When I started my consulting business, I imagined that I would be working with larger firms as part of a team, with in-house web and marketing resources, applying my SEO/SEM skills to a given situation for others to carry out.
While it does work that way with larger accounts, I am frequently called to apply technical changes for small companies that have little or no marketing and/or the technical expertise. (It is unlikely they employ anyone who knows what an <H1> tag is, or how to configure an .htaccess file.)
The long and short of this is that my focus is SEO and SEM services, working directly on your website or through your team to implement changes. I provide additional services through relationships with local designers, programmers, and copywriters. Some of these folks I know from my days as an in-house marketer, others I have come to know and respect through client projects.