCNs were established as groups of local GP practices working together with other health and care providers. Their current mandate is to deliver “care at scale”, for instance, by hiring specialized staff such as pharmacists or physiotherapists, which individual small practices could not afford on their own, while focusing on proactive management of chronic diseases.

While these intentions are laudable, leadership is often faced with the near-impossible task of merging two distinct worlds. Historically and internationally, primary and secondary care remain separate because they operate on different logics. Primary care is high-volume and preventative, whereas secondary care, such as hospitals, is episodic and acute. By attempting to force integration through the ICB structure, the system risks making the patient journey more complex than clinically necessary. Dr. Balki points to the US as a cautionary example, where costs have increased substantially as large providers have blurred the lines between primary and secondary care, creating significant administrative bloat. 

A similar friction exists within PCNs. Despite their collaborative ambitions, the model has largely struggled to adapt to the realities of the UK healthcare landscape. In practice, PCN programmes often lead providers to “chase” subjective, box-ticking targets. This diverts vital funds from direct patient care into administrative overheads. In addition, naturally occurring larger-scale providers of 3-4 practices are forced into disparate PCNs, exacerbating issues of scale in provision.

“Trying to integrate primary care into the massive machinery of secondary care is like trying to ‘boil the ocean,’” Dr. Balki observes. From a “first principles” perspective, if a management layer doesn’t directly facilitate a clinician seeing a patient, it is an encumbrance. If the PCN structure is to remain intact, its role must be strictly redefined. Rather than acting as another management layer, it would be best used to pursue broad public health outcomes, such as large-scale vaccination drives, where “at-scale” coordination provides a tangible benefit without interfering with the core relationship.

The Foundation: Lessons from Industry and the APMS Success Story

Dr. Balki’s perspective is rooted in a career defined by high-level international collaboration. Before focusing on primary care, he worked alongside global industrial and pharmaceutical leaders, including Atmel, SCA Hygiene, Cadence, VMWare, Sun Microsystems, ASML, SAP, AstraZeneca, Roche, Merck, and Apple. These organizations operated within environments governed by rigorous, shared metrics, where performance was absolute. This experience informed his later work in the North East, where he helped establish the Institute of Ageing Health, the UK’s first Virtual Learning Centre of Excellence, and the Knowledge House Information System (KHIS), which remains the largest third-strand project and finance system for universities.

Applying this industrial discipline to healthcare, TCG Medical spent over a decade stabilizing “hard-to-run” practices through Alternative Provider Medical Services (APMS) contracts. This success was built on a robust EU Procurement legal framework that prioritized open and competitive tendering.

“As an example of the problem with the new structure,” Dr. Balki explains, “the previous EU-aligned framework mandated an objective assessment of providers. Contracts were awarded based on a ‘Most Economically Advantageous Tender’ (MEAT) basis, which removed local bias. It gave providers the confidence to invest because they were judged on measurable data and clinical quality.”

However, the current ICB structure has led to the winding down of the APMS regime. Dr. Balki cites this as a symptom of the UK’s retreat into institutional isolationism, discarding established legal wisdom in favor of reinventing frameworks that are often less fair and more subjective. Decisions about contracts are no longer as objective or transparent; instead, they are frequently decided in opaque ways that lack the rigor and accountability of the previous competitive model.

The “Efficiency Miracle” and the Financial Reflection

Today, the UK’s primary care Global Sum, set by the BMA and NHS England at £121.79 per weighted patient in the 2025/26 GP Contract, is an efficiency miracle that covers 90% of all NHS contacts.

“This level of hyper-efficiency is unheard of in any other healthcare system in the world,” notes Dr. Balki. “Perhaps the Australian system comes close, but actuarially, it is more expensive per capita. We really need to wake up and recognize how superb our primary care system truly is. It objectively receives the least amount of funding, yet it remains the jewel in the crown of the NHS, consistently punching far above its weight class.”

The financial consequences of the current structural complexity are stark. While core clinical funding for primary care is approximately £122 per patient per year, an additional £46 per patient is allocated to non-direct patient structures (derived from the 2025/26 ICB Primary Medical Care allocations).

By reimagining and reducing these administrative layers, the system could redirect more funds toward direct clinical care. If these administrative funds were reinvested in the core Global Sum, baseline funding for every patient could increase by approximately 22%, a significant boost achieved without requiring an additional penny from taxpayers. It is, in essence, a simple choice between funding patient care or funding bureaucracy. This shift would also create a positive “knock-on” effect, reducing secondary care spending, as greater access to and time in primary care lead to earlier interventions and fewer hospital admissions.

The Roadmap to Resilience

The status of the NHS now hangs in a delicate balance, threatened by an unprecedented convergence of systemic pressures. A rapidly ageing population burdened with complex multi-morbidities is placing immense strain on services. At the same time, a chronic shortage of specialized skills and an expanding workforce gap leave many frontline teams overstretched. The service faces a profound funding crisis. Taxes and National Insurance contributions are rising to levels that are becoming unsustainable and unaffordable for the working population, exposing the limitations of the traditional model that equates success with simply injecting more money into the system.

To secure the NHS for the following years, Dr. Balki advocates a fundamental yet pragmatic structural shift. The most effective first step, he argues, is to decouple primary care from the ICB regime and manage it through a streamlined, direct-to-government intermediary; a model that previously provided clear contractual links and proved highly effective.

This systemic re-evaluation must also redefine the purpose of management layers that currently prioritize subjective targets over clinical necessity. By redirecting administrative savings back into the primary care Global Sum, the system would empower clinical providers to make decisions guided by the specific needs of their patient populations. Supported by a return to internationally recognized, objective procurement frameworks, this approach would recenter the NHS on clinical excellence and strengthen its resilience against future threats.

“The goal is simple,” Dr. Balki concludes. “We must stop funding the process and start funding the patient.”