Are Britain's Ketamine Clinics in Need of Regulation? Part Two: Delivery, Testimonials, and Regulation

The Ethics of Testimonials

Save Minds' marketing runs through Online Marketing For Doctors, an agency with a “7 Step Patient Generation System to Get More Patients Than You Can Handle”. The agency instructs clients generally to solicit reviews “every time a patient walks out your door” via a QR code, “with as little friction as possible,” and to incentivise staff with competitions for the most reviews gathered.

The American Psychological Association, the National Association of Social Workers, and the UK Council for Psychotherapists all prohibit soliciting testimonials from current therapy clients specifically because of the risk of undue influence. Save Minds does not offer psychotherapy. But this suggestibility to influence is heightened when a mind-altering drug is involved. We could not confirm whether Save Minds itself engages in direct solicitation of reviews or its timelines for doing so. A number of its Google reviews, promoted on the clinic website, are posted during treatment programmes. One published Save Minds review is explicitly labelled with treatment-stage updates: “Update 1 · 4 weeks,” “Update 4 · Ongoing,” “Update 6 · 8 months”, showing testimonial content extensively during a treatment course. Many reviews praise Dr Yadhu’s compassionate and warm personality. Some reviewers have ranked him among the most impressive people they have ever met.

This article does not allege that any clinic has fabricated patient testimonials. Some testimonials are presented in forms that make independent verification difficult, though. The Ketamine Clinic – now trading as The Emerge Clinic – published highly similar recovery narratives attributed to cartoon-avatar figures described as “Steven, Builder” and “Nigel, Architect.” The clinic did not respond to this article’s request to clarify whether those accounts reproduce real patients’ words.1 Ketana’s testimonial images appear to correspond to stock photographs available elsewhere online.2 That observation alone does not establish that the underlying patient accounts are inauthentic.

Aion Clinic includes testimony from a reviewer alongside precise percentage changes in his anxiety and depression scores (“−22.2%” and “−47.8%”). Such percentage scores would be precise ways to record reductions in standardised psychometric evaluations. This article does not dispute that the reviewer or their reported experience is genuine. However, presenting an individual experience with highly precise outcome figures may give readers an impression of evidential weight that the page itself does not substantiate.3 Persuasive percentage claims disproportionately shape perceived credibility among consumers with lower health numeracy. What is more, Aion Clinic displays a revolving carousel of reviews from the same few individuals, which may give an impression of greater volume. At least three clinics have variously claimed to be the first in the UK. Save Minds calls itself “the UK’s first private clinic,” Cognacity claims the same “first” title, and Aion’s founder separately claimed to be “England’s only” such clinic in July 2025.

Do Ketamine Clinics Engage in Home Delivery?

Neuro Reset Clinic, which shares premises with Eulas, is led by a named consultant psychiatrist and publishes no headline success-rate statistic. However, it also markets ketamine as “uniquely effective” for treatment-resistant cases, and its own CQC registration could not be confirmed by the author.4 North London Psychiatry Practice is more tentative still, stating plainly that ketamine “is not licensed for depression” and separating bladder risk from “large doses as a drug of abuse” versus supervised treatment, “much less so.”5

The Owain Winfield/Ozase/Inspire pathway offered substantive clarification. Dr Arun Dhandayudham, a consultant addictions psychiatrist since 2005 and former CQC specialist inspector, described three distinct roles. Winfield refers patients and delivers therapy; Dhandayudham conducts assessment, prescribes, and is present on-site during dosing; Inspire dispenses only, “for possibly other ketamine prescribers as well.” He denied unsupervised home use entirely, with the home option limited to clinically supervised sessions for patients with mobility issues or severe anxiety – and described exclusion criteria including a BMI of 16 or under and prior ketamine dependency, alongside KSET screening. He confirmed GP records are obtained before prescribing and that no patients under 18 are treated. He characterised bladder damage, dependence and persistent perceptual disturbance as not “major or common risks” with proper patient selection.

Psychotherapist Owain Winfield insisted that “home treatment” on his site meant a clinician-attended session – leaving unresolved why Inspire Pharmacy’s own site advertises oral ketamine “for measured dosing at home” by post. Winfield was also measured generally, telling this article, “I don’t regard ketamine as risk-free.”6

Eulas’s “Clinical Director” title is held by Sean Gillen, a former jockey and addiction-rehab worker with no medical qualification. Gillen has separately agreed that treatment is priced beyond most people’s means and hopes eventually to partner with the NHS.7 The site names Dr Pamela Walters as Medical Director and Consultant Psychiatrist, and states ketamine’s effects “are often short-lived.” Its site lists “suicidality and suicidal ideation” among conditions treated through self-referral, promising “sustainable, long-term recovery”. Its reference list also omits several publications with null findings for ketamine. Its FAQ specifies who it may decline – uncontrolled blood pressure, psychosis, severe personality disorder, pregnancy, severe liver disease – stating plainly “not everyone is suitable.” Eulas declined to share its consent documentation as commercially sensitive and explained that all references to ketamine had been scrubbed from the site under strict advertising rules.8

The Burlington Clinic, led by a consultant psychiatrist, markets itself to those for whom “nothing else has worked,” but was more circumspect in its own claims: “it is a treatment rather than a cure… a benefit cannot be guaranteed.”9 It required a separately priced £200 psychiatric assessment before booking and obtained patients’ GP records beforehand. Its home-visit service was clinician-attended throughout, though the Clinic had since shifted to an exclusive offer involving a “controlled clinical setting” on Harley Street. It has now discontinued ketamine treatment entirely.

The Royal College of Psychiatrists (RCP) holds that “significant gaps” remain in understanding long-term effectiveness and safety. These informational patterns are not unique to ketamine. Separately, direct-to-consumer health advertising research found only 43% of ads reviewed were “objectively true.” Pharmaceutical companies have historically oversold many staple psychotropics, including SSRIs. Non-commercial actors have substantially misled patients. In 2019, the RCP conceded that the popular “chemical imbalance” theory of depression, widely promoted to patients, was “an over-simplification”. NHS Inform omits any mention of the controversies surrounding SSRIs and their effectiveness. The stakes might be higher with ketamine. Being off-label, there is less clinical infrastructure and best practice. It is physically risky and sold privately at up to £15,000 per course, which could raise the bar for transparency rather than lowering it.10

Operational Failures?

Operational problems have affected a few companies, though their weight differs case to case. Klearwell appears, on archived records, to have continued hosting a non-refundable £280 assessment fee and displaying a “Regulated by CQC” badge for some period after its registration was archived and the company entered liquidation. This point was raised with Dr Arun Dhandayudham, a former Klearwell/Awakn director, who replied that he had forwarded it on as it was “not information within my purview,” adding there was “no timescale” for a fuller answer. No further substantive response had been received by publication.11 Cognacity’s most recent published inspection found that the clinic was unsafe. The inspector found that medicine prescribing was inappropriate. Staff had breached privacy and safeguarding restrictions by photographing sensitive prescriptions on their phones. Cognacity told the author that it has since been reinspected and no longer offers ketamine-assisted therapy.12

A January 2026 CQC inspection of Transforming Mind Solutions found that ketamine was dispensed without GP records. It also revealed that a staff member who undertook post-dose monitoring after self-administration of oral ketamine had not completed first-aid or basic-life-support training. Still, patients reported positive experiences and the premises were well maintained.13 Transforming Mind Solutions also specialises in Transcranial Magnetic Stimulation (TMS), a NICE-endorsed antidepressant. Their website frames mental health as a “business opportunity”, appealing to “business owners” and “entrepreneurs” with a “Proven Business Model” of franchise with the company. The implications for the company’s safety record are not known. If a provider has had systemic weaknesses, an expansion campaign through franchise or satellite arrangements could make problems worse.

The ketamine sector is not altogether thriving. Awakn’s collapse was followed by Pasithea Therapeutics abandoning its UK ketamine presence in 2022.14 One problem is that ketamine treatments are so expensive. A £595 infusion or £5,000 course reflects largely room, consultant time, and margin. Some clinics finance treatment through consumer credit.15 The ethics of this cut both ways. Regulated credit can expand access to treatment people could not otherwise afford, which could boost their earning power in repaying any accumulated interest. At the same time, the expense and uncertainty that surround ketamine sit uneasily with the effects that severe mental illness may have on decision-making. One study found 31% of hospitalised patients with severe depression lacked capacity for treatment decisions altogether. This is a concern that affects all medical credit and does not prove any clinic prioritises revenue over welfare. People with problem debt are three times as likely to attempt suicide as those without one. Financial carelessness is a well-evidenced indicator of suicidal ideation and behaviour.

What the Regulators Told Us

Britain has several bodies for protecting patients, but each appears responsible for only part of the picture. The CQC regulates providers, the MHRA acts on unlawful medicines promotion, the ASA applies advertising rules, and the CMA enforces consumer law – but no single body routinely examines the full pathway of private off-label ketamine treatment. The ASA has never formally ruled against a UK clinic advertising ketamine or esketamine. Five clinics have been actioned by the MHRA since 2021, including Save Minds in December 2021, asked only to change its wording rather than fined.16

An MHRA FOI response identified 194 Yellow Card reports concerning ketamine or esketamine between 2019 and 2025. Yellow Cards are spontaneous reports of safety that cannot establish causation. Only 35 were identifiable as psychiatric or off-label through manual searching, since none carried “off-label use” as a searchable field in the database.17 GP liaison looks inconsistent. A CQC inspection found Cognacity’s doctors did not consistently contact GPs. Klearwell and Eulas both say they review GP records first, among others.18 Oxford’s NHS service, by contrast, will not accept a referral from a therapist alone.19 Most private clinics check eligibility at a paid consultation against what the patient reports, and since none publishes its decline rate, this article could not establish how consistently criteria are applied.

A national registry tracking who receives ketamine, at what dose, and with what outcomes has been proposed. Yellow Cards, being voluntary, cannot characterise risk at scale. British Columbia has turned a clinical consensus guideline into a binding accreditation standard for non-hospital IV clinics, which Britain could follow.20 The Advisory Council on the Misuse of Drugs has recommended a registry since 2013 and again in 2026, though the Home Office confirmed that dangers in recreational use, not clinical settings, had prompted the latest review. The Royal College of Psychiatrists recommends ketamine be used only in specialist, psychiatrist-led settings, and one coroner has warned Class B status may understate the drug’s danger.

The government has indicated no timeline for a formal response.

Notes

1. This article put the testimonial-provenance question directly to The Ketamine Clinic/The Emerge Clinic in writing: “are these verbatim accounts from real, identifiable, consenting patients?” No answer to that specific question was received in an otherwise substantive exchange covering several other points (see main text). Non-response to one question is reported here as exactly that. It is not evidence, and should not be read as evidence, that the underlying testimonials are false.
2. The ASA’s published guidance on testimonials does not automatically prohibit stock photography, provided the underlying testimony reflects a genuine consumer experience and is not presented in a way that misleadingly implies the pictured person is the patient. This article was otherwise unable to establish whether the underlying accounts reflect real, identifiable, consenting patients. That absence of confirmation is reported as a finding in itself, not as an assertion that either account is invented.
3. The graphic in question, reviewed on Aion’s own site, names the reviewer (“Harry S”) and is accompanied by video in which he appears on camera. There is no reason to doubt his identity or that his experience is genuine. The concern raised here, and put generally to the ASA in this article’s correspondence, is narrower: presenting a single patient’s outcome to two decimal places invites readers to treat an n-of-1 anecdote as though it were audited clinical data, and Aion’s wider testimonial page features a smaller number of distinct reviewers appearing more than once. Nothing here suggests the reviews are fake; the point is that a testimonial wall can create an impression of scale that a handful of repeated voices does not support.
4. Neuro Reset Clinic’s lead clinician, Dr Wayne Kampers, is a consultant psychiatrist (MRCPsych) rather than an anaesthetist or surgeon treating psychiatric illness. Its FAQ states ketamine therapy is “available only following a full psychiatric eligibility assessment” and “not suitable for everyone.” Against that, its own pages separately describe ketamine as “uniquely effective for patients who have not responded to conventional pharmacotherapy” – a claim this article was unable to reconcile with the placebo-controlled trial evidence discussed earlier in this article. The clinic operates from premises (ZEN Hampstead and ZEN Knightsbridge) that also host the Eulas London service and a further, separately branded ZEN ketamine offering; this article could not establish, from public material alone, whether “Neuro Reset Clinic” holds its own CQC registration at these addresses or delivers treatment under another entity’s registration, and this is reported as an open question for the clinic and CQC to clarify, not a finding of unregistered practice.
5. North London Psychiatry Practice’s published treatment page states plainly that ketamine “is not licensed for depression” and can only be prescribed off-label, and explains that dissociation can be a clinically relevant sign that a therapeutic dose has been reached rather than simply an unwanted side effect. It also states explicitly that bladder problems are “common when ketamine is taken in large doses as a drug of abuse, but much less so when it is taken as a prescribed treatment for depression” - a risk-differentiated disclosure this article found on few other UK provider sites. No pricing was published on the page reviewed, and this article was unable to independently verify the practice’s CQC registration status.
6. Owain Winfield, the psychotherapist in this referral chain, stated plainly that he has “never professionally been involved with unsupervised home ketamine dosing” and that any home sessions in his own practice are clinician-attended. He was unable to speak to Inspire Pharmacy’s own marketing, which separately advertises oral ketamine solution “for measured dosing at home” delivered by tracked post, referring that question to the prescribing clinician and to Inspire Pharmacy directly. Neither had, at publication, clarified whether any patient in this specific referral pathway receives ketamine for genuinely unsupervised self-administration. Separately, Owain Winfield’s own published fee schedule shows roughly three-quarters of a typical £4,300 six-session course is psychotherapy and integration fees rather than medical or prescribing costs.
7. Sean Gillen’s background as a former professional jockey and addiction-rehabilitation worker, rather than a clinician, is documented in BBC Scotland’s June 2025 profile of Eulas. The same reporting quotes Gillen acknowledging the treatment’s cost is prohibitive for most people and stating he would like to see it eventually offered through the NHS - an admission this article considers a fair and relevant piece of context alongside the title/qualification point.
8. This article put to Eulas, and does not assert as fact, two Google reviews – posted under the names “Danny Wang” and “Daniel Salter,” whose true identities this article could not verify – alleging that a named individual became dependent on ketamine following treatment at the clinic and subsequently died, and, in the second review, that the clinic pursued payment after a patient became dependent. Eulas’s registered manager, Sean Gillen, said the reviewer had a documented pattern of posting hostile, unrelated reviews across many businesses and that Eulas had reported the material to Google as fraudulent, though he could not confirm whether it had been removed as a result. This article was unable to independently verify either the underlying allegation or Eulas’s account of its provenance, and it is reported here, as agreed with Eulas in advance, solely as a disputed and unverified claim.
9. The Burlington Clinic’s main site described ketamine infusions only within its “Harley Street suite” under “continuous physiological monitoring by medical staff throughout”, while its own /at-home-care page, its Squarespace subdomain, its Google Business listing and Ianthe House’s website all separately advertised home-visit intravenous ketamine. Dr Seneviratne’s first reply directed this article to “the West London and Oxford Neuromodulation clinics” as “the leading centres” for ketamine treatment generally, rather than answering the questions put about Burlington’s own practice. A follow-up letter narrowed the request specifically to home-visit staffing, monitoring, CQC registration, and the relationship with Ianthe House. The clinic’s substantive reply, received shortly before publication, confirmed the service’s closure and answered most of the outstanding questions (see main text). It also disclosed a change of operating entity: the clinic’s email signature in August 2026 named “SMS Healthcare Limited” (company number 6509198) as the operator, while its September reply named “The Burlington Clinic Limited” (company number 17135465). This article was unable to establish from the correspondence alone whether this reflects a routine corporate restructuring or a more significant change of operator.
10. Historical parallels between overconfident health marketing and underlying evidence have been drawn across medicine, especially opioid prescribing in the 1990s and 2000s – where manufacturer claims, including that addiction risk was below 1%, were later found by US courts to have understated the true risk, contributing to settlements and a 2020 guilty plea by Purdue Pharma. Any such comparison is structural, about how confident marketing can outrun a limited evidence base under commercial pressure, not a claim of legal or moral equivalence between distinct treatments, sectors or companies.
11. Klearwell provides an illustration of market fragility. Companies House records show its operating company, Klearwell Ltd (formerly Awakn London Ltd), entered creditors’ voluntary liquidation on 3 October 2024, two weeks after its CQC registration was archived on 18 September 2024. Archived Wayback Machine captures indicate the klearwell.com website nonetheless remained live for a further period, continuing to display a “Regulated by Care Quality Commission” badge and to solicit a non-refundable £280 upfront assessment fee, before the domain eventually went offline. It is unknown whether the fee was charged. This should be weighed alongside caution in its clinical protocol while it operated: its published exclusions screened out a history of psychosis, bipolar I disorder, schizophrenia, and high suicide risk; patients were required to be escorted home rather than to drive themselves, and its own FAQ acknowledged that “the course of therapy is brief” and patients “may benefit from further therapeutic support”.
12. The CQC’s October 2025 inspection of Cognacity issued a Regulation 17 warning notice concerning medicines management, safeguarding notifications and record-keeping. Specific findings included no clinical records on the electronic system for three inspected patients; two missed safeguarding notifications to the CQC; doctors who “did not consistently liaise with patients’ GPs,” with comprehensive assessments, treatment plans and risk assessments absent for three reviewed patients; and a system for managing void prescriptions that relied on staff using personal smartphones to photograph and transmit prescription images. Breaches were also found under Regulation 12 (safe care and treatment) and Regulation 13 (safeguarding). Cognacity told this article it was “happy to answer questions on the many actions taken to address CQC concerns” and confirmed it had undergone a further, more recent CQC inspection whose draft report it was awaiting at the time of writing, but maintained that a ketamine-specific feature was no longer relevant to its current service. Notably, an older page still discoverable on Cognacity’s own site (consistent with the clinic’s own explanation that search results can surface “an old page”) states plainly: “We do not know how Ketamine helps people recover from depression, but we do know that it stimulates the brain to form new connections”.
13. The CQC’s report on Transforming Mind Solutions additionally noted that the service “worked collaboratively with another healthcare provider to offer patients treatment at satellite locations”. Separately, the clinic’s Medical Director, Professor Alex O’Neill Kerr, is a credentialled NHS-trained neuromodulation psychiatrist and a clinical anchor for the brand’s core TMS service. The franchise and governance questions in the main text concern the corporate model built around that clinical core, not his individual competence. Transforming Mind Solutions did not respond to requests for comment.
14. Pasithea Therapeutics Corp (Nasdaq: KTTA) disclosed in SEC filings that its UK clinical arm, Pasithea Clinics, operated ketamine infusion services at ZEN Healthcare’s Knightsbridge and Marylebone premises under a revenue-share agreement entitling Pasithea to 30% of treatment revenue (less certain staff costs). The company publicly pivoted away from ketamine clinics toward drug development by early 2022. Pasithea’s own Chief Operating Officer and Head of UK Clinics, Dr Yassine Bendiabdallah, was separately disclosed in the same filings as a co-founder and 25% shareholder of Purecare Ltd (now ZEN Wellness Ltd, the Knightsbridge operating entity) - disclosed here as an ownership and history fact, not as an allegation of impropriety; his current shareholding may have changed since the 2021 filing.
15. Documented consumer-credit partnerships in the sector include Transforming Mind Solutions’ arrangement with Fusion Lending/Loans Warehouse (spreading £1,000–£50,000 over 12–60 months with soft credit checks); Eulas Clinics’ registration as an Introducer Appointed Representative of Ideal4Finance, spreading a roughly £6,000 six-week ketamine-assisted therapy programme from £177 a month at 6.2% APR; and Circle Health Group, offering 0% APR over ten months or up to 9.9% APR over five years for sums between £250 and £25,000. Phoenix Hospital Group also makes use of Chrysalis Finance.
16. Save Minds (Dec 2021); Nightingale Hospital London / Spravato (Mar 2022); SMS Healthcare Ltd t/a The Burlington Clinic (Jan 2026); Neuro Reset Clinic (Feb 2026); and a further action naming “Infusion Therapy London” (Jun 2026). The Burlington Clinic has since confirmed the January 2026 action directly, in correspondence with this article, stating it “amended website wording at the MHRA’s request to ensure compliance with the Blue Guide”; it said it was unable to confirm whether the June 2026 entry naming “Infusion Therapy London” concerned the same business.
17. The coroner in the Gemma Weeks case (Dorset, HM Coroner Brendan Allen, report dated 19 August 2025) recorded a ten-year history of ketamine use escalating to an estimated £500 a week, with significant weight loss and ketamine bladder syndrome causing “considerable pain and incontinence” prior to death. A second, contemporaneous Prevention of Future Deaths report (Joshua Forsdyke) separately raised concerns about easy illicit access to ketamine via student accommodation. Both cases are cited here strictly as public-health and policy context; neither individual is alleged to have had any contact with the private clinics named elsewhere in this article.
18. Some clinics reviewed for this article describe only optional, consent-based GP liaison after the fact, rather than obtaining records beforehand. Eulas’s site states that, “with your consent, we will also review your medical records held by your GP” as part of assessment.
19. In full, Oxford Health’s FAQ states: “We will not be able to see you without a referral from your GP or psychiatrist... because we need a full medical background, the referral letter must come from a medically qualified doctor who has been responsible for your clinical care,” and explicitly declines referrals from psychotherapists or psychologists alone, however detailed. This is a materially different verification standard from an online eligibility form or a single paid consultation based on patient self-report, since it requires an independent clinician with an existing treatment relationship to corroborate the history before an appointment is even offered.
20. The Canadian Network for Mood and Anxiety Treatments (CANMAT) consensus recommendations for ketamine in depression have been adopted by the College of Physicians and Surgeons of British Columbia as a binding accreditation standard for non-hospital IV ketamine facilities, specifying continuous monitoring during infusion, a minimum 60-minute post-dose observation period, mandatory validated screening for sleep-disordered breathing before treatment, and explicit caution against open-ended maintenance dosing without documented, periodic reassessment. No equivalent binding standard exists in the UK for private ketamine provision.