I make it a policy to chuckle when I hear of some mild British institution being likened to Nazi Germany or Stalin's Russia by someone who hasn't understood much history. Even law lords do it.

So the significance of weekend attacks on those "Soviet-style polyclinics'' Lord Darzi is supposed to be dreaming up for the nation's GPs is political, not organisational. It signals that doctors' leaders are softening up voters for a fight over the surgeon-politician's blueprint when it surfaces.

Health secretary Alan Johnson's midweek attack on Britain's excessive "sick note'' culture (remember, he is a former work and pensions secretary) will also upset GPs, though "well notes'' that state what an employee can do seem fair enough to me.

Suddenly we seem to be in choppy health waters again after a lull. The British Medical Association and Unison both seem to have encouraged The Observer's attack on ambulances "stacking'' patients outside accident and emergency departments to meet that four-hour target. Does that reflect badly on the target, as they seem to think, or upon a hospital's management ethos, I wonder?

But what caught my eye was the Audit Commission's report, The Right Result? on the impact that payment by results has had on financial efficiency. It has been smaller than expected and has "contributed to'' greater awareness rather than driven the process, the report concluded.

The answer? To cut the tariff to the level attained by the most cost-effective hospital providers, not the average cost, according to the Audit Commission. A "sledgehammer approach" is the way King's Fund's chief economist John Appleby put it when I rang to check.

What some hospitals need is help rather than the single lever of the price mechanism - which must ignore a lot of local factors - to aid them in becoming more efficient. "It's not as if they're lazy bastards doing it on purpose,'' he says.

Quite so. But it is a symptom of the kind of pressure that will grow in what I recently heard described as "the healthcare century ahead''. First the good news: medical technology, ever-larger health budgets (it's an iron law that they increase with affluence) and personal incentives will revolutionise healthcare, provided we can control costs.

Unless we do, on present trends health will consume 96 per cent of US GNP (52 per cent of ours) by 2100. Who says so? Nicolaus Henke, who oversees health matters across much of the world for McKinsey, the cult management consultancy.

You may have seen Mr Henke in action, since he is a regular on the conference circuit. He sets out what needs to be done, citing examples as good as Singapore and as bad as Egypt (bureaucratic) and the US (expensive) on his journey.

Governments should get out of healthcare as much as they can. Competition over costs must become more effective. The quality of medical services must improve. (Regulation is OK for delivering safety and minimum standards, less good at driving innovation.)

How? By getting what Mr Henke calls "data meaningful to his performance'' down to the frontline doctor. Central prescription does not work. Instead, ask GPs which 10 things they would most like to improve, then measure the 10, he told The Guardian's public services summit.

Next, healthcare systems must rationalise capacity. Getting the number of hospitals right is less important than getting the workforce (80 per cent of costs) to work right: Lord Darzi please note. Patients must be made more "value-conscious'' too.

Thus in authoritarian (my label) Singapore, where life expectancy is 77, the same as the US (but Singapore spends 3.5 per cent of GNP on health, the US 15 per cent), citizens are offered choices. You want a single-bed room? You pay for it. Six-bed rooms are free. Etc. It all helps to change behaviour.

Funding? Mr Henke seems to favour co-payments (ie shared costs) as a means of racking up individual contributions and calls UK spectacles tariffs "private funding by stealth".

And, of course, there is prevention. Britain's anti-smoking budget is "poorly managed", but it still offers what may be the highest return on healthcare investment.

I know what you're thinking. He's just a management consultant. But he may also be the future.

Michael White is assistant editor (politics) of The Guardian.

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