Medical software's free future ============================== # All software developed at public's expense should be licensed as open source {#article-title-2} EDITOR—The open source model for software is so sensible that it is bizarre that closed source models have held sway for so long.1 Unfortunately, the title of Carnall's editorial gives the impression that open source software costs you nothing. This is not generally true. Open source software is “free as in speech, not as in beer.”2 Commercial companies can make money out of open source software by charging for services such as distribution, warranties, support, installation, and tailoring. But these fees are likely to have some relation to the work involved. The up-front licence fees charged for closed source software are out of line with the cost structure. In no other industry are the products deliberately kept secret when that secrecy cannot be justified by safety or security concerns. An obvious route forward for the public sector would be to state that all software developed at the public's expense be licensed as open source, although the General Public License may not be the optimum licence.3 Licensing the software as open source provides optimum protection for the taxpayer; crown copyright, as it is currently used, does not do this. The gift culture ethos of the open source movement should fit in well with that of the NHS. As Carnall has argued elsewhere, “Open source is the future: all we have to do is build it.” ## References 1. 1.Carnall D.Medical software's free future.BMJ2000; 321:976. (21 October.) [FREE Full Text](http://www.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMjEvNzI2Ny85NzYiO3M6NDoiYXRvbSI7czoyNDoiL2Jtai8zMjIvNzI5MC84NjMuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 2. 2.Raymond ES.The cathedral and the bazaar.Sebastapol, CA:O'Reilly and Associates,1999. 3. 3.1. Di Bona S, 2. Ockman S, 3. Stone M , eds. Open sources: voices of the open source revolution.Sebastapol, CA:O'Reilly and Associates,1999. # More and better programmers are needed {#article-title-4} EDITOR—Carnall is correct when he says that the NHS is having problems with software procurement, but his view of open source development is too rosy.1 Any large data handling project is a huge undertaking and needs expert developers, who have to make a living. The NHS simply does not employ these people in quantity, and it seems unlikely that developers working elsewhere will program software for altruism's sake. As with all open source projects, these developers would gain income from support, leaving us just as tied in to their system as to any other and still paying for the system. Free software is free as in “free speech.” The idea that having the source code would allow us to fix problems and take over the system's development is again optimistic. Reading code written by another developer, even if it is well structured, is extremely difficult. Bugs are as likely to be introduced as fixed. The real problem with lots of the software used in the NHS is that it is badly written. Because we need so much so quickly, large numbers of low ability programmers can make money with low quality software. The ubiquity of Microsoft Windows as a desktop operating system, with its visual development tools, has meant that it is frighteningly easy for someone with little or no knowledge of good system design to turn out, say, a database. Often such systems work well in the author's setting, with the constant support and tweaking that that brings, but they are incapable of configuration for a different site with different requirements. The real cost of a data system is the cost of collecting and inputting the data, its real value the information that you can get out of it; the cost of licensing software is trivial in comparison. The real software problem is that we need better programmers—lots of them—and we need to pay for them. ## References 1. 1.Carnall D.Medical software's free future.BMJ2000; 321:976. (21 October.) # Summary of rapid responses {#article-title-6} EDITOR—We received 34 responses to this editorial in addition to the letters published above.1 Most (31) were in favour of a wider adoption of free software in the healthcare domain, but several authors raised notes of caution. Richard Stallman noted that the GNU General Public License does not require software authors to publish any changed version of the software but compels them to respect the freedom of their users if they do. Steve Hajioff argued that free software did not have clearly established lines of accountability in the event of error and that, as its manufacturers' main revenue stream is from support, they have a perverse incentive to increase the number of support calls. Obstacles that still stand in the way of the adoption of free software, according to Saal Seneviratne, include primitive user interfaces and inferior office software compared with proprietary equivalents made by companies such as Microsoft. Jan Paleta noted that the costs of licensing software tools are small in comparison to overall costs of a project, and Iain Buchan, Jonathan Honeyball, and Barry Tennison point out that most commercial entities choose to share the risk of maintaining critical software by buying software and that if they do not have software development as a prime function they would pay more and gain less than from using free software. These contributions were themselves the subject of debate: read it in full at [www.bmj.com/cgi/eletters/321/7267/976](http://www.bmj.com/cgi/eletters/321/7267/976). ## References 1. 1.Electronic responses.Medical software's free future. bmj.com 2000;321 ([www.bmj.com/cgi/eletters/321/7267/](http://www.bmj.com/cgi/eletters/321/7267/976)976; accessed 19 Mar 2001).