With Christopher Cloke Browne and Roger Houston, Directors at Owlicity

HOST: Welcome to Confidence to Thrive, the podcast helping growing practitioners and healthcare entrepreneurs navigate the challenges and risks of regulation while building brands that matter. Every episode, we tackle a different issue facing healthcare practitioners or entrepreneurs, or we interview a guest who is working on the leading edge of private healthcare, building something that matters in their sector or profession. 

On today's episode, I'll be discussing with Christopher Cloke Browne and Roger Houston, directors at Owlicity, about the unique challenges around marketing and promoting a functional medicine practice or healthcare business, and some of the issues that arise on a regular basis. We discuss what information needs to be provided and available to clients and what claims can be made around treatment, and providing evidence to support this. 

So, let's get over to the discussion.

HOST: So, what is the burden that is placed on functional medicine practices in terms of how they market and promote their business and their services and attract patients? Is there specific guidance? Who is the body that effectively polices how businesses promote themselves in this area?

CHRISTOPHER CLOKE BROWNE: I think it's very much a GMC issue for doctors and really maintaining within the GMC guidelines. As Roger and I often say, the GMC rules by guidelines, which become absolutely rigid when they want them to be. So you do have to be very aware of those, particularly for the more—the less well-accepted treatments. So when it's mainstream, it's really about managing patient expectations as to what the treatment is and what the possible outcomes might be. I think you have to not give people the impression of some kind of miracle cure or somehow it's going to be so much better than what's generally available on the NHS. And you have to be very clear and realistic in what the treatments are and what the expected results might be.

ROGER HOUSTON: Yeah. So you have a duty that's akin to a fiduciary one in the sense that the GMC requires that you act in the patient's best interest. And they specifically mention that this includes situations that are contrary to your financial interest. So you have a very high duty.

CHRISTOPHER CLOKE BROWNE: That's—I mean, they don't call it a fiduciary duty, but in other areas of life, that's exactly what it is. So yeah, that's the duty. Again, dentistry is very similar. So those who are entering the profession, having qualified abroad, often fall foul of that. The idea that you have an obligation to direct patients to the NHS where you know that treatment's available free at the point of delivery. Functional medicine is slightly different on the basis that the whole, if you like, medical ideology of it is that it is not mainstream medicine. It is something that's different. It looks at things in a systemic way. It doesn't treat in isolation or doesn't treat symptoms. It tries to get to root cause. All of that's admirable, but it has to be declared specifically and it has to be referenced in consent that's applicable to the patient's own particular circumstances. And then you get into risks and benefits once you've determined what you need to do and what the cost is, because you can't determine whether you've got an overall benefit unless you know the cost and the risks.

HOST: And when does the marketing become an issue? Is this something that becomes an issue further down the line when there's a particular issue with a patient, or when they decide they don't want to pay the bill?

ROGER HOUSTON: It's very much like a contract, you know. You only worry about the marketing when there's a dispute. So it always comes back to, you know, "You promised me all this and nothing's happened. I paid you. I went to your website. I saw this amazing thing that was going to be better in three weeks. I've turned up to you, who I paid all this money, and it's three weeks and I feel worse than ever."

CHRISTOPHER CLOKE BROWNE: Yeah. The other pitfall that I'm finding quite a lot on the complaints and claims side is that there's not a clear understanding with patients about privately funding investigations that may remain available elsewhere on the NHS. So there's a timing issue with that, possibly. But again, you know, there's also a communication issue in that. So a lot of functional medicine has blood tests, but they do enormously detailed blood tests. They look at hundreds of indicators, but blood tests are available on the NHS. But the NHS blood tests are far narrower and blunter. So you go along to a functional medicine practitioner and they say, "Oh, we'll do a blood test." You go, "Well, the NHS would have done that for free." And those blood tests are expensive—they're hundreds of pounds. So that's where you need to be very clear about why you're doing this private blood test, what the difference is, and what the markers are.

Interestingly, you know, one of the big differences between NHS medicine and functional medicine is that NHS medicine has very particular thresholds. So when a blood marker—you're fine until your blood marker gets to a certain number, and that number is normally a fairly critical number in terms of health. So once you flip through that number, whichever way up or down, then you're sick in NHS terms. In functional medicine land, if your numbers are heading in the wrong direction and in the wrong end of the spectrum, then there's something a bit off and we need to find out what it is and start to correct it. So there's a big difference in mentality. But you can imagine for somebody who's presented a bill for several hundred pounds and says, "Well, I could get that in the NHS."

ROGER HOUSTON: Yeah. So I recently had a case where there was an awful lot of heat and noise around the case, and it came down to poor communication, as Chris says, on the basis that the plan had been outlined, but running parallel with that and really underpinning that was a whole host of tests which ran into multiple thousands. So the patient was saying, "Well, I've gone through all this and nothing's happened. Nothing's new. You've prodded and pushed and taken an arm for blood. And for what effect?"

I mean, I liken it to a builder. So builder A doesn't give you a detailed schedule of works, just asks you periodically for money that you can't relate to work done. Builder B takes you through a step-by-step schedule and you can see where the pricing adds up by way of an interim payment. Who are you going to trust? So once that's gone, it's very difficult to get it back.

I would say probably somewhere between 40 to two-thirds, 40% to two-thirds of complaints—as distinct from claims—that I deal with are predicated on miscommunication. And it is so often not around scope of works. If you like, when I use that construction term, it's about what people say are non-treatment-related costs. And there's also the fact that you need to communicate the contingency because people form a view. They do the test to test that view. It either confirms a view or doesn't. In the case it doesn't, then there's something else that they might need to do. And of course, it's not the NHS. All of these things cost. So as Roger says, these things can ramp up.

CHRISTOPHER CLOKE BROWNE: And we were discussing this with one of our clients a few weeks back, didn't we? And it was exactly that discussion: you know, "How do you manage that process with the patient to say, 'Yeah, you've just done one expensive test and I still don't know what the problem is. So I need to do another expensive test to try my next idea.' And you need to be very clear in your communication on that because you can imagine people just start to scratch their head."

HOST: So when it comes to the whole area of marketing and promotion and bringing patients on board, it seems like there are some distinct stages where you very clearly have to do certain things. So there's the marketing side—you know, the kind of things that you put out that communicate on social media, in terms of your advertising, in the way that you actually bring people in. But then there's also the other elements that you more closely control, which seem to be the processes by which—when someone has shown an interest—you're talking about reasonable expectations and making all of these things clear. And all of these things are very clearly about getting the processes right and getting that in place to ensure that everything else falls into place.

CHRISTOPHER CLOKE BROWNE: Yeah, I think it's also a cultural shift. So quite a lot of our clients—in fact, the majority—have come from the NHS. They want to do something different. Functional medicine is that platform. But they've gone through training, they've gone through rotation, they've become senior in what they do. But they've never really—doctors in the NHS, they don't sit down and talk about money with patients. And you know, you can't assume that people will equate further investigations with an additional bill. I mean, quite a lot of people think, "Well, you've done the wrong test, so why should I pay for you to do the right test?" And in reality, all you're doing is a scientific investigation from a medical perspective, and it's standard practice, it's standard routine. But it's not something that's dealt with from a financial point of view within the NHS because it just isn't. It's all free at the point of delivery. There is a cost, but not to the individual doctor nor the patient. So you've got to switch that mindset. Think of the builder going through the schedule of works. So it's a cultural aspect on both sides.

ROGER HOUSTON: I've had conversations with clients where they say, "Well, of course, there'll be an additional cost." Why "of course"? You think it's obvious, but the patient doesn't know that. You're assuming too much. So I think if you go back to the marketing, the marketing has got to start with that, setting the groundwork for that. But if you like, as discussed in any business, any interaction with a business is marketing. So all of your interactions with the business have to have that concept in mind. At the end of the day, you are exploring and, to a degree, experimenting, and the patient is paying for that. So they need to understand why it's sensible and why it's worth the cost.

HOST: In terms of thinking about the front-end marketing, because of the nature of functional medicine, people who are attracted to it have already kind of have an interest in it—they're quite knowledgeable, not necessarily deeply knowledgeable about what happens, but knowledgeable because they've heard other claims, which might have been in the media, or they've been in circles where they've heard those. So they come with a certain level of expectation. Particularly as functional medicine becomes more mainstream, we hear more and more stories in the media, we hear more stories being shared on social media. So people are coming to that with a level of expectation.

ROGER HOUSTON: I would almost say it's the other way around. So what's appearing in the press now is, you know, nice clickbait. Big headlines: "I did these 10 things and you know, it cured my cancer." Sort of headline. And so people then read that and expect to be able to do those 10 things and it to cure their cancer or whatever it is. Or, you know, massively reduce their weight without surgery or you know, whatever it is. It's the headlines are based on big promises for people—quite unhealthy people—and it's based on something that might or might not have worked for somebody without an awful lot of tracking details as to what actually happened and why it worked. Remember, this is personalized medicine. So what works for person A doesn't necessarily work for person B. So I think it's more that problem. So you need to very much tackle that issue. You need to tackle the personalized nature of it. And you might have read some great headlines, but I can't guarantee you that we'll get anything to work for you.

CHRISTOPHER CLOKE BROWNE: I guess it breaks into two categories. One, I would say, is that they come with a tabloid diagnosis, as Chris has described. The other is a Google diagnosis. Both need to be dealt with, particularly on the basis that—as you could say—it's personal, but you have to determine what it is. So I mean, I've spoken to lots of people on the complaint side where the opening conversation, the initial consultation, is "I've looked this up on Google. I have this. Can you do this for me?" Yes. And yeah, that's almost certainly wrong or partially wrong. And then you need to try to sort that out. That's what underpins informed consent—you know, to say we have to go through this journey. But don't forget the cost schedule because otherwise you end up in that camp. So yeah, it's a slightly different slant. I mean, it should be the same in the NHS but it's not. So yeah, these things about communication and understanding—there will be underlying trust and an expectation that you are the specialist in the room. Or they wouldn't be there. So you start on the plus side. The patient relationship and trust is yours to lose, and that's how you lose it. In our experience.

ROGER HOUSTON: And I think it's also our very strong advice: the marketing is great and you want to attract patients, but you also want to have a fairly serious filter as to who you actually want to take on. So our very strong advice to practitioners is to be—and I appreciate it's difficult because when you're starting a business, you want revenue and you'll possibly be attracted to things that you wouldn't be once you're more established—but you want to be really quite careful about the patients that you take on. So, you know, if someone marches in and says, "I read this in the Mirror last week and I want the same," that's not the kind of patient you want.

CHRISTOPHER CLOKE BROWNE: I mean, that's the difference between marketing and a consultation, isn't it?

ROGER HOUSTON: There's two levels, as you say. And I guess we would also be very careful about using articles in the press or on Google or anywhere else for your own marketing. You really have to describe the process and what it is and what the benefits of that process are. And again, interestingly, just into my head, this is one place where case studies might not be—might be a double-edged sword—in terms of marketing. Because, you know, if you say, "Oh, I did this for person X," well, person Y might not be the same. So it's you use case studies with care, I would say. You know, by definition, to make them relevant, you almost have to breach the patient's confidentiality, don't you?

CHRISTOPHER CLOKE BROWNE: Yes. And therefore you need to be very careful about how you get permission from people to use case studies. You know, because if you want it granular enough to make it relevant, that's a re-rehearsal of their notes. And their notes in functional medicine are, you know, their family's sort of medical history in minute detail—up to the grandparents or something. It's incredible. I mean, the intake forms are 40 pages long with all sorts of very personal questions in them.

HOST: Have you seen any particular examples of practices or healthcare businesses that have done this well? That managed to balance the need to grow, the need to attract people, bring people into this world with just getting it right in terms of how they did it? Because what you mentioned there, in terms of sharing articles, that's been extremely prevalent in terms of people making the case for functional medicine generally. There's some advocates of functional medicine generally sharing things like that. But are there examples of the kind of approach that you would suggest for, say, a new business who wanted to do the right things, who wanted to stay on the right side in order to make sure that they were going to avoid any of the problems that people run into?

CHRISTOPHER CLOKE BROWNE: Yes. I think in my experience, it's really several levels. The marketing, as you describe it, are broad descriptions of categories of suffering, almost putting a sort of label on it. So, you know, "Do you have untreated Lyme disease?" And, you know, the key symptoms of Lyme disease are this. If you feel that you're getting nowhere, then please call us. Then you get into the details of their case. So it's striking that balance between being too specific and therefore almost wrong and therefore misrepresenting what it is you can do for that individual versus the broad swathe of people that you think you can help and you know are being poorly served elsewhere. That's probably the way to describe it. And you can go through, you know, what's low-dose naltrexone? What's Lyme disease? What are the symptoms? So it's almost, you know, "Are you lethargic? Are you this? Are you that? Do you feel that your current arrangements are not sorting out your long-term problems?" So you almost sort of bring them in through an acknowledgement that they've got a problem and they don't feel they're being well served. That's about as specific, I think, as you can get.

Because then you need to start detailing, screening people as Chris said. So you don't really want the Daily Mail reader who's looking for a cure when it doesn't exist. That doesn't mean you can't do something for them, but it's not what they think it is. So again, you've got to be honest with people.

The best doctor I know of that is an aesthetic client of ours who is absolutely brutally honest with people. You know, "You are not a basket of fruit and you're never going to be. But I can do this. Here are the risks. Here are the benefits."

HOST: So when it comes to content like testimonials and case studies in order to attract people, when it comes to content like that in terms of marketing, then the best way to stay on the right side would be to avoid claims being made in things like testimonials and case studies and instead focus maybe on the quality of the care, the quality of the clinic, the quality of the processes, and avoid anything around like, "Oh, I was cured of this," simply because of the personalized aspect of it.

ROGER HOUSTON: Yeah. Because no serious physician, no serious functional medicine doctor ever uses the word "cure." And yet it's tabloid fodder. Everyone is seeking a cure. This idea of perfection—it doesn't exist. So you will never hear a medical professional use the word "cure," and that's no coincidence.

HOST: Is there any way that a functional medicine practice can stay on the right side of this and suggest the results that they've got from a particular client? Is there any way of doing that?

CHRISTOPHER CLOKE BROWNE: Providing it's suitably contextualized and qualified. I mean, the other thing in terms of medicine, in terms of ethical duty, is by definition you're appealing to a cohort of people who are compromised in some way. So the emotional balance is not equal, and that's where the whole misrepresentation thing comes in. Now, advertising standards deal with that in some way. Medical ethics deal with it in another. But the root cause is the same.

ROGER HOUSTON: Yeah. And that was interesting because again, at the IPM that we were at recently, there was a lot of talk and there was a lovely 82, 83-year-old lady who came zooming around to us to tell us all about how she had her dementia reverse through diet, exercise, and lifestyle. And you know, she thought that was a small miracle, which in some ways it is.

CHRISTOPHER CLOKE BROWNE: Well, for her it was, yes.

ROGER HOUSTON: And so the reality is that there is a doctor in the States who's created a protocol and there's actually thousands of people to whom that's happened. So that's great news and great news for promoting it. But the issue is you don't want to say to anybody, "We'll cure your dementia with diet, exercise, and lifestyle" because there are numerous factors which mean that that might not happen. So it's all about presenting, you know? You need to present it as "These are the results that we're getting," but not everybody gets those results.

HOST: Yeah. I mean, it's not a cult. That's the other thing.

CHRISTOPHER CLOKE BROWNE: You're speaking to the man behind cults, yeah. Have you not read his book? Have you not read his book, How to Start a Cult?

CHRISTOPHER CLOKE BROWNE: Yeah. Yeah. So this is, yeah, this is specifically not that. Sorry to say that, but it's not.

In the sense that if you define a cult as a following that's irrational, and I'm not suggesting you are for a moment, you can have a medical following based on a whole load of successful outcomes from a variety of people, providing you—you know—you deal with that. Because you're selling, if you like—you're not selling faith. Are you? You're selling buying into a medical process that has some—increasingly some very sophisticated biochemical rigor behind it.

ROGER HOUSTON: Yeah. That is a thing, and I do think increasingly that is the way to sell it. Is, I mean, what utterly blows my mind in all of this is the detailed scientific knowledge. And I'm going to say "scientific" to differentiate it from "medical" because all of these practitioners have an incredible knowledge of the biochemistry circuits and pathways and how those work and how those interact. And in fact, I have been talking to a number of practitioners to really understand what that level of knowledge is, and it is much higher than I always anticipated. I mean, it's, you know, well, this might be for a different podcast actually. There's a big difference emerging between clinical—which would be medical practice—and a sort of scientific biochemistry. And actually, nutritionists versus dietitians is to me the absolute leading edge.

So a dietitian is actually an HCPC-registered individual. So they do have the capacity to diagnose, basically, nutrition-related disease. So obesity, even cancer, diabetes—all those sort of metabolic diseases. So if you're a dietitian, you're HCPC-registered and you can make those diagnoses. If you're a nutritionist, you are not registered with a recognized regulatory body. Most nutritional therapists are members of BENT, the British Association of Nutritional Therapists, but that isn't a recognized medical body. So "dietitian" is a protected title. It means that you have to be qualified and registered and so on to use it. "Nutritionist" isn't. But the nutritionists do a lot more biochemistry.

And interestingly, when I looked at all our sort of leading clients and practices, all of their ancillary staff—bar one—who did that kind of stuff were nutritionists. And the one dietitian who did it called himself a therapeutic nutritionist and was a member of BENT. So there seems to be a sort of science-clinical divide developing, and the clinical end is—and I think this is what functional medicine is trying to get away from—and I've heard in conferences, the clinical approach is: you have a list of symptoms—which, you know, "pasty face," "diluted pupils," "fat around the middle," you know, whatever—a whole list of them. And you know, if you get more than 65 percent of the symptoms ticked off, then that's the diagnosis. So it's very much a sort of pattern-matching thing, you know, just look at the person. Whereas the whole approach of functional medicine is this root-cause medicine. They test and they test and they test, and they're looking at all the bloods and the biomarkers and you know, all sorts of other tests. They test saliva. They test stools. They test urine. There are more and more and more tests, which gets back to that expense thing. But you know, they would argue, "We're not guessing just by looking at somebody and poking them. We're actually looking at what's happening in these processes. We understand how they affect the body."

Yeah, and that's the tragedy of it. When I get to speak to them, I mean, that's a really good story that they ought to be telling. And costing. And not be ashamed of it. I mean, that's the other thing. NHS doctors are always ashamed to talk about money.

Well, they're in business now. That's the other point.

And but by the time they get to me, they've had a series of emails and rude phone calls and people want to check in the post, you know. And they could have avoided all that by having some sensible conversation and notation in the notes. So it's a shame.

I'm sure we'll get there, and hopefully podcasts like this. Because again, to come back to an old adage: your problem avoided is far better than one overcome. And they start from this, you know, they have the moral high ground, the ethical high ground, and the trust. And it seeps away because they don't explain things to people. And they're not unintelligent, you know, they're not arrogant people. It's not like, "Oh, you know, pat on head, doctor knows best." It's not that. They're absolutely not that way. But they end up with a whole world of trouble, which could have been resolved from a 15-minute conversation.

ROGER HOUSTON: So to me, it's almost like a checklist with our people to say, "This is—we're not telling you how to suck eggs, but please cover off these things. Don't forget the costs. You almost need a schedule running by the side of the treatment plan. You know, if you've got the treatment plan on the left-hand column and what you're going to do, you want the right-hand column to deal with cost.

So really, it's more of trying to overcome the cultural element around having a discussion around money.

CHRISTOPHER CLOKE BROWNE: And actually, so many of the challenges that you see, the issues that come across your desk, could simply be avoided by...

ROGER HOUSTON: Yeah. So, in fact, if a judge talks about competing parties, he puts one side's case on one column and the other side's case and looks at them. That's called a Scott schedule, named after the judge that first introduced it or dealt with it. So I think we need the electricity schedule for treatment and cost.

CHRISTOPHER CLOKE BROWNE: Yeah. I mean, the good news of that is that's a relatively simple presentation. It's not like they don't know it. It's how they present it which makes it all the more tragic when they don't, and it goes horribly wrong on them and they're giving money back. I mean, some of our people in their initial stages work for nothing because they're giving it all back in refunds.

ROGER HOUSTON: They're giving back in refunds or they're doing the follow-ups for free. Yeah. Yeah. So it's really—it's funny, isn't it? It sounds like a lot of money, and this is maybe one for the whole podcast on the whole nature of the business. But, you know, it sounds like a lot of money, but what's actually going in is fast. So really, when you work it out, it literally ends up with the practitioners in their early stages effectively working for free. I mean, they might take a little bit, but they're effectively working for free.

HOST: And that's very NHS-like, isn't it?

ROGER HOUSTON: Yes. I'm working for free at the point of delivery, but I'm not getting a salary. Wonderful. Yeah. And so, so that's a big thing. And a big thing in managing the business is keeping your patients happy whilst not working for free. And in fact, sort of go full circle—I think what we see is they are, you know, we have four or five clients who are very successful practices. You know, they have at least 10 different staff. You know, they have growing revenues. You know, everybody's paid. The owners are doing—you know, I wouldn't say they're going to be the next billionaire—but you know, they're making a living out of it and growing it nicely. But I think their approach is very much focusing on starting again: functional medicine is root-cause medicine, and you need to communicate root-cause practice. That is being a proponent of the process rather than why the process is so much better rather than specific results as some kind of miracle.

HOST: Sorry, Roger. No, no. I agree. Absolutely. Yeah, yeah. Okay, so I think that's a really good place to finish up the discussion. I'm sure there's more we can discuss around this as this progresses as well. So thank you very much, and I will see you on the next podcast.

CHRISTOPHER CLOKE BROWNE & ROGER HOUSTON: Thanks. Cheers.