NHSX has listed open source as one of its priorities. For Ewan Davis, there is a keen sense of déjà vu – and a desperate desire for the many lessons of the past to be heeded.

Open source seems to be back on the NHS agenda, courtesy of NHSX. The body lists one of its responsibilities as: “Making sure that all source code is open by default so that anyone who wants to write code for the NHS can see what we need.”

As a new organisation NHSX has no corporate memory and so I thought it might be helpful to share my observations on what happened last time the NHS got excited about open source.

It started when Tim Kelsey (peace be upon him) – then NHS England national director for patients and information – went on a trip to the USA. He saw the open source EHR VistA operating in the US Veterans Administration, decided it would be good for the NHS, and wrote it into Tech Fund 1 like Brighton through a stick of rock.

I got involved, working for NHS England with guys from World VistA and OSERA to establish what would be needed to localise VistA for the NHS. We came up with a plan but the cost was more than NHS England was willing to pay. NHS VistA was doomed.

Our work did lead to the creation of an open source programme within NHS England, though, which rapidly absorbed and refactored Tim’s next idea: Code4Health.

We set out to demonstrate how open source could work in the NHS for both vendors and users, and to dispel many of the myths that existed about open source. We created the NHS Open Source Foundation (now The Apperta Foundation), a not-for-profit designed to act as a custodian for quality assured NHS open source software, adapting the model developed by OSERA in the US for VistA.

We identified a number of issues which we worked hard to address.

  • A concern that open source software could not be safe and secure. Here we were able to convince people that, with our custodian model and the ability for anyone to inspect source code, the opposite was true.
  • A failure to understand how NHS organisations could “procure” open source software. Despite excellent guidance from the Cabinet Office, this is something that many NHS organisations still don’t understand.
  • A failure to understand that open source software was “free as in air” not “free as in beer” and that successful open source projects need someone to pay professional developers to create and maintain it. Tim’s original concept for Code4Health – to “teach 50,000 clinicians to code” – was not helpful here. This remains an issue and one I believe NHSX will need to address.
  • Vendors struggling to find economically sustainable business models based on open source software. This is the core problem that the NHS could fix, but hasn’t. Could NHSX finally crack it?
  • Confusion from both vendors and customers on how intellectual property rights and software licences operate in an open source project. This is a complex area where we were available to offer expert advice to help vendors understand the options and access to tools to help ensure licence compliance.

We had some successes – among them persuading IMS Maxims to open source their EHR and Marand to do the same for their electronic prescribing systems, now OPENep. We were also able to provide support to some existing open source projects, notably openEyes, Open-eObs and the Ripple Foundation’s open source openEHR stack. And we were able to create a number of Code4Health communities who are working on new open source projects.

Some issues remain

The whole of the team running the open source programme and Code4Health are being made redundant by NHS Digital at the end of March. But since the Apperta Foundation was created as a free standing entity, we can hope their work will live on.

So what are the challenges NHSX is going to face if it truly wants to see open source software as a significant part of the NHS’s digital landscape?

Firstly, it is important to understand that open source is primarily about getting better software, not cheaper software. Although an open source approach will eliminate profiteering by vendors, software development and maintenance still needs to be funded.

And so NHSX needs to create an environment in which economically sustainable business models can be created for open source software. There are many possible such models, but the central issue is persuading NHS organisations to contribute to open source projects that deliver value to them. In the short term some significant pump-priming of open source projects by the centre is going to be required.

Finally, NHSX need to give teeth to its commitment on open source. That could mean requiring business cases demonstrate open source options have been properly considered, and proof that proprietary systems are only procured when there is no better open source alternative.

Will it happen this time? My heart hopes it does but my head says it probably won’t. My plea: please, NHSX, make sure you learn from the work that’s gone before.

Ewan Davis is a digital health strategist, chief executive of inidus and a non-executive director at Digital Health