The full consequences of Mike Richards' review of top-ups will only become apparent over the coming years. Managers and clinicians are scratching their heads trying to solve the problem of 'separation of care' between private and NHS patients.

Trusts will be keen to treat as many private patients as possible or risk losing income to other providers. However, many oncologists do not do private practice. Will trusts ask them to take on these patients? If consultants refuse to do private practice, continuity of care will be lost, as patients need to be referred on to be managed by other consultants, possibly in a completely different centre. Loss of continuity of care effectively represents a different tier of care based on the lottery of whether a consultant does private practice or not.

Doctors and managers alike should respond vociferously to these recommendations: we must fight for a fully tax-funded healthcare system.

Dr Clive Peedell, consultant clinical oncologist, James Cook University Hospital, Middlesbrough