“29. … As I have already noted, to the extent that the witnesses expressed their opinions on the documents they discussed I have discounted their evidence.”
“33. It does not in any way follow from the wording of that provision that, in order for the provision of medical care to be exempt, it must be supplied within the framework of a confidential relationship between the person providing the care and the person being treated. 34. Moreover, to add such a condition is unwarranted in light of the objective of that provision of reducing the cost of medical care and making that care more accessible to individuals … to the extent that those services are of sufficient quality … without the existence of a confidential relationship between the patient and the person providing the care being decisive in that regard.”
“(i) Patients have sought treatment to address cosmetic concerns rather than to address any disease or health disorder (either psychological or otherwise). (ii) There is no record of any clinical diagnosis of any disease or health disorder having been made or any treatment plan having been directed towards addressing it. (iii) In some instances, there is reference to a diagnosis of ‘psychological concerns relation [sic] to appearance’ but there is no adequate specification of the nature of those concerns or any diagnosis of any psychological disorder. These references do not amount to a clinical (or other professional) diagnosis.”
“‘independent clinic’ means, subject to subsection (2A), a clinic which is not comprised in a hospital and in or from which services are provided by a medical practitioner, dental practitioner, registered nurse, registered midwife or dental care professional;”
“When new patients register with the Clinic, they most commonly find us via a recommendation from a friend or from online research and self-referral”
“I consent to my photographs being displayed on the clinic social media sites”
“Dr McKeown has provided 100 sets of patient records. All of the treatments listed appear to be cosmetic. Examples of the “conditions” treated include the following: i. Botox for wrinkles on forehead ii. Botox for wrinkles on eyes iii. Use of “fillers” for lips iv. “Hump in nose” v. Wrinkles on upper face vi. Volume loss around cheek region…. In relation to every single one of his patients he has noted the presence of psychological concerns.”
“Sometimes, the photographs provided by these patients show that they still have active acne which needs to be cleared up before we can begin to treat the scaring. In these circumstances, our doctor would recommend that the patient first see a dermatologist, and we usually refer that patient to a local dermatologist with an interest in treating acne.”
“Did the treatment improve patients (sic) self confidence?”
“Whilst the fact that a patient is taking psychiatric medicine is not necessarily a contraindication to treatment, it is something that must be carefully explored during the consultation.”
“… I typically encourage my patients to think about their options before choosing to undergo treatment. … I occasionally prescribe and administer very minor interventions during the initial consultation (for example, where I have decide to prescribe a small dose of Botox® to alleviate the face wrinkles of a patient with a simple medical history and who may have undergone similar treatment elsewhere or has undertaken detailed research before their consultation”
“For aesthetic practice a ‘good’ medical record would also include examining a patient’s concerns and reasons for seeking a procedure and psychological/emotional assessment screening for anxiety, Body Dysmorphic Disorder or for any other form of presenting mental health condition.”
“…prove that a service or treatment is medical and not purely cosmetic a practitioner needs also to show that the presenting reason for referral or ‘complaint’ has a specific medical element to it (i.e. physical, psychological, preventative, curative, etc) and that the purpose in performing the subsequent treatment is in response directly to the complaint. It is important to document this in the medical record as part of the clinician’s duty of care…”
“The question is not whether the supplies are ‘medical’ in nature and therefore exempt or whether they are cosmetic in nature and therefore standard rated. One of the central questions is whether supplies which involve treatments which are cosmetic in nature can nevertheless be classified as medical care and therefore exempt.”
“Thus, services such as those at issue in the main proceedings, in so far as their purpose is to treat or provide care for persons who, as a result of an illness, injury or a congenital physical impairment, are in need of plastic surgery or other cosmetic treatment may fall within the concept of ‘medical care’ in Article 132(1)(b) of the VAT Directive and ‘the provision of medical care’ in Article 132(1)(c) thereof respectively. However, where the surgery is for purely cosmetic reasons it cannot be covered by that concept.”
“It is important to note however that is not the case that a particular aesthetic procedure is always ‘medical’ by definition or determined by the rationale for electing to receive the treatment. For instance, a dermal filler lip augmentation could be regarded as a ‘medical’ procedure for one patient and ‘cosmetic’ in another based on the patient’s reason for seeking to procure and to receive the treatment.”
“32. That interpretation does not contravene the fiscal neutrality principle, which precludes in particular two deliveries of goods or two supplies of services which are identical or similar from the point of view of the consumer and meet the same needs of the consumer, and which are therefore in competition with one another, from being treated differently with regard to VAT (see, to that effect, judgment of17 December 2020 , WEG Tevesstraße, C‑449/19, EU:C:2020:1038, paragraph 48 and the case-law cited), since, in the light of the objective pursued in Article 132(1)(c) of Directive 2006/112, nutrition monitoring services provided with a therapeutic purpose and nutrition monitoring services without such an objective cannot be regarded as identical or similar from the point of view of the consumer and do not fulfil the same needs on the part of that consumer.” (Emphasis added)