Prioritising health rather than hospital design

Sadly, but not unexpectedly, my 9500-word essay submitted to a competition concerned with hospital design failed to progress into the final stages of the competition. The question posed was: How would you design and plan new hospitals to radically improve patient experiences, clinical outcomes, staff wellbeing, and integration with wider health and social care? I gave an example, early on in the essay, showing how what is good for the hospital can conflict with what is good for the patient, and went on to explain how the Social Policy Bond concept could maximise what, in my view, we should be trying to achieve: improvements in health, rather than hospital design.The essay can be seen on my website here, and a pdf downloaded from here. A shorter treatment, also describing the application of the Social Policy Bond concept to health is here.

Social Policy Bonds and their variants

Partly to simplify the exposition of the bonds, I haven't delved into  variants of the basic Social Policy Bond principle. These variants include such possibilities as:

• bonds that expire; ie, if the targeted social or environental goal isn't achieved by a certain date, they become worthless;
• bonds that yield a partial payout if the goal is only partially achieved;
• redemption funds that are not placed in escrow, but guaranteed, either by public- or private-sector bodies; and
• payouts indexed to some measure of inflation.

There are many other possible variations on the basic theme: the Social Policy Bond concept is a versatile one and, because it is best deployed on large scale and for long-term social problems, it would be worth exploring the potential of variants on a case-by-case basis. 

On a related note, I have been asked what would happen to the funds intended to be paid out if the terms of a Social Policy Bond issue were not met. I would think that much would depend on who is undertaking to redeem the bonds. If it's a government body, or some supranational body (like the United Nations), I would imagine that any funds placed in escrow could be diverted to other uses within that body. More likely, though, such bodies, being credible, would merely guarantee payout, as in my third bullet point above. These bodies would want to minimise any perception that they will not pay out, partly to reduce their costs (ie, bolster the float value of the bonds) and partly to maintain faith that they will pay out in future bond issues. 

What about smaller bodies, such as a group of philanthropists, with less credibility? In such an instance the funds could remain in escrow, hopefully earning interest, until the goal is actually achieved and sustained. It's likely that these smaller bodies would target goals with a shorter overall time horizon. If, say the goal were the elimination of serious armed conflict: while a UN body, say, could target a sustained period of peace of, say 30 years, I could envisage that a group of philanthropists or non-governmental organisations would have a less ambitious target; perhaps peace in the Middle East sustained for a period of five years. Then, if a conflict were to erupt within that five-year period they need do nothing with the funds; they could patiently wait until a five-year period of peace arises. Or when issuing the bonds, they could have specified the time period during which the goal had to be achieved and, if the bonds fail to achieve the goal within that period, they could simply withdraw their funds from escrow.

For this and further queries see the bonds' FAQ page.

Social goals and the Karpman Drama Triangle

I've written about the crippling limitations imposed on Social Policy Bonds by making them non-tradeable here and here. And I'm sometimes asked why Social Policy Bonds haven't yet been issued, either by government or the private sector, whereas their non-tradable variant (most often known as Social Impact Bonds), are now issued in about 25 countries.

My thinking goes like this. Governments and non-governmental organisations including charities, do not want to relinquish their power to decide who shall supply the goal-achieving services (and so benefit from redeeming the bonds). Nor do they wish to lose complete oversight over how the targeted goals shall be achieved. Ultimately, in my view, it's about power and control, which to many of us are not key drivers, so we may find it difficult to understand their potency. This also, and more disappointingly, applies to philanthropists as well as politicians: it is gratifying to be seen to be granting funds directly to beneficiaries or to people who help those beneficiaries. It is not so appealing merely to contribute to a fund whose eventual beneficiaries cannot be identified. As well, Social Policy Bonds are best deployed when they aim to achieve long-term goals and on a large scale, where the beneficiaries are even less easy to identify and, indeed, might not yet be born.

Another explanation is that, at some level, governments, foundations and philanthropists might be playing the role of Rescuer in what is known as the "Karpman Drama Triangle", involving a Victim, Persecutor and Rescuer, as modelled in transactional analysis. Perhaps this paragraph, from here is pertinent in some cases:

The Rescuer: The rescuer's line is "Let me help you." A classic enabler, the Rescuer feels guilty if they don't go to the rescue. Yet their rescuing has negative effects: It keeps the Victim dependent and doesn't allow the Victim permission to fail and experience the consequences of their choices. The rewards derived from this rescue role are that the focus is taken off of the rescuer. When they focus their energy on someone else, it enables them to ignore their own anxiety and issues. This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.

I had hoped that SIBs would be stepping stone on the way to Social Policy Bonds. That is still possible, and new technologies are generating are encouraging more interest in my original concept. However, it is also possible that the lack of evidence (pdf) justifying the SIBs that have been issued could discredit the whole bond concept. We shall see. 

Make Xenophobia History: Introducing the Consortium of the Competent

A short, unpublished article, suggesting that people in failed states and badly-run countries be allowed to vote for, or otherwise install, politicians and ex-politicians from different countries who have a record of competence and integrity. It has nothing to do with Social Policy Bonds.

Bees, war, and root causes

From the current issue of the Economist: 

Detecting covid with bees, meanwhile, involves a method that goes back to ivan Pavlov and his dogs. The insects are offered sugar-water alongside SARS-CoV-2-infected saliva samples, but not with uninfected samples. The thus learn to extend their probosces when they sniff covid. The nose knows: Flies, worms and bees could help detect illness, the 'Economist', 31 July

What does this have to do with Social Policy Bonds? It's often suggested that in order to tackle such social and environmental problems as crime, violence, war or climate we need to identify the 'root causes' before we can devise ways of solving them. I disagree. I think our first step should be to clarify exactly what we want to achieve, and then reward the achievement. Let investors in the bonds decide whether it's worth looking for root causes or whether it's more efficient, and quicker, to find different ways of solving our problems. We could (and, effectively, do) delay, say, reducing conflict, by postulating some ideal world in which there is no poverty and everyone is nice to each other. The implicit assumption is that war is an intractable part of human nature, as the ancient Greeks thought. It's a convenient excuse, especially as the search for root causes - usually the task of people whose lifetime earnings are correlated with the time taken to find them - need never end. As Tolstoy put it:

The deeper we delve in search of these causes [of war] the more of them we discover, and each single cause or series of causes appears to us equally valid in itself, and equally false by its insignificance compared to the magnitude of the event.  Leo Tolstoy, 'War and Peace', Norton Critical Editions, New York, 1996 (page 536)

Just as we can train bees to detect covid without knowing about the mechanisms underlying how they do so; so we can target such goals as world peace, reduced crime, or the elimination of poverty without wasting time and energy on endless searches supposedly aimed at identifying their root causes.