Richard Smith: Time to scrap offices (and reduce face-to-face consultations) to reduce carbon consumption

I’m pleased to see from Twitter that most people agree with my recent assertion that most meetings could be held virtually rather than face-to-face, saving tonnes of carbon (and time). The responses have led me to think that we mostly don’t need offices either, again saving the tonnes of carbon consumed in the frustrating, wasted time of commuting, and in heating and lighting offices.

My first encounter with a virtual company was 20 years ago when I met a man from San Francisco who ran one. His employees were scattered around California, and he told me how he had hired and fired people he had never met face-to-face. But the story that sticks in my mind was his story of how he and his deputy who lived in Sacramento would meet face-to-face once a month. I hear face-to-face enthusiasts say, “Ah, I knew it.” But the story is remarkable because they cancelled the monthly face-to-face meetings—because they tended to save up problems to discuss rather than getting on and fixing them.

My main experience of a virtual company is being the chair of Patients Know Best, a company that sucks together patients records from general practice, hospitals, mental health, and social care and puts them under the control of the patients. We have contracts with NHS bodies that look after millions of patients.

All sensible companies start as virtual companies. Why would you pay for offices when you have only a handful of employees and your main worry is cash flow? But there is a tradition that as you grow you get an office—rather as a newly independent country creates a national airline, essentially an assertion of arrival. But Patients Knows Best now has about 70 employees and we are still virtual. We probably always will be.

The first advantage of being virtual is not financial, but your capacity to employ the most talented people. Many of our employees are software developers, people who when good are in great demand. We can employ the very best people because we can hire from anywhere—and we have people from many countries. Plus many people like to work from home, avoiding having to dress up and commute. It also means that you can live in a beautiful place (so long as you have high speed broadband, government please note). Working from home makes work-life balance much easier. We don’t care if you do your work in the middle of the night (as suits some people anyway) because you have been helping in your children’s school.

Being virtual also means that we can employ staff who sell and support customers where our customers are. This limits the distance staff travel (and so the carbon they consume) but also means that we can employ people with local knowledge and contacts. Some of our best contracts have come because of salespeople who knew well the local NHS and its needs.

In order to run a virtual organisation successfully you need to plan. You need excellent technology and to give staff fast and efficient ways to communicate—and allow communication not just of information vital for the enterprise, but also the chatter that builds relationships and stimulates new ideas. Then you probably do need to bring staff together every so often. The staff of Patients Know Best meet every two months, and we have a wonderful day of learning that leaves plenty of time for chat and ends in the pub.

Doctors reading this will think “Well, that’s all very well, but you have to see and touch patients, which is why we need hospitals and surgeries.” Of course you do, but a considerable amount can be done virtually—or not at all. I’ve met a GP who 20 years ago managed to do 40% of his consultations by phone without seeing the patient. With arrival of the internet at the very least a fifth of consultations can be carried out virtually. 

The same goes for hospital outpatients, and if you trust your patients and have good communication then you can avoid many consultations altogether. Most patients have long-term conditions, and the nature of the condition is usually that they are well most of the time but have acute episodes. If you see all your patients every six months you spend most of your time seeing patients who are relatively well. This may make life less stressful and ironically is lucrative for the hospital, which is paid for the number of outpatients not their complexity. But if you have good communications with your patients [provided, for example, by Patients Know Best: competing interest] you do not need to see those who are relatively well but can concentrate on those in the acute phase—or, better still, those about to enter an acute phase.

We need to think along these lines because one in 20 journeys on British roads is attributable to the NHS—employees driving to work, patients driving to consultations, ambulances collecting patients, and lorries and vans making deliveries. The carbon load is huge.

There is one group for whom working from home does not work well—young people. The problem is not only that they often live in cramped accommodation that doesn’t make home working comfortable but also work is one of the main places to make friends and find partners. But if you can work virtually you can live somewhere where accommodation is much cheaper than in big cities and use dating technology to find a partner, which does seem anyway to be the modern way—and broadens the field of candidates.

What can seem unthinkable to many of us now can not only allow us to reduce carbon consumption, which we must do urgently if we want to continue to flourish, but also find better ways to live. I’ve been working from home for 15 years now and simply couldn’t bear to dress up and go to an office.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is the unpaid chair of Patients Know Best but has equity in the company. He is also the chair of the UK Health Alliance on Climate Change.