I spent the better part of a decade buying MSK practices before I ever helped anyone sell one.

I founded a physiotherapy clinic group in my twenties, growing it from a single site to 36 locations. Acquisitions were a significant part of how we scaled. I would sit opposite an owner, run the numbers, and work out what I was prepared to pay, doing this more times than I can count. Aged 30, I went through my own exit to a private equity firm.

This experience and the lessons it taught me form the foundation of Verilo, the specialist brokerage firm I now run. Our team has advised on over 100 transactions representing more than £30 million in deal value. We work exclusively with health, medical and wellness business owners, sitting opposite buyers of every kind; from individual practitioners picking up their first clinic, to consolidators and private equity groups acquiring at scale.

I explain this because this article’s themes are not theoretical; they are based on practice, where we observe the same patterns and mistakes being made. The reality of what makes an MSK practice more or less valuable to a buyer is often different to its owners’ assumptions. And that value is rarely based on the things people spend money on in the months before going to market.

What a buyer is really paying for

When I was acquiring clinics, I was not looking for the nicest waiting room or the fanciest website. I was looking for something that would hold together once I had taken over. The right foundations: a loyal patient base, a team that was not built around a single person, and a local reputation that had taken years to build and could not be replicated overnight.

Those foundations pointed to something more important: a business that could run, retain patients, and generate revenue regardless of who was at the centre of it. Repeatable systems, consistent revenue, and a predictable diary. That kind of business takes years to build. When I found it, I found something genuinely worth paying for.

The mistake I kept seeing was sellers spending money on the wrong things. A new waiting room, a rebrand, a website refresh – all fine, but none of them moved the dial for me as a buyer. If a business was performing well despite a dated website or an unloved interior, I saw that as upside. Mine to capture, once I took over. Far more appealing than paying a premium for improvements the seller had already funded.

Not every buyer thinks like me, and investment is not always wasted. But the principle holds: cosmetics are easy to fix. The foundations of a business are not.

What walks out the door with you?

If I had to reduce everything about MSK practice saleability and valuation down to a single idea, it would be this: the more transferable a business is – and therefore the lower risk a buyer perceives – the higher its value and the more likely a sale. When you exit, how much of what you’ve built walks away with you? And how much stays?

The lease is a good place to start. Most buyers want security of tenure above all else – confidence that the practice can continue trading where it is. Long-term certainty reads as an asset; the absence of it creates risk. A short, rolling or unrenewed lease may feel like flexibility to a seller, but a buyer sees it differently: a problem to be priced in or resolved before exchange. If you are approaching a sale with less than three years remaining, exploring renewal or extension options is almost always worth doing, even if your own timeline is uncertain.

Brand identity follows a similar logic. A brand that patients associate with the practice rather than the person running it is transferable; one synonymous with the owner has an expiry date. Evolution should happen gradually and well in advance, creating time to establish patient associations a buyer can actually see and value.

A well-maintained, GDPR-compliant client database is also crucial. It is a transferable asset in its own right – one that gives a buyer the ability to market to existing patients, re-engage lapsed ones, and model value from day one.

Concentration risk: people and revenue

Ask MSK practice owners what their biggest asset is, and the answer is usually people. The clinicians who have built patient relationships over years, the owner whose reputation draws referrals, the contract that keeps a reliable income stream flowing. These are what make a practice valuable, but they are also what make concentration risk one of the most significant devaluers we encounter. A buyer has to price what happens if any walk away.

This concentration tends to show up in three ways: clinical team concentration, where patients follow one practitioner and leave with them; owner dependency, where the practice relies on the owner’s clinical output or reputation; and contract concentration, where a significant share of revenue ties to a single source. That last one is often the most overlooked. NHS contracts held in a rolling or holding-over position can be vulnerable to external factors, and a practice dependent on one such contract is a riskier proposition than one with a diversified private income base.

When the concentration sits with the owner, an earn-out is a partial solution. If you are willing to stay with the business through a defined transition – usually six months to two years – you can protect some of the value. The buyer is paying for continuity you are providing, and it is worth considering seriously if you are the primary clinical draw.

Where the concentration sits with an associate or employed clinician, the answer is harder. You cannot contractually guarantee a buyer your best physiotherapist will stay. The only real solution is taking time to build a team where no single departure would damage revenue.

How are you finding new patients?

For many owners, a full diary built entirely on word of mouth is a badge of honour – and, in one sense, rightly so. It speaks to clinical quality and the kind of patient trust that cannot be manufactured. But to a buyer, it raises a different question: if nothing is driving that growth deliberately, how confident can they be that it will continue?

What a buyer actually wants to know is your strategy for getting new patients consistently. Can you demonstrate someone else could do it after sale? If the answer is yes, you become considerably more attractive.

Well-documented marketing strategies, an updated Google profile, a referral partnership with a local GP, email automation for re-engaging lapsed patients, or proven paid advertising all tell a buyer growth is not accidental.

Practices that can show a strong word-of-mouth reputation and a good grasp of patient acquisition are genuinely rare, and therefore worth a premium.

The finances: what buyers actually look at

Every business is different, and value is often more art than science. It is ultimately determined by the market, by what a motivated buyer will pay. That said, we regularly see most experienced buyers follow a similar financial assessment process.

Most buyers use a multiple of adjusted EBITDA, or earnings before interest, tax, depreciation and amortisation. In plain terms, it is the underlying profit the business generates, stripped of financing and accounting decisions: what the business actually earns before the owner decides how to structure it.

Your EBITDA may be different from the profit figure on your tax return. Owners often pay themselves at non-market rates, and structure finances to minimise tax rather than demonstrate commercial value. Before a sale, these figures are normalised to reflect what a buyer would actually earn. What remains after those adjustments is your adjusted EBITDA – the number a buyer will base their offer on.

In the MSK sector, multiples typically run between three and five times EBITDA, though we have seen transactions exceed that range. What pushes a multiple higher is the combination of factors covered in this article. Buyers are essentially pricing risk. The less risk they perceive, the more they are prepared to pay. Clean, well-maintained financial records support that process – they make it straightforward for a buyer to assess the business, build confidence in the numbers, and move quickly.

Size matters

Not every practice will attract the same buyers, and turnover is one of the biggest factors in determining who comes to the table.

At around £100,000 or below, the market is limited. These businesses are typically owner-operated, harder to model financially, and appeal mainly to individual practitioners or local competitors after a bolt-on. Valuations are variable and the likelihood of completing is lower.

As turnover grows towards £250,000 to £500,000, the buyer pool widens: regional operators, multi-site acquirers, portfolio builders. Deals become more structured and valuations more predictable.

Above £500,000, things change substantially. Consolidators, smaller private equity groups and family offices enter the picture. Buyers are no longer constrained to your postcode, competition between them increases, and that competition is one of the most reliable mechanisms for improving what a seller receives.

Driving turnover is not just about building a bigger practice. It is about expanding the range of people who want to buy it.

The process matters as much as the preparation

There is a point in every sale where preparation stops being the main variable and process takes over. How a business is presented to the market, and how that process is structured and managed, shapes a significant part of the final outcome.

A well-run process creates competitive tension; with multiple credible buyers in conversation simultaneously and aware of each other, thinking tends to sharpen, conditions get clearer, and offers improve.

The data on this is compelling. Based on a study published in The Quarterly Journal of Finance, represented sellers achieve between 6 and 25% higher purchase prices than those who go to market alone. [1] Unrepresented sales are also 60 to 70% less likely to complete at all.

The reasons are fairly straightforward: fewer buyers in the room, higher emotion, avoidable problems surfacing too late, and the risk of getting too far down the road with the wrong buyer before realising it. If your primary deal falls through and there is no second or third option, you negotiate from a position of weakness. Time passes, momentum is lost, and the business often goes back to market at a discount.

Having someone who understands the sector and knows the buyer landscape is not a luxury reserved for large transactions. For most practice owners, it is one of the most significant levers available once the preparation work is done.

Build the better business first

Looking back across every transaction I have been part of – as buyer, seller, and now advisor – there is a clear pattern. The owners whose sales go well are almost always the ones who thought about transferability before it was urgent.

A settled team, clean records, a secure lease, a respected brand, predictable client acquisition… None of these things require a sale to be on the horizon. They are just what a well-run practice looks like.

Whether you plan to sell in two years or twenty, building something transferable is building something better. The exit is just one of the rewards, not the only one.

References

[1] Agrawal, A., Cooper, T., Lian, Q. and Wang, Q. (2023) ‘Does hiring M&A advisers matter for private sellers?’, The Quarterly Journal of Finance, 13(1). Available at: https://doi.org/10.1142/S2010139223500040

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