He Learned How to Grow a Clinic From a Fruit & Veg Stall | with Jonathan Shearer, BOAC #57

0:00When I was 16, I had an ingrown toenail. I remember they did this procedure on me for the ingrown toenail and I thought I could do that. And the pain I was in with ingrown toenail and how much difference it made to me was absolutely incredible. So that was the moment I thought I'd like to be a film actress. You can't work anywhere there's no trust. I felt like that in many of the trusts that are working for the NHS. Being a cactus owner, unless you've got a certain level of turnover, you're almost better to be employed at a really great cactus and where you get a fee share as well as the employment.

0:27I would say if I was 20 years now, I would possibly consider that because it is really hard to run a practice i used to work on a market stall on a fruit and vegetable when i was a teenager and for a short period of my life and it's my best ever job if i didn't do i'm not sure i'd go back to do something like that i enjoyed connecting with people i got to connect with a lot of people and what i realized it's all about relationships and people will come back and buy a few again and again if they build the relationship with you the first thing is i have this rule it's called no one gets out of life so no one is going to leave that building without having my leaflet and maybe a little voucher to come to the clinic.

1:00If you want to go far in a clinic, you've got to put yourself out when it's not convenient. You won't go as far if you're not prepared to do that.

1:13Hi, everyone. We're back with another episode of the business of a clinic. My name is Jared. I'm one of the co-founders at Coherent Healthcare. Today, very excited to be joined by Jonathan, who is a podiatrist, a clinic leader, a serial networker, as we're seeing going to learn, and also the current director of a practice up in Birmingham, where he specializes in sports therapy and podiatry. And we'll learn more about that. Jonathan, thank you so much for joining. We just had breakfast, so we know each other, but other people don't know you. Can you maybe give us the very short version of how your life took you here to this chair?

1:49How did you get here? How did it get to this point? So just to give you a little bit of my background, I did a traineeship odiatrist in Connifoli 99 from Southampton. And I basically went to work for the NHS like a lot of people do for about seven years. And I also did a bit of locum work for six months for shop via a locum agency. And I set up my own private practice in the town of Tamworth, which is just on the outskirts of Birmingham, near Litchfield as well in the county of Staffordshire. So we set up this practice over 20 years ago. and it's our 20 year anniversary so yes as our tour to celebrate that we're really excited um that we've been going 20 years and how to get to this point was when i was 16 i had an in-grown toenail and i remember they did this procedure on me for this in-grown toenail and i thought i could do that and i the pain i was in with in-grown toenail and how much difference it made and was absolutely incredible so that was the moment i thought i'd like to be a podiatrist and found out more about the profession did a bit of work experience that type of thing as you do and do about fact finding and I've actually did a degree at Southampton in it and really enjoyed it had a fantastic time but more than anything that the reason I became podiatry was to make people better so it is to get outcomes and I want to get people better the thing I liked about podiatry was I liked how quick you could make someone feel better in podiatry how quick the results are so I like quick results and it really suited my personality and it was a good fit for me I think podiatry so I went to the NHS for seven years and to several different trusts and I started to shift into the private sector and work for Shoal I ended up having to go back to an NHS trust for a short period and I would have what I earned not to go back to the NHS trust because I didn't realise how I'd say oppressed I was or actually how limited I was in my scope of practice so it wasn't until I went to the private sector that I actually started to grow I would say I was a limited growth in the that chance.

3:46Got it. And then you enter private practice, you built your clinic 20 years later. Yeah, here we are. Okay, got it. I understand. So it sounds like the podiatry bug bit early, which is interesting. A lot of times we speak with the leaders, we say, how did you end up here? They don't say, I knew this when I was 16. So that's interesting. There was a calling there, you had this experience, you were treated, served by someone, and you said, wow, this is a way to really impact someone's life. Yes. Which is great. And that's a good reason to get into the practice better than others. I guess the, we were talking earlier, you obviously trained as a podiatrist, you spent a lot of time patient facing.

4:26And now 20 years later, actually, you said something like less than 5 % of your week or your clinical time is actually patient facing. Yes. And so take us on the journey how did that change from probably being 100 or almost 100 patient facing at the earlier part of your career what changed when did it change what was the sort of gradual decline of patient facing time and now spending more time running the directing the practice yeah okay so there's a number of paths that took some of the first things that happened was that when i set the practice we're all very naive when we set these practices and none of us are really trained nurse and i qualified we're trained to how to run a practice we had about two hours with a um person in private practice and that was about it and someone came in did a lecture about private practice for about two hours private practice was very much in its infancy i'd say in those days there's i think there's some limitations of what you could have couldn't advertise and so with the internet it opened up a whole new avenue so i think with the internet it grew it also at the same time and to give you a bit of background the NHS as a shift they suddenly started discharging a lot more people and started moving towards this we'll only see high risk people people who are diabetic or people who've got really bad ulcers no circulation that kind of thing so there was a shift with the internet and also the NHS discharging so also at the same time as a protection of the podiatry title where there wasn't that before so those three key things are the thing that really was a gear shift for podiatry.

5:59I think if I was looking at my personal journey, I think there's a couple of several things that I could point to. We started practice in 2006. I didn't really have any clients when I started, just friends and contacts. And I had a home visit round of about 50 people. And so I had to market and grow that practice. So that was the first thing that I had to do. My first advert basically cost a thousand pounds in the local paper took out a full page and my first week's work came to a thousand pounds and that basically paid for that and what i realized is it was a repeatability of those clients coming back so okay that being once it's costing a thousand pounds so i had to work hard at building the relationships with those clients obviously it doesn't always come naturally because some of the people you may not always get on well with and kind of thing like that so you have to try and work hard at building the relationships and connecting with people so the first stage of my journey was starting the clinic and building it I had an associate come and join me within the first six months a lot of associate come and join me later on and it grew very fast over a period of year I was originally told when I first started the practice that it would take for every year of practice would give me a day's work and I listened to that that was the mantra we were told when we were growing up in university and things not by the lectures but that was a general rule of thought and i just want to say it's the biggest lie that's ever been told and so we had a sort of a full week after a year of podiatry after two years we had two weeks full after three years we had three weeks full so very quickly we build a practice along that journey you have to learn very fast the way i learned was i visited five of the private practices some weren't always the best practices but I learnt from going to visit those practices.

7:50So again, a bit of networking, connecting people. And sometimes it's people who are lecturing at the Broad College Conference. So I go and say, you just lectured on private practice, wouldn't you mind if I came and observed you, and just see how it works, and just have a chat with you. And that would happen, and they were absolutely fine with that. So I'd look at the ways they ran their practice and things. Also, software for private practice was very in its emphasis as well. So that was very an early stage. So we, there wasn't much choice with the private practice software at that point. And it was very much locally hosted on a server or on your computer.

8:24So it didn't need to link to any internet and necessary, but we grew that. And we used a company called rushlip.com and private practice software at the time, and they've been with us ever since. And we've basically used that software that we've learned by finding, talking to people and connecting people to find out how practices are best run. So basically the practice grew very quick here over the first three to four years. I connected with the local sports office from the local football club and he basically came to see me and he was collected by the commercial manager at the time from Tampa Football Club and he brought one of the players to me and I had a look at his foot and I treated it and he was ready to play for the next day and we built up that level of trust and so he started sending the players to me and I got more involved with the football club and to this day we're still involved with the football club and for 20 years we've been involved with our football club and they had some ups and downs hopefully all the way up now and so we treated the players for a long time and what happened was a sports therapist came and worked in our clinic and we started running sports therapy and the podiatry and sports therapy really work well together and they're happy to work alongside you and there's a lot of cross referrals especially with in the msk space what happens as time's gone on there's new equipment that's become available so for example things like and shockwave laser you've got obviously ultrasound which is a new thing for podiatry and you've got lots of new equipment that's now readily available that wasn't available at the time we first started so it's developed considerably with technology and we're using some software and some equipment from Gait Emotion, which allows us to analyze pressure and people's gait and walking.

10:09And also there's more software available to help you prescribe orthotics that wasn't available before. I guess what you're describing is a transformation in the industry. The industry has gone from less mature commercially, less mature from a technology, from a diagnostics perspective, from an operational perspective, that journey, I guess, has followed the arc of the practice. It's allowed you to mature your service to a point where now, I guess those are the building blocks that have given you that time to step away from the patient-facing experience. Is that the sort of journey you've been on with the practice?

10:46Yeah, absolutely. We did a shift about three years ago where we shifted, I think, the way all practices around, whether it's dentist, osteopath, chiropractors, podiatrists physios they would have associates ever was a self-employed and the big shift was with us was to move to more of an employed model and so we work on employed model and the the employees team and they still can benefit from the fee sharing but they've got the security of employment but also it allows you to build more of a team and although we had the best group of associates I could have ever wished for it was very hard to build a team cohesiveness and also that what ends up happening in a lot of the practices where you've got associates the practice owner tends to work all the hours under the sun struggles to get any time off and basically they're spending all the time not just running it but also treating so you find often in this practice owners that are just suffering from burnout I look at all the forums and there's lots of people suffering from burnout and they're not really getting any quality of life so the associates probably get a lot more quality of life the practice only doesn't and also you find a lot of practice don't charge enough you have to charge a lot more money to pay your team so it motivates you as well to increase your charges on a regular basis and i think podiatry has historically been a profession where we've not charged enough i think health private healthcare is maturing and with having to charge more because there's more risk involved, more litigation, more insurances, more regulations, and you've got to get that right.

12:24And that's the difficulty. And I think building a team, it allows you more cash flow, which allows you to invest and also in your team to invest into training and things. So then you can really build a high level standard of service. It's interesting. We spoke about long ago to a gentleman named Handro based out in California, who came up through working the front desk in an orthopedic practice. I think it was orthopedics. Now he's the CEO of a 150-side orthopedic provider network. And he was saying, and I remember this very clearly, the idea that the way in which the fee model for healthcare provision, product healthcare provision in the U.S., of course, came about fails to accommodate for all the things that don't happen when the patient is in front of you.

13:13And he gave this point of comparison to plumbers. And he said, when you call a plumber, you get a call-out fee. You get a fixed-it fee. You get the supplies that they needed to fix-it fee. Yes. Then you also get the come-back-and-check-in-a-month fee. And all those fees happen separately, and they're charged separately. And so when you hire your plumber, you expect them to show up and then to change the nature of the cost model based on what they find. And I think sometimes that happens at Bible practice, but what he was arguing, I think it sounds in a similar world to you're saying, we're not charging enough, is that a lot of things go into the one hour that someone actually spends in front of you.

13:53And those things are not easily itemized on an invoice, X percent of my insurance covering Y percent of my associate fee and Z percent of my replaceables and consumables. but those things ultimately factor in to that cost model. And I think it's oftentimes the, to your point, it's the gap between how much does it actually cost to deliver that one hour of care to a high standard? Because it probably costs much less to deliver it not to a high standard. If you're really going to try and be a premium provider, understanding the true versus the tangible and the intangible direct costs, yes, versus just the tangible direct costs is a sort of different game.

14:29And it sounds like that's playing into your thinking as well. Yeah, 100%. There's so many extra costs that people don't even perceive or put any value on. And I think you've got to put those costs in because it's in your best interest to invest into those things. Because if you haven't got the cash flow because you're charging too low, you won't be able to invest into the training or the equipment or advancement or pushing yourself or training yourself as a killing lead. And it's really important that you do so you can grow that practice. Yeah, we see it a lot. It's interesting. Some of the clinics that we work with, they will focus that investment largely in the clinical side of the house because ultimately that's what patients are coming from.

15:10And two, they're moving around the clinical journey. Some places that we can find that investment is maybe not where it needs to be because it's being diverted elsewhere and because you have limited funds to invest. But sometimes we find that investment in the sort of service side, as opposed to the clinical side, obviously they work together, but the service side is sometimes a little bit softer. Using the language, the patient experience is very rich, is very developed, is very thought through. The customer experience is sometimes the second fiddle. Has that been your experience? If so, how do you handle that?

15:49Yeah, so I think you were talking about investment in the practice and yeah, charging more ultimately allows you to deliver a better experience because you need the resource to do that. And I think that makes a lot of sense. The thing that we sometimes find in the clinics that we work with is that a lot of that investment, that continuous improvement, the first place that it goes, probably rightly, is the clinical experience. Yes. And then usually the sort of second class citizen, if you will, the afterthought is let's also do a little bit of development on the service side of the experience for patients.

16:25the clinical experience being the thing that happens in the clinic room or in the clinical domain and the service side being the patient handling, the patient relationship, patient engagement, the way in which patients are supported when they are physically there and not physically there. That's more on the service side as opposed to clinical side. I'm curious in your experience, have you seen, how do you think about investing in growing the practice? Where does that, where does the money go? I guess is the question. Yeah, I think, I think it's always important to you're investing to all of those areas you've mentioned and I think a lot of people don't underestimate investing to improving the service side I think aesthetically some even some of the clinics that first experience people don't invest into of how the clinic looks how does it feel and and how does it feel from when a person's walk through your threshold there's a lack of investment of how it looks how it feels so we put a lot of effort into that whole front rowing experience I think we're always looking to improve.

17:25The clinics that are going to do well are the ones that always are refining and looking at themselves. And I think whether it's the front part or the service part, we're looking at both. And it's sometimes both sides can get neglected. I think it's really important to have continuous training and just resetting as well because things change in a different social context as well. And I think it's really important that we are constantly the refining and review what we actually do. Can I ask if you're comfortable to use the word? Yeah. Because sometimes things aren't working or they need to work better.

18:01Are you comfortable or able to give us an example, probably not your deep, dark trade secrets, but are you able to take us into an example where you needed to take a step back and say, hold on, we need to change this. We need to change that. We need to reset this thing in your practice, in your clinic. What did that look like? How did you handle it? okay i think and the first thing is that very quickly sometimes things can look tired and or the paint gets scrubbed or knocked or things that look new four years ago don't look so new now so the first thing that i always do is look at the aesthetics of things and say well does this couch need recovering does the paint need repainting do you need to get a new plant in here that's quite an old picture and looking at that for example one of the things i've done recently He's bought this new TV that kind of plays YouTube videos continuously and puts scenery on.

18:52And the patients love it. Other clients love it. And so it's a much better kind of experience. So we're not trying to sell anything on that screen. We're just trying to make it more comfortable. Because it can be nerve-wracking coming to a clinic that you don't know. Or maybe you've been once or you're bringing someone else who's nervous. So it's important we keep up and relaxed. We try and be careful with the music choices that we make. I think that's important. I think also we're always evaluating the furniture and things like that and always looking to improve that whole experience where the leaflets are, what leaflets we're promoting, who we're promoting.

19:27We try and keep it very still, very simple. I think in terms of service, we always do internal training as well as external. So we do an hour training a week, which we record on AI. and then we've got that on record and then the next team member who comes to be higher can go through the training program but i think it's continuous training once a week is minimum that you need to do as a clinic it's interesting i don't even when i was running clinic i we did not train once a week i think we'd be lucky if we did an hour training a month there were dedicated three hour half days or four hour sessions or something where we went deep on a certain topic but i think the idea of making it more regular in the practice probably has staying power in a way that a professional development day that you get to put the check mark next to but doesn't actually become part of the habit probably doesn't have the same effect have you have you always done an hour is that no it's more recent if the clinic ever goes through quite a patch so usually autumn in photography is usually a bit quieter if you took to all the clinics across the country usually october and then rather quieter months and it hots up again usually in december summers april to september is always a busy story october november a bit of quiet time and then december starts to pick back up again usually with most financial clients across the country so october november is a really good time to do intensive training so we've always done i would always say that we try on extra training now put people on courses so i've always been interested in developing people and putting people on training people in courses when you've got an employed team it's in your best interests and that's why that employer model that shift because they're more invested in your practice you're more going to invest into their practice and you want them to be the best they can be also people have career development they're more likely to stay with you interesting so we're in basically in september now yeah october november around the corner do you have a hip list these are the top two or three things that i want my team to be focused on thinking about training on up leveling upskilling what is this year's focus for you as a plan leader we have a list of things and we get the team to come up with a list so there's a list of subjects we want to go through and so we'll be going through those in this next stage and sometimes I might do one or two topics and we kind of brainstorm and we're not all perfect so we're looking for best practice all the time.

21:58If I can see there's more gaps in the diary I can block that time off. We've also got platforms that we also pay for the team that they can access some CPD when they've got the gaps and we sometimes say to people would it be possible if you can go through that subject. If it's a specific area that we have a quick look for will be sometimes bring a trainer in for that equipment and say could you train our team on this or they're offering a training course at another clinic or another location so for example shock wave would be the one that we always try and get people to do on a regular basis so it just is a refresher but i think the internal training you can't put a value on that because it encourages each other and you're there to support each other and i think you can learn from anything you do and no one's got all the answers in any profession so we all can learn from each other and so we try and do it as a productive thing rather than i know better than you and what's the what are the sort of two top topics or two topics like if you said october november is usually a good time of year to do that training because maybe it's a bit slower for podiatry practice do you have at this stage a sort of sense of this is the key area of interest probably a lot of topics i don't want to cover but this is sort of the headline is x for this year do you have a sense of what that is yeah i think there'll be two or three things that we'd want to cover i think sort of skin conditions or neurological conditions so we want to focus more on that so we get better at it all of us or we always get vulnerable each other say okay where's our weak areas let's be honest here and you usually find that this some of us are more weaker at msk than other people there's some aspects of MSK that we don't understand or know and that we want to develop other people in the practice so I say probably so dermatological conditions and I'd say musculoskeletal conditions that would be two headers but also improving the service from a practice owner we'd be looking at improving some of that patient journey so new patients what are we going to do that kind of thing or rebooking how does that look even based practical basic steps as well we'll be looking at for a practice owner.

24:05Three areas, musculoskeletal, dermatological, and I think I wrote practice. God, I think that was. You used the word in talking about the team dynamic. You said, my words aren't yours. We try to be vulnerable with each other, what we do know, what we don't know. I think for me, when I started running clinic, I don't come from a clinical background. Yeah. So my my headline to the team was always assume I know nothing about the clinical side of the business. And I come from this commercial and operational perspective. And for that reason, speak to me like I'm a five year old. I don't I don't have the clinical domain knowledge that you would have running your practice.

24:48So that's the background. And accidentally, more than intentionally, I think that gave people the space to be very upfront about the things that they didn't know. say, hey, I don't really know about this thing. I know about this thing. So speak to me like I'm a five-year-old. Tell me about how you do this thing. I'm curious, from taking a step outside of running the clinic and maybe occupying the headspace of being a clinic leader and leading a team, because you have a big team that you're working with, yeah, vulnerability feels like a big tenet of the culture that you're trying to build. And you talk a lot about, you've already mentioned having people employed, being able to invest in that team, have that team dynamic come around the practice, enable its success.

25:33I'm curious, how does vulnerability show up in your day-to-day? So when you go in on a Monday, on a Tuesday, on a Thursday, on a Wednesday, whatever it might be, what does it actually look like if I'm in clinic? If I'm in your clinic, how do I see, how do I understand that vulnerability? Where does it show up for your staff? I think it shows up by each other asking for help. So it shows up by team members asking for help. Maybe when they're seeing a patient, I've got a, I've got a, this client's got a problem. I'm not sure what it is. Could you just come and help? We usually look for the person that's available.

26:07So it might be myself or maybe, and by actually not being on the tools all the time, it's allowing me to help support the team. Some are better at some conditions than other people, but we, again, we can all support each and get a second opinion. So if you were unsure what something was or how to treat something, you may call one of your team members to come in and help. That's the first thing. And so I always try and build a culture where we're helping each of that and also building trust all the time. You can't work anywhere where there's no trust. And I'm going to be honest with you, I felt like that in many of the trusts that are working for the NHS.

26:42It's called a trust, but there's no trust. So that's how I felt at times. and personally where with this it's like we are trying to build trust support each other and and we can all learn from each other none of us are perfect we all get it wrong we all make mistakes we're human beings we're not AI we're not a robot but the key thing for me is that we and we try and encourage a culture where we help each other I never mind if one of the team members calls me I never mind at all I never ever say you should know the spine area what do you think and I never try and be a little bit of the difference to the client.

27:16I always try and help and support them. And that's what we want every team member to do. It's interesting that some of the people that we speak to come from a different medical background. Yeah, I'll leave it there. We'll say what kind of medical background, but different medical background. And I think that there is a very real difference in what you're describing in the said medical backgrounds where you are expected to be the unquestioned expert sort of god syndrome if you will where you are you know all and people are coming here for you and your expertise is is a not to be questioned b ultimately the thing that will send the practice of it it sounds like that's radically different than what you're describing where actually this is all of us together trying to solve the problem for the patient the best way that we can.

28:11Yes. How do patients experience that? On the receiving side, how do you think a patient receives support by team as opposed to support by individual? I think a lot of them receive it very well. And sometimes, for example, a member of the team might be treating a patient and in the private sector, in the client, and we say, okay, you've got this problem. And I actually think you might be better than seeing Fred or Bob in the team. and that could help you more basically you may be better to see bob or fred and we'll book you now in to see them and they're over the moon because of actually they're looking for resolution of their problems it's not a popularity contest and i'm always honest with people i'm not the best person about to see you i can treat that today but i think you'd be better off next time to see fred sometimes fred just happens to have a cancellation at the time that they're free and And I'll pull Fred in and say, would it be OK if you treat, let's call her Mrs Smith, Mrs Smith.

29:11And they'll go, yep, that's lovely. And they'll have a peek because they're busier. And we have, we work with all the team to never be frightened to cross from further to each other. And to get people in. And there is wide space within our diaries. We have admin space each day. So there is places where we can shuffle things around. And all clinics get cancellations each day. And so it gives us that little bit of space. So always try and get people as quick as it can to see the best person in the practice if we can't resolve the problems on the day. It's interesting, the thing you're describing, one of the things we believe at Coherent is that good clinic is good business and good business is good clinic.

29:50And I think what you're giving is an example of that, whereby supporting the patient with the right person as opposed to the most senior person or the most experienced person with the right person is probably right for them clinically. and consequently as you're describing if there's white space in their diary actually you're improving business performance, the clinic is becoming more performant, it's more efficient and those things are working together profitability and clinical outcomes can and should pull in the same direction and I think you're giving a very for clinic owners they know that reality of someone's got dead space and they're actually a better person to see the patient, why wouldn't we make that change, why wouldn't we offer that sort of efficiency and quality of service, I think it makes a lot of sense I guess I'm curious in the journey you've been on the last 20-ish years in building and scaling your practice, that would not have been possible at the beginning because it was just you.

30:41Now it's not just you. It's, of course, possible. I'm curious about the way you mentioned before, the way the patient experiences it. You said you receive it very well, which I believe and I think I would as a patient. how has the patient experience changed for you over the last 20 years might be a long time of the last five years six years what has changed in your thinking about what excellent patient experience looks like as you've gone on this journey of scaling the practice has you've become further from it personally because you're not seeing every patient in the way you would have day one so now you're almost one maybe one degree removed or half a degree removed from that front line how do you keep your how do you keep your fingers on the pulse and still make sure the quality is there without being the one who's right on top of it i think i'm always reviewing patient experiences and obviously you've got things like google reviews etc i think you can tell if people aren't rebooking back what their experience was or not what their experience was and people will come back if sometimes not all not all patients will come back if they're not happy you just stop going somewhere so but we sooner will come back if they're not happy or what's happened so you can work out and you then find if there's a training need there so we turn it around into a positive say is there a training need here let's work with the practitioner on these things or maybe there's a miscommunication most things are miscommunications I was thinking in when people are unhappy so it's basically I also treat patients still myself a little bit so knowing her on the scale that I was but I do treat patients still I'm aware of what's happening in my practice I also get feedback from the team so the team will always feedback about things as well so and always spend a lot of time with someone who's starting on our team so we haven't scaled to multiple sites or anything like that so we've got one main site so we spend a lot of time in that site and also I'm aware of what's going on and I try to pick things up early on if people need help with anything and we're always on we're always trying to have that vulnerability where we can ask and say look can we help you with that but obviously you've got to have the highest standards you can especially at the moment with health care it's it's and it's going to become more like that i think the standards need to be really high all the time the highest you can get so people's expectations are much higher i think than they were before 20 years ago they weren't the expectations that they are now and as it's getting more expensive people's expectations rise they're with a service customer client as you're saying so we're continually always reviewing what we're doing how we're doing it why we're doing it and we'll also do group training over for the whole clinic there's a whole team we try and meet monthly that's not that doesn't always happen we try and meet monthly as a team and we do a thing called team alignment day and the team alignment days are afternoons they're not all let's sit in a classroom and go through everything we might break it up and do an escape room in the afternoon and escape and have some lunch together or we might do we did we recently did a whole day trip to london actually and went to saw a musical and took everyone out for lunch and went to booking palace not for lunch obviously but it was a fantastic experience and we took the team so we try and build that team culture so people then can work are more accepted to working together if you're spending time if it's just in a clinic you're never going to build a team culture you've got to do outside the room as well It's interesting.

34:03There's a private equity group that we work with and the person on that leadership team who's responsible for identifying potential acquisitions, clinic acquisitions, and integrating them into the practice says that when you buy a clinic, you buy two things. You buy the EBITDA and you buy the culture. Those are the two things. And it's very easy to look at the EBITDA. It comes out the end of a financial statement. You can see it. There's no uncertainty, but it's much harder and oftentimes more important to figure out what culture you're buying. Yeah. And when you're thinking about exiting, scaling, selling, buying on either side of that value chain, the financials matter a lot, but also an acquirer is ultimately procuring a team.

34:46And if the team gets up and walks out the next day, or if the team degrades, or if there's cultural breakdown, that EBITDA disappears like that. So actually that cultural foundation is the only, it's the only asset that probably doesn't show up as cleanly on the PNL. So it's interesting to hear you said that's a huge part of what you're trying to cultivate is this culture as an asset, as much as critic as an asset, culture as an asset. It's a team. It's a team that needs to deliver this. It's very interesting to hear you say that. I'm wondering, has it always been good? have there been bad patches where culture has you had a bad actor a bad apple a bad team member of the wrong cast of characters have there ever been bad moments in 20 years where you said oh hold on a minute we gotta do we gotta do something about this yeah i think that there have been bad moments and like every narrative story there's always bad parts and as well as the good parts as the bad parts yeah there has been moments where that has happened sometimes we've got the hiring wrong sometimes people when they join the team their expectation of what they were coming into is different from the reality no matter how much you tell them it's very different from the reality they expected or thought that they should where it should head so what you sometimes have to do is what we do now is test drive the clinic we invite people if they've been successful candidates we invest in in we both invite candidates to come and test drive us for a day we can see them but they can also see us it's a two-way process ask as many questions what I do I step off the my foot off the gas and I try and encourage them to go in with the whole team so I even go out the building so they can be free to ask anything they want and then they can find out so if they say actually I accept this job I've come and joined it they at least saw it for one day if they want to come back for a second or third day that's fine because we'd rather someone came to the right place then spent three months resigning from another position realised it was a mistake or we realised it was a mistake and then it's a six month process of pain that you created that you didn't need to for that person or for yourself.

36:52So I think test driving I think gone are the days where you're giving someone a 20 minute interview and giving them a job at the end of it I think the bad patches were I would say we had the best group of associates you could ever have I think we did amazing in there's moments that were fantastic and having a great group but though that lasted for short periods because there's always someone in that group that's leaving or going somewhere else and essentially when you've got associates are essentially working for themselves not for the clinic and it's that's and they often see that the patients are theirs not the clinics and sometimes and there can be misunderstanding and no one's going to work as hard as a practice owner and etc so you have and then why would you ever invest into someone who doesn't actually be employed for years it's really hard we used to call group trainings we try and walk us team meetings people wouldn't come it was impossible and with 10 people you're herding cats that's what i said actually happens but i think there has been bad moments as well where we've had the wrong fit we've actually had to ask people to leave and i always try and soft land it if someone's leaving so this sounds really nuts but we would make sure they've got a month's salary or month's pay of what they would have as an associate because sometimes it's not right for them or for you it's a two-way relationship not just one way and I think that you need to know in your team in your clinics you've got the right people and it is an ever-changing model especially in today's age got a lot of the days where someone is working for a company for 30 years and they're going to stayed with that company for 30 years if you get a solar community for five years you've done very well but what we work on is that career development which helps helps people feel like they're developing their career and they are and that's what we want to offer people some people used to think the ultimate was either becoming a lecturer or at university on a pediatrics degree or we're in a practice now if you do the the lecture at university you no longer are enumerated that you it's no longer the best paid job in town.

38:56Being a practice owner, unless you've got a certain level of turnover, you're almost better to be employed at a really great practice and where you get a fee share as well as employment. I would say if I was 20 years now, I would possibly consider that because it is really hard to run a practice. It's not all plain sailing. There's a lot of work that goes into it and a lot of hours that nobody ever sees that people think you're lucky, but actually they don't see all the hard work that's gone behind that and goes on behind the scenes and the firefighting so we often firefight so the team aren't affected because we want them to perform and to the best they can it's really interesting the i think you're right and you're one of the things right about any of the things one of the things that i have also seen and we see in the clinics that we support is the the tenure of employment in clinic is changing dramatically you don't get 30-year engagements 20-year engagements 10-year engagements you'd be lucky to do five years and that's on the clinical side on the administrative side it's even worse it's you'd be lucky to get a year you'd be lucky to get two years and what we find is that sometimes that discontinuity at the front line being front desk front line being patient engagement layer pre-clinical yeah to your point we were discussing earlier this like service and delivery and expectations that you want to set for the patient the experience you want to deliver which is affected by not just the clinical team, but the administrative team as well, that administrative revolving door actually is a huge problem.

40:22It's a mess. You're constantly retraining. You're constantly trying to close the gaps. You're constantly trying to keep people up to speed and regress it as to whoever's there the longest, even if that person's not very good. So I think it makes a lot of sense. I know from conversations we've had before today that a huge part of building your practice has been about your relationships to the ecosystem and the network you've built to support the practice directly and indirectly. And yeah, so the question is distilling some of the things that have allowed you to achieve success in your practice.

40:55We talked about this idea of culture, of team, of vulnerability, of togetherness makes sense. We've hit on a few other pieces. And I know from discussions we've had previously before this episode, that active network development of the supplier ecosystem, of the collaborator ecosystem, of the market, in addition to the clinic has been a big part of that which i don't think is obvious for new clinic owners i don't even think it's obvious for existing clinic owners who typically get very focused on their four walls yeah so where did that come from and can you give us some examples of how investing almost sideways yeah has really paid dividends for your work yeah i think and where does it come from i'm going to be brilliant honestly it's definitely gonna shock you i used to work on a market stall on a fruit and vegetable when i was a teenager and for a short period of my life and it was my best ever job if i didn't do so much i'd go back to do something like that i really enjoyed it and i enjoyed connecting with people and the first group you have to connect with on the market stall is the other traders because they need to know you're there and you need to know they're there because you can support and help each other and that's the first people that you connect with second people is you've got to connect with the customers but you've got to create your own customers because there's no it's not like a shop where someone's walking into people might walk past your store and buy something they may or may not what i used to be charged with at the towards the end of the day was to get rid of all the fruit and vegetables left over because fruit and veg will rot and will be obsolete after a day or two if not being bought or eaten especially on a market store so you've got to sell the stock that's left as this almost wasted stock so I used to get rid of all the stock for the owner and over the last couple of hours I'd be shifting everything and people that came past I'd be trying to get a good deal on the fruit of edge but I got to connect with a lot of people and what I realized it's all about relationships and people come back and buy a few again and again if they build the relationship with you and I think so building the network with the market storeholders and also the customers is really key and I think also looking after your customer suite at the end of the day we give a really good deal so if you walk past my store all the time you get a really good deal I didn't do it for long enough but I wish I had I really enjoyed that job I've done other things similar and I learned how to connect with people when we started with the practice we didn't really have a massive marketing budget it wasn't the internet working like it is now we didn't even have a website most podiatry practice in 2006 did not have a website and if they did it was very poor and i think it's 2007 we got our own website and we started to produce professional leaflets but what i learned was to and the first people that need to know you're there are all the local businesses all the other clinics and the doctor surgeries and you might say i can't speak to the doctors they won't let me in but you can speak to the receptionist they can have your leaflets and everybody in town needs to know you're there because if they don't know you're there how's anyone else going to and what the problem is with i think society and some kind of carriers not all or you've got a culture that's very digital and they forget about the connecting and networking and the first thing i always say to a practice owner is go and connect with your local ecosystem community so every shopkeeper so we connected for example with the local sweet shop lady and she's sending everyone to us and it's not your best paid marketing spend is the speech we took a bunch of leaflets let's you took them all in put poster up for us and we invited people to our opening we found that the paper at the time most of what we get in the paper was paid advertorials we did an advertorial which kind of looked like a news article we did actually get some editorials when we did stuff with the fucking club we try and get them to grigion to release some stuff but we took leaflets into all sorts of places and we still do that not enough as we should we go and try and connect with for example where there could be a symbiotic relationship so we the way i always say to the people to work is this give first is my principle if you give first it's amazing what can happen so i always say give first build trust and so we started sending everyone to this running shop and they send people to us now so it works both ways because people think you're just trying to extract something from them or it's a parasitic relationship they're less likely to give to you so if it's a symbiotic you're trying to help each other and so we recommend lots of other people and we want to recommend people that want a symbiotic relationship it works both ways so people where it's just one way we might review who we've got that relationship with and start thinking let's look at who we can work with and we also work with some of some medical practitioners we've referred to and they've referred to us and it's amazing we start to get referrals from we've never recommended them but they're referring to us and they don't have the how they've heard of us but it's always worth reaching out to some of the people that are referring to you so do you want to meet up for a coffee and get to get to know you and stuff it's really interesting first of all i think it's it's easy to say those things and yet you practice what you preach because when we first spoke a couple weeks ago within about five minutes of getting off a call you had made three different whatsapp introductions to people here they come a lot of people will say oh yeah i can introduce you to someone then five weeks go by and they don't follow up and literally within five minutes yeah you had gone ahead and honored your word and saying i'm gonna i'm gonna give and i haven't given it back yet but i'm gonna give and i think certainly for me as a as an ecosystem player the relationship matured much more quickly than it might otherwise because actually there was there was that that reciprocity or the beginning of reciprocity very quickly so i think it makes a huge difference.

46:35I agree with you. I think what you're saying about the sweet shop, it's, I think it's somewhat entertaining, but also there's something very real about that because from a clinic perspective, one of the things that we see in market is that to your point around rising costs, rising expectations, there's also rising competition. And it is, it has never been harder to acquire and retain patients. It has never been, there are more providers than there ever were. It's only getting worse. People are opening retail healthcare clinics like they are corner stores in some cases, especially in certain industries.

47:02And so as acquisition cost of your patient base, customer base goes up, you need to think very differently about how you go about building those inroads into the clinic. And I think what you're describing is it's old school, and yet it's also very new school because it's not nearly as colluded as Facebook ads, meta ads, Instagram ads. Actually, there's one person who can build that relationship with the sweet shop across the street, and it's you or it's someone in the clinic. And that's a very ownable referral channel in a way that a meta ad never would be yeah absolutely so this personal personal connection we also just to tell you about another clinic that we did we did a second site and we sold that on later on in midlands and basically to cut long story short we'd spent too much money on doing it up and hiring the team and the equipment and when we came to do the marketing we did some marketing and it didn't work in the same way as the first clinic did And I learned a lot of lessons through that.

48:00So I thought let's go back to basics. So we did something slightly different. And what we did, we went to all the local shopkeepers and all the local businesses. And we gave the owners, not every person in the office, but we gave them some vouchers for a free treatment because we didn't have any customers. So we got some free vouchers to come in for a 30 minute treatment. Now we had a tree sports therapy. We also had, we ended up doing a lot of beauty because my wife was involved and the beauty side exploded and the aesthetic side exploded and pediatrics became a very small part and we ended up selling that on but to start off with what we did we had to build relationships quickly with people because we had no relationships so I said what we're going to do is we're going to go to every shopkeeper and we give them a free voucher and invite them into the clinic and I would go and meet some of the business owners and quite a few came into the clinic I'd say we retained about five percent of the people that came for free treatments and which is a good result from that so that's free marketing in a sense i thought what does an advert cost and the second thing that i noticed was the shop front we analyzed where people were coming from the shop front was actually 30 percent of what came in the door and so what we did we improved the shop front and that whole experience the shop front suddenly the passing tray increased even further so we invested a lot of money for the shop front and we're always changing improving it the other thing was one of One of the methods we went and got people and succumb to the clinic was that we got invited to a PTA night.

49:31And on the first weekend, we got invited to this PTA night. And I said to the team, is there any way you can do this PTA night? They've just been let down by this other clinic. And the team said, yeah, we will. And then we'll go along. Of course we will. And we went along. And they'd already got people, clients booked up for morbid therapists and things for that night. And we're in a side room. so I went into the main room and everyone's in the main room there's like a clothes show a catwalk going on and there's a DJ there's all the stalls around this main hall no one knew you were in the building so what I decided the first thing is I have this rule it's called no one gets out of life so no one is going to leave that building without having my leaflet and maybe a little voucher to come to the killing and so I won't get somebody so and anyone comes in the room gets one of those So that's my first thing.

50:22Second thing is I went to there's a committee that kind of organized this whole PTA night and I thought what can I do here? And so I thought if I go to one of them they're going to say no. So I'm going to go to the person that's going to say yes and I said is there any way I can get on the mic for two minutes? And we're the most amicable person and they said yeah sure. I said so I went to DJI said I've just been given permission to go on the mic. Is it okay to do it at the end of the catwalk? He said yeah that's fine. basically I got on the mic and I called the whole team on the catwalk and introduced every single one and there's 200 people listening to us that went out on leaflets and the return of that investment of that note was incredible and it helped launch our business and it was just by chance but it's taking opportunities that are there I could have said when that woman came into the shop now we're busy sorry it's too short notice if you want to go far in a clinic you've got to put yourself out when it's not convenient.

51:18You won't go as far if you're not prepared to do that. That's the message I'd give any younger generation. You've got to put yourself out. It's not always convenient and you've got to put yourself out there and things will come to you when it's not convenient, when you've got things planned, even sometimes with a family or friends. I'm not saying you've got to be a family's home, but you've sometimes got to take that call. Put yourself out. It makes the world of difference and opportunities and things open up. Seeing the player when the sports therapist brings them and a day when you should have finished an hour earlier see that patient will open up doors and i think that's what makes the difference to our clinic is going the extra minor it's really i want to recognize the time you've given us very generously i'm also always keen to try and pull out the how did we get here story much like we started what's the five minute version of how you got to this chair it feels like one of the ideologies the belief systems that has enabled the success that you're describing comes from your time as a teenager in a fruit stall, thinking about the other traders on the floor and how that impacts your business.

52:22But equally, what you just said is almost thinking of the clinic as a place that serves the community, staying open that extra hour, seeing that extra person, dealing with something that's slightly outside of the standard process, because that's where the dividends and the reciprocity and the relationship really gets built with the community. And ultimately, these are physical locations. And the people who attend said clinics are often people who live within a certain amount of walking distance, driving distance to that clinic. So I can see it. I can see how the idea that the clinic is a place for the community is a very powerful way of improving the quality of service, but also improving the growth of the clinic.

52:59I want to try and wrap up in the time we have and rewind to the beginning and saying, you started as a one man band. Yes. 20 years later, you are not a one man band. You have a thriving clinic. You've got a big team. Along the way, some of the things that have become part of the Dolphin Toolbox are investing in the team in some ways, almost as if they are as responsible for the outcomes of the clinic as you are, obviously not quite that way, but thinking of the team as a unit that moves together underpinned by vulnerability and by trust. And likewise, thinking about community relationships, suppliers, partners, I'm going to call it the sweet shop dynamic.

53:38I might steal that. I'll always give you credit for it, but I might steal like, how do you think about your sweet shop? Because that ultimately gives to you as much as you can give to it. For those listening, there may be stories and there are lessons and there are things that jump out. I want to thank you, Jonathan, for giving us that time on the business of a clinic and giving us, I think it's a different perspective on what it takes to really do the zero to one journey because oftentimes people think about i want to go from one successful clinic to 100 but actually the hard yards happen from zero to one everything on top of that is more of what works but figuring out what works is really really hard so thank you so much for coming thank you so much for sharing the story it's really wonderful thank you very much for having me i've got one other thing please yeah so i want to more two stories two things i could finish on two more points yeah go ahead absolutely one saying in house i came with a saying is you've got to go where the buffalo are you can't stay within the four walls of your clinic something you said only about four walls of your clinic spoken to people where they said i've written to people i've i've tried to make a call and i said have you actually turned up there no so you've got to actually go where people are so we go to a lot of sports clubs we go to the training we sponsor them as well so it's a symbiotic relationship so there's a lot of clubs we sponsor locally to us so we're not just looking to extract there's a transactional value we're looking for transformation and so what we do is we try and build these relationships but it's you've got to go where people are and you've got to connect with people that's what i'd say that makes the difference in this digitized age don't just think oh it's on instagram it'd be fine i've watched certain clinics pop up and they're doing pictures videos everything but i think that yeah it makes a difference it's good having that but what really can make a difference is your relationship with your clients your existing clients and what keeps them coming back is your existing relationship but it's also the relationship you have with other people outside of that sphere and that will make the difference to your clinic and help it grow.

55:32Makes perfect sense. Thank you so much, Jonathan. Thank you everyone for joining us.