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Open source and the NHS: Two huge disorganised entities without central control

Nay dragons here, me lad - these be long lost lovers

To outsiders, Britain’s National Health Service must look like a monolith, with more than a million staff marching under one three letter acronym to provide healthcare free at the point of delivery, paid for by the taxes.

But the NHS is actually an assortment of several hundred organisations. Each UK nation runs its own health service - Scotland already has independence in terms of how it operates its health services, as do Wales and Northern Ireland, and England has particularly weak central controls. Healthcare, like the stage, is an industry where some of the workers are more powerful than their supposed bosses; in both cases, much power lies with those who perform in theatres.

In the English NHS, the clout of senior hospital doctors makes the organisations that employ them, acute NHS trusts, disproportionately powerful. Also, these trusts run the local hospitals that for many embody the NHS.

All this makes it difficult for the government to exert central control over the acute trusts, even in benign ways. The following comments overheard at the start of an NHS IT conference this summer illustrate this:

Delegate 1: “The NHS Number is mandated.”

Delegate 2: “Mandated, but...”

Delegate 1: “Mandated, but not widely used.”

Both the health secretary Jeremy Hunt and NHS England have said NHS organisations must move to using the NHS Number – the system’s ID number – as their main identifier. While there are plenty of reasons to oppose national ID cards and numbers, using a single code to join up patient records across what is meant to be a joined-up healthcare system is not usually one of them. But many acute trusts are treating primary use of the NHS Number as a suggestion rather than an order. They are taking a similar approach to Mr Hunt’s insistence that they become paperless by 2018.

Last decade, the previous Labour government attempted to press standardised software on every acute NHS trust through the National Programme for IT. This foundered for the reasons already outlined, that trusts and their doctors tend to obstruct central attempts to order them about.

So with open source software, which could jump-start trusts’ IT development, NHS England is wisely offering encouragement rather than pressure. This includes around £20m of a £240m technology fund (for which applications closed in mid-July), under which trusts bid for central funding on the condition they match it themselves.

“This isn’t about 100 per cent open source, even 50 per cent,” Richard Jefferson, head of business systems for NHS England, told that recent conference. “Even if we get to 15-20 per cent, that would be fantastic.” Adding that there is no specific target, he added: “Even if we just challenge normal vendors that will be good.”

NHS England need not have pitched things so low, at least for this audience of open source enthusiasts. When Shane Tickell, the boss of UK healthcare software firm IMS Maxims, stood up to announce that his company was moving its flagship product to open source, he was given rock-star levels of applause at the event. “It’s a big step,” he said, an appropriate phrase given Tickell was wearing a plaster cast after injuring himself during a 212 mile walk to raise awareness of early signs of cancer.

Malcolm Senior, the IT director for Taunton and Somerset NHS foundation trust, which runs a 700-bed hospital, recently awarded IMS Maxims a contract to replace its electronic patient record system, its core suite of software.

Senior says IMS Maxims’ new commitment to open source helped, but not for ideological reasons:

“It made it affordable,” according to Senior, recalling a two-hour session being cross-examined on open source software by the trust’s board. “It’s just another option to pursue, and we’re going to give it a go.”

He asked a pointed question:

“Despite hospitals all doing the same thing and reporting the same way, we all feel we need to be different. Do we really lads? Come on!”

If NHS acute trusts can overcome their collective belief in their own uniqueness, one of the most promising sources of open source software for the NHS will be other parts of the NHS. Moorfields Eye Hospital NHS foundation trust in London has created an open source electronic patient record system called OpenEyes, and it has already been adopted by a handful of other trusts in England. OpenEyes has also been taken by Cardiff’s NHS health board with an eye to adoption across Wales; the Welsh Government manages to run its health services in a more centralised fashion than England.

OpenEyes is easy on the eye of the user, as well as hopefully the patient. It takes the government’s paperless target seriously; it even aims to stop clinicians doodling diagrams to explain things to patients through EyeDraw, a sophisticated graphical function that allows them to create digitised diagrams of eye conditions – and for these diagrams to be stored for future reference, rather than chucked in the recycling bin.

Moorfields is one of the few acute NHS trusts in a class of its own, partly through its world-class clinical reputation, partly because it is the only acute trust that specialises purely in eye treatment (most trusts provide a wide range of services). The latter might sound like a problem for reuse of its software, but most functions are common to most hospital work, including modules for prescriptions, clinical correspondence (such as between a surgeon and a family doctor), appointment booking and – this being the NHS, which partly manages demand through delays – waiting lists.

The eye-specific parts can be adapted, too: an NHS Hack Day event saw OpenEyes tweaked so it could be used for heart surgery, under the name OpenHeart. Some have suggested it could be used for orthopaedics and dentistry, possibly under the names OpenArms and, yes, OpenWide.

You can go deeper than just apps, and really get into the nitty gritty of document management and workflows. One option is Alfresco, the British open-source venture specialising in content management systems (CMS).

John Newton, Alfresco chairman, points out Alfresco has been involved in “the successful bits” of the initially nightmarish IT for the US government’s Obamacare sign-up website, and is used by well-respected US healthcare provider Kaiser Permanente.

Newton argues open source is well suited to systems that need to be transparently stable and secure, where a lot of people have an interest in collaborating. He adds it is favoured by intelligence services for exactly these reasons, and if it’s good enough for spooks, it should serve for hospitals.

Alfresco hit its initial end-of-year download target of 10,000 in the first week, with eventual downloads numbering in the millions for the initial release of its software in 2005. “You want to join the cool party,” Mr Newton said. “That’s what open source is all about.”

The idea of NHS IT being cool is charmingly far-fetched, but as a group of organisations that need reliable, safe and cheap software – and, even if they don’t like to admit it, can often use much the same system as their neighbours – NHS acute trusts are well-suited to open source. NHS England wants to encourage its use, and those attending this event were more than enthusiastic.

But it is likely to be a struggle to make this happen at scale in England. IT staff may love it, but NHS acute trusts are headed by general managers, with senior doctors often having de facto veto rights over new initiatives. As Taunton and Somerset’s Malcolm Senior notes, such people can be persuaded, but doing so is a job of work, and it is likely to be lower costs, rather than high-minded “libre rather than free beer” arguments, that will convince them.

And even then things tend to move slowly, with many trusts making decisions on new IT only when the old system becomes unusable. New software and better IT hardware would help many NHS acute trusts do a better job.

But with a few far-sighted exceptions, most trusts put IT a long way below coping with the urgent and never-ending need to treat more patients for the same money – even if open source and other technologies could help them do exactly that. ®

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