What the Latest Ruling Means for VAT for Medical Staffing Agencies

The First-tier Tribunal (FTT) delivered an important ruling in 1st Alternative Medical Staffing Ltd v HMRC [2025] TC09678. The Tribunal held that employment costs reimbursed to a medical staffing agency are fully taxable for VAT purposes. The case examined whether these costs, linked to the supply of nurses and care workers to hospitals and care homes, could fall within the VAT exemption for medical or welfare services. The ruling provides important clarification on VAT for medical staffing agencies, particularly where the agency is not subject to statutory regulation and does not deliver medical care directly. The Tribunal dismissed the agency’s argument and confirmed that VAT exemption applies only when the supplier is officially regulated and provides medical care themselves. The decision highlights HMRC’s strict approach to VAT relief in the healthcare staffing sector and reinforces how such services should be treated for VAT.

What Was the Case About?

1st Alternative Medical Staffing Ltd (AMS) supplied nurses and care assistants to NHS trusts, private hospitals, and care homes. These professionals were qualified and registered. All staff worked under the client’s direct supervision, direction, and control.

AMS invoiced its clients by splitting charges into:

– Employment Costs – covering wages, PAYE tax, and other staffing-related costs
– Commission – AMS’s own service fee

AMS charged VAT only on its commission. It treated employment costs as VAT exempt, arguing they related to exempt medical care.

HMRC’s View

HMRC disagreed with AMS’s VAT treatment. They originally planned to inspect AMS’s VAT returns but were prevented when AMS cancelled the visit.

Following correspondence, HMRC assessed that all amounts received—including reimbursed employment costs—were standard-rated for VAT. The tax authority issued VAT assessments totalling £265,590 for the relevant periods.

AMS challenged the assessments, arguing their services were VAT exempt. They also brought a judicial review, claiming HMRC acted against their “legitimate expectation”. The review failed.

AMS then appealed to the First-tier Tribunal (FTT).

Tribunal’s Decision

The Tribunal rejected the appeal. It found that AMS was not state regulated. To qualify for the VAT exemption for medical services, suppliers must meet strict conditions set out in Group 7, Schedule 9 of the VAT Act 1994. One of these conditions is regulation by a statutory health authority.

AMS was not approved, licensed, or registered by a statutory health authority. This disqualified them from relying on VAT exemption for medical care services under Note 8.

Supplies Not ‘Closely Related’ to Medical Care

Even if the entity had been state-regulated, the services must still be “closely related” to medical care.

The Tribunal held that:

• AMS simply supplied staff, not medical care itself.
• The staffing function was not “indispensable” to medical treatment.
• The services resembled those of any commercial staffing agency. 
• Granting exemption would create unfair VAT treatment in the market

The Tribunal concluded that AMS’s services were taxable. The appeal was dismissed.

Why Does This Matter?

This ruling is a clear reminder that supplying qualified staff is not enough to secure VAT relief. Agencies operating in healthcare must meet strict exemption criteria before applying zero or exempt treatment. Many businesses in this sector now need to reassess the VAT treatment for healthcare staffing, especially when charging employment-related costs.

Applying the VAT exemption for medical services incorrectly can result in substantial VAT assessments and penalties. HMRC continues to enforce the rules strictly, and businesses must understand the legal conditions before relying on any exemption.

Reimbursed employment costs are not exempt merely because they support the delivery of medical care. If the agency does not deliver regulated medical care itself, VAT applies to the full charge. This view aligns with HMRC’s long-standing interpretation of the legislation.

Apex Accountants’ View

At Apex Accountants, we believe it’s crucial for healthcare staffing agencies to thoroughly assess their VAT treatment, especially when reimbursed employment costs are involved. Misapplying VAT exemptions could lead to costly financial consequences, including penalties from HMRC.

We recommend that all healthcare staffing agencies review their invoicing structure, contracts, and VAT treatment in light of this ruling. Our team of VAT specialists can provide tailored advice, ensuring that your agency remains compliant and avoids unnecessary tax liabilities. If you’re uncertain about your VAT position or facing an HMRC review, we can help you navigate these complex issues with confidence.

Key Takeaways for Employers and Agencies

• VAT exemption applies only when strict legal conditions are met.
• Being part of the healthcare delivery chain does not automatically mean exemption.
• Staffing firms must review their VAT treatment, especially on employment costs.
• HMRC may assess VAT on total consideration, not just service fees.
• Cancelling a compliance check can lead to stronger scrutiny from HMRC.
• “Legitimate expectation” arguments are unlikely to succeed if the legal framework is clear

Expert Support on VAT for Medical Staffing Agencies

At Apex Accountants, we support employment agencies, care providers, and healthcare staffing firms with all aspects of VAT compliance. Our team will assess your contracts, invoicing structure, and operational model to confirm the correct VAT treatment for healthcare staffing in line with current legislation.

If you are facing an HMRC review, unsure about your VAT position, or need to challenge a tax decision, we offer practical guidance tailored to your business model. From preventing costly errors to representing you in disputes, we are here to protect your interests.

Contact us today to get expert VAT advice that keeps your business compliant.