Get a Drip Limited v The Commissioners for HMRC [2025] UKFTT 500 (TC)

[2025] UKFTT 00500 (TC)Case No TC09509
FIRST-TIER TRIBUNAL
TAX CHAMBER
Hearing Heard on: 2 – 8 July 2024Date Judgment date: 1 May 2025
Taylor House, London
Appeal reference: TC/2018/07628
VAT – whether supplies of intravenous vitamin drips and vitamin injections were within the exemption for “medical care” in Item 1, Group 7, schedule 9 VATA 1994. Held that the supplies contained in 11 representative samples were supplies of “medical care” and within the exemption. Appeal Allowed.
Before
JUDGE VIMAL TILAKAPALAMEMBER DUNCAN McBRIDE
Between
GET A DRIP LIMITEDAppellantTHE COMMISSIONERS FOR HIS MAJESTY’S REVENUE AND CUSTOMSRespondentMr James Rivett KC and Mr Emile Simpson, counsel, instructed by Azets for AppellantMr Joseph Millington, counsel, instructed by the General Counsel and Solicitor to HM Revenue and Customs for RespondentsDECISION

Introduction

[1]This is an appeal against a decision of the Respondents (“HMRC”) of 14 May 2018 (the “Decision”) as upheld in a review conclusion letter of 11 September 2018, that supplies made by the Appellant, Get a Drip Ltd (“GAD”) in the VAT quarter ended 10/2017 were standard rated for Value Added Tax (“VAT”) purposes.[2]The supplies in question consist of intravenous “vitamin drips” and injectable “booster shots” (collectively, the “Supplies”).[3]GAD maintains that the Supplies are exempt from VAT as they fall within Item 1, Group 7, Schedule 9 of the Value Added Tax Act 1994 (“VATA”) which exempts the supply of services consisting of the provision of medical care by certain listed practitioners.[4]There were initially four issues for determination in this Appeal. These were:(1) Issue 1 – whether the supplies in issue qualify for the exemption from VAT under Schedule 9, Group 7, Item 1 of the VATA 1994.(2) Issue 2 – whether, alternatively, the Supplies are zero rated.(3) Issue 3 – whether, in any case, the Decision satisfies the “best judgment” requirement.(4) Issue 4 – in respect of the period from 24 July 2020 onwards (which was the date on which GAD was registered with the Care Quality Commission – the “CQC”) its supplies became exempt under Schedule 9, Group 7, Item 4 of VATA.[5]At the outset of the hearing Mr Millington objected to GAD raising the issue of zero rating (Issue 2). This was on the basis that GAD had not indicated prior to the hearing that it intended to do so. As a result, HMRC were unable to adequately prepare their case on zero rating and so raising it at this stage would, in Mr Millington’s view, be prejudicial to HMRC.[6]Mr Millington explained that HMRC had on two separate occasions (23 April and 20 August 2020) asked GAD to clarify its grounds of appeal in order for HMRC to formulate an amended statement of case. The answer to each query was, however, insufficiently clear for HMRC to understand whether zero rating was to be a ground of appeal. The first time it became apparent that it was to be a ground of appeal was, said Mr Millington, on GAD’s circulation of its skeleton argument.[7]We agreed with Mr Millington that given those circumstances, allowing HMRC to raise Issue 2 in this hearing could be prejudicial to HMRC. Taking into account the discretion afforded to us under the Tribunal Procedure (First-tier Tribunal) (Tax Chamber) Rules 2009, and the overriding objective of those rules which is to enable cases to be dealt with fairly and justly, we therefore refused permission for GAD to raise zero rating at this hearing.[8]During the course of the hearing Mr Rivett notified the Tribunal that GAD had decided not to pursue Issue 3 (best judgment) and Issue 4 (exemption under Schedule 9, Group 7, Item 4).[9]The only issue for determination in this Appeal is accordingly Issue 1 (exemption). Background Procedural history

Background

[10]On or around 4 October 2017 GAD applied to register for VAT on the basis that its Supplies were zero rated. This was on the basis that they were within Item 1, Group 12, Sch. 8 VATA – which zero rates supplies of goods designed or adapted for use in connection with any medical or surgical treatment (with limited exceptions) where the goods are dispensed to an individual for that individual’s personal use on the prescription of an appropriate practitioner.[11]On 9 November 2017 GAD filed its first VAT return for the quarter ended 10/2017 on the basis that the Supplies were zero rated. That return contained a claim to repayment and was selected for verification around 28 November 2017.[12]On 7 December 2017 in response to questions from HMRC, Richard Chambers (“RC”) the owner and founder of GAD, confirmed that its Supplies were zero rated, providing a selection of random prescriptions in support of its position and explaining that each had been signed by a registered prescribing nurse. The prescriptions were in the form of a list of the substances provided and headed with the “package” that had been supplied – these included “Detox Drip”, “The Full Works”, “Basic Hydration”. RC also provided, inter alia, a list of its main expenditure.[13]On 11 December 2017 HMRC (Officer Peters) asked GAD for additional information including as to what the prescriptions were “actually for”, whether there was a diagnostic system to determine the appropriateness of the treatment for the patient, the documentation provided by the nurse, the qualifications of the nurse, whether the drugs could be supplied separately and whether people were referred or could just book directly.[14]In a letter dated 13 December 2017, before hearing back from GAD but after having heard from the HMRC VAT consultant, Officer Peters contacted GAD. She informed GAD that having reviewed its website, HMRC had concluded that the Supplies were neither zero rated under Item 1, Group 8, Sched, 12 VATA nor exempt under Item 1, Group 7, Sch 9 VAT but were standard rated. On 14 December 2017 the Supplies were accordingly assessed on the basis that they were standard rated.[15]On 15 December 2017 RC replied to Officer Peters initial questions and on 22 December 2017 provided further, more detailed information including as to its website and the nature of the physical conditions treated and products used. He also asked for further explanation of the standard rating decision.[16]In a letter dated 24 January 2018 Officer Peters informed GAD that she had revised her opinion “in light of further research and information” and now considered the Supplies to be exempt. This was on the basis that the primary aim of GAD’s customers was to “seek diagnoses and be provided with treatment to make them feel well, not the single supply of medicines”.[17]On 31 January 2018 RC responded saying that he disagreed with the decision, maintaining that in his view the Supplies were zero rated and setting out his arguments as to why the conditions for zero rating were met.[18]On 19 February 2018 Officer Peters informed GAD that the matter was to be sent to HMRC’s policy team.[19]On 22 March 2018 Officer Peters informed GAD that having consulted with her colleagues:
“On the evidence provided I believe that Get a Drip is making a single supply with three constituent parts - Diagnostics, supply of ‘drugs’ and administration of the product – all being closely linked. Each part does not exist without the other, When the customer approaches the clinic I believe it is with a view to obtain the entire package and not the individual items, I believe this to be exempt under Item 1 Group 7 schedule 9 VATA 1994.”
The letter also offered an independent review.[20]On 10 April 2018 RC asked for an independent review, his position being that the Supplies were zero rated. In his email to HMRC, RC summarised HMRC’s position saying that, from what he understood, HMRC saw GAD’s main supply as being a medical service rather than a supply of a good (i.e. the Drip). He stated “I would like to highlight to you again that we are not CQC registered (Care and Quality Commission – the independent regulator of Health and Social Care in England) and do not fall within the scope of CQC and so we cannot provide any treatment or medical diagnostic prior to the Drip, other than a high-level health assessment of blood pressure etc. before administering the Drip. This is ancillary to the main supply of the Dip [sic] itself i.e. the main supply that the customer is paying for is the Drip and no the administrative service (medical check) that is carried out prior to his which ensure they meet our criteria to have Drip”[21]On 14 May 2008 Officer Peters e-mailed RC explaining that for a review decision to be made she had been requested to first make a firm decision as to whether she believed that the Supplies were exempt or standard rated. She went on to say that based on RC’s email of 10 April 2018, and her initial thoughts, she believed that the Supplies were standard rated. On that basis she proposed that GAD’s initial appeal be withdrawn and that GAD should confirm that it wished to appeal against the new decision that the Supplies were standard rated.[22]In a letter dated 22 May 2018 GAD was informed by the reviewing officer that Officer Peters’ decision that the Supplies were exempt was to be withdrawn and therefore the review of the original decision would not go ahead. The letter said that a new decision would be made and fresh review and appeal rights would arise.[23]On 25 May 2018 RC emailed Officer Peters asking for clarification of what was happening. Officer Peters responded to RC on 7 June 2018 by email. In it by way of explaining what had happened, she stated; “In this case I had conflicting information that made me look at the liability from different perspectives. The one decision I felt from the beginning was that your supply was not zero rated. I advised you of that and also that you could ask for an independent review, The initial review that I submitted argued that I believed that your supply was not zero rated but I did not state which liability I believed it to be, my submission was that it was either standard rated or exempt. This was queried by the reviewing officer at an early stage. As you will be aware I was advised that I had to make a decision on the liability I believe is relevant to your supply.” She went on to ask RC to confirm whether he wanted to appeal against her new decision that the supplies were standard rated.[24]On 8 June 2018 RC requested an independent review of the 14 May 2018 decision that the Supplies were standard rated.[25]On 9 July 2018 the independent reviewer notified RC that further information would be needed from GAD and on 17 July 2018 Officer Peters asked RC for further information. The request was in the form of a list of questions as follows: How many employees do you have on site and what are their roles? is the pharmacy you use on-site? what is the status of the pharmacy (i.e. is it registered under any legislation, is it licenced to dispense)? what other drugs/qualifying goods does the pharmacy dispense? And to whom? Can you provide a sample copy of the medical questionnaire? Is there any kind of contract between the company and the customer? Apart from the website – do you provide the customer with any promotional literature”[26]Internal HMRC correspondence included in the bundle indicates that these questions were asked as HMRC’s solicitors were litigating or preparing to litigate a similar matter and it was important to clarify the details of GAD’s circumstances in order to ensure consistency.[27]RC responded to that request on 24 July 2018.[28]On 7 August 2018 Officer Peters asked for further information. RC responded to that request on 8 August 2018.[29]In a letter dated 11 September 2018 HMRC notified GAD that the review had upheld HMRC’s decision of May 2018 that the Supplies were standard rated.[30]On 12 October 2018 GAD’s legal representatives (Campbell Dallas) wrote to HMRC asking them to review the position again. The letter highlighted HMRC’s inconsistency in first finding the Supplies to be exempt and then standard rated. GAD also now took the position that the Supplies were exempt as they met the conditions for the provision of medical care.[31]On 13 November 2018 GAD filed its notice of appeal.

The Hearing and the Evidence

[32]The hearing took place over five days. We had written witness statements and heard oral evidence from Mr Richard Chambers and from Dr Richard Breeze, an expert witness instructed by Azets for GAD.[33]We were provided with a hearing bundle of 2286 pages and a supplementary bundle of 70 pages.[34]We also received, following, the hearing, an agreed note from the parties containing an overview of the legislative background to the CQC and the Health and Social Care Act 2008. Each party also provided us, after the hearing, further submissions relating to evidential aspects of the appeal.

The Single Ground of Appeal

[35]GAD’s sole ground of appeal is expressed in its original Grounds for Appeal, as follows “As the supplies are carried out by appropriately qualified medical practitioners, working with their qualifications and are for the protection, maintenance or restoration of the health of the patient involved, we consider that they fall under VAT Act 1994 Schedule 9 Group 7, and should be exempt from VAT” Decision in principle[36]This decision is a decision in principle and considers only whether the exemption for supplies of medical care is engaged or not. The parties have not raised, and we do not consider, the quantum of any liability that may follow the outcome of this Appeal.

Burden of Proof

[37]The burden of proof in this appeal lies with GAD, the standard of proof being the ordinary civil standard which is the balance of probabilities. The decision contains specific discussion of the burden of proof in the particular circumstances of the Appeal.

The Relevant Legislation

[38]Chapter 2 of Title IX of Directive 2006/112/EC (the Principal VAT Directive or “PVD”) contains exemptions for certain activities in the public interest. So far as relevant to this Appeal, Article 132 PVD provides: Article 132 Member States shall exempt the following transactions: [ … ] (c) the provision of medical care in the exercise of the medical and paramedical professions as defined by the Member State concerned;[39]The PVD exemptions are given effect in the UK by s 31(1) of an Item 1 Group 7, Schedule 9 VATA which provides: 31 – Exempt supplies A supply of goods or services is an exempt supply if it is of a description for the time being specified in Schedule 9. [ … ] Schedule 9 - Exemptions [ … ] Item No. 1 The supply of services consisting in the provision of medical care by a person registered in any of the following - (a) the register of medical practitioners [ … ] (d) the register of qualified nurses, midwives and nursing associates maintained under article 5 of the Nursing and Midwifery Order 2001[40]The term “medical care” used in Article 132 PVD and Item 1 is not defined in the legislation. Its meaning has, however, been considered judicially in a number of cases, principally decisions of the CJEU, but also by the UK courts and tribunals.[41]Under the European Union Withdrawal Act 2018 (“EUWA”) certain aspects of EU law including the application of CJEU decisions continue to be recognised and enforced in UK domestic law, including the application of decisions of the CJEU in binding lower courts (s 6(3)(a), (4) and (5A) EUWA).[42]Amendments to the EUWA were made by the Retained EU Law (Revocation and Reform) Act 2023 which provides that s 3 (abolition of supremacy of EU law) and s 4 (abolition of general principles of EU law) of that Act do not apply in relation to anything occurring before the end of 2023. However, s 28 Finance Act 2024 effectively reverses s 4 of the 2023 legislation and reinstates general principles of EU law in relation to VAT and excise duties. Additionally, s 28(4) provides that EU law (such as the VAT directives) continue to have effect for the purposes of interpreting VAT and excise law.

Key Case Law

[43]The meaning of medical care was considered by the Court of Appeal in Mainpay Ltd v HMRC [2022] EWCA Civ 1620 (“Mainpay CA”). In that case, the Court had to determine whether the supply of doctors by an agency to NHS Trusts was within the exemption.[44]In her judgment, Whipple LJ noted a series of propositions relating to the medical exemption that had been compiled by the Upper Tribunal (“UT”) (at [89]) following its review of the relevant case law ([2021] UKUT 270 (“Mainpay UT”). She regarded this as accurately setting out the law (see Mainpay CA at [61]). We set the relevant paragraphs of the Mainpay UT extract out below together with three additional propositions stated by Whipple LJ which she considered were not in dispute. [89]. The scope of the exemptions for medical care contained in Article 132(1)(b) and (c) of the Directive (and its predecessor Article 13A(1)(b) and (c) of the Sixth Directive) have been the subject of a number of decisions by the CJEU. The main principles can be summarised as follows:(1) The exemptions envisaged in art 13 of the Sixth Directive are to be interpreted strictly since they constitute exceptions to the general principle that VAT is to be levied on all services supplied for consideration by a taxable person: e.g. Ambulanter Pflegedienst Kügler GmbH v Finanzamt für Körperschaften I in Berlin (Case C-141/00) EU:C:2002:473, [2002] ECR I-6833 ('Kügler') at para 28.(2) Those exemptions constitute independent concepts of Community law whose purpose is to avoid divergences in the application of the VAT system from one Member State to another (Card Protection Plan Ltd v Customs and Excise Comrs (Case C-349/96) EU:C:1999:93, [1999] STC 270, [1999] 2 AC 601, at para 15, EC Commission v France (Case C-76/99) EU:C:2001:12, [2001] ECR I-249, [2001] 1 CMLR 1244, at para 21, and Kügler at para 25).(3) [ … ](4) [ … ](5) The application of art 132(1)(c) is not dependent on the legal form of the person supplying the medical care. Thus, a limited company supplying medical care through medically qualified staff fell within the exemption: Kügler at para 41.(6) The concept of 'provision of medical care' does not lend itself to an interpretation which includes medical interventions carried out for a purpose other than that of diagnosing, treating and, in so far as possible, curing diseases or health disorders: D v W (Österreichischer Bundesschatz intervening) (Case C-384/98) [2002] STC 1200, [2000] ECR I-6795, at para 18.(7) Although the provision of medical care must have a therapeutic aim, it does not necessarily follow that the therapeutic purpose of a service must be confined within an especially narrow compass. Thus, medical services effected for prophylactic purposes may benefit from the exemption under art 132(1)(c). Even in cases where it is clear that the persons who are the subject of examinations or other medical interventions of a prophylactic nature are not suffering from any disease or health disorder, the inclusion of those services within the meaning of provision of medical care is consistent with the objective of reducing the cost of health care, which is common to both the exemption under art 132(1)(b) and that under (c) of that Article: D’Ambrumenil v Customs and Excise Comrs (Case C-307/01) EU:C:2003:627, [2005] STC 650, [2004] QB 1179 (‘d'Ambrumenil’), at para 58.(8) It is the purpose of a medical service which determines whether it should be exempt from VAT. Therefore, if the context in which a medical service is effected enables it to be established that its principal purpose is not the protection, including the maintenance or restoration, of health but rather the provision of advice required prior to the taking of a decision with legal consequences, the exemption under art 132(1)(c) does not apply to the service: d'Ambrumenil at para 60.(9) [ … ](10) [ … ][45]Whipple LJ’s three “basic propositions” are as follows: [61] I record three basic propositions of law which are not in dispute: First, the exemptions constitute independent concepts of community law which must be placed in the general context of the common system of VAT (Kügler [25]). Secondly, the exemptions are to be interpreted strictly (but not restrictively) since they constitute exceptions to the general principle of taxation (Kügler [28]). Thirdly, the analysis of what is being supplied depends, in any given case, on economic realities of the transaction, that being a “fundamental criterion” for the application of the common system of VAT (see Airtours Holiday Transport Ltd v HMRC [2016] UKSC 21; [2016] 4 WLR 87 at [48], citing Case C-53/09 and C-55/09 Revenue and Customs Commissioners v Loyalty Management UK Ltd and Baxi Ltd [2010] ECR I-9187; [2010] STC 2651 at [39]-[40]); the contracts are the most useful starting point in that exercise, but not necessarily the end point: see WHA Ltd v Revenue and Customs Commissioners [2013] UKSC 24; [2013] 2 All ER 907. The UT recognised this approach in terms at UT [96], see paragraph 33 above, and their encapsulation of the approach was not subject to any challenge in this appeal.

The Facts

[46]Most of the facts below were found from written and oral evidence given by RC, the founder and CEO of GAD.[47]RC has no medical or scientific qualifications although he has developed some familiarity with medical and scientific literature relating to Gad’s supplies. In his witness evidence RC made several references to the medical and scientific aspects of intravenous drips and nutrient deficiencies. His written evidence also included copies of academic research papers relevant to the general subject. We did not accept RC’s evidence as to medical or scientific matters. This was because RC is not an expert witness nor was he in a position to provide expert evidence given his lack of qualification in this area and his lack of impartiality.

RC and the development of GAD

[48]RC is an ACA Chartered Accountant. He worked for Price Waterhouse Coopers (“PWC”) for five years. He left PWC to start GAD in 2017 and has been CEO of GAD since its inception.[49]RC established GAD in order to improve access to healthcare based on his own experiences as a type 1 diabetic.[50]He explained how he had numerous hospital visits each year due to illnesses contracted when his immune system was run down due to depletion of vitamins and nutrients. He said that those visits resulted in him receiving hydration and other vitamins and minerals via an IV drip in order to increase the number of vitamins and minerals in his body.[51]Access to this care was, in RC’s experience, always “long and tedious” as he had to go via his GP or a hospital accident or emergency (A&E) department. He gave the example of once having to wait 16-24 hours in A&E for an IV drip prior to the establishment of GAD.[52]Prior to establishing GAD, RC researched for his own use, medical providers of IV drip treatment in the UK. He considered that the prices they charged made their treatment largely “inaccessible” and that the décor and fit out of the providers was “typically medical and dreary”. This led him to start researching the possibility of launching his own clinic.[53]Having conducted that research he launched GAD with a view to trading(i) at a lower price point than other providers, in order to make treatments more accessible to the general public and(ii) with a branded clinic design intended to not appear “medical” or “intimidating” to customers.

Why customers attend

[54]When asked, customers typically said that they found GAD by typing their symptoms into Google, from word of mouth from existing customers or from passing by the physical clinics.[55]Customers are sometimes referred to the clinic by medical practitioners. These would generally be informal referrals or generic recommendations rather than specific referrals to GAD. As a private service, GAD does not receive formal referrals from the NHS.[56]Informal recommendations might be made by a customer’s GP, other doctor, dietician, nutritionist or other healthcare provider. This would be noted on that customer’s file and form part of the material used for the customer’s assessment by GAD’s medical professionals.[57]GAD does not have commercial agreements with insurance providers and takes no referrals from them.[58]RC estimated that some 70% of customers were repeat customers.

How GAD provides its IV drips and shots/how it operates

[59]GAD’s website advertises specific treatments. However, customers cannot book those specific treatments. The particular treatment administered will be based on an assessment of the customer by medical professionals when the customer attends the clinic.[60]The medical professionals in GAD’s clinics are either doctors registered with the General Medical Council (“GMC”) or nurses registered with the Nursing and Midwifery Council (“NMC”). In each case they act within the scope of their medical qualifications and within the remit of their registered bodies.[61]Currently only nurses are physically present in the clinics whilst doctors work remotely. Initially some doctors were physically present in the clinics.[62]GAD’s doctors will get involved when something in a customer’s medical history or current condition requires their involvement because it is legally outside the remit of an NMC registered nurse. RC gave as an example a situation where there might be an interaction between the ingredients used by GAD and a customer’s current medication. Here a doctor would get involved remotely[63]Nurses operate under Patient Group Directions (“PGDs”).[64]A PGD provides a legal framework which allows certain registered health professionals (including NMC nurses) to supply and administer specified medicines to a pre-defined group of patients without them having to see a prescriber. (The evidence included as exhibits some of the PGDs used by GAD.)[65]Where circumstances fall outside a PGD, a doctor (or another prescriber) is required to provide a prescription.[66]GAD currently has a team of 3 “GMC prescribers” who provide prescriptions remotely throughout each day. The prescriptions are based on the medical notes taken in the clinic. The prescriber team have remote access to the medical computer system in the clinics.[67]Currently all prescribers are GMC registered doctors – but GAD has formerly employed nurse prescribers

What happens in the clinics (the “Patient Pathway”)

[68]The following steps take place when customers attend the clinics. RC described this as the “patient pathway”.[69]On arrival customers are required to fill in, in the presence of a nurse or doctor, a questionnaire on an electronic tablet (currently only nurses are present).[70]Once the first part of that questionnaire is completed the questionnaire locks and the nurse (or previously the doctor) is required to input the remaining information as they carry out an assessment of the customer.[71]The initial information completed by the customers includes(i) their name, address, contact details, date of birth, and(ii) their medical history. They are also required to sign a “patient disclaimer”.[72]The assessment by the nurse or doctor involves talking through with the customer their medical history and any medications they are taking. Customers will also be asked why they have come to the clinic, what problems they are trying to resolve, what they want to achieve from the treatment, whether they have long term underlying issues and whether they are on special diets.[73]If customers have requested a vitamin D drip they are required to fill in a “Vitamin D treatment form”. A blood test is also taken which helps to determine the dose of vitamin D required.[74]There is then an initial physical assessment. This includes a check of; blood pressure, pulse, temperature, weight, alert/voice/pain/unresponsive, respiration rate and the site of cannulation or injection. Documentation is assessed and confirmation is sought of any underlying medical and health issues.[75]The assessment results in the customer being told what, if any, the recommended treatment is and what outcome is expected.[76]Following the assessment a prescription is created or, where appropriate, an assessment is made that the customer fits the criteria in a PGD.[77]Treatment is then prepared and administered by the nurse (previously the doctor).[78]After the treatment additional observations are made of the customer’s blood pressure and pulse and treatment and aftercare notes are given to the customer.

The Samples

[79]A sample of the treatments given to 11 customers (labelled A-K) (the “Samples”) was provided. A summary of those Samples is attached as Appendix 2 to this decision.[80]The Samples were selected as a random sample by RC based on his training on sampling as an auditor. As he described it:
“I picked a single day being 10 June and then gathered all the clients on 10 June for the years 2018, 2019, 2020 and 2021 covering pre and post our CQC registration. I then selected at random a sample size of 11 patient example case studies.”
[81]No challenge has been made by HMRC as to the representative nature of the Samples.

Additional Information

[82]A high percentage (estimated at 90%) of customers end up having a different treatment to what they initially thought they needed.[83]GAD’s largest selling products are its instant vitamin D blood test which then results in a tailored course of vitamin injections based on the customer’s blood test results, weight and other factors and a vitamin B12 injection. RC said that patients would often come for the B12 injections as they could only get it done every three months at their GP and they felt a need for it more frequently. Other popular products were the Energy Drip and the Immunity Drip. These products together made up the bulk of what was sold by GAD. RC added that as each customer was different they would all get something slightly different.

GAD’s website and marketing

[84]GAD advertises specific drips on its website under names such as “Anti-ageing Drip”, , “Detox Drip”, “Energy Drip”, “Hydration Drip”, Party Drip, Vitamin D Drip. It also advertises packages including “The Full Works” and “Basic Hydration” and what are labelled as “longevity services”.[85]As quoted by HMRC in its letter of 11 September 2018 GAD’s website stated the following:
“Are you feeling run down, jet lagged, recovering from exercise, illness or a big night out? Get a Drip can help you get back on your feet by restoring your body’s natural balance using just an IV Vitamin Drip or Booster Shot. The process is easy. Simply book an appointment, and after a quick assessment with one of our healthcare professionals we can help you select the IV Drip or Booster Shot therapy that is right for you. Effects can be instantaneous, so you’ll be back performing at your highest and happiest potential before you know it”
[86]The website also included (at the time of the HMRC letters) the following disclaimer:
“our products are not intended to diagnose, treat (including a disorder or injury), cure or prevent any disease. Our products are designed to help boost your overall Health and Wellness.”
[87]We note that GAD has said that it has no cached copy of the website and so is unable to verify the extracts. However we also note that GAD has not at any time in its correspondence with HMRC disputed the accuracy of these extracts and it sought instead to explain the background to them.[88]GAD has, as part of its marketing strategy, uses celebrity “influencers” to promote its services.[89]GAD’s advertising and marketing is driven by its marketing team rather than its medical team.[90]Restrictions placed upon the marketing of medical treatments by the Medicine and Healthcare Products Regulatory Agency (“MHRA”) and the Advertising Standards Authority (“MSA”) mean that the terms used by GAD in its promotion of its business do not necessarily reflect the underlying medical nature of the treatment it supplies.[91]The labels given by GAD to its services – such as “longevity wellness services” and the individual names given to the drips – e.g. “Anti-Ageing Drip” are labels used by the marketing team for “search engine optimisation”.[92]Similarly, the reference to a “menu” of drips on GAD’s website is for marketing purposes only. It does not mean that customers can choose the drips that they want. As outlined in the “patient pathway” above, the actual drips given to customers are those prescribed by a medical professional after an in-clinic assessment.

The medicinal products supplied by GAD

[93]The list of medicinal products administered by GAD is set out in Appendix 1 of the decision. The products are a mixture of prescription only and non-prescription only medicines. In nearly all cases a prescription only medication is used as a vehicle to administer the treatment intravenously.

The Care and Quality Commission regulation and registration

[94]The CQC was established by the Health and Social Care Act 2008 (the “HSCA 08”) and is England’s independent regulator of health care services and was.[95]Its role is, inter alia, to monitor, inspect and regulate services that fall within the scope of its registration. It is an offence to carry on a regulated activity without being registered.[96]A variety of regulated activities fall within the CQC’s “scope of registration”.[97]A service provider cannot register with CQC unless the services it provides include activities within CQC’s scope of registration.[98]Regulated activities within the scope of registration include:(i) the “Treatment of Disease, Disorder or Injury”, and(ii) “Diagnostic and Screening Procedures”.[99]The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the “Regulated Activities Regs”) provide in Sched 1 that regulated activities include a list of certain activities under the heading “Treatment of disease, disorder or injury” (para 4, sched 1) and a list of activities under the heading “Diagnostic and Screening Procedures” (para 7, Schedule 1).[100]The CQC scope of registration guidance (as at May 2022) summarises the scope of “treatment of disease, disorder or injury” for regulatory purposes as follows: Treatment of disease, disorder or injury What is included in this regulated activity? - Any treatment that is for the treatment of a disease disorder or injury. What is excluded from this regulated activity? - Purely cosmetic interventions - Most alternative and complementary therapy - First aid where it is delivered by: - Health care professionals in unexpected or potentially dangerous situations requiring immediate action. - Non-health care professionals who are trained to deliver such treatment - Treatment provided in a sports ground or gymnasium (for people taking part in, or attending, sporting activities or events). - Treatment provided through temporary arrangements for sporting or cultural events (such as festivals, championship sporting events or motor sport events).” - Hyperbaric oxygen therapy provided to workers in connection with their work or when governed by the Diving at Work or Work in Compressed Air regulations. - Activities authorised by a license granted by the Human Fertilisation and Embryology authority. Sometimes, 'treatment of disease, disorder or injury' is provided as a minor component of a service – for example, a large care home that has just a few intermediate care or specialist palliative care beds. 'Treatment of disease, disorder or injury' if carried out by or under supervision of a listed health care professional will still require registration in its own right and in addition to any other activities that the provider may need to register for that service. […] The following WILL constitute the activity of 'Treatment of disease, disorder or injury': - A situation when a nurse or health care professional is required to either prescribe or administer medication. - When the nurse or health care professional is required to have knowledge or training to undertake the administration of the medication, or when a person would not normally be considered to be able to administer the medicine by themselves. - Administration of an intravenous (IV) antibiotic or other IV drug (requiring training in reconstitution, mathematical calculation, examination and care of the IV site and more). - Administration of chemotherapy in a person’s home or a residential home, or any other setting. This will require training in administration, IV pumps, blood result checks, examination and care of the IV site, and what to do if extravasation occurs.” CQC guidance summarises the scope of “Diagnostic and Screening procedures” for regulatory purposes as follows: Diagnostic and screening procedures “The activity includes instances of taking a sample or biopsy because it captures procedures if they involve removal of tissue, cells or fluids from the body, for the purpose of diagnosing disease, disorder or injury or monitoring its cause or extent. Therefore, anyone who 'removes' tissue, cells or fluids from the body for diagnostic reasons must register.” GAD has been registered with the CQC since 24 July 2020 for both of these regulated activities. CQC introduced in December 2021 specific guidance covering IV Drip treatments. This guidance was updated in June 2022 and currently provides as follows: “Intravenous (IV) products Intravenous administration of vitamins and products that are prescription only medicine (including 0.9% saline) that are used to improve or enhance wellbeing constitutes treatment of a disease or disorder. We consider a ‘disease’ to include a pathophysiological response to internal or external factors, and a disorder to include a disruption to regular bodily structure and function. If you provide intravenous administration services, you will need to register for the regulated activity if the procedures you offer: are delivered by, or under the supervision of, a listed healthcare professional, and include administering prescription-only products intravenously or products that require a prescription when delivered in intravenous form, and claim to alter a person’s physiological state in response to a defined concern. We do not consider this type of procedure to be alternative or complementary medicine. “[101]GAD appointed “CQC Assist” a specialist consultant, in December 2019 to help with its CQC registration.[102]On 24 July 2020 GAD became registered with CQC under the heads(i) Treatment of Disease, Disorder or Injury”, and(ii) “Diagnostic and Screening Procedures”.

The Expert Evidence

[103]The following is a summary of the key points of Dr Breeze’s written report which takes into account his response to questions asked during the proceedings. Focus on his oral evidence on the Samples is contained later in the Decision.[104]Dr Richard Breeze’s qualifications and roles are set out in his report as follows:
“I, Rich Breeze BSc MBBS FRCA DICM FFICM have been a dual accredited consultant in Intensive Care Medicine (ICM) & Anaesthesia for fifteen years. I am currently the Clinical Director for Critical Care at LGT and led our units through the recent pandemic. I have other roles at the Trust - being the Clinical Lead for Organ Transplantation, the Trust’s Designated Individual to The Human Tissue Authority and until recently the Faculty of Intensive Care Medicine Tutor in charge of ICM training. Finally, I represent the Trust at The Southeast London Critical Care Network to ensure that all deserving critically ill patients in our sector have equity of access to tertiary critical care”
[105]He is also presently the clinical director of two London Intensive Care Units based at Lewisham University Hospital and Queen Elizabeth Hospital Greenwich.

The meaning of “health”

[106]When asked for his view on the meaning of “health”, Dr Breeze referred to the World Health Organisation (“WHO”) definition of health which he said was widely used within medical practice. This defines health in the following terms: “A state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity”.[107]He said that this definition was recognised by “a body of medical opinion” and that the understanding of medicine had developed towards what he referred to as a “more patient collaborative model where the patient’s perception of their diseased state is pre-eminent” and doctors “have a responsibility to try to treat any disease process they present with; but not only that, but to make sure their holistic appreciation and how we can help them feel in themselves well, is part of our duty of care to the patients just as much as giving them antibiotics or ventilating them on the intensive care unit”.[108]In response to our questions as to the degree of acceptance in medical practice of the WHO definition of “health” he stated that the definition was reflected in the GMC’s document “Good Medical Practice” which had been updated “last year”. He added that the Good Medical Practice document was “recognised throughout the NHS”. In summary he said that the WHO definition “is the accepted definition that doctors in this country are expected to work to” and that was a result of the GMC.

The meaning of “disease state”

[109]Dr Breeze defined “disease state” as an “umbrella term” for a range of states exhibited by a patient. Some disease states would be immediately apparent – such as a fractured limb, others – such as psychiatric conditions might not be apparent on immediate inspection. He saw a disease state as a very broad term – which in essence was “anything that constituted ill health, either from the perception of the patient or after history, examination and investigation by the clinician.”

The meaning of “diagnosis”

[110]Dr Breeze considered that “diagnosis” was also an “umbrella term”. He explained that there were different levels of diagnosis. Usually clinicians would operate in the absence of a definitive diagnosis – and would make a provisional diagnosis when a patient first presented which diagnosis might evolve into a differential diagnosis if there were a number of potential disease states that they were trying to decided between. As further history and information and investigations arrived the diagnostic process would be honed in the hope of finally arriving at something definitive. An example of a definitive diagnosis was that a patient had cancer. He added that a lot of the time it was not possible to make a definitive diagnosis and that the majority of healthcare in the UK operated in the absence of definitive diagnoses.[111]He referred to a “firm diagnosis” which he described as a diagnosis “at the more determinative, certain end of the diagnostic spectrum”, with “a working diagnosis or provisional diagnosis or differential diagnosis” all constituting diagnoses that would hopefully lead to a more definitive diagnosis.[112]He gave as an example of a “provisional diagnosis” the type of diagnosis that might be made by a general practitioner (GP) when patients had a 10 minute slot. A patient might go in with a headache and the GP might say “based upon what I know or have seen … I will now diagnose that you just need paracetamol”. He said that there might be no process other than simply “I have seen you, I have heard from you, I have decided X and that is the end of it”.[113]Dr Breeze considered that a diagnosis could be inferred from a prescription – in that most doctors would not prescribe a treatment without having considered the requirement or cause for that treatment. The determination of that requirement or cause would be the diagnosis. Such a diagnosis might not he said be particularly narrow or complete – but in his view - he could not envisage an instance where he would prescribe something in the absence of something diagnostic.

The meaning of treatment

[114]Dr Breeze defined treatment as a term “whereby attempts are made to improve the health or diminish the disease states of a patient”. As with “diagnosis” he saw this as “a dynamic process”. He added that there were a relative minority of conditions that patients present that can actually be cured and that “most of the time [we] are managing their conditions, mitigating the consequences of those disease states”. His view of GAD’s activities Diagnosis

His view of GAD’s activities

[115]Dr Breeze considered that diagnosis was not the primary aim of the service provided by GAD. He thought that whilst there might be a benefit arising from a diagnosis where incidental findings were revealed, this would be an occasional secondary benefit.

Treatment

[116]In his written statement Dr Breeze concluded that; “GAD manifestly provides private prescriptions for treatment for either actual or perceived derangements or deficiencies in human physiology. Importantly BOTH of these (actual and perceived) constitute treatment.”[117]He also said:
“It is self-evident that some patients seeking the treatment offered by GAD will have a physiological derangement completely or partially corrected by that treatment” “It is also self-evident that the treatment provided by GAD will sometimes have no appreciable effect on the physiological state of the patient – but the patient believes that the treatment will be beneficial and that belief in an of itself constitutes a treatment.” “The well-being of GAD’s patients is improved either physically, psychologically, or most commonly both, by their treatment.”

Well-being

[118]Dr Breeze emphasised the importance of well-being and its increased prevalence in medical literature and the medical environment generally. He also emphasised how in his intensive care units he sought to ensure the “well-being” of his staff and how valuable that was to his staff.[119]In his description of well-being he said “I understand what “wellbeing” means to me. What wellbeing means to other people is best enunciated by them and enabled by whoever has the means, it is enormously dependant [sic] on feeling empowered to effect change. [ … ] Whatever constitutes wellbeing, it is real and had real socio-economic consequences for individuals and society.”[120]He went on to refer to the impact on an individual of their expectation of a drug effect as well as the actual effect of the drug, stating that it was impossible to separate the two on an individual basis. He suggested that whatever proportion of the patient’s wellbeing that was improved by the placebo effect is “a real and valid component of that treatment and ensuing improvement to the patient’s wellbeing” and that “Wellbeing is an authentic therapeutic target”.[121]He concluded by saying that in choosing to seek GADs services the patients would in his view, have “without exception [ … ] the aim of improving their wellbeing, whatever their perception of their wellbeing deficit is … “

Cure

[122]Dr Breeze thought that the services provided by GAD were unlikely to “cure” any medical conditions but that they “may well mitigate the detrimental physiological sequelae of a wide variety of acute or chronic deficiencies and lifestyle choices”.[123]He put this into context by saying that only a minority of medical conditions could in in fact be “cured – as in eradicated in a permanent fashion” and that in reality a large proportion of medical treatment was to manage or lessen “the gradient of inexorable decline”.

Prevention

[124]Similarly Dr Breeze thought that the reasons for which people sought GAD’s services were unlikely to be “prevented” by the provision of those services, although he acknowledged that “the negative consequences of some of those fundamental reasons will be attenuated”.

Specific evidence on the case studies

[125]Dr Breeze was asked during the hearing to review specifically each of the Samples and we set out later in this decision his comments on each Sample.[126]His written report contained the following general observations on the Samples:(1) They fell into very few categories “which almost all include tiredness, and fatigue, or the promotion of energy levels and wellbeing”.(2) They were all “very real complaints that are notoriously challenging for GPs and emergency departments to offer treatment for, either for reasons due to the triage process eventuating in a perceived lack of severity compared to other patients with more acutely life threatening pathology or a genuine lack of awareness as to what constitutes effective treatment”.(3) The treatments given are treatments that he considered “valid treatments for self reported or chemical pathologically proven derangements of physiology” and all are provided on a regular basis in his ICU departments. He was confident that they “absolutely improve physical and mental wellbeing”.

The submissions

[127]There is no dispute as to the legal tests to be applied to the issue under appeal. It is clear that in order for GADs supplies to fall within the Medical Exemption it is necessary for those supplies to:(1) Be supplies made by persons registered or enrolled on the register of medical practitioners at Item 1(a) or the register of qualified nurses at Item 1(d);(2) Be supplies constituting the provision of medical care.[128]For the supplies to constitute the provision of medical care they must be medical interventions the principal purpose of which is diagnosing, treating or, in so far as possible, curing diseases or health disorders, or to protect, maintain or restore human health[129]GAD’s assertion that the supplies in question are made by suitably qualified medical professionals employed by GAD (whether GMC registered doctors, NMC registered nurses (or registered nurse prescribers)) has not been challenged by HMRC.[130]HMRC has not contended that those medical professionals were acting outside the scope of their professional registration.[131]Additionally, HMRC has also not challenged the assertion that the Supplies constitute medical interventions.[132]We do not therefore consider those issues further.[133]The central issue in this appeal is whether the purpose test is satisfied.

HMRC’s submissions

[134]HMRC submit that the Supplies do not have the requisite purpose to fall within the Medical Exemption.[135]Specifically, Mr Millington submitted that the Supplies do not involve any “diagnosis, treatment or cure” and further that there was no evidence of GAD’s customers suffering from a disease or health disorder.[136]Mr Millington referred to the statements made by GAD to HMRC in its correspondence prior to September 2018 – which, together with the references on its website (as quoted by HMRC), stated clearly that GAD did not aim to treat, diagnose or cure diseases or health disorders.[137]He referred also to statements made by RC in his evidence as to the medical benefits of intravenous vitamin drips and in relation to nutrient deficiencies, asking us to discount that evidence as RC is not medically qualified and not therefore in a position to give what amounts to expert evidence.[138]Mr Millington further submitted that neither the Samples nor Dr Breeze’s expert report supported GAD’s position. In particular(i) the notes accompanying the Samples showed that GAD’s emphasis was on the promotion of general wellness or wellbeing - and did not appear to identify any actual diseases or health disorders, and(ii) Dr Breeze’s written report showed no real disease/health disorder – its focus being on treatment and wellbeing – as well as confirming diagnosis was not a main purpose[139]His key point was that the concept of general wellness or wellbeing was outside the scope of the Medical Exemption. Although included in the WHO definition of “health” and so relevant in UK medical care, that definition was not necessarily relevant for the Medical Exemption. In this regard he also pointed out that Dr Breeze was unable to define with any clarity what the term actually meant. In effect it was an entirely subjective concept.

GAD’s submissions

[140]GAD submits that its Supplies are provided for a therapeutic purpose as they either(i) involve the diagnosis and treatment of health disorders, or(ii) protect maintain or restore human health (i.e. they are prophylactic).[141]Mr Rivett developed this submission by explaining that to the extent Dr Breeze had confirmed that each of the Samples identified that conditions characterised as health disorders were being treated, it should be clear that the Supplies had a therapeutic purpose.[142]He submitted that to the extent the conditions were not characterised as “health disorders”, the treatments should be regarded as within the Medical Exemption on the basis that they were prophylactic. This was because human health had a broader meaning when considered in the context of prophylactic treatment and should be regarded as encompassing any form of health care.[143]He added that as the therapeutic purpose is the only purpose of the Supplies the question of “primary purpose” does not arise.[144]In support of his submission he noted that the question as to whether something is therapeutic was a medical assessment and should be based on findings of a medical nature made by a person qualified for that purpose (as per PFC Clinic and other cases).[145]Finally he submitted that GAD’s registration with CQC was supportive of its position – given the scope of one of the heads of registrable activities (treatment of disease, disorder or injury) under which it was registered.

Discussion

[146]There are a number of complications in this appeal.

Inconsistency

[147]The first is that it appears to us that GAD provided conflicting information to HMRC about the nature of its Supplies.[148]As cited by Mr Millington, the initial descriptions of its Supplies given by GAD to HMRC state clearly that those Supplies were not intended to diagnose, cure or treat diseases and either that there was no diagnosis or that any diagnosis was ancillary to the Supply. To strengthen its position GAD had also stated specifically that its Supplies were not within the scope of CQC regulation.[149]As well as the information provided to HMRC by GAD, the excerpts provided of the information set out on GAD’s website were consistent with that description of its Supplies.[150]The information provided supported GAD’s claims (at that time) for its Supplies to be zero rated.[151]However, GAD’s position changed materially in October 2018 – when, through its advisor (Dallas Campbell), it claimed that the Supplies in fact met the conditions for the provision of medical care as they were provided by a suitably qualified medical professional working within their qualifications and the primary purpose was to improve overall health or deal with a specific ailment, and should, therefore, be exempt.[152]GAD subsequently become registered with the CQC in July 2020 for(a) treatment of disease, disorder or injury; and(b) diagnostic and screening procedures.[153]A central pillar of GAD’s case is that the nature of its Supplies has not changed materially from the time it commenced business to the current date (and therefore pre or post CQC registration). That is the basis on which its submissions have been made. It is also the basis on which the Samples have been accepted as representative of the supplies made by GAD despite the fact that those samples cover a period which post-dates the period which is the subject of the assessment.[154]Mr Rivett put it to us that, as RC explained in his evidence, the inconsistency is a function of GAD having to be mindful about how it described its activities prior to receiving CQC regulation and that(a) there were uncertainties at the time as to whether its activities would fall within the scope of CQC regulation (there being some confusion as to the technical meaning of “diagnosis” and “treatment”), and(b) as a start up GAD did not have the resources to seek expert advice on the CQC position. Mr Rivett also reminded us that RC had explained that rules governing the advertising of medicines influenced what GAD could state on its website and further that the website should be seen in context – as an advertising and marketing platform rather than something that should bear clinical scrutiny.[155]We accept that at the relevant time there were some uncertainties as to the scope of CQC’s regulation in respect of IV drips, and we note, as pointed out by Mr Rivett, that CQC now has guidance covering IV Drips whereas no guidance existed prior to GAD’s registration.[156]We also accept that statements made on GAD’s website need to be assessed in context.[157]However, notwithstanding any regulatory uncertainty and taking into account the caveat in respect of the website, we find it difficult to square GAD’s inconsistent descriptions of its activities with its assertion that those activities have remained the same throughout.[158]It is also the case that HMRC focused, naturally, on the initial descriptions provided to it by GAD in making its determination in 2018 of the VAT treatment of the Supplies. Mr Millington also cites those initial descriptions in support of his submission that GAD does not satisfy the purpose test necessary for the Medical Exemption to apply.[159]However, in the context of this appeal, HMRC has not challenged, and Mr Millington confirmed that he had no intention to challenge, GAD’s assertion that the Samples are representative of GAD’s supplies. There has also been no challenge to GAD’s assertion that its activities have not changed materially since its business commenced. There has also been no suggestion of dishonesty or an attempt to mislead on the part of GAD or RC.[160]As Mr Rivett has made clear in his submissions, the consequence of the parties’ approach is that our assessment of GAD’s supplies in this Appeal must focus on the Samples.[161]We agree with Mr Rivett that given the parties’ position, our decision should be based on how we view the Supplies as they are shown in the Samples.[162]On that basis the inconsistency of GAD’s initial descriptions of its activities becomes of less significance as our focus is on those activities as shown in the Samples.

HMRC’s expert evidence

[163]The second issue is that HMRC was, for certain reasons, obliged to withdraw the evidence of its medical expert after the proceedings had started. This meant that the joint expert witness report included in our hearing bundle was withdrawn and we were asked to disregard all references to HMRC’s expert and the views of that expert contained in the documents before us - including Mr Millington’s and Mr Rivett’s skeleton arguments. It also meant that HMRC’s proposed cross examination of GAD’s expert witness was impacted. However, there was no application to adjourn the proceedings and we proceeded having agreed to disregard in its entirety all of the affected material.

GAD’s expert evidence

[164]The third issue relates to GAD’s expert witness.[165]Mr Millington pointed out that Dr Breeze’s written report contained no references to any supporting literature or other material as it was required to do (under the Civil Procedure Rules). It also gave no indication of what the views of other medical professionals might be on the issues considered by Dr Breeze – or indeed that there might be a range of opinions on those issues or where Dr Breeze felt that he sat within that range.[166]Mr Millington also noted that in his report Dr Breeze had not gone through the Samples individually – and had instead made observations in relation to them generally[167]In other respects, particularly in relation to the meaning of “health” and “well-being”, Mr Millington considered Dr Breeze’s report to be more of an academic thesis than an expert report.[168]In short Mr Millington’s view was that Dr Breeze’s report did not contain expert evidence sufficient to inform the Tribunal as to the issues it needed to determine. In Mr Millington’s view this mean that the foundation for Dr Breeze’s opinion could not be tested – as he had not told the Tribunal what that foundation was.[169]He added that this was not a criticism nor a challenge of Dr Breeze’s competence as a medical professional, it was more a reflection he thought of his inexperience as an expert witness and a lack of awareness as to the requirement of the role.[170]Mr Millington expressed his concern that it was only after he had highlighted in cross examination the perceived deficiencies in Dr Breeze’s report that Mr Rivett then took Dr Breeze through each of the Samples specifically to address those highlighted points. He asked us to take into account the differences between the answers given by Dr Breeze in his oral evidence and the evidence contained in his written report. He added as a separate point a potential concern that Dr Breeze might not be entirely impartial on the issue of wellbeing and vitamin deficiencies given that he had expressed particular interest and belief in the area.[171]Mr Rivett responded by emphasising that Dr Breeze was a practising clinician rather than an academic expert and his undoubted experience and unchallenged expertise gave credibility to his views notwithstanding the lack of reference materials to support those views.[172]He added that in his oral evidence relating to the Samples Dr Breeze had explained that there were a range of views on particular issues and that Dr Breeze saw his views as “balanced”. He noted that Mr Millington had not challenged Dr Breeze as to whether he was an outlier in respect of his views and had not accused him of being one.[173]Mr Rivett further noted that given the nature of Dr Breeze’s experience in leading two London A&E departments he was a clinician very used to diagnosing new patients and prescribing treatments. The evidence he gave at the hearing ought therefore to be given weight accordingly.[174]Mr Rivett also sought to argue that although Dr Breeze had not submitted any academic literature or other material to support his views, he had confirmed that he had read and agreed with RC’s written evidence which included, as exhibits, several scientific and medical reports. We did not give weight to this argument as it was in our view by no means equivalent to Dr Breeze providing support for his opinion in the manner contemplated by Mr Millington.[175]We noted Mr Millington’s concerns and we agree that Dr Breeze’s written report did not address the key issues relevant to this Appeal in the manner that might have been expected.[176]However Dr Breeze’s competence and his expertise were not in question and we regarded him as a credible expert. We agreed in particular with Mr Rivett’s view as to the likely relevance of Dr Breeze’s clinical experience as an A&E leader in terms of diagnosing and treating new patients on a rapid basis. Also, as Mr Rivett pointed out, Dr Breeze’s competence was not challenged by Mr Millington.[177]We note that as per Civil Procedure Rule 35-5 expert evidence is to be given in a written report, unless the court directs otherwise. In our view, the fact that Dr Breeze’s key evidence was given in his oral testimony rather than in his written report does not prevent that evidence carrying weight in the context of this Appeal. Mr Millington had the opportunity to (and did) cross examine and challenge Dr Breeze and, the fact that HMRC withdrew its expert once proceedings had begun cannot be allowed to prejudice GAD. Further, Dr Breeze’s oral evidence addressed Mr Millington’s specific concerns as to the lack of granularity and detail in his approach to the Samples and the evidence given was not inconsistent with the views given in his written report.[178]With these points in mind we turn to the legal issues for determination.

The Samples

[179]As we state above, this Appeal hinges to a large extent on the analysis of the Supplies as shown in the Samples and it is necessary to turn here to the expert evidence available.[180]We note in this regard the guidance in the CJEU decision PFC Clinic as to the determination of the therapeutic purpose of treatment being a medical assessment that needs to be based on findings of a medical nature made by a person qualified for that purpose (PFC Clinic at [34] – [36]).[181]Here we considered the oral evidence given by Dr Breeze in relation to each of the Samples and the more general evidence given in his written report.[182]We found Dr Breeze’s written report to be of less assistance than it might otherwise have been. As Mr Millington pointed out, the report was rather general in nature and failed to consider the Samples on an individual basis, instead making high level observations in respect of them as a whole.[183]We also agree with Mr Millington that the concept of “well-being” as explained by Dr Breeze is vague and appears to be entirely subjective. It is not in our view, at least not in the form expressed by Dr Breeze, a suitable term to determine application of the Medical Exemption.[184]Mr Rivett, having taken into account Mr Millington’s cross examination of Dr Breeze, asked Dr Breeze to go through the Samples individually and to give his clear opinion in respect of each of them. Dr Breeze’s responses are summarised below. The Sample notes to which the comments relate is attached as Appendix 2 to this decision

Patient A

[185]Dr Breeze identified two diagnosed health disorders. These were:(1) a provisional diagnosis of a “deficiency in folic acid” which was treated by “Pabrinex” - folic acid being one of the components thereof.(2) a “headache” in respect of which B2 and/or glutathione were a reasonable treatment.[186]The patient was given the Detox Drip which comprised “Compound Sodium Lactate (Hartmann's) 1000mL’; ‘Glutathione 600mg/4ml (IV Push) 150mg’; ‘Pabrinex ampoule 1 + 2.”[187]Dr Breeze confirmed that Pabrinex was a reasonable treatment for a deficiency in folic acid as folic acid was one of its components, and that vitamin B2 or glutathione were reasonable treatments for a headache. Both Pabrinex and Glutathione were included in the Detox Drip.[188]Dr Breeze also identified as a disease state “dissatisfaction that the patient is feeling in their current levels of energy and health generally” which he considered was a “state of psychological disharmony”. He qualified his view recognising that this might not generally be regarded as a disease state.

Patient B

[189]Dr Breeze identified two diagnosed health disorders. These were:(1) dehydration(2) depleted potassium levels caused by insulin use[190]The patient was given the Detox Drip (ingredients as above for Patient A) and the “Party Drip” which comprised: ‘Compound Sodium Lactate (Hartmann's) 1000mL’; ‘Ranitidine (Zantac) 50mg/2ml 50mg’; ‘Ondansetron 4mg/2ml 4mg’; ‘Paracetamol 1g/100ml 1g’.[191]Dr Breeze confirmed that Detox Drip was a reasonable treatment to deal with the dehydration. He also confirmed that the replacement of insulin through electrolytes was a reasonable treatment – adding for the condition adding that he did that “every day”.

Patient C

[192]Dr Breeze identified two diagnosed health disorders. These were:(1) eczema(2) fatigue[193]The patient was given a B12 hydroxocobalamin injection.[194]Dr Breeze affirmed that the provision of B12 was a reasonable treatment for the symptoms associated with chronic eczema and also a reasonable treatment for fatigue.

Patient D

[195]Dr Breeze identified “dehydration” as a diagnosed health disorder. He also noted that the patient had an underactive thyroid gland.[196]The patient was given: “IV - Hartmann's - Compound Sodium Lactate 1000mL’, ‘IV - Vitamin C - Ascorbic Acid 12.5g/50ml 12.5g/50ml”.[197]Dr Breeze affirmed that the treatment addressed the dehydration and that a high dose of vitamin C would, in his opinion, be beneficial for the underactive thyroid although he acknowledged that “not everyone agreed”.

Patient E

[198]Dr Breeze identified as a diagnosed disorder “nerve pain” which he affirmed was a symptom of a health disorder and which could be a symptom of a B12 deficiency. He also identified “headache” as a diagnosed health disorder.[199]The patient was given the “Energy Drip” which comprised:
“IV - B Complex 2ml’; ‘IV - Amino Acids 10ml’; ‘IV - Magnesium Sulfate 50% 0.5g / 1ml’; ‘IV - B12 Methylcobalamin 5mg / 2ml’; ‘IV - Hartmann's - Compound Sodium Lactate 1000mL”
[200]Dr Breeze affirmed that B12 was a reasonable treatment to address a B12 deficiency and that B12 and magnesium were recognised treatments for a headache. Both B12 and magnesium were components of the Energy Drip.

Patient F

[201]Dr Breeze identified as a diagnosed health disorder a deficiency of B12 which in this case was metformin induced.[202]The patient was given:
“IV - Hartmann's – Compound Sodium Lactate 1000mL’; IV - Vitamin C - Ascorbic Acid 12.5g/50ml 12.5g/50ml’; ‘IM - Vitamin D – Ergocalciferol 300,000units/1ml vial 30,000 units’; ‘IV - B Complex 2ml B1 (10mg), B2 (5.1mg), B3 (40mg), B5 (6mg) & B6 (4mg)’; ‘IM - B12 Methylcobalamin 5mg / 2ml”
[203]Dr Breeze affirmed that the prescription of B12, methyl B complex, vitamin D and “slimshot” indicated in the notes was a reasonable treatment of B12 deficiency.

Patient G

[204]Dr Breeze identified two diagnosed health disorders. These were:(1) fatigue(2) metformin-induced B12 depletion[205]The patient was given:
“IV - Vitamin C - Ascorbic Acid 12.5g/50ml’; ‘IV - Hartmann's - Compound Sodium Lactate’; ‘IM - Vitamin D - Ergocalciferol 300,000units/1ml vial’; ‘IM - B12 Methylcobalamin’; ‘IM - B Complex”
[206]Dr Breeze affirmed that B12 was a reasonable treatment for the disorders.

Patient H

[207]Dr Breeze identified two diagnosed health disorders. These were: i. a malabsorption issue due to poor gut health ii. dehydration[208]The patient was given: “IV - Hartmann's - Compound Sodium Lactate 1000mL’; ‘IM -Vitamin D - Ergocalciferol 300,000units/1ml vial 30,000 units”.[209]Dr Breeze affirmed that the treatment given was a reasonable treatment for both disorders.

Patient I

[210]Dr Breeze identified fatigue as a diagnosed health disorder.[211]The patient was given:
“IV - Pabrinex Ampoule 1 + 2’; and ‘IV - Hartmann's - Compound Sodium Lactate 1000mL”
[212]Dr Breeze affirmed that the treatment given was a reasonable treatment for the disorder.

Patient J

[213]Dr Breeze identified two diagnosed health disorders. These were:(1) vitamin B12 deficiency(2) fatigue[214]The patient was given: “IV – B12 Methylcobalamin 5mg/2ML”.[215]Dr Breeze affirmed that the treatment was a reasonable treatment for both disorders.

Patient K

[216]Dr Breeze identified as a diagnosed health disorder a vitamin absorption issue.[217]The patient was given:
“IV - Hartmann's – Compound Sodium Lactate 1000mL’; ‘IV - B12 5mg / Methylcobalamin 2ml’; ‘IV – Magnesium 0.5g / Sulfate 50% 1ml’; ‘IV - Amino Acids 10ml Per 1,000ml - Isoleucine 5.85g, Leucine 11.4g, Lysine 8.93g, Methionine 5.7g, Phenylalanine 5.7g, Threonine 5.4g, Tryptophan 2.1g, Valine 7.2g, Arginine 16.05g, Histidine 5.25g, Alanine 22.35g, Glycine 19.2g, Aspartic Acid 7.95g,Acetylcysteine 0.5g, Glutamic Acid 16.2g, Proline 7.35g, Serine 3g, Tyrosine 0.5g’; ‘IV - B Complex 2ml B1 (10mg), B2 (5.1mg), B3 (40mg), B5 (6mg) & B6 (4mg)’; ‘IM - Vitamin D – Ergocalciferol 300,000units/1ml vial 30,000 units’; ‘IV - L-Carnitine 1g/5ml - 5 Doses 1g’; ‘IV – Taurine 1,000mg / 20ml’; ‘IV – Glutathione 600mg/4ml – 16 Doses 2,400mg.”
[218]Dr Breeze affirmed that the treatment given was a treatment for the vitamin absorption condition.

Fatigue as a health condition

[219]Dr Breeze identified fatigue as a health disorder in three of the Samples.[220]When questioned as to his view on fatigue being a health disorder he answered that it was very much so and that he thought it was very important. He added that “fatigue” was a broad term “with a huge number of potential underlying aetiologies or causes, many of which are amenable to simple treatment”. He further explained that chronic fatigue, which was one type of fatigue, was an example of a very debilitating illness and anything that could be done to improve a patient’s condition would be of enormous benefit. In other words fatigue could, as we interpreted it, be a disorder in itself or an indication of another underlying disorder.

Conclusion on the medical evidence

[221]It seems clear to us that Dr Breeze has identified in each of the Patient Samples at least one condition which he recognises as a health disorder, together with treatment, which he considers to be suitable or appropriate for that disorder, being provided by GAD.[222]We note that there is a lack of clarity as to “fatigue” - it may be a condition in itself (as in the case of “chronic fatigue”) or it may be an indication of an underlying condition. It could also, as Mr Millington pointed out, be a natural consequence of a day’s shopping in one of the centres in which a GAD clinic might be located. However, the fact that fatigue has such a broad spectrum should not, logically, exclude it from being a medical condition. We also note here Dr Breeze’s evidence in relation to the difficulties generally in medical practice of making a definitive diagnosis. The uncertainty in relation to fatigue does not therefore impact our view of the evidence provided.[223]Mr Millington also expressed the view that some of the medical conditions mentioned were in his view minor – such as headaches. He was also sceptical, as general observation, that treatments aimed at hangovers or parties should be within the Medical Exemption.[224]In response Mr Rivett pointed out that there was no requirement of severity that a medical condition had to meet in order to fall within the Medical Exemption. He added that there was also no moral judgment – and the circumstances giving rise to a medical condition should not impact availability of the exemption. We agree with Mr Rivett.[225]Mr Rivett drew a parallel with the position in Wood v Holden [2006] EWCA Civ 26. Although the statutory provisions in question were different, that case also involved a taxpayer having to prove that an HMRC assessment had been wrongly made. The case centred on establishing where the central management and control of a company was located. In that case, in discussing the burden of proof, Chadwick J referred at [30] to the High Court decision under appeal and to Moses J’s comment at [59] of the High Court decision that:
“there plainly comes a point where the taxpayer has produced evidence which as matters stand then, appears to show that the assessment is wrong. At that point the evidential basis must pass to the Revenue”
He went on to say (at [32]):
“as the judge pointed out, the revenue had produced no positive material to show where the central control and management of [the company] was, It was not enough (as the judge thought) for the Revenue to criticise the lack of evidence …”
[226]Mr Rivett made the point that in the context of this appeal, the only evidence before us from a medically qualified expert is that each of the Samples show a customer with a medical disorder who received medical treatment for that disorder. It was in his view encumbent upon HMRC to adduce medical evidence to the contrary and in circumstances where they had not done so or were unable to do so it was not open to them to say that there was a basis on which the Tribunal could properly find otherwise.[227]We agree largely with Mr Rivett, noting of course that we have not accepted without question the evidence of Dr Breeze. As outlined above, we considered carefully the factors relevant to his evidence and, having questioned him and taken into account Mr Millington’s and Mr Rivett’s points, reached a conclusion as to the weight to ascribe to that evidence in assisting us with the legal determination that we need to make.[228]Having weighed up all the evidence before us, for each Sample we have evidence from a medical expert who we regard as credible, that at least one physiological health disorder has been diagnosed and appropriate treatment for that disorder prescribed. Reasoning has also been provided by the medical expert for those determinations.[229]We consider therefore that on the balance of probabilities the Supplies do constitute the provision of medical care.

Main purpose

[230]Mr Rivett asserted that it was clear that the only purpose of the Supplies shown in the Samples is therapeutic – in each case customers went to the GAD clinic with a health concern, had at least one health disorder identified and treatment was given.[231]Mr Millington referred to the fact that GAD described its clinics as “wellness clinics” and that HMRC’s basic position was that GAD did not satisfy the purpose test as general improvements and enhancements of wellbeing were outside the Medical Exemption (at least currently).[232]We agree with Mr Rivett. It is difficult to identify a non-therapeutic purpose to the Supplies and even if it were possible to identify one it would be hard to see it being a “main purpose”. We considered that Mr Millington’s comments to be of a general nature rather than focusing on the Supplies as shown in the Samples.[233]We conclude therefore, on the basis that there is no dispute as to the Supplies amounting to medical interventions or that they are supplied by suitably qualified medical professionals acting within the scope of their qualifications, the Supplies as described in the Samples are within the Medical Exemption.[234]With regard to Mr Rivett’s other submissions:

CQC Regulation

[235]We agree with Mr Rivett that the fact that GAD’s activities are within the scope of CQC regulation for “Treatment of Disease and Disorder” is supportive. However, CQC Regulation within that head does not mean that the regulated activities are necessarily within the Medical Exemption. As Mr Millington pointed out, the HSCA 2008 and the CQC regulations are entirely separate from the relevant VAT provisions and have a different regulatory purpose.

Prophylaxis

[236]Given our conclusion as to the Supplies shown in the Samples constituting the treatment of medical disorders, it follows that we do not need to consider Mr Rivett’s alternative submission as to their therapeutic purpose being a prophylactic purpose.

Disposition

[237]For the reasons given above, the Appeal is allowed.

Right to apply for permission to appeal

[238]This document contains full findings of fact and reasons for the decision. Any party dissatisfied with this decision has a right to apply for permission to appeal against it pursuant to Rule 39 of the Tribunal Procedure (First-tier Tribunal) (Tax Chamber) Rules 2009. The application must be received by this Tribunal not later than 56 days after this decision is sent to that party. The parties are referred to “Guidance to accompany a Decision from the First-tier Tribunal (Tax Chamber)” which accompanies and forms part of this decision notice. 239. Appendix 1 240. The medicines used The list of medicinal products used by GAD is as follows:a. B12 - Hydroxocobalaminb. Pabrinexc. Hartmann’s Solution / Sodium Lactate (main drip product)d. Amino Acid Complexe. Seleniumf. Magnesiumg. Compound Sodium Lactate Solutionh. Paracetamoli. Ondansetronj. Ranitidinek. Calciuml. Vitamin Dm. Vitamin Cn. Alpha-lipoic Acid (ALA)o. B Complex (B1, B2, B3, B5 & B6)p. B12 Other Forms – Hydroxocobalamin, Methylcobalamin, Adenosylcobalaminq. Vit B7 - Biotinr. Glutamines. Carnitinet. Methionineu. Taurinev. Glutathione APPENDIX 2 The Samples Patient A The notes state:
‘Medical. Client came in today as they would like to promote full body detoxification for health and wellness boost. Wants to aid hydration and promote general vitamin levels to maintain energy and improve health. No previous medical history. Nil known allergies Taking a mix of oral vitamin supplements and occasional ibuprofen for aches and pains and headaches. Recommended the detox drip. The b vitamins in this will help promote overall health, including a healthy nervous system. The b2 will help with headaches and migraines. Glutathione will also help prevent headaches, while promoting detoxification and liver health. Will benefit from electrolytes and full hydration. May be deficient in folic acid, due to ibuprofen use. Advised to add folic acid to oral supplements. Already taking b12 orally and nil complaints of fatigue or symptoms relating to b12 deficiencies. Medical observations are within range and stable. Cannula inserted using aseptic technique Flushed and patent. Nil concerns during administration Glutathione administered as a slow push. Post obs within range. Client feeling well with no side effects noted. Advised of aftercare’.74 The treatment given Patient A was given the ‘Detox Drip’ which comprised: ‘Compound Sodium Lactate (Hartmann's) 1000mL’; ‘Glutathione 600mg/4ml (IV Push) 150mg’; ‘Pabrinex ampoule 1 + 2’
. Patient B The notes state:
‘Medical Client came in today to improve hydration as feeling dehydrated and nauseous. Would like to replenish electrolytes and energy levels as feeling run down and generally not on form lately. Is a type 1 diabetic and self administers insulin. Prone to potassium drug induced depletion from insulin. Nil other medications or medical history We recommended the detox drip for this client. To provide hydration and replenish electrolytes, replacing depleted potassium from insulin use and b vitamins. Helping to promote energy and neurological health. The glutathione will aid a detoxification and promote organ health while protecting against free radicals damage and helping to stabilise blood sugars. Observations stable. Cannula inserted using aseptic technique Flushed and patent Drip administered IV with nil concerns Advised client of aftercare Post obs within range’
. The treatment given Patient B was given the ‘Detox Drip’, as stated in the notes. Patient B was also given the ‘Party Drip’ (which comprised:
‘Compound Sodium Lactate (Hartmann's) 1000mL’; ‘Ranitidine (Zantac) 50mg/2ml 50mg’; ‘Ondansetron 4mg/2ml 4mg’; ‘Paracetamol 1g/100ml 1g’). Patient C The notes state that: ‘Medical. Client reports long term fatigue and also suffers from Eczema and has found the having B12 injections really helps to relieve the symptoms of chronic Eczema. Not taking any medications or supplements. Nil other medical history noted. We Recommended B12 injections monthly to help with the symptoms associated with chronic eczema. This will also help to alleviate the fatigue symptoms by helping to maintain levels and prevent deficiencies. Low levels of B12 are associated with both fatigue and skin conditions including eczema, so maintenance doses are essential for symptom control to prevent flare ups. Client feels well and able to proceed with injection. Administered IM into left Deltoid using ANTT. Nil concerns noted. Advised client of aftercare’
. The treatment given Patient C was given an injection of B12 Hydroxycobalamin. Patient D The notes state:
‘Medical - returning Customer Client wants to re-hydrate as has been feeling a bit fatigued, and have some vitamins to help improve her general health and prevent illness and viruses. PMHx hypothyroidism on levothyroxine. Recommended high dose vitamin C to help improve her hydration, immunity, preventing getting sick/fatigued and to help promote and maintain overall good health and wellness with protection against free radical damage in the body. Observations stable Pink cannula inserted no issues. Flushed and patent. No other concerns voiced. Client comfortable’
. The treatment given Patient D was prescribed:
‘IV - Hartmann's - Compound Sodium Lactate 1000mL’, ‘IV - Vitamin C - Ascorbic Acid 12.5g/50ml 12.5g/50ml’.94 Patient E The notes state: ‘Medical. Client is looking for something to help improve nerve functions and nerve pain. History noted on the questionnaire. Feeling weak most of the time. No pmhx [past medical history] noted. Client expresses he has occasional dizzy spells. Takes cocodamol and pregabalin for pain. Recommended the energy drip to help boost his energy levels and target nerve pains with the b complex, specifically the B2 and magnesium for headache symptom control and B12 as nerve pain is a symptom of deficiencies, and to help promote and maintain overall good health. *Be cautious with Taurine or Glutamine, as these amino acids can enhance the effects of pregabalin medications. Monitor if administering and educate client* Cannula inserted. Flushed and patent. No other concerns voiced. Client comfortable’
. The treatment given Patient E was given the ‘Energy Drip’, which comprised ‘IV - B Complex 2ml’; ‘IV - Amino Acids 10ml’; ‘IV - Magnesium Sulfate 50% 0.5g / 1ml’; ‘IV - B12 Methylcobalamin 5mg / 2ml’; ‘IV - Hartmann's - Compound Sodium Lactate 1000mL’. Patient F The notes state:
‘Medical. Client is a regular Who suffers from fatigue, lack of energy and is also looking to be fit and loss weight. Client is taking metformin which depletes the body of b12. Recommended b12 methyl, b complex, Vit d and slim shot to help improve faster metabolism, improve energy/mood levels, aid with weight lose, prevent fatigue/getting sick and to help promote overall good health and wellness. Client is diabetic and suffers from mental health issues. No other concerns voiced. Injection given with ANTT. Post care advice given. Client happy and feeling well post injections. B12 methyl R lower deltoid. Vit d upper R deltoid. B complex L arm. Slim shot left gluteus’
Treatment given Patient F was given the following prescription:
‘IV - Hartmann's – Compound Sodium Lactate 1000mL’; IV - Vitamin C - Ascorbic Acid 12.5g/50ml 12.5g/50ml’; ‘IM - Vitamin D – Ergocalciferol 300,000units/1ml vial 30,000 units’; ‘IV - B Complex 2ml B1 (10mg), B2 (5.1mg), B3 (40mg), B5 (6mg) & B6 (4mg)’; ‘IM - B12 Methylcobalamin 5mg / 2ml Patient G The notes state: ‘Medical - returning customer. Client looking to boost immunity in preparation to change in season. Recently been feeling tired. PMHX [past medical history] - hypertension, diabetic, hyperthyroidism. Medications - metformin depletes b12, amlodopine, clopidogrel, ezetimibe, linsopril, omeprazole. Recommended the immunity drip with extra Vit c to help improve immunity/hydration and prevent sickness during this time in preparation to change in season. B12 recommended to help improve energy levels, prevent fatigue and deficiency as metformin depletes b12 in the body, help combat stress and anxiety. Vit d to help improve mood levels, prevent deficiency due to the lack of sunlight in the U.K. Pink cannula inserted. Flushed and patent. Nil concerns. Client comfortable’
. Treatment given Patient G was given:
‘IV - Vitamin C - Ascorbic Acid 12.5g/50ml’; ‘IV - Hartmann's - Compound Sodium Lactate’; ‘IM - Vitamin D - Ergocalciferol 300,000units/1ml vial’; ‘IM - B12 Methylcobalamin’; ‘IM - B Complex’
. Patient H The notes state:
‘Client advised she has a malabsorption issue due to poor gut health and as a result is deprived of vital nutrients and vitamins in diet and feels fatigued and drained. PMHx malabsorption (seen by functional doctor). We recommended; Multivit drip in normal saline to boost energy production in the body through nutrients and foods consumed. Improve immunity and help fight infections in the body. Improve eyesight and DNA repair and supports skin health. Improve stress levels and replenish vital body salts and hydration. Vital signs carried out by client on her own blood pressure machine. Client visibly dehydrated and appears to have poor venous access. Venous access gained with good flush back on 4th attempt. Infusion running with no concerns’
. Treatment given Patient H was given:
‘IV - Hartmann's - Compound Sodium Lactate 1000mL’; ‘IM -Vitamin D - Ergocalciferol 300,000units/1ml vial 30,000 units’.114 Patient I The notes state: ‘Medical. New client arrived in clinic today reporting experiencing fatigue as well as low mood, the client disclosed she has history of depression and would like to have a drip to improve the symptoms she has described. The client reports taking Lamictal (Lamotrigine) and so unfortunately cannot have amino acids within the drip, therefore I recommended the MultiVit drip as this includes vitamin C, Vitamins B1,2,3 and 6 as well as glucose. The combination of the vitamins with the basic hydration will replenish electrolytes, rehydrate the body, improve mood, boost energy levels and maintain a healthy immune system as well as overall wellness. The client was happy and consented to proceeding with the recommended drip. Observations checked and safe to proceed. The client reports no allergies that she is aware of and disclosed the current medication she is taking. Blue cannula inserted to the left ACF using aseptic technique, good flashback noted, cannula flushed and patent, no concerns expressed by the client and drip administered’
. Treatment given Patient I was given:
‘IV - Pabrinex Ampoule 1 + 2’; and ‘IV - Hartmann's - Compound Sodium Lactate 1000mL’
. Patient J The notes state:
‘Non Cosmetic. New client arrived in clinic today reporting feeling low in energy and would like a booster shot, he explained he has had B12 injections in the past and worked really well for him. The client also has a vegetarian diet in which he is at risk of vitamin B12 deficiency, the common symptom of this deficiency is fatigue, the client also feels as though he may also be deficient in vitamin D. I explained we offer 2 types of vitamin B12: Hydroxocobalamin (the inactive form) and Methylcobalamin (the active form), as well as vitamin D testing. As the client is unsure if he has the gene to convert the inactive form, I recommended the B12 Methylcobalamin as this will improve energy levels, promote production of healthy red blood cells, aids healthy digestion, promotes healthy skin and nails, as well as overall health. The client was happy with the recommendation and consented to proceed with the B12 Methylcobalamin and also requested for the Vitamin D test. The client reports no allergies that he is aware of an not taking medications. B12 injection administered to the left deltoid using aseptic technique, plaster applied to the site, aftercare explained and no concerns expressed by the client. Vitamin D results explained in which he is level 3-sufficient vitamin D. The client reports feeling well when leaving clinic and aftercare also sent via email’
Treatment given Patient J was given ‘IV - B12 Methylcobalamin 5mg / 2ml’. Patient K The notes state:
‘Medical. Client arrived in clinic today reporting feeling a bit low in energy and booked in for the energy drip with the addition of L-carnitine + taurine and glutathione as a push after the drip, she is also for her Vit D maintenance dose of 30,000 units. The client had taken a DNA test from us previously which had showed low levels of absorption for these vitamins and so we are able to recommend the specific vitamins required for her body. The combination of the chosen vitamins will improve energy levels, promote a healthy immune system, replenish electrolytes, rehydrate the body, detox the body, regulate sleep pattern, maintain healthy brain and nerve system function as well as maintain overall health and wellness. Observations checked and initially Bp was below 90 systolic, she reports her Bp usually is low and so I advised to drink water and I will re-check after 15 minutes. Bp re-checked and increased to over 90 systolic, I contacted senior nurse Sanny who advised was safe to proceed with drip, to run slowly and continue to monitor during the drip. The client reports no allergies and not taking any medications. Blue cannula inserted to right ACF using aseptic technique, cannula flushed and patent, no concerns expressed and drip commenced slowly, Vit D administered to right deltoid using aseptic technique, plaster applied to site. Bp checked 20 minutes into drip =88/64, drip is running very slowly and the client reports feeling fine’
. Treatment given Patient K was given: ‘IV - Hartmann's – Compound Sodium Lactate 1000mL’; ‘IV - B12 5mg / Methylcobalamin 2ml’; ‘IV – Magnesium 0.5g / Sulfate 50% 1ml’; ‘IV - Amino Acids 10ml Per 1,000ml - Isoleucine 5.85g, Leucine 11.4g, Lysine 8.93g, Methionine 5.7g, Phenylalanine 5.7g, Threonine 5.4g, Tryptophan 2.1g, Valine 7.2g, Arginine 16.05g, Histidine 5.25g, Alanine 22.35g, Glycine 19.2g, Aspartic Acid 7.95g, Acetylcysteine 0.5g, Glutamic Acid 16.2g, Proline 7.35g, Serine 3g, Tyrosine 0.5g’; ‘IV - B Complex 2ml B1 (10mg), B2 (5.1mg), B3 (40mg), B5 (6mg) & B6 (4mg)’; ‘IM - Vitamin D – Ergocalciferol 300,000units/1ml vial 30,000 units’; ‘IV - L-Carnitine 1g/5ml - 5 Doses 1g’; ‘IV – Taurine 1,000mg / 20ml’; ‘IV – Glutathione 600mg/4ml – 16 Doses 2,400mg