· 7 min read · Jason Youngjin Koh
Four steps from ad to chair
Four steps sit between the ad and the chair, each with its own drop-off and its own owner. Most disputes between a clinic and its agency are two people describing different steps and assuming they are describing the same one.
Between the ad and the chair there are four steps. An enquiry arrives. A consultation is booked. The consultation is attended. A case is accepted. Each step has its own drop-off, its own causes, and its own owner, and almost every argument between a clinic and its agency is really two people talking about different steps.
We buy the attention. That gets you to step one, and it materially influences step two. It cannot reach step four. Being specific about where our influence stops is not a disclaimer, it is the only way either of us can tell a bad campaign from a good campaign that ran into something else.
The chain, with owners attached
| Step | Who owns it | What moves it | What it looks like broken |
|---|---|---|---|
| Enquiry arrives | Us | Targeting, creative, offer, landing page, budget | Volume is fine but the enquiries are outside your catchment or asking about a different treatment |
| Consultation booked | Shared | Ours: who we attract and what the ad promised. Yours: how fast the call goes out | Enquiries arrive and nothing is in the diary a week later |
| Consultation attended | Yours | Confirmation, reminders, the gap between booking and date | The diary fills and the room is empty |
| Case accepted | Yours | The consultation itself | Full room, nothing proceeds |
Read that table as a diagnostic rather than a division of blame. If step one is healthy and step three is not, no amount of work in the ad account fixes it, and a campaign judged on the final number will look like it failed. If step one is unhealthy, nothing downstream matters and it is squarely ours.
Why cost per enquiry is nearly meaningless alone
Cost per enquiry is spend divided by a count of contacts. It reports instantly, it is the same shape of number in every business, and it is the only figure both parties can see without doing any work. That combination is why it dominates the conversation and why it is the wrong number to argue about.
It carries no information about who those contacts were. Halving cost per enquiry is trivial: broaden the targeting, weaken the offer, ask for less information, and the number improves while the business gets worse. We can produce that result on request and it will look like a win in every report for about six weeks.
The figure that means something is cost per accepted case, and it only exists if the four steps are joined up. Until they are, cost per enquiry is not a bad metric so much as the only metric, which is a different and more dangerous problem.
For high value treatment in particular, where this gets sharper: why the denominator decides the whole argument
What advertising can and cannot move
Advertising decides who arrives. That is a larger lever than it sounds, because who arrives sets the ceiling on everything after it, and it is also a hard limit, because it does not touch what happens once they have arrived.
We can change the treatment being asked about, the suburbs people come from, whether they are price led or practitioner led, whether they arrive expecting a consultation or expecting a quote, and how many of them there are. We do that with targeting, with the offer, and mostly with what the ad promises, because the promise in the ad is the expectation people walk in with.
What we cannot move is the consultation. Nobody outside your clinic can attend it, and no adjustment in an ad account survives contact with a room. This is the honest boundary and it goes in the engagement in writing: we can fill a consult diary, and we cannot make anyone say yes in the chair.
There is one exception worth naming, because it is the most common way we damage step four without touching it. An ad that overpromises produces a consultation with a person expecting something different from what is on offer, and that consultation was lost before it started. When acceptance falls after a creative change, the creative is the first place to look, not the last.
The arithmetic that makes people uncomfortable
Four steps multiply. That is the entire reason step level measurement is worth the trouble, and it is easiest to see with round numbers.
Take 100 enquiries. Suppose 55 book a consultation, 75 per cent of those attend, and 40 per cent of the attended proceed. The figures are constructed to show the shape of the argument and are not benchmarks. That chain leaves roughly 16 accepted cases, or about one in six of the enquiries you paid for.
1 in 6
Accepted cases per enquiry when 55 per cent book, 75 per cent of those attend and 40 per cent of those proceed. Illustrative working, not an industry benchmark.
Now move one step by ten points and hold the others. Lifting the booking rate from 55 to 65 per cent adds about three accepted cases from the same spend and the same ads. Lifting attendance from 75 to 85 per cent adds about two. Neither of those is an advertising change, and both are larger than most of the optimisation work that gets done in the ad account in a quarter.
That is not an argument for spending less on advertising. It is an argument for knowing which of the four numbers is the low one before anybody starts optimising, because a campaign and a booking process fail in a bank statement in exactly the same way.
What we need back from you
This is the request that gets ignored most often and it is the one that decides whether any of the above is real. The ad platform can see step one. It cannot see steps two, three or four, because those happen in your practice management software and in whatever record your treatment coordinator keeps.
The joining does not need software and it does not need clinical detail. It needs a reference, a date and a status.
- An identifier for the enquiry and the date it arrived. A row number is fine. We do not need names, and we would rather not have them.
- Whether a consultation was booked, and the date it was booked for.
- Whether it was attended. This is the single most valuable field on the list and the one most often left blank.
- Whether a case was accepted, and the value. If value is sensitive, a band is enough to work with.
- The source, as recorded at the enquiry rather than as remembered later.
Privacy is a real constraint here and not an excuse. You are handling health information, and the answer is to send us less rather than to send us nothing. An identifier and a status carries almost all of the analytical value and almost none of the risk.
What changes when the chain is joined
Three things, all of them arguments that stop happening.
The cost conversation gets a denominator, so a campaign is judged on what it produced rather than on what an enquiry cost. The blame conversation gets a location, so a drop is attributed to a step instead of to a party. And the optimisation conversation gets a target, so effort goes to the weakest number in the chain rather than to whichever number has a dashboard attached.
An agency that will not tell you which step it cannot reach is describing a service that does not exist.
None of this requires new systems. It requires agreeing which four numbers matter before the first ad runs, and agreeing who owns each one. That conversation takes an hour and it is the highest return hour in the engagement.