The Human Side of Selling and Scaling a Clinic | Teresa Harvey #48

0:00I've been on Osteopath for 30 years. I'm based in Scotland and Glasgow in the southwest. I have four clinics there as a group which we have just successfully completed a sale of to join a larger group. My husband had a bit of a hell's scare probably four years ago and we started to think, oh god maybe we should be thinking about an exit plan. So I started to do some research, started to speak to a few people in the industry about what, you know, how do you create a saleable asset. You don't want to spend on growth because if you're going to employ a new member of staff or double your floor space, it takes you six months to a year to fill that.

0:35I've had three patients in the last month who have come to see us and me before they even try to get in with their GP or they may have tried to make an appointment, couldn't get an appointment. So rather than having a standard robotic, oh, I am from the Austria Pulse and this is that, it becomes really personal and authentic and is absolutely part of the whole kind of feeling of community and friendliness that often are the keywords that people use to describe our clinic. If we pulled all the keywords out of our Google reviews, one of the main things that people say is that I felt listened to and I felt heard.

1:11That's where AI really enhances our care. I think that looking into someone's eyes and having that honesty and authenticity and genuineness from a practitioner is something that's going to be really invaluable.

1:33Great. Hey, everyone. This is Jared from Coherent Healthcare. Very excited to be back for the business of a clinic. And today it's a pleasure and a privilege to host Teresa. Maybe, Theresa, do you want to start with an intro? Hi, yeah, I'm Theresa Harvey. I've been an osteopath for 30 years. I'm based in Scotland and Glasgow in the southwest. I have four clinics there as a group, which we have just successfully completed a sale of to join a larger group. And my background is initially started in nursing and then specialised in neuro and spinal nursing, doing my neuro course in Cambridge at Addenbrookes.

2:19And I had a junior sister's post and did that for a couple of years. And with the usual kind of paradox in healthcare and traditional career progression model, the better sort of clinicians tend to become less hands-on in terms of their clinical care. So I was only 25 at this point and I thought I don't really want to lose my clinical expertise and hands-on clinical care. So I looked around and decided to pursue osteopathy. Got it. So a bit of a winding journey into osteopathy, which is very exciting. I appreciate this is you've been running clinic now for quite a number of years. Do you remember at all the sort of the aha moment for you that said, I'm going to go in, this is the direction I'm going to go in, as opposed to, I'm sure at that point, it could have been maybe pursuing nursing in a different capacity.

3:17What was the sort of trigger moment for you that said, I'm going to go and pursue osteopathy as a core area of practice, and then later on, obviously, start your own practice as well? What was this sort of, I guess, the emotion? Why do that? What was the emotional draw for you to pursue that? at? I think I'd gone into nursing at a very young age. I worked at 16 as an auxiliary nurse and I didn't leave school with great academic qualifications. I really fell into nursing a family full of nurses and I never really felt like I'd made that career choice for myself and I loved nursing but after a couple of years as I say I began to think do I really want to do this for the next 40 years and having done the course the neuro course in Cambridge we'd gotten a lecture from a visiting lecturer and osteopath and it was a very different approach to spinal health a very holistic approach to health care I'm used to the medical model which even more now is quite reductionist and I thought that's using the skills that I already have and my father was self-employed, had his own business.

4:26And at that time I was very clear about how I wanted to practice and probably much more opinionated then about a quality of practice and how efficient things were run and the standard of practice. So I knew I was going to work for myself at some point and osteopathy seemed like a great way to do that. You used a few things or a few words that you use that I'm quite curious to pull on. One of them was this idea of reductionist. For people a bit further away from your world, what does that mean in the context of your journey, setting up practice at that time, when you say a lot of provision might be reductionist?

5:12How does that show up in terms of one's, either as a patient or practitioner, in terms of your healthcare experience providing or receiving care? As an example, when I was working on neurosurgery and spinal surgery, at that time there was a lot of spinal surgery for disc injuries happening. Subsequently not because it shows that the outcomes are no different than having left a disc injury alone. So at that time it was quite invasive, radical spinal surgery, laminectomies I don't know if it's people understand what that means but taking quite a big part of the spine away and you're really I think it was looking at the patient as a small piece of anatomy and removing that disc that's impinging on the nerve whereas from an osteopathic point of view as an example if you had injured your ankle 10 years ago and it was quite a bad injury and you were herpling about on it for a year or so, that will change your gait and the way you use your lower limb and changes the biomechanics and the impact and the shock absorption through your knee and your hip and your low back.

6:30Osteopaths will look at taking away the predisposing factors rather than being crisis-led dealing with the disc injury at source. So So you're looking at the things that might have caused it to happen in the first place in order to reduce the symptoms. Does that answer your question? I think it absolutely does. And it makes me think about when I was growing up, my uncle, I'm not an osteopath, it's obvious at this stage, but my uncle, I remember he had persistent back issues and he went to a whole bunch of, using your framework, of maybe slightly more reductionist or more invasive, aggressive responses rather than thinking about root cause.

7:15And then eventually he ended up going to an osteopath who noticed that he put his wallet in his back pocket and he had a very thick wallet. And so he spent the majority of his day getting misaligned because one side of his body was higher than the other and just stop sitting on your wallet. And then gradually the body, it felt like magic back then. And I I think it's what you're describing now is actually understanding the fullness, the whole person as an integrated being rather than acute moment. Yes. And acute resolution, which is very interesting. And yes, maybe I now understand it much better as well.

7:51Yeah. And one of the interesting things for me about osteopathy and which actually makes me want to continue in my clinical role is I find it really challenging. and I particularly like seeing quite complex patients who have had an injury for a long time invariably in Scotland osteopaths are not so well known as they are in the southeast so we often see people at the end of the line and it's figuring out why they haven't gotten a resolution of their pain or better or their pain keeps recurring despite having seen multiple practitioners before so for me it's that's the kind of like the detective let's try and work out what is happening and what's causing it and invariably it's something that happened way back and plotting a timeline of injuries and you can almost plot that breakdown and compensation so you know I had a bit of knee pain and then and that was fine and that sorted itself out and then my hip started and then I started to get this neck pain and then headaches and you think there's something happening through that whole system of biomechanical system that's when and we can treat the symptoms it depends on the patient's model of health and we absolutely see joiners self-employed joiners and builders who come in they want their back fixed and they want to go back to work and that's fine because like that's a contract we have with them and say look i think this is causing your pain and we can sort this we can make you feel better in a couple of treatments but if you want to resolve it completely let's look at these predisposing factors and give you some control over it rather than you having an acute back every every year and you're off work for a week it's an interesting thing we i think there's a macro narrative the speed at which you can identify, diagnose, treat, resolve is connected to the efficiency of the practice and or the expertise of the practitioner and or some other positive outcome.

10:04What I'm hearing you say is that actually going slow to go fast makes a big difference in your practice taking the time to go deeper in order to understand and then maybe make different decisions that lead to resolution more quickly might actually be different than in another clinical MSK environment where perhaps the or clinical environment more generally where the response is problem solution. Am I understanding that correctly? That this is a more consultative journey where you're trying to understand all the decisions, the actions, the history, as you're saying, build that puzzle picture and then move from there?

10:43Is that, have I understood the beginning of a patient's journey with you correctly? Yeah, I think so. And we choose to spend an hour with our patients in that initial assessment. And we'll often, staff will often extend a 30-minute return clinic time with a patient, but no extra charge to them if they feel they need that little bit more time. But I think what we do and what we train and encourage our new graduates to do are set short-term, medium and long-term goals. And it's so the patient really understands not just, as you say, their back pain, you know, fix the pain in that set, but understands maybe their whole body and what may have caused that breakdown in the first place.

11:32It doesn't mean that patients commit to that long-term approach. As I say, it depends on their model of health, but that's with informed consent. If we say to them, you can come and see me and we'll get you 100 % better in a couple of treatments. But these are the things that might have caused it to break down in the first place, that breakdown in compensation. And we can deal with that as well. It's just whether you choose to come back for that extra two or three treatments. And some people come as a maintenance every three months, six months, every year. But being honest about that, I think, and having that hour to develop that trust and that relationship with patients.

12:13I think we often, we don't get patients normally who will go elsewhere. Or if they go and try elsewhere, they will often come back. and I think you know another benefit of that sorry is and what I've noticed and really quite distinctly in the last month or so is that we spend a lot of time taking a full medical history and we take BPs we do all of those kind of as much screening as we can as a baseline and we really understand the patient's medical health and we often see people with complex medical conditions and past histories and what we are finding now is that we are really becoming primary health care practitioners.

12:59I've had three patients in the last month who have come to see us and me before they even try to get in with their GP or they may have tried to make an appointment couldn't get an appointment. We're their trusted MSK practitioner they know we can screen them so they come to see us because they know we've got the skills to triage them and three of those patients have gone back to their GPs with a letter and that one had a fractured shoulder, one had spinal compression, spinal cord compression and the other one had secondaries from a prostate and cancer in the lumbar spine. Pretty distinctive clear red flags but that's what we're seeing and it's not just MSK.

13:45You have to have the skills and give clinicians the time to be able to assess and make those decisions. As you were describing the journey with the patient, you used two words. One of them was trust, one of them was relationship. And I think that it's interesting. One of the things that we often talk about with practices that we work with is how, I wouldn't say easy, it's not easy, but how accustomed and practiced clinical leaders are in their ability, or I should say good clinical leaders, not all clinical leaders, but good clinical leaders are in their ability to build those relationships and that trust.

14:28and how hard it is to actually maintain over the course of the patient's journey. Because when the patient is there physically in the clinic in front of you, there is that almost two people leaning together, that shared intent. But obviously life is busy. Patients may leave clinic, may disengage, may get better enough that it's not an acute issue for them every day when they wake up, even though it's not fully resolved. As a practitioner, I would be curious to understand how you think about the word that we can use as retention, but I think the way you're describing it is actually it's like clinical retention.

15:06Getting through a program of support, of care, is potentially long-term. It's many weeks, many months, and possibly has top-ups, check-ins, proactive work as well. how have you found that as you've grown now you're in four sites your patient body has grown compared to when you start how have you found that the practice has dealt with this we've got x number of patients that we see every day but we've got 10x those patients that we've seen in the last month or in the last year that we also need to support or engage with to help them continue with their program of care. How does the practice deal with those things?

15:52I think as osteopaths, we tend to look at the body as a whole and entropy and a breakdown in compensation. So it's easy to speak from an osteopathic point of view. From a business point of view, there's a number of different things that we do. And particularly for new graduates we we monitor our returns and our new patients and the cancellations without rebooking and we do that every week and we support our new graduates in doing that we often one of the key things that that I learned in my first job the very experienced osteopath at that time that's 30 years ago used to make me call up the patients that had cancelled without rebooking to see how they were and that is just cringe worthy as a new grad because you always assume it's because you're rubbish and a really difficult thing to do but actually was a massive learning experience and more often than not the patient might have been a little bit sore after treatment and decided that didn't want to come back or as you say felt well enough that they thought oh that's me sorted now but unless a new grad is explaining or anybody is explaining look you're going to feel a bit tender after treatment or you're going to feel good for a couple of weeks but then it's going to return and then we're going to start dealing with the reasons that it's causing it to return otherwise you've got a patient who goes away and says they made me worse or they got me better but it came back and every clinician will recognize patients who have come from another clinic where the the patient will say those very things I think it's making sure at the outset the practitioners are really clear about a patient's expectations and when they come back for that second visit be really forensic about the fact that yeah you were tender for two days or you've come back to me in the seventh day and you say that you have been really sore for the last couple of days no let's take you back to the previous five where invariably you were feeling good that's what you will experience and then it'll creep back so let's get you back in in that seventh or sixth day to try and change those tissues for the longer term sort of thing auditing self-auditing is really a way of training your practitioners to communicate in an informed way with patients right from the start about their expectations and a way to re-engage with those patients too when often patients will be delighted that a practitioner has phoned and shown an interest in them and is genuinely interested in what's going on with them and We record all those telephone conversations in terms of our notes.

18:47We look at our data every three and six months and look at who's maybe due to come back or you've maybe negotiated that they will come back in a year or actually they're quite happy not to come back. And that's okay as well. It sounds like you're caveating as you started talking about the, there's the clinical perspective on engagement, on relationship management. There's obviously the commercial perspective as well. I'd be curious to understand for yourself coming in from a more clinical background and then building a business, which ultimately what you did, you went from single site to four sites, you have a team.

19:29I'm sure there are hundreds of things that you can pull out of the hat of, this was a really important thing that we did. This was a thing that we should have gotten right and we didn't. I'm curious if you have to think back and say, this was the one thing that I'd go back and do differently. This was the one thing where we went left, we should have gone right, and we paid for it. And we had to dig our way out of that challenge. Do you have recollection in the time that you've been building your crew, what was that sort of fork in the road moment where actually, in hindsight, maybe you should have taken the other path?

20:10yeah I think we subsequently have taken another path and I think it's building for new staff across the board it's building a really clear three to six month mentorship program and having just not had a formal program I think we saw a real sort of leak in patient numbers is patients not coming back and when that's just not income that's reputational so I think that's really important to get right from the outset our new grads will shadow for often the first two or three weeks completely they'll have extra time with extra length lengthy appointment times we talk about a framework because no matter what therapy you train in then they don't tell you how to manage patients when you come into private msk they don't teach you that can i push i just it's so easy to me they don't tell you how to manage patients can you can you when in your head you have a it sounds like you have a definition of what you when you manage patients What does that mean?

21:29Because people go... I think... What does it actually mean to manage a patient as opposed to to treat a patient? I guess these are very different things. Treating a patient, managing a patient. I think managing their expectations of treatment and educating the patient is really what I mean about recovery and what to expect. some people think they'll come for one treatment and be 100 % better and that's not how anything in the body works and I think making sure that new grads patients understand that if you come in to me with an acute low back so I generally give and it's a bit dictatorial but we say that when we're giving our staff this framework to work alongside to give them to give them the confidence to say we're going to see you weekly for the next two to three weeks we're going to use we set a very um functional or quantifiable measure so it can be a visual analog scale we'll see you weekly until your pain scale is five out of ten rather than ten out of ten or we'll have set those measures in that first hour that we speak to people and say okay we're going to you can only walk 100 yards and your pain comes on we're going to get you to the point where you can walk 200 yards and then we're going to see you two weekly and then we're going to see you three weeks after that and we're adapting that and we're booking that in the diary ahead so that's easier to manage a patient's a clinical list but also we make it really clear and these functional measures are meaningful to the patient but we make it really clear that's flexible you're not committing to a course of care we assess using those measures at each treatment and if it's not working we sit down and work out why it's not working why is that not changing what are we not doing are we the right people for you to see and we say that at the outset the first visit as well and say look if we if this is not changing we're not going to go on treating you hoping it will change and by the 12th treatment you've had enough.

23:37We will assess at every treatment. We sit down and review between four to six if you're still with us at that point. And if we're not getting change, we begin to really look at why is that not happening. And we will refer you to the right person to see. And we recognise and reassure patients that we may not be the right person for you to see. So we'll send you with a letter back to your GP for further investigation or their opinion, or we'll send you to a more specialist physio that we can't provide or whatever it is that you need to do. We will send you with a letter to go and try and resolve this problem.

24:18I'm recalling I used to work in clinic and we were treating completely, they're mushering skin. But the idea of actively managing expectations with patients, ultimately customers, we can call them patients, we can call them customers, it was really important. We did something very similar to what you described, which was, in your case, I guess it was, we're going to set a benchmark of what the test or review looks like. It's going to be walking this far, feeling this, and it's going to be when we can not be the presented or the treated issue from 10 feet away, from 5 feet away, from 2 feet away.

24:53We had a very similar sort of thing where you were working toward this removal of something on the skin. And so it is very evocative for me remembering those conversations and also the challenges that you can very well get into with patients. And in some cases, confrontations, because as you're suggesting, that active expectation management. Yeah, when it goes badly, it really goes badly. It can really go badly. Yeah, and it's often associates will call me into the room and say, this guy's not getting better. And you sit and you really talk to the patient about what their experience has been post-treatment.

25:32And as I said before, invariable, they'll be like, I was a bit sore for 12 a day. You've got to give patients responsibility as well. And that's, I think, one of the things is coming from a medical model in the NHS, but also for new grads. It's like, OK, you only have the patient for an hour or a half an hour. there's only so much you can do it has to be a contract between you and i you have to actively try to get better and take our advice lovely it's an interesting thing an idea of contract and i personally don't know of any health care providers who actually had a contract maybe they do exist i don't know but i think you're right that there's a we're going on a journey together yeah part yeah to help us get that part of the journey you're going to do your part it's quite similar weight loss or exercise management you can exercise for an hour in the gym if you go home and eat whatever you want and do whatever you want you can exercise the next 20 years nothing will change so i can completely appreciate that i guess the thing i i find myself wondering in in your practice how many patients do you see on a given week month year ballpark what's your sort of patient pitch lab oh gosh i don't know the numbers off the top of my head.

26:45We're not massive. We have, I think we had 150 new patients last month and that was probably about 20, 24 % of our total patient numbers. Okay. So you're seeing hundreds of patients a month. Maybe a hundred patients a month. Yeah. That's part of, and your team is only so big, you have four sides, but you don't have the same number of practitioners and client care staff as you have patients. So it's not a one. How, at a practice level, at a group level, what have you, what has been your playbook? Or I guess, what have you learned? How have you learned to support sort of one-to-many contract where you have a number of practitioners, client care team, you have 10X or 5X or 20X, the number of patients that are in active management, have you found that there are things that you're doing in practice, personal tricks or tips that you've acquired over the last decades of parietal service patients where you said, actually, if we structure conversations this way, if we help the patient understand these things, then that soft contract is more likely to be successful.

28:04It's more likely that we have held, without giving away the secret sauce, obviously, that's trade secrets. What have been the sort of key unlocks for you as a practice leader? Again, not wanting to seem dictatorial, I'm beginning to sound like a dictator, but it's basically developing in the easiest way for me, for everything from admin and reception, the way people answer the phone to the way a practitioner brings a patient into the treatment room or the way they speak to them on the phone when they're calling up to see how they are after they've cancelled giving them a really clear script of what to say as a way of that does a number of things a lot of receptionists and practitioners will feel uncomfortable about trying to find a language to initiate or carry on that conversation.

29:02So giving them a script and telling them just to act apart initially, just go with me on this, just take yourself into your head somewhere and act apart. You're this amazing practitioner, which of course they are. And they carry out that script and pretty soon they're making that their own and they're really comfortable with it and it's really authentic. and it's them and it's just wonderful to see so rather than having a standard robotic oh I am from the Austrian paths and this is that it becomes really personal and authentic and it's like absolutely part of the whole kind of feeling of community and friendliness that often are the key words that people use to describe our clinics yeah that sets the standard right from the start work so staff admin staff all the practitioners are really clear what the expectation is from our values and our standards in our clinic and then you can make it your own but you know where you're starting off we're starting here we're not starting here if i took tweezers and looked at the thing you pulled out a few things that you just said you said authentic make it your own standards values that carries across the entire practice.

30:26And I think from the providers that we work with, a lot of the work that we do is on the admin side of the house, not the clinical side of the house. So we will spend a lot of time with administrative teams and administrative leaders, practice managers, operations directors, et cetera. And consistently what stands out is that they will say versions of what you just said. Voice, this sense of consistency, no matter how you can knock on the front door, the side door, the window on the second floor with the, no matter how you try and get into this clinic, this healthcare provider, the experience will feel like the person that's answering the phone or engaging the patient.

31:03There may be some nuance in that, but generally it all reads from the same songbook. And often the songbook is, particularly in private healthcare, that songbook is often one that is very empathetic, putting that patient at the center of the experience. And it's funny, you also use the words, I take my tweezers, use the words, not robotic. And that leads me, people will think we scripted this in advance of the conversation, which we of course didn't. It will very naturally ask the question, we are living through a technology moment with AI-ification of everything. And with it comes great things and bad things and artful things and sloppy things.

31:43There's a whole mess that comes with AI. but obviously one of the places that practices have considered implementing AI and we're in the early innings of that still, the thought about it is very much at that sort of front door, virtual front door, the phone, the correspondence handling, et cetera. I'm going to make an assumption that I know where you fall on this spectrum just based on what you just said, but I am curious. understand how have you thought about pros and cons do or not do have you considered implanted have you implanted it's in some ways counter to the things you said not robotic authentic those things are not necessarily aligned fully with an ai receptionist or something to that effect how do you what is your vantage point on this whole thing that's happening in in administrative patient management when it comes to AI?

32:36How have you decided to, what has been your posture? What has been your group's posture on how that's going to show up or not show up? Yeah, we already use AVA, a system of telephone answering for AI. We're using AI. And on a practical level, that's if patients engage with it, that's really successful and amazing. And we have a very mixed demographic of patients unlike a sort of in the centre of London maybe where you've got a different demographic we have some patients who absolutely love it and some who just hang up and we've gone down that road because we've always used a telephone answering service always had a human on the other side of the phone but recently the service had become so bad that that we thought we might as well try it.

33:28And I suppose it's only as good as AI, but it's only as good as the script that you give it and the options that you give it as well. So I think as long as you are really particular about the different patient journeys that are there, then I'm happy to do that. I think as time goes on, people will become more familiar with that. We also use note writing scripts. We're piloting that. and what a difference for practitioners. The benefit of that for us is that I can sit, instead of constantly looking at my computer, I'm making eye contact with the patient, I'm really actively listening and that can make a huge difference.

34:10And one of the things that, if we pulled all the keywords out of our Google reviews, one of the main things that people say is that I felt listened to and I felt heard. that's where AI really enhances our care again you have to put the work in to make sure that you're capturing all the right information and setting up your templates properly and so from an AI point of view I'm quite happy and open to integrations that will enhance our clinical practice and the experience for patients and what Ava means is that our phone is answered 24-7. So even with the best human telephone answering service, they still take the bank holidays and stop at six o 'clock in the evening.

34:56And we're trying to use it, as I say, where it does really improve the patient experience rather than isolate them and make it feel less, less human. We will not, I know there are some practices where there is no receptionist. And again, I think our clinic is a really kind of family, community-based clinic, although Scotland's quite different, even though we have a clinic in the city. Our rural clinics are often lots of little suburban areas and lots of villages. So that's a really community feel and having that relationship with our amazing reception team is all part of our service, I think.

35:44I'm bringing together this idea that you're trying to improve patient experience. Obviously, there's some efficiency that comes with that as well. But now you have a clinical benefit to the patient. You have a business benefit to the practice. You've also just gone through a sale. Of course, congratulations on that. One of the things I'd be curious to understand is what was that experience like? found going through the the the selling the diligence the the the integration to what is now a larger group as far as i understand about the group it is also itself up and coming and so it's sort of yeah acquisition by fire it's not a sort of 25 year long-standing they've done this 600 times where there's a lot of new in there which is very exciting i think there's probably some very interesting perspectives about how to do things differently more efficiently to the benefit patient, et cetera.

36:33But if you have to give us sort of the summary page of your experience going to and through the acquisition, to the extent that you can share things, obviously, what was that experience like for yourself? What were your sort of nuggets of wisdom? I think a lot of people always say, and I know this experience for me as well, prepare early. And that always, of course, that's true, prepare early, but I don't know how actionable that is for people so if you had to think about the experience that you had and the one two three things that actually you really could have done that would have made that experience maybe be better what would those things be how do you reflect on it now having just gone through it we had been doing a bit of research over the last few years my husband had a bit of a health scare probably four years ago and we started to think oh god maybe we should be thinking about an exit plan so I started to do some research started to speak to a few people in the industry about what you know how do you create a saleable asset because we were both very clinically hands on and are very clinically hands on in the clinics and and honestly we had started to systemize our clinics just for ease and for all the reasons that I've said as we grew it just maintained that quality of service and all the rest of it and and we'd actually been kind of tentatively approached by a couple of people before and it just didn't seem right it felt like there was it felt more of an acquisition than a joining a group and I've built the business from just a one practitioner, paper diary, mobile phone and it's important for us that we pass on that kind of a bit of a legacy really and we have a responsibility to our patients to make sure things are maintained at a certain quality.

38:34When we were approached by MSK we did a lot of due diligence on them around the industry and we were down in London, we met them face to face, we really grilled them about lots of different things and of what their vision was and and I think the key for us is that their vision and so far that's been reinforced by our experience is that they want to get best in industry clinics together with motivated founders who are obviously really keen to develop their service which we are we are keen still to grow and for us that was that that was a big attraction we are getting to work with people that we have a lot of professional respect for that we can learn from and we can work together and I love to I've learned so much from industry and non-industry groups in order to improve the experience for our patients when we were really comfortable with that we decided to proceed and we actually did a lot of the due diligence I say ourselves but that's the royal way my husband really did it when that was relatively surprisingly easy according to him because we had all these systems in place we had all our accounts all sorted and so it was doable and we rattled through that quite quickly actually so and we had a lot of support up to that point talking to msk and we've got a fantastic accountant who's also a friend and she's got a little bit of Our partner and husband has got a little bit of experience in M &A.

40:14So we felt really informed and supported through that whole process. That experience was fantastic, really. No, a bit stressful at times with some of the doting eyes and leases and things like that. But yeah, as long as we were really happy that we were joining a group rather than being acquired and weren't sure what was going to happen afterwards, we got a lot of assurances. and did you ask about the experience afterwards as well i've kind of lost the track of what you asked yeah i think you've been through this now and it sounds like which is exciting to hear because i think a lot of people will go through the experience and their eyes will roll backwards and say oh never again but actually it sounds like that was not your experience it actually sounds like you actually had a

41:01yeah and as i say i think that's because we were so well supported by people around us and any question and we trusted their judgment and their advice it didn't feel like we were like blindly finding our way through this and didn't know if we were asking the right questions and didn't know if we were getting the right feedback and when it comes down to it the numbers are the numbers really you can't really make them any different than they are so that honestly wasn't too bad we were expecting the worst we were stealing ourselves but and maybe that's the key expect the worst and experience something much less but yeah I think the key thing for us that it was and it's not to say it's not stressful or tiring but I think the the caught in the headlights thing is that you're suddenly hitting the ground running and but again what has made that a kind of exciting experience is that the MSK team are amazing it's like my wish list for a team that I've wanted to have for the last 10 years really it's fabulous it's so much fun and they're all really good at what they do it's like having the best industry experts and you can see the change from a marketing point of view.

42:21I'm coming from a time in the last 30 years, 30 years, where I've gone from, we're the generation of yellow pages, and that's all there was, and talking to local WRVS groups after the Flower Arranger. And then we've gone straight through that digital and AI sort of journey. So as you said, mentioned before, like every small business, you learn on the way, you're not trained to do that. We've had a little bit of help from different companies along the way but it's marketing as it's like giving a Mario Kart boost to our routine unbelievable it's fabulous it's I love I do like marketing as much as I moan about it it's just fascinating to see how it really all works in the engine room and he's managing it from newsletters to facebook ads to google ad that's it's great to have that support and similarly with the rest of the team legal support hr support which is that whole nerve-wracking thing from managing people to employing people so from that point of view since we joined and we were we opened a new clinic last year we've got the support developing that and we wanted we had the opportunity to grow but I'm not sure if you would have had the confidence to actually commit to a much bigger space but we spoke to MSK about that and and I spoke to them last year about what surely an FP1 who you don't want to spend on growth because if you're going to employ a new member of staff or double your floor space it takes you six months to a year to fill that surely an air now disincentivizes that gross risk we spoke very frankly about that and msk have financed our expansion so we've doubled the floor plan of our core clinic and we managed to rebuild and fit that out and turn it around within six weeks so we've now got extra treatment rooms we already had extra staff coming on board we they're enabling and that they are allowing us to work in the way that we want to work so that extra space we were already running pilates classes and we developed a program with a little bit of help from a physio colleague called stronger for longer which is classes for 60 to 90 year olds And that clinic space is used for that.

45:05And if you're going to look at that from a business point of view, that's not a profitable way to use that space. But I think MSK have been very respectful of the fact that we want to have that patient journey from presenting with pain to rehabilitation to maintaining that strength and independence of patients and running a community class that's affordable is the way that we choose to do that. So, yeah, they've basically given us, I gave my senior staff a shopping list, a blank shopping list and said, go and give me a list of what you want to buy for this gym space and for the classes. And it's fantastic.

45:50I think there'll be a lot of people who are thinking about a future. they are joining a group. And it is really wonderful to hear the positive examples of that, because unfortunately, it isn't always the case. We had a gentleman on recently who runs a shared ownership dental group, multi-site dental group. And it actually sounds very similar philosophy to some of the things you're describing, where there is that togetherness that comes, but equally that independence to continue and acting as you see fit. I want to be respectful of your time. I have one final question I was asking fresh at the end is if we roll the clock forward five years, ten years, you can pick the timeline, three years, one year, whatever the time might be, as far out as you can see into the future.

46:37I will typically find myself asking, what is the one thing that will change that will be different from today? But actually, I find myself wanting to ask the question, what is the one thing that will not be different? Because so many things are changing right now. What do you think is, we can have this conversation in 20 years, if you were still doing this in 20 years, I don't imagine that you will be, but if you're doing this in 20 years, what is the one thing that won't change while everything else around yellow pages to AI does change? What is the one thing that does not change in your view?

47:12I think having face-to-face interactions and touching patients having that kind of physical touch if that's incredibly powerful having understanding a patient as a whole I think people will choose to maintain that as their worlds become much more isolated and screen driven then that won't change yeah when speaking to someone that you trust that you don't think is actually the algorithm is adapting what they say in response to what you say i think i think that looking into someone's eyes and having that honesty and authenticity and genuineness from a practitioner is something that's going to be really invaluable cool it's so funny in my head you're saying lots of examples of of a thing and and i'll be reductionist about it for a minute and i'll say actually that thing feels just like the humanity the human elements care are going to be yeah it's important arguably more important in a world where so much too many other things may in fact be non-human teresa thank you so much for the time I'm very happy with listening in.

48:30This is Teresa, multi-decade clinic owner, now on the next phase of growth. I'm sure that if you have any questions, you want to reach out to her, you can find her details online. Reach out to the clinic. You may get an AI answering service, but they will then direct you into the clinic to have that conversation. Thank you so much for joining us. It's really been a pleasure. Really appreciate your taking time to spend with us today. Thank you. I really enjoyed it. Thank you for making it so comfortable and conversational.