Those who are worried that the current top-down reconfiguration of the NHS will be the last of its kind received some good cheer last week, when the seven lucky recipients of its £1.5bn private finance initiative bailout scheme were announced.

As ever, the interesting development was who was left off the list, rather than those who appeared on it.

Barts and the London Trust’s latest estimated unitary payment to turnover rate is 9 per cent, which will rise to 10 per cent if the planned super merger with Whipps Cross and Newham University Hospitals trusts (the latter with its own PFI costs of around £15m a year) goes ahead.

Barts then looks at least as hard pressed as North Cumbria University Hospitals, with its unitary payment nearer 8 per cent. And yet the east London mega-hospital is not currently due to receive any of the £1.5bn bailout funding.

Neither is University Hospitals of Coventry and Warwickshire Trust, whose unitary payments eat up some 15 per cent of annual income – at least as much as Barking, Havering and Redbridge University Hospitals and St Helens and Knowsley trusts, which are due to benefit from the DH’s largesse.

The question then is “why?”, as both trusts clearly applied for the funding, planting themselves firmly in the “unaffordable” camp.

The answer appears to lie in the place that each loser occupies in the strategic vision for their patch. In London, for example, strategic commissioners – still glowing from their successful rationalisation of stroke services – are now eyeing the new cardiac facilities being built as phase two of Barts’ £1.15bn PFI scheme.

Those facilities are due to be completed in around two to three years’ time.

As heart services are currently configured across London, Barts may struggle to use all its shiny new facilities – exacerbating its PFI woes further still. Has the DH deliberately stuffed it?

Given it has underwritten its £6.8bn in scheduled remaining PFI payments, that is hard to conceive. Rather, the decision to withhold bailout funding for the trust looks like a significant vote of confidence in the future enduring power of top-down rationalisations to shift patients around and substantially increase hospital revenue and volume where it is needed.

Sally Gainsbury is a news reporter for the Financial Times.