OPEN SOURCE SOFTWARE AND THE NHS: WHITE PAPER
Principal Consultant, NHS Information Authority
Open Source Software (OSS) is software whose source code is openly published,
is usually available at no charge, and which is often developed by voluntary
efforts. It has come to prominence by starting to take a significant market
share in some specific parts of the software infrastructure market where OSS
products have demonstrated better quality and reliability than commercial equivalents
at a lower cost. OSS offers the NHS a proven alternative to commercial software
in the Server domain and merits consideration for use on the Desktop .
The availability of open source healthcare applications would provide healthy
competition to the existing closed source commercial market, encouraging innovation
whilst promoting compatibility and interoperation. This ultimately will lead
to systems that are lower cost, better quality and more responsive to changing
clinical and organisational requirements. A number of significant clinical applications
are already available, or are under development by healthcare organisations
across the world.
The UK government has recently published a draft policy on OSS. This proposes
that all UK Government departments (taken in this context to include the NHS)
should consider OSS solutions alongside proprietary ones in IT procurements,
and also should obtain full rights to bespoke software code and all customisations
of COTS (Commercial Off The Shelf) packages that they procure. Comments on this
have been invited and there is an urgent need for a response by the NHSIA.
There are a number of barriers to the more widespread use of OSS, and initiatives
discussed in this paper that the NHSIA could undertake to remove these are:
- Promoting awareness of the potential of OSS among NHS users and healthcare
- Developing and publishing a specific NHS policy on OSS, based upon
the government proposals.
- Provision of guidance on the licensing of software developed and procured
by NHS Trusts and Health Authorities and information generally about open
source in healthcare - applications, projects, licensing issues etc.
- Encourage the development of an OSS market in Healthcare systems by evaluating
applications and identifying companies willing to support OSS products.
Taking part in or supporting open source healthcare developments in order
to improve the availability of high quality, cost effective healthcare systems.
The potential benefits to the NHS from OSS are considerable and limited actions
by the NHSIA along these lines could have a significant impact on the implementation
of the NHS Strategy and the achievement of the objectives of Information
A full and readable explanation of open source, and a discussion of all of
the issues that surround it, can be found in the report by the EU ISTAG working
group on open source software  and in a more recent
consultancy report commissioned by the UK Government .
A brief overview is provided here for completeness.
Open Source is the generic term for software that is distributed in its source
code form with a licence that allows the recipient to use and modify this code.
The concept of source code distribution is not new, but in the last few years,
fuelled by the Internet, a whole “open source” movement has grown up. Major
components of the Internet (notably Domain Name Server software) have been developed
by software engineers collaborating over the Internet, with source code written,
tested and debugged in a completely open manner. The LINUX operating system
has been developed in the same way.
There are a variety of types of published open source licences 
- no license at all, allowing software to be incorporated into commercially
- licenses like the BSD License that place relatively few constraints on what
a developer may do (including creating proprietary versions of open source
- the GNU General Public License (GPL) and variants which attempt to constrain
developers from "hoarding" code, i.e., making changes to open-source
products and then not contributing those changes back to the developer community,
but rather attempting to keep them proprietary for commercial purposes or
- the Artistic License, which modifies various of the more controversial
aspects of the GPL;
- the Mozilla Public License (MozPL) and variants (including the Netscape
Public License or NPL) which go further than the BSD and similar licenses
in discouraging "software hoarding" but which still allow developers
to create proprietary add-ons if they wish.
The intent of these various forms of licenses is to ensure that the code remains
open for all to use, validate, modify, and improve. The Open Source Organisation
 now provides a definition of the characteristics
of a licence that can be termed Open Source. The distribution terms of open-source
software must comply with the following criteria:
- Free Redistribution: The license shall not restrict any party from
selling or giving away the software as a component of an aggregate software
distribution containing programs from several different sources. The license
shall not require a royalty or other fee for such sale.
- Source Code: The program must include source code, and must allow
distribution in source code as well as compiled form. Where some form of a
product is not distributed with source code, there must be a well-publicized
means of obtaining the source code for no more than a reasonable reproduction
cost–preferably, downloading via the Internet without charge. The source code
must be the preferred form in which a programmer would modify the program.
Deliberately obfuscated source code is not allowed. Intermediate forms such
as the output of a preprocessor or translator are not allowed.
- Derived Works: The license must allow modifications and derived works,
and must allow them to be distributed under the same terms as the license
of the original software.
- Integrity of The Author's Source Code: The license may restrict source-code
from being distributed in modified form only if the license allows
the distribution of "patch files" with the source code for the purpose
of modifying the program at build time. The license must explicitly permit
distribution of software built from modified source code. The license may
require derived works to carry a different name or version number from the
- No Discrimination against Persons or Groups: The license must not
discriminate against any person or group of persons.
- No Discrimination against Fields of Endeavor: The license must not
restrict anyone from making use of the program in a specific field of endeavor.
For example, it may not restrict the program from being used in a business,
or from being used for genetic research.
- Distribution of License: The rights attached to the program must
apply to all to whom the program is redistributed without the need for execution
of an additional license by those parties.
- License Must Not Be Specific to a Product: The rights attached to
the program must not depend on the program's being part of a particular software
distribution. If the program is extracted from that distribution and used
or distributed within the terms of the program's license, all parties to whom
the program is redistributed should have the same rights as those that are
granted in conjunction with the original software distribution.
- The License Must Not Restrict Other Software: The license must not
place restrictions on other software that is distributed along with the licensed
software. For example, the license must not insist that all other programs
distributed on the same medium must be open-source software.
1.2 Benefits of OSS
Open source proponents vary in their motivations and in the benefits that they
believe come from OSS development. Some claim that developing software in an
entirely open manner, enables the most brilliant software developers across
the world to collaborate and thus out perform even the biggest commercial developers
such as Microsoft. Some even go so far as to suggest that open source development
is the only way to develop the most complex software systems .
Recent benchmark tests have found favourable comparison between LINUX and Windows
Others argue from an ethical viewpoint, claiming that access to information
is in some way a fundamental right, and should not be obstructed by commercial
interests. The ethical argument is particularly relevant in healthcare, where
the use of closed application systems that hold clinical knowledge and practice,
contrasts with the general ethos of freedom of sharing of knowledge that exists
in all other areas of healthcare. Midgley  claims
also that the NHS (and in particular the GP sector) is not currently well served
by commercial software owned and developed by companies, as these often have
a short lifetime, frequently going out of business, leaving their users of their
products unsupported. He believes that if NHS systems were comprised of peer
reviewed, open source code, this would lead to better, more fit for purpose
software, able to develop over years or decades to meet evolving clinical practice,
without the sudden discontinuities, brought about by company take-overs and
changes in policy.
A discussion of the specific benefits that might accrue to the NHS from use
of OSS follows in section 6.
As software developers cannot use software license fees with open-source software,
other ways of generating revenues and profits must be found, based on services
to the customer. There are several ways to do this, for example (courtesy of
OpenSource.Org and ):
- "Support Sellers," in which revenue comes from media distribution,
branding, training, consulting, custom development, and post-sales support
instead of traditional software licensing fees.
- "Loss Leader," where a no-charge open-source product is used as
a loss leader for traditional commercial software.
- "Widget Frosting," for companies that are in business primarily
to sell hardware but which use the open-source model for enabling software
such as driver and interface code.
- "Accessorizing," for companies which distribute books, computer
hardware and other physical items associated with and supportive of open-source
software services in exchange for franchise fees of some sort.
Although frowned upon by OSS purists, it is also possible to combine OSS licences
with traditional software licences:
- use of different licences for the same product, depending upon the user
(e.g. for-profit organizations vs. not-for-profit organizations vs. individuals)
and/or the use (e.g. intranet vs. extranet use, use on one platform vs. another,
and so on);
- alternately, a company might license source widely to any and all users,
and even allow "evaluation" licensing at no charge, but still charge
"right-to-modify" license fees and restrict re-distribution of modified
versions in some way.
Not withstanding these possible business models, it is not yet clear that open
source will provide a viable alternative to commercial software in all areas
of software. The most successful open source projects to date have been in the
area of software infrastructure where there is a very large (global) user base:
Internet utilities, operating systems etc. The Internet has enabled a very large
pool of resources to be tapped to contribute to some common objective, normally
to provide a better product than commercial alternatives) or one that can be
freely modified to meet local or regional requirements. Some established major
manufacturers of general-purpose applications: e.g. Netscape, Sun, IBM, Microsoft,
are beginning to recognise that there may be commercial advantage in adopting
it as the means of distribution of some of their own products. The QINETIQ report
 predicts that within five years, OSS could take
50% of the volume of the software infrastructure market, and that in the developing
world, OSS on the desktop may soon become a significant competitor to Microsoft.
However, the motivation for open sourcing domain specific applications
software that has a smaller market is less clear. This is discussed
further in section 5 in the context of NHS applications.
It is clear that EU governments in particular are beginning to look favourably
on OSS as it is seen as a possible counterbalance to the dominance of (US based)
Microsoft products in the EU Information Technology infrastructure. A number
of European Governments  are currently considering
legislation that would make all software developed as part of a public sector
procurement, available under an open source licence.
The UK government has recently responded by publishing a draft policy on OSS
by the Office of the e-Envoy (OeE) and Office of Government Commerce (OGC).
The key proposals are:
- UK Government will consider OSS solutions alongside proprietary ones in
IT procurements. Contracts will be awarded on a value for money basis.
- UK Government will only use products for interoperability that support open
standards and specifications in all future IT developments.
- UK Government will seek to avoid lock-in to proprietary IT products and
- UK Government will obtain full rights to bespoke software code that it procures
and all customisations of COTS (Commercial Off The Shelf) packages that it
uses wherever this achieves value for money.
- UK Government will explore further the possibilities of using OSS as the
default exploitation route for Government funded R&D software by academic
In this context UK Government is taken to include, central government
departments and their agencies, local government, the devolved administrations
as voluntary partners, and the wider public sector, e.g. non-departmental public
bodies (NDPBs) and the National Health Service.
As note above, the concept of Open source finds particular resonance among
the healthcare IT community. There are a number of active OSS developers from
across the world  who participate in OSS healthcare
developments, and there are an increasing number of available applications.
The EU sponsored SPIRIT project  disseminates best
practice in OSS and news about OSS projects.
In the USA the Freedom of Information Act (FOIA) is being used to force the
release of the source of software which has been developed with public funding.
Notably a very large and comprehensive patient based Hospital Information System
– the Department of Veteran’s Affairs VISTA system is now being made freely
available  under this Act.
Object Technology encompasses a set of related software engineering techniques
which can be applied at all stages of Information System (IS) development, from
requirements analysis to coding . While benefits
of Object Technology are realised within a single programme or system, its real
power is realised when it is combined with network technologies to enable the
creation of object based distributed systems. A natural extension
of objects that are specific to particular system and to one supplier, are objects
that are general enough to be used on different platforms, across networks and
by different applications. Such objects are called components.
By providing software developers the same level of interoperability as is available
to, for example, manufacturers of electronic circuit boards, component technology
is radically altering the way software is developed. Major software suppliers
such as Microsoft, SAP, IBM, Netscape and COREL, make extensive use of component
technology within their own developments, and in many cases publish interfaces
for use by third party developers.
The wide availability of software components within the healthcare sector would
reduce the effort required to build reliable, large and complex healthcare systems,
thus lowering the entry level for new suppliers into the market.
By their nature, components provide openly defined and available standard interfaces.
Components embody a set of underlying data structures and knowledge concepts,
and could thus also provide a mechanism for the direct implementation of EHR
standards. Paper specifications have to be interpreted by system developers,
and the complexity and inherent ambiguity in many standards together with the
fact that few of them use formal definition languages, frequently leads to problems
of incompatibility between systems which claim conformance to the same standard.
Use of software components built around EHR standards would ensure interoperability
as well as reducing development effort.
Within the NHS the concept of source code distribution of healthcare applications
is not new. During the 1970’s and 80’s most NHS systems were developed and maintained
by in-house staff at a number of Regional Centres. It was common practice for
applications to be exchanged between these Regions and modified for local use.
This was a time of rapid innovation in the early application of IT in the NHS.
The beginnings of a collaboration between several Regions to develop a comprehensive
patient based hospital system was halted by the outsourcing of all of these
development centres in the late 1980’s. Many of these applications sold at the
time to commercial companies, often at very low cost, remain in operation today.
The NHS FHS Computer system is the one remaining major national system the source
code of which is owned by the NHS. However, there still exist a significant
number of applications in NHS hospitals, the source code of which is still owned
by the Trust. Some of these have been developed by NHS Trusts staff for local
use, others have been acquired under software escrow contracts, when
the supplier has gone out of business without making alternative commercial
maintenance arrangements. All of these systems could be made available under
open source licences, allowing the possibility of low cost systems, providing
healthy competition to commercial companies.
In the last 10 –15 years the NHS has moved to the current situation in which
systems are almost exclusively purchased from commercial suppliers. This gives
rise to a number of problems:
- In secondary care, the market for systems is increasingly dominated
by a small number of US based companies. These systems originate in a high
cost, privatised healthcare system and are expensive to buy and maintain.
Because the UK represents a relatively small part of their market, global
suppliers are unresponsive to request for local variations, and/or provide
them at very high cost.
- In other sectors there are a large number of suppliers, mostly of UK origin.
Many of these are quite small, some offering systems of unproven quality.
The Requirements for Accreditation (RFA) is slowly improving this situation
in respect of GP system, but this applies only to newly procured systems,
leaving a legacy of systems that do not comply with the latest standards.
Company failures and take-overs can lead to forced changes of system and/or
suppliers, with consequent user dissatisfaction .
- Getting the degree of universal standards conformance necessary to implement
National policy for information sharing and interoperability, solely through
the enforcement of standards in the procurement process (RFA and STEP), has
proved to be ineffective. Evidence for this is the length of time it has taken
for the NHS to implement the relatively technically simple task of electronic
pathology test reporting, first set as an objective in the early 1990's.
One of the main objectives set out in Information for
Health, is to develop and implement person-based Electronic Health Records
(EHRs), providing the basis of lifelong core clinical information .
Currently Electronic Patient Records (EPRs) from which the EHR will be created
are stored in differing formats on computer systems from many different suppliers,
and information cannot easily be transferred between them. The code running
these systems is in most cases proprietary, as is the format of each of a patient’s
clinical records. The EHR cannot be implemented until these systems are able
to exchange clinical information safely and securely. The issue of standards
is thus central to the Strategy, but it is difficult to see how the complex
sharing of EPRs between heterogeneous systems, necessary for effective shared
care, can be achieved by the current sole reliance on commercial suppliers to
implement defined standard interfaces.
Key to the success of the Strategy is the availability of
specifications for the format, content and exchange protocols for healthcare
information in the NHS. Currently we are in a time of rapid development of healthcare
record standards and of considerable debate within the main healthcare Standards
Development Organisations (SDOs): HL7, CORBAMed, CEN TC251 and ISO TC215 [3,4,5,7].
Many of the standards under development have adopted and taken forward the products
of the Information Authority's Health Care Modelling Programme. However, the
time scale for the necessary international consensus on these standards to emerge
is not yet clear, and even when published, such standards are necessarily of
a generic nature, and specific versions will need to be produced for use in
EPR system suppliers will not invest in the necessary software development
resources until stable, mature specifications are available. Even then, as noted
above the current process whereby national standards are enforced in the procurement
of new systems via the mechanisms of STEP and RFA, takes a long time to produce
results, and does not effect the bulk of legacy systems. It is difficult not
to conclude that a radically different approach to achieving standards conformance
is needed in order to meet the time scales for the implementation of the EHR
as set out in Information for Health.
Among the potential benefits of open source code for the NHS are:
- Quality security and reliability. Open source software developments
involve large number of people who collaborate closely. Frequent and close
peer review of code results in software that is better engineered, more secure
and with fewer ""bugs" than commercial products. Adoption of
the Linux operating system by IBM is evidence that even highly complex open
source software can be made reliable through the open source approach. The
Open Source Apache web server remains the most popular web server on the market,
and suffers from fewer bugs and security breaches than its main commercial
rival. There is as yet no evidence that open source applications are
more reliable than commercial products, but the free availability of the source
code will offer the possibility of immediate local fixes to problems identified.
- Interoperability. As noted above, the failure of commercial suppliers
to offer effective means of exchanging information with systems from other
suppliers is a fundamental inhibitor of progress towards the objectives of
the NHS Information strategy. By its nature, the Open Source approach promotes
interoperability, because the availability of open source code, instantiating
NHS standards, will facilitate the implementation of these standards in systems.
Applications that are themselves open source will quickly be enabled with
the necessary interfaces, commercial suppliers will be forced to respond.
- More responsive systems System enhancements are frequently required
at short notice to meet changing local or national requirements. The failure
of their application suppliers to keep pace with new data requirements is
frequently cited by Trusts as a cause of poor data quality. The availability
of source code frees users from dependence upon one supplier for enhancements.
The user is free to buy support, maintenance and development from different
companies, or even use in-house resources. Thus users of OSS systems are likely
to be able to move quickly and economically to meet evolving data and interoperability
- Encouragement of innovation Computer systems that cannot be economically
evolved to meet changing healthcare patterns is a frequent complaint. The
free interchange of the source code of healthcare information systems will
encourage innovation – new concepts from wherever these originate – suppliers,
users, Universities etc. will become more rapidly incorporated into operational
- Economic. Commercial license costs, although only one element of
the Total Cost of software ownership, are nevertheless considerable. There
is the potential for Open Source software to offer economic benefits to the
NHS. Use of licence-free LINUX rather than NT, as the basis for application
and Intranet servers could bring immediate savings for NHS Trusts. LINUX rather
than Windows on the desk-top is a more difficult change, but one where determined
Trusts might find considerable economic benefit.
In summary, Open source healthcare applications would provide
healthy competition to the existing closed source commercial market, encouraging
innovation whilst promoting compatibility and interoperation. This ultimately
will lead to systems that are lower cost, better quality and more responsive
to changing clinical and organisational requirements.
Open source healthcare applications could be made available to the NHS in a
number of ways:
- Existing “NHS owned” source could be subject to an open source
licence. Examples are:
- Locally developed systems - these are normally small departmental system,
but some large teaching hospitals own and operate comprehensive hospital
- Software acquired by a Trust due to a contractual arrangement – either
as part of a development contract, or as a result of an escrow arrangement.
At least one comprehensive PAS acquired in this way is owned and maintained
by a Trust.
- The code of the national FHS and other NHSIA software could readily be
Lack of awareness of the benefits of OSS and understanding of OSS licensing
issues currently inhibits such initiatives
New development contracts, both centrally and locally funded,
could specify that the source code is subject to an open source licence. As
noted in the introduction, the proposed UK government policy on OSS would
make this a requirement of all NHS procurements. Again however, lack of OSS
awareness and information on licences mean that few software contracts are
let in this manner.
Open source software from outside of the NHS. The USA VISTA
system noted above provides an example of a complete open source hospital
system, already used in a number of other countries. A number of other development
projects  could result in systems of potential
use in the NHS. A number of open source implementations of standards based
healthcare components  are available and more
are under development.
Mots NHS organisations do not have enough IT expertise among their own staff
to implement information systems. The widespread use of open source software
depends therefore on the emergence of companies prepared to build their business
on providing installation, training, on-going maintenance and other support.
As noted in a recent report by the NCC , commissioned
by the DTI, the open source movement is relatively new and unfamiliar to IT
professionals so that there are a number of barriers to its wider use. However
while it is difficult to assess precisely its impact on the NHS, the potential
benefits are considerable. A limited initiative by the NHSIA at this stage,
to overcome some of these barriers in the NHS, could have a significant impact
on the implementation of the NHS Strategy and the achievement of the objectives
of Information for Health. There are possible actions by the NHSIA in
a number of areas:
Policy. As noted above, the Cabinet Office, e-envoy 
has proposed a UK Government policy on OSS. Responses to this proposal are required
by the end of February 2002. In this context UK Government is
taken to include the National Health Service. There is an urgent
need for an NHS response to this proposal.
A specific NHS policy on OSS, based upon the government proposals,
should be developed and conveyed to NHS Trusts together with specific guidance
on the procurements and use of open OSS.
Promoting awareness. A campaign should be conducted aimed at increasing
awareness among NHS IT users and suppliers of the potential benefits of OSS.
Licensing. An assessment should be made of the applicability of various
Open Source licenses to NHS Trusts and Health Authorities. Guidance will be
issued on the licensing of software developed and procured by NHS Trusts and
Information. The NHSIA should provide a source of expert advice on open
source in healthcare - applications, projects, licensing issues etc.
Market stimulation. Measures should be taken to encourage the development
of an OSS market in Healthcare systems. The NHSIA should identify open source
healthcare applications originating both from within and from outside of the
NHS and evaluate these for possible NHS use. Where such applications are of
an adequate standard, but support is not readily available, the NHSIA should
identify companies willing to provide such support.
Open Source development. Fostering the development of standards based
healthcare OSS components is likely to be a cost effective way of encouraging
compliance with NHS standards and interoperability between heterogeneous IT
systems, necessary for the achievement of many of the objectives of the NHS
strategy. OSS component development by the NHSIA does offer the possibility
of influencing suppliers in a more direct way than through specifying standards
in procurement. By developing high quality open source software components that
embody NHS EHR standards, and supplying them free to software developers, the
NHSIA would facilitate the rapid implementation of these standards in systems
developed for the NHS. The NHSIA is not prevented from developing open source
code, as this does not compete with commercial software. Software development
is not currently considered to be a necessary, or even a legitimate role for
the NHSIA, but the need to maintain the legacy FHS computer system has provided
us with a body of skilled software developers. OSS, standards based, component
development would enable the NHSIA to make best use of these skills By taking
part in or supporting other open source healthcare initiatives, the NHSIA would
also contribute to the general availability of high quality, cost effective