Health institutions

Foreword

This notice cancels and replaces Notice 701/31 (February 2007). Details of changes to the previous version can be found in paragraph 1.2.

1.Introduction

1.1 What is this notice about?

This notice explains:

• the VAT liability of goods and services supplied by hospitals, and other institutions that provide medical care or treatment;
• the VAT liability of goods and services supplied by third parties on the premises of a hospital or other institution that provides medical care or treatment;
• when drugs or medicines dispensed to in-patients, residents or other people attending the premises of a hospital or other institution may be relieved from VAT; and
• when institutions that provide medical care or treatment should register for VAT.

1.2 What has changed?

This notice replaces the February 2007 edition of Notice 701/31 Health and care institutions. The notice has been revised and provides additional guidance on independent pharmacies operating within hospitals.

Advice about supplies made to and by welfare institutions can be found in Notice 701/2 Welfare. This notice and others mentioned are available on our Internet website at hmrc.gov.uk.

1.3 Who should read this notice?

You should read this notice if you are:

• a hospital or similar institution that is approved, licensed or registered under the appropriate social legislation, or is exempted by such legislation from obtaining approval or registration, or
• any other business that provides goods or services to hospitals or similar institutions, or to patients, or other persons attending the premises of such an institution.

1.4 What law is covered in this notice?

The VAT Act 1994, Schedule 9, Group 7, item 4 provides exemption for the provision of care or medical or surgical treatment and, in connection with it, the supply of goods, in any hospital or state-regulated institution.

2. Exemption for care and treatment provided in qualifying institutions

2.1 What is a qualifying institution?

An institution is qualifying when either of the following conditions is met:

• The institution is a hospital;
• The institution is either a hospice or nursing home, and is either:
  approved, licensed or registered under the relevant social legislation, or
  exempted from obtaining such an approval or registration by the relevant legislation.

An institution may be qualifying regardless of whether its activities are carried out on a charitable or commercial basis.

2.2 What services provided by a qualifying institution are exempt from VAT?

Supplies made by a qualifying institution are exempt when both of the following conditions are met:

The supply consists of care or medical or surgical treatment in connection with the health of the beneficiary; and,

This care or treatment is provided under the terms of:

• an approval, license, registration or
• an exemption from registration under the appropriate social legislation.

2.3 What is medical care or treatment?

Examples of medical care or treatment supplied by a qualifying institution include:

• performing medical or surgical procedures with the aim of protecting, maintaining or restoring the health of an individual.
• nursing sick or injured patients in a hospital, hospice or nursing home.
• meals and accommodation provided to in-patients, residents or other care beneficiaries.

2.4 What services provided by a qualifying institution are not exempt?

Examples of services that are not exempt include:

• any service that is not provided under the terms of an approval, license, registration or exemption from registration, granted under the appropriate social legislation;
• any service provided to a person other than an in-patient, resident or other beneficiary of care or treatment. This includes any supply made to visitors. However, special rules apply to the supply of meals and accommodation to parents staying in hospital with a sick child (see paragraph 2.11 below), and;
• any goods or services that are separable from care or treatment provided within the institution. For example, charges made for the use of telephones.

2.5 Class 3B and 4 lasers and Intense pulse light source (IPL) machines

Class 3B and 4 lasers and IPL machines are now used in many medical and cosmetic procedures carried out on the premises of approved, licensed or registered institutions. However, it should not be assumed that all treatments using this equipment are exempt from VAT.

Where the procedure using this equipment is supplied as part of a treatment programme drawn up by a registered health professional following the diagnosis of a medical condition, this treatment is exempt from VAT. But where it is carried out for a cosmetic reason rather than as an element of medical or surgical treatment, this service is taxable at the standard rate of VAT.

2.6 Transport supplied or received by a qualifying institution

Transport services are exempt when:

• the transport is an integral part of the exempt supply of care and treatment provided by a qualifying institution.
• the transportation, by any provider, of sick or injured persons to or from a place of medical care or treatment, in a vehicle specially designed or adapted for the purpose.

The following services are zero-rated, regardless of who makes the supply:

• passenger transport in any vehicle designed or adapted to carry not less than 10 people; and
• passenger transport in any vehicle constructed or modified to carry disabled passengers where, prior to such a modification, the vehicle was capable of carrying not less than 10 people.

All other supplies of transport services are liable to VAT at the standard rate. Further information on passenger transport services and details of the input tax rules that apply to vehicles with special facilities for carrying disabled people can be found in Notice 744A Passenger Transport.

2.7 Goods supplied as part of a package of care and treatment in a qualifying institution

Most goods supplied by a qualifying institution as part of a package of care or treatment are exempt. Examples include:

• incontinence products; drugs and medicines; bandages; plasters and ointments supplied to hospital patients;
• meals and refreshments provided to in-patients, residents or other beneficiaries of care or treatment, and;
• toiletry products provided to in-patients, residents or other beneficiaries of care or treatment, for which no additional charge is made.

Any items that are separable from the care and treatment provided by the qualifying institution are not exempt. Examples include:

• cigarettes;
• use of bedside phones and televisions;
• toiletries provided to in-patients for an additional charge;
• newspapers;
• merchandise such as commemorative T shirts, and
• goods provided to any person other than the beneficiary of the medical care or surgical treatment. However, special rules apply to meals and accommodation supplied to parents staying with a sick child in hospital (see paragraph 2.11).

The VAT liability of goods that are not exempt under this paragraph should be determined in accordance with the normal liability rules.

2.8 Drugs and other items supplied to patients in a hospital or nursing home

Drugs, medicines, bandages, plasters or ointments provided by a qualifying institution in the course of care or treatment are exempt when provided to:

• an in-patient of a hospital.
• any person attending the premises of a hospital for medical care or treatment.
• any other person or establishment where the item is for use by, or in connection with, either of the above.

If you are not a qualifying institution, drugs or medicines that you supply to any of the above people are usually standard rated, even when the items are dispensed on the prescription of a medical practitioner. However, by concession, HMRC allow pharmacists (including those operating from an independent pharmacy within hospital premises) to zero rate drugs, medicines and other qualifying goods that are supplied to:

• an in-patient of a hospital or
• any person attending the premises of a hospital for medical care or treatment

where all of the following conditions are met:

• The items dispensed are qualifying goods designed or adapted for use in connection with medical or surgical treatment.
• The items are dispensed by a pharmacist in the normal way, on the prescription of a medical practitioner who is providing primary health care services.
• The items are intended for self-administration by the person named on the prescription.
• The items are supplied separately from, and do not form any part of, any medical services, treatment or care provided in the hospital or nursing home.
• In the case of NHS prescriptions, the pharmacist is acting under the appropriate NHS Pharmaceutical regulations, and is reimbursed for the dispensed items by one of the NHS bodies that pay for community pharmacy services.

The application of this concession must not give rise to any abuse of the VAT system. HMRC may withdraw or restrict the application of this concession if they have reasonable cause to believe that it is being used for tax avoidance purposes.

2.9 Other goods supplied to disabled people in a hospital, nursing home or other qualifying institution

Goods supplied to disabled people qualify for zero-rating where all of the following conditions are met:

• The relevant conditions detailed in Notice 701/7 VAT reliefs for people with disabilities are met.
• The goods are provided for the domestic or personal use of the customer (see paragraph 2.10).
• The goods are not provided, ordered or paid for by a hospital, nursing home or other qualifying institution.
• The goods are not integral to care or treatment provided in a hospital, nursing home or other qualifying institution.

2.10 When are goods not provided for domestic and personal use?

For the purposes of this relief, domestic or personal use excludes any items (other than wheelchairs) purchased by:

• an in-patient of a hospital;
• any person attending the premises of a hospital for medical care or surgical treatment and;
• any other person or establishment where the goods are for use by, or in connection with, either of the above.

Where the items in question are intended for use in the course of care or treatment provided in the hospital or nursing home. Items excluded from the zero rate by this provision include:

• incontinence products.
• medical and surgical appliances.
• bandages, plasters or ointments.

Special rules apply to the supply by a charity of goods, other than spectacles and contact lenses, that are designed for use by a visually handicapped person (see Notice 48 Extra-statutory concessions).

2.11 Supplies made to relatives visiting residents in a hospital

Where a qualifying institution supplies accommodation and meals to a relative staying in hospital with a sick child, those supplies are exempt. No other supplies to visitors, relatives or carers qualify for exemption.

3. Supplies made by providers that are not qualifying institutions

3.1 Goods and services supplied on the premises of a qualifying institution

Some qualifying institutions allow outside businesses or practitioners to operate from their premises. Examples of businesses that might make supplies from the premises of a qualifying institution include:

• retail outlets or independent health professionals that occupy areas within a hospital building.
• self-employed hairdressers.

For a supply made by such a business to qualify for exemption, they need to be providing care or medical or surgical treatment and all of the following conditions must be met:

• The goods or services supplied must form part of the medical care or surgical treatment provided within the qualifying institution.
• The goods or services supplied must be of a type commonly provided to beneficiaries of such services.
• The supply must not consist of drugs, medicines, incontinence products, bandages, plasters, ointments or any other items that are integral to the care or treatment provided in the qualifying institution.
• The supply must involve direct contact between the provider and the beneficiary, and must contribute directly to the treatment of the beneficiary.
• The supply must not take place in a qualifying institution for reasons of geographical convenience only. This means that the supply must not be of a type that might equally be provided at a location other than the premises of a qualifying institution.

There are very few supplies made by outside businesses that meet all of the above conditions. Examples of services that meet these conditions include:

• care supplied by nursing staff and other carers and
• treatment supplied by outside contractors providing renal dialysis services in hospitals.

Supplies made by health professionals or charities from the premises of a qualifying institution may be exempt under separate provisions, even when all of the above conditions are not met, for example:

• health or home care services performed by, or under the direct supervision of, a registered health professional (see Notice 701/57 Health Professionals) and
• welfare services (including care or treatment) provided otherwise than for profit by a charity, where any supply of accommodation is ancillary to the provision of care or treatment (see Notice 701/1 Charities).

4. Qualifying institutions and VAT registration

4.1 Should qualifying institutions register for VAT?

You are only required to register for VAT when the value of your taxable supplies exceeds the VAT registration threshold. If you are a qualifying institution providing care or treatment, it is likely that the majority of your supplies will be VAT exempt, and you may not be required to be VAT registered. A qualifying institution that makes taxable supplies below the registration threshold may apply to register for VAT on a voluntary basis. Notice 700/1 Should I be registered for VAT explains the rules that apply to VAT registration.

5. Supplies received by a qualifying institution

5.1 Can qualifying institutions buy goods and services VAT free?

In general, a qualifying institution will incur VAT on its purchases in the same way as any other organisation. Depending upon its status however, a qualifying institution may be eligible for the following zero rates and exemptions from VAT:

• Zero rating of certain goods and services purchased by charities (see Notice 701/1 Charities).
• Zero rating of certain equipment, vehicles and repair and maintenance services purchased by charitable institutions, or by hospitals using charitable funds (see Notice 701/6 Charity funded equipment for medical, veterinary etc uses).
• Exemption for human blood.
• Exemption for human organs or tissue and for products derived from human blood, when these are purchased for diagnostic, therapeutic or research purposes.
• Exemption or zero rating of certain transport services (see paragraph 2.6).

Exemption does not, however, apply to synthetic blood products such as those of animal origin, or to any genetically engineered products, or to the storage of stem cells.

5.2 The letting on hire of specialist equipment or other facilities

The hire charge is exempt if the equipment or facilities are provided with, and ancillary to, the services of a health professional who either:

• operates the equipment;
• oversees the use or operation of the equipment or the facility by another person, or
• provides care, treatment or diagnosis.

Notice 701/57 Health Professionals explains the exemption that applies to the services of health and medical professionals.

The hire of equipment or the provision of facilities to a qualifying institution is standard-rated when:

• the equipment or facilities are provided without the benefit of the services of a health professional who is qualified to operate or oversee their use, or
• the services of a health professional are ancillary to the main supply of the equipment or facilities.

Your rights and obligations

Your Charter explains what you can expect from us and what we can expect from you. For more information go to hmrc.gov.uk.

Do you have any comments or suggestions?

If you have any comments or suggestions to make about this notice, please write to:

HM Revenue & Customs
VAT Liability Policy Team
3rd Floor
100 Parliament Street
London SW1A 2BQ

Please note this address is not for general enquiries.

For your general enquiries please phone our Helpline on 0845 010 9000.

Putting things right

If you are unhappy with our service, please let the person dealing with your affairs know what is wrong. We will work as quickly as possible to put things right and settle your complaint. If you are still unhappy, ask for your complaint to be referred to the Complaints Manager.

For more information about our complaints procedures, go to hmrc.gov.uk and under ‘quick links’ select ‘Complaints’.

How we use your information

HM Revenue & Customs is a Data Controller under the Data Protection Act 1998. We hold information for the purposes specified in our notification to the Information Commissioner, including the assessment and collection of tax and duties, the payment of benefits and the prevention and detection of crime, and may use this information for any of them.

We may get information about you from others, or we may give information to them. If we do, it will only be as the law permits to:

• check the accuracy of information
• prevent or detect crime
• protect public funds.

We may check information we receive about you with what is already in our records. This can include information provided by you, as well as by others, such as other government departments or agencies and overseas tax and customs authorities. We will not give information to anyone outside HM Revenue & Customs unless the law permits us to do so. For more information go to hmrc.gov.uk and look for Data Protection Act within the Search facility.

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