According to the recently published Department of Health report on the first quarter of 2010-11, no primary care trusts are forecasting a deficit this financial year. 

Only four recorded a deficit in 2009-10: Surrey, Peterborough, Enfield, and Sutton and Merton, which together were in the red to the tune of £39.2m.  And this year, there will be no deficits at all.

Quite an achievement, as PCT negotiating power evaporated when their demise was announced. Convenient too, given the understandable reluctance of commissioning consortia to begin life with anything less than a clean sheet. But how is it being done?

Commissioners have two real options to reduce spending in the short term. They can find a way of denying treatment to would-be patients, or a way of deferring it until next April: ration, or delay.

In principle, rationing should be the outcome of arranging everything that modern healthcare can do in priority order; matching this league table with the available funds; and drawing a line. Above the line, treatment is funded. Below the line, it isn’t. Simple?

Not at all. On what basis can PCTs prioritise and deny treatment? Using whose values? And with what legitimacy?

In 2010 it is plain that some tired old favourites - IVF, gender reassignment, acupuncture - are coming below the line. One can probably add psychotherapy, tattoo removal and some aspects of physiotherapy. Is there a transparent process suggesting these have limited clinical value?  No, but there is safety in numbers, it feels like taking action, and following the herd at least mitigates the risk of a “postcode lottery”. If people in Warwickshire can’t get acupuncture on the NHS, goes the argument, why should ours?

Meanwhile, let’s play safe. Plan B is to delay as long as possible, using internal bureaucratic processes, and hope to take spending into 2011-12. It is aided by the DH’s abandonment of those awkward targets on access. 

Will these measures be enough?  We will know a little better when the quarter 2 figures finally appear.