Repeat Dispensing in Australia

The patient hands their repeat prescription to the pharmacist who passes it under the barcode reader. Without further input the pharmacy computer prints all the labels, produces the next Repeat Authorisation, prepares an order to replace the stock, and produces an electronic invoice against which the NHS will make payment. The assembled products are passed under the barcode reader by the pharmacist and the pharmacy computer confirms that they are the correct products for the prescription. The labels are then applied by hand.

This is the reality of Australian pharmacy today.

The copyright licensing notice below applies to this document.

Copyright © 2004 Robert Gartside

Permission is granted to copy, distribute, and/or modify this document under the terms of the GNU Free Documentation License, Version 1.1 or any later version published by the Free Software Foundation; with no Invariant Sections, with no Front-Cover Texts, and with no Back-Cover Texts.

A copy of this license is included at the end of this file.

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21^st. March 2004

Repeat Dispensing in Australia

A report by R Gartside, FRPharmS.

A). Executive Summary

The Health Service system of repeat dispensing in Australia makes use of pharmacy computers to provide a first class, secure, service which makes minimal demands on prescribers, patients, pharmacists, pharmacies, and the payment authority while ensuring patient convenience and free choice of pharmacy.

The basis is that the patient holds a document which is an authority for pharmacists to dispense their medication on a fixed number of occasions and also a document which acts as a pharmacy payment instrument when a supply is made. A new payment instrument is produced by the pharmacy dispensing an instalment of the supply, given to the patient, and this is then used by the next pharmacy to claim payment for the next supply.

The system is described in detail; it is recommended that it be further investigated both as an insurance policy in case the proposed British system encounters unexpected problems during roll-out and also because the Australian system preserves patient choice of pharmacy on each and every occasion of dispensing and this may become important at a later date to ensure optimum take-up of repeat dispensing.

B). Notes.

1).The Pharmacy Benefits Scheme (PBS) in Australia is viewed as providing subsidies for the purchase of medicines. Not all medicines are included in the scheme, and disadvantaged patients still have to pay a small amount towards the cost of their medicines (unless they need very large numbers of prescriptions). There are also restrictions on products, disease indications, quantities prescribed and numbers of repeat prescriptions. These are discussed in Appendix 5. since they do not affect the principle of the repeat prescription scheme.

2). Prescriptions which do not comply with PBS can be dispensed as private prescriptions if the patient so desires, even if written on NHS paper. However, it is not possible to have both private and NHS items on the one prescription form – if the private dispensing option is exercised then it covers all products on the form.

3). It is hoped that HealthConnect, the new Australian scheme to provide secure access to medical and pharmaceutical records across the health system will begin to roll out in Tasmania and South Australia on July 1^st. 2004. It has not proven possible to ascertain how the computer systems described here will interface with HealthConnect since it will not be rolled out in Western Australia for some time.

C). Method.

Visits were made six pharmacies in Perth, Western Australia during February and March 2004. Discussions were held with the Health Department of Western Australia, the Pharmacy Council of Western Australia, the Health Insurance Commission Western Australia, and the Pharmacy Guild of Western Australia.

Mr. Mark Wilson, of the Medical Centre Chemist, Sir Charles Gairdner Hospital (a private pharmacy situated inside this teaching hospital), Mr. David Haig of the Western Australia DoH, Mr. Bob Brennan of the Pharmacy Council of Western Australia and Mr. John Jack, retired pharmacist of Chidlow, WA, were particularly helpful but thanks are due to all the persons interviewed.

D). Basic Principles of the Repeat Dispensing Scheme.

1).The prescription is written by the physician as an ‘Original’ (O) and a ‘Pharmacy/Patient Copy’ (PPC); they may be hand-written using NCR paper or they may be computer printed, both copies are signed by the physician.

2).The patient takes both (O+PPC)to the pharmacy of their choice, where the first dispensing is made and the patient signs a detachable strip at the bottom of the Pharmacy/Patient Copy and this is then stapled to the Original (O) as a receipt.

3).The Original (O) is retained by the pharmacy and later submitted to the Health Insurance Commission (HIC) for payment; this alerts HIC that there is a new repeat prescription for this patient.

4).The pharmacy prints ‘Repeat Authorisation One’ (RA1) of the prescription, sample as Appendix 1, (with the repeat number less one dispensing) which is given to the patient together with the Pharmacy/Patient Copy (PPC), and the medication.

5).The patient takes the Repeat Authorisation One (RA1) and the Pharmacy/Patient Copy PPC) to a pharmacy of their choice when the second dispensing is needed and the patient signs the bottom of the Repeat Authorisation One (RA1) as a receipt.

6).Repeat Authorisation One (RA1) is retained by the pharmacy and later submitted to HIC for payment.

7).The pharmacy prints Repeat Authorisation Two (RA2) which is given to the patient together with the Pharmacy/Patient Copy (PPC) and the medication.

8).This process is repeated until the final dispensing, when all repeats are exhausted, and at this stage the final pharmacy retains the Pharmacy/Patient Copy (PPC) and keeps it for twelve months in case an audit is required. The final Repeat Authorisation (RAn) is signed by the patient as a receipt and is submitted by the pharmacy to HIC for payment.

9). In practice, good pharmacy computer systems make the process simple and rapid. For example, some software prints a barcode on the Repeat Authorisation and if the patient returns to the same pharmacy the whole process can be done automatically by using a bar code reader.

10). Prescription payments are actually made against floppy discs, which are accompanied by the paper Pharmacy Copies for random audit.

11). A flowchart outlining the flow of documents follows as page 4.

E). Numbering

1). Much use is made of identification numbers, which enable complete computer control and audit of the whole process.

2).No prescription is valid unless it carries the patient’s NHS number and the prescriber’s NHS number, and it will not be priced if it does not carry the pharmacy dispensing number.

3).All patients were issued some years ago with a card carrying their NHS number, pharmacies are allowed to keep this number on machine file and add it to the prescription with their endorsements. GPs apparently initially resisted putting patient numbers on prescriptions but now are beginning to appreciate the wider value of patient NHS numbers.

4).All GPs and all pharmacies have a unique identifying NHS number and these must also appear on all prescriptions submitted for pricing. It seems that these, and all other numbers, are structured to both provide extra information (addresses or localities or categories) and to enable computer authentication checks. Of course computers make all the numbering easy.

5). It occasionally happens that the patient NHS number does not co-incide with the name and/or address on the prescription, for example if the patient has married. In such cases the labels for the medicine will carry the name and address written on the prescription, but the data submitted to HIC will carry the name and address from the patient’s NHS card. Obviously checks will be carried out before the prescription is dispensed and normally the reasons will be marriage or change of co-habitation but there must remain a lingering doubt, as in UK, as to the possible extent of patient deception; modern medicines are high value items.

6). A minor convenience is that the same telephone (132 290) and PO Box numbers (GPO Box 9826) are used for HIC throughout Australia.

F). Pharmacy Computer Systems.

1). Examples of two common pharmacy computer systems have been examined and operation of them observed. Examples of other systems could not be easily found in Perth, Western Australia.

2). Both systems produced Patient Medication Records, labels and orders and both could be seamlessly linked to Epos (Electronic Point of Sale) systems. Both could also seamlessly cope with the private prescription option.

3). Both systems produced pricing reports on floppy disc for HIC. As previously stated these could be submitted, together with supporting prescriptions, weekly, fortnightly, or monthly depending on the particular pharmacy’s volume and the choice of the pharmacy.

4). With either system (FRED, with WINIFRED as the windows based system, or L.O.T.S.) entry of a repeat prescription previously dispensed by the pharmacy is by entering either complete patent details, the patient number or the pharmacy prescription serial number from the pharmacy produced copy prescription. The entry by barcode reader from the Repeat Authoristion was a particularly quick and accurate operation.

5). Both systems had the capability to confirm by bar code reading that the correct product(s) had been selected for dispensing. This is a legal requirement for pharmacy computer systems in the state of Victoria and is increasingly used elsewhere on a voluntary basis. It is beginning to become a Professional Liability Insurance requirement.

6). Both systems produced several labels at the same printing. Examples are attached as Appendix 2. The small labels are for attaching to the prescription as endorsements, there are also a bag label and various others used for stock control purposes. Notable is the facility to produce narrow product labels for eye drops and inhaler cans.

7). Both systems could cope with Monitored Dosage Systems (MDS) and with homes and both could also cope through other modules with narcotics maintenance programs, although demonstrations of these two capabilities were not seen.

8). Future developments include an automatic patient recall system which will remind patients that they have not picked up a repeat when it is due. This is a pharmaceutical industry initiative and pilots currently in progress are being industry funded, it being expected that industry funding will be forthcoming if the pilots are successful and the system widely adopted. The hope is, of course, that increased patient compliance and concordance will lead to better disease control and fewer episodes of hospitalisation.

It is also hoped that Just In Time ordering systems can be developed so that patients taking rare or expensive medication can nevertheless expect their medication to be waiting for them when they call in to the pharmacy for a repeat.

G). Submission of prescriptions for pricing.

1).Submission of prescriptions for pricing is by floppy disc, accompanied by the paper prescriptions (originals and repeats) for audit purposes. All of the pharmacy computer systems have the ability to produce floppy discs for pricing in an agreed format.

2).Prescriptions must be sorted into numerical order based on the pharmacy’s own computer generated numbers. These numbers are structured so as to identify the dispensing pharmacy and it is possible that the number also provides information on the prescriber and, perhaps, the patient. Certainly there is a belief by some pharmacists that this may be the case.

3).Pharmacies are required to submit prescriptions monthly. Busy pharmacies may submit fortnightly or weekly since this helps both them and the pricing office and can improve their cashflow.

4).Information on the audit process is, naturally, retained within HIC as confidential. It is believed by pharmacists that 10% of all scripts are randomly audited but confirmation of this did not prove possible.

5). Electronic submission for pricing is under consideration but has no high priority because the floppy discs work so well and submission of the paper copies for audit is in any event going to remain essential, so there is little gain from e-submissions.

H). Payments for prescriptions.

1). Patients make a co-payment for their prescriptions up to a maximum cost of A$23.70 (c.£10.00) for general patients or A$3.80 (c.£1.70) for concessional patients holding one of several kinds of concessional card. There are minor differences between States as to the concessions allowed. There is a Safety Net Scheme for patients needing large numbers of prescriptions; this becomes operative once a patient has exceeded a payment threshold for the year.

2). Pharmacies are paid the basic cost of the prescription medicine plus 10% (5% for very expensive items) plus a dispensing fee of A$4.66 (c £2.00) with additional fees for narcotics and extemporaneously dispensed items. A general impression was formed that there may be an additional element of profit through prudent purchasing but confirmation of this could not be obtained.

I). Problem solving.

1). The responsibility for problem solving lies squarely with the physicians and pharmacists concerned who are expected to use their professional knowledge and expertise to handle problem situations; there are thus few, if any, formal guidelines.

2). Examples of various problems were put to a number of pharmacists and the following summarises their responses:-

a). The two copy prescriptions presented by the patient do not agree.

If the problem is simple, i.e. differences in dosage, the pharmacist would question the patient and amend the next copy prescription. More complex problems, i.e. changes in strength of product, or different product, would be for the pharmacist and physician jointly to solve.

b). Patient who has already presented repeat prescription now presents an extra ‘normal’ prescription for the same product.

This is a matter for liaison between pharmacist and physician.

c). Patient is suddenly called away and needs several months supply of medication.

This is at the pharmacist’s discretion under ‘Section 24’ for most products. For products on which there are special restrictions, Authorisation can be obtained by phoning the Department of Health where there is always a pharmacist on duty to issue Authorisation Numbers. The DoH employs community pharmacists on a one day a week secondment basis to undertake this rôle.

d). Patient has lost or spoilt their supply of medication and requires the next supply before the due date.

By custom and practice this is at the pharmacist’s discretion for a few days, otherwise a matter for the pharmacist and physician.

e). Physician wishes to cancel prescription ‘mid-life’.

The physician would be expected to contact the pharmacies direct, this may not be too difficult since most patients use the same pharmacy on a regular basis.

f). Patient insists that the original prescription is ‘wrong’.

This is a matter for liaison between pharmacist and physician.

g). Patient (or physician) wishes to change product, strength, dosage or quantity.

Must be referred to physician who will produce new prescription.

h). ‘Hospital’ have allegedly told patient to alter dosage strength or frequency, or both.

A new prescription will be necessary.

J). Discussion.

1). The system as here described has evolved over a considerable period of time from a system for private prescriptions which owed much to the British model. One notable characteristic of all the people interviewed was a pronounced pragmatic willingness to consider changes to the system in response to events or in response to changed circumstances. It seems that change in the system is relatively easy to agree and produce. Perhaps as a result, there was a strong feeling of ownership of the system which all concerned strongly believed to be the best in the World -- “because the actual working pharmacists designed it and are responsible for its maintenance”

2). The system is undoubtedly highly popular with patients, physicians, and pharmacists; it is noteworthy that no serious adverse comments were encountered from any quarter.

3). Careful consideration of the system shows that it contains a number of checks and balances which make for accuracy and that it also produces a robust audit trail. The Pharmacist/Patient Copy prescription is largely responsible for this since it acts as a continuous record of the physician’s original prescription against which the copies can be checked. The extensive use of numbers is also an important safeguard which is easy to operate because of the sensible use made of computers in the whole process.

4). The necessary pharmacy software is well proven and in discussion with the manufacturer’s representatives they felt that there would be little difficulty in providing software which would operate only the repeat function without the other functions necessary under the Pharmacy Benefits Scheme. It should be noted, however, that these discussions were with sales staff and not with programming staff. There appeared to be good interest in servicing the British market, whose size had not previously been realised.

5). In an Option Appraisal report to the Scottish Executive, RPSGB, Alison Strath in June 2001 came to the conclusion that a ‘master/slave’ model with one pharmacy dispensing all repeats should be implemented for UK because it made minimal demands for new computer programs and because it was felt that having all of a patient’s prescription dispensed at one pharmacy would facilitate record keeping and medicines management. It was also argued that the imminent roll-out of electronic transfer of prescriptions would render any paper based system quickly redundant.

However, electronic transfer of prescriptions has now been subsumed into the work on the single patient record and will be some years in the future. It has also to be said that the history of previous large and ambitious government IT initiatives has not been encouraging – cost over-runs and long delays have been frequent and have even led to the abandonment of programs after much work. Back-up may be prudent.

There is no doubt that repeat dispensing can show great cost savings, of the order of 14%, as well as being convenient and time-saving for patients and NHS staff; it is also possible that more regular medication may lead to lower hospitalisation rates although this question has not been addressed in the studies so far carried out. For all of these reasons, the aim should be the best possible uptake of repeat dispensing and it may be here that the weakness of the master/slave model shows itself because of the need for the patient to always return to one pharmacy. This may not always be convenient and there is always the possibility that the patient and the pharmacy may come to a permanent disagreement. A system which allows the patient free choice of pharmacy on each occasion of dispensing is therefore preferable.

K). Recommendations.

1). A more detailed study should be carried out of the Australian system of Repeat Dispensing both because it is not yet certain that the proposed British system will pass unscathed through scale-up trials and because the Australian system offers the important advantage that the patient has a totally free choice of pharmacy on the occasion of each dispensing. It is possible that the need to use a single pharmacy for all supplies will prove a serious obstacle in the way of widest possible take-up of the proposed British system.

2). British pharmacy computer system manufacturers should be encouraged to open discussions with their Australian counterparts with a view to mutual co-operation. Although the Australians have much more highly developed repeat dispensing systems, their management information systems and their control of product use is much less sophisticated than is that provided by British systems and upgrades in this area will become necessary as the size of Australian pharmacy companies increases. A trend towards larger pharmacy companies is now well underway, although perhaps twenty to thirty years later than in Britain.

3). Immediate consideration should be given to encouraging large pharmacies in Britain to submit prescriptions for pricing and payment more frequently than monthly since this simple move will, at little cost, produce benefits for both the pharmacies and the PPA.

4). Progress in Britain towards electronic pricing of prescriptions has been slow; the principle obstacle being believed to be the lack of a uniform drugs code. Pricing by weekly or monthly floppy disc with the paper prescriptions as an audit back-up is shown by the Australian experience to be both practical and economical and it appears to be compatible with more sophisticated electronic systems. It should be accorded the highest priority, if need be by buying in the Australian system.

5). The Pharmacy Benefits Scheme will not normally pay for more than one month’s supply at a time. There is ample evidence to show that such a restriction in Britain would produce substantial cost savings and its introduction simultaneously with a Repeat Dispensing Scheme should be seriously considered since such a Repeat2 Scheme obviates the need for large quantities to be supplied at one time.

6). Consideration should be given to allowing prescriptions written on NHS paper to be, optionally, treated as private prescriptions, with the proviso that all of the items on one form would be treated as private. As well as cheap items, if recommendation 5).were to be adopted this would give patients the opportunity to have large quantities if they were prepared to pay for them.

7). Consideration should be given to allowing patients with generic prescriptions to make an extra payment direct to the pharmacy for the supply of a branded product in lieu of the generic. The Australian experience appears to be that this exerts a powerful downward pressure on manufacturer’s prices.

8). The Western Australian practice of having community pharmacists working one day per week on secondment in the Department of Health appears to have considerable benefits to both the Department and to pharmacists in the community and consideration should be given to the introduction of such an arrangement in Britain.

Appendix 1

Pharmacy Repeat Authorisation

Appendix 2

Composite label set.

These label sets are printed in one pass and comprise a choice of label sizes, a bag label, and small labels to be fixed to the prescription as pack and product endorsements.

NB. These are separate labels on one backing paper when printed, but the reproduction process has not shown the slits in the paper.

Appendix 3

Sample page from the Schedule of Pharmacy Benefits (SPB)

Appendix 4

Initial page of SPB announcing restricted availability of etanercept

Appendix 5

Aspects of the Australian Pharmaceutical Benefits Scheme (PBS).

1). The scheme is regarded as providing a subsidy for the purchase of prescription medicines.

2). Only medicines listed in the Schedule of Pharmaceutical Benefits (SPB) will be subsidised, all other medicines must be paid for in full either by way of private prescriptions or by straightforward retail purchase.

3). Only the quantities listed against each individual medicine in SPB will be subsidised; larger quantities must be purchased, by private prescription if necessary.

4). Only the number of repeats listed against each individual medicine in SPB will be subsidised, greater numbers of repeats will take the prescription out of PBS.

5). Any prescription on PBS paper can be treated as a private prescription, but all items on the prescription must be treated privately. Thus if a PBS prescription calls for a medicine not listed in SPB, or for a greater quantity or more repeats of one item than allowed by SPB, all items on the prescription must be treated privately.

6). PBS prescriptions are normally dispensed generically but where a patient wishes to have the branded drug they make an extra payment and these payments are listed in the SPB.

7). There are different rules in different states as to the frequency or timing of repeats, but there is freedom allowed to the pharmacist under Section 24 to occasionally, in special circumstances, supply all of the repeats at one time – the patient still pays the charge for each repeat, however.

8). The maximum co-payment for general patients is A$ 23.70 (c £10.00) while the maximum charge for concessionary patients is A$3.80 (c £1.1.70).

9). A Safety Net operates for patients who have large numbers of prescriptions. The safety net threshold for general patients is co-payments of A$726.80 (c £320.00) and for concessionary patients the threshold is A$197.60 (c £86.00) in any one year; these thresholds are equivalent to 31 and 52 prescriptions respectively. Once the threshold is reached then further prescriptions for concessionary patients are free in that year, while general patients only pay the concessionary rate on further prescriptions in that year. Records of prescriptions are kept on a patient card, there is provision for pharmacists to make a charge of A$6.87 (c £3.00) for the issuing of the card.

10). Where a prescription calls for a smaller quantity than a standard pack, a ‘wastage table’ is used to determine how much more than the cost of the ordered quantity must be paid for to ensure that the pharmacy is compensated for the wastage involved. This appears to be easier to administer by computer than the ‘broken bulk’ arrangements used in Britain, and can be no less fair and economical.

Appendix 6

Useful addresses

Health Department of Western Australia, PO Box 8172, Stirlig St., Perth, WA 6000

phone Ms L. Fry, (08) 9388 4980

Pharmaceutical Benefits Branch, Health Insurance Commission, Western Australia

11^th. Floor, Bankwest Tower, 108, St. George’s Terrace, Perth, WA 6000

phone 132 290

www.hic.gov.au

Pharmacy Council of Western Australia

21, Hamilton St., Subiaco, Perth, WA 6008

phone Mr. Bob Brennan, 61 8 9388 2886

email pcwa@iinet.au

The Pharmacy Guild of Australia, Western Australian Branch,

1322, Hay St., Perth, WA 6005

phone 08 9324 2355

email guild.wa@guild.org.au

L.O.T.S. computer system, associated with AMFAC.

Pharmasol Pty Ltd., PO Box 2248, Caulfield Junction, VIC3161

Phone (03) 8531 9200

Email lots@pharmasol.com.au www.pharmasol.com.au

WA contact Ms Sandra Cooke, Cosmos Ltd.,

41, Walters Drive, Osborne Park, Perth, WA 6017

phone 61 8 9446 9366

email sandra.cooke@cosmos.com.au

FRED (for DOS) and WINIFRED (for Windows) computer systems.

Pharmacy Computers Australia Pty. Ltd.,

40, Burwood Road, Hawthorn, VIC 3122

phone (03) 9810 9965 or 1300 73 1888

email info@pharm.com.au

WA contact Nu-Systems Ltd., Unit 12, 502, Balcatta Rd., Perth, WA

Details of more computer suppliers have been promised from Australia.

N.B.

Pharmacy Computers Australia is owned by the Victoria Branch of the Pharmacy Guild of Australia. It was set up in its present form in 1993, having originated in 1983. Programs currently available include:-

Fred – Fast, Reliable, Easy, Dispensing for DOS systems.

Winifred – the Windows version of Fred.

Bill – a billing suite for homes and doctor’s accounts with pharmacies.

William – the Windows version of Bill.

Homer – a Home Medication Review program.

Phred – a Private Hospital version of Fred.

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may not be included in the Modified Version.

N. Do not retitle any existing section as "Endorsements"

or to conflict in title with any Invariant Section.

If the Modified Version includes new front-matter sections or

appendices that qualify as Secondary Sections and contain no material

copied from the Document, you may at your option designate some or all

of these sections as invariant. To do this, add their titles to the

list of Invariant Sections in the Modified Version's license notice.

These titles must be distinct from any other section titles.

You may add a section entitled "Endorsements", provided it contains nothing but endorsements of your Modified Version by various parties--for example, statements of peer review or that the text has been approved by an organization as the authoritative definition of a standard.

You may add a passage of up to five words as a Front-Cover Text, and a passage of up to 25 words as a Back-Cover Text, to the end of the list of Cover Texts in the Modified Version. Only one passage of Front-Cover Text and one of Back-Cover Text may be added by (or

through arrangements made by) any one entity. If the Document already includes a cover text for the same cover, previously added by you or by arrangement made by the same entity you are acting on behalf of, you may not add another; but you may replace the old one, on explicit

permission from the previous publisher that added the old one.

The author(s) and publisher(s) of the Document do not by this License give permission to use their names for publicity for or to assert or imply endorsement of any Modified Version.

5. COMBINING DOCUMENTS

You may combine the Document with other documents released under this License, under the terms defined in section 4 above for modified versions, provided that you include in the combination all of the Invariant Sections of all of the original documents, unmodified, and list them all as Invariant Sections of your combined work in its license notice.

The combined work need only contain one copy of this License, and multiple identical Invariant Sections may be replaced with a single copy. If there are multiple Invariant Sections with the same name but different contents, make the title of each such section unique by adding at the end of it, in parentheses, the name of the original author or publisher of that section if known, or else a unique number. Make the same adjustment to the section titles in the list of Invariant Sections in the license notice of the combined work.

In the combination, you must combine any sections entitled "History" in the various original documents, forming one section entitled "History"; likewise combine any sections entitled "Acknowledgements", and any sections entitled "Dedications". You must delete all sections

entitled "Endorsements."

6. COLLECTIONS OF DOCUMENTS

You may make a collection consisting of the Document and other documents released under this License, and replace the individual copies of this License in the various documents with a single copy that is included in the collection, provided that you follow the rules of this License for verbatim copying of each of the documents in all other respects.

You may extract a single document from such a collection, and distribute it individually under this License, provided you insert a copy of this License into the extracted document, and follow this License in all other respects regarding verbatim copying of that document.

7. AGGREGATION WITH INDEPENDENT WORKS

A compilation of the Document or its derivatives with other separate and independent documents or works, in or on a volume of a storage or distribution medium, does not as a whole count as a Modified Version of the Document, provided no compilation copyright is claimed for the compilation. Such a compilation is called an "aggregate", and this License does not apply to the other self-contained works thus compiled with the Document, on account of their being thus compiled, if they are not themselves derivative works of the Document.

If the Cover Text requirement of section 3 is applicable to these copies of the Document, then if the Document is less than one quarter of the entire aggregate, the Document's Cover Texts may be placed on covers that surround only the Document within the aggregate. Otherwise they must appear on covers around the whole aggregate.

8. TRANSLATION

Translation is considered a kind of modification, so you may distribute translations of the Document under the terms of section 4. Replacing Invariant Sections with translations requires special permission from their copyright holders, but you may include translations of some or all Invariant Sections in addition to the original versions of these Invariant Sections. You may include a translation of this License provided that you also include the original English version of this License. In case of a disagreement between the translation and the original English version of this License, the original English version will prevail.

9. TERMINATION

You may not copy, modify, sublicense, or distribute the Document except as expressly provided for under this License. Any other attempt to copy, modify, sublicense or distribute the Document is void, and will automatically terminate your rights under this License. However, parties who have received copies, or rights, from you under this License will not have their licenses terminated so long as such parties remain in full compliance.

10. FUTURE REVISIONS OF THIS LICENSE

The Free Software Foundation may publish new, revised versions of the GNU Free Documentation License from time to time. Such new versions will be similar in spirit to the present version, but may differ in detail to address new problems or concerns. See http://www.gnu.org/copyleft/.

Each version of the License is given a distinguishing version number. If the Document specifies that a particular numbered version of this License "or any later version" applies to it, you have the option of following the terms and conditions either of that specified version or

of any later version that has been published (not as a draft) by the Free Software Foundation. If the Document does not specify a version number of this License, you may choose any version ever published (not as a draft) by the Free Software Foundation.

ADDENDUM: How to use this License for your documents

To use this License in a document you have written, include a copy of the License in the document and put the following copyright and license notices just after the title page:

Copyright (c) YEAR YOUR NAME.

Permission is granted to copy, distribute and/or modify this document

under the terms of the GNU Free Documentation License, Version 1.1

or any later version published by the Free Software Foundation;

with the Invariant Sections being LIST THEIR TITLES, with the

Front-Cover Texts being LIST, and with the Back-Cover Texts being LIST.

A copy of the license is included in the section entitled "GNU

Free Documentation License".

If you have no Invariant Sections, write "with no Invariant Sections" instead of saying which ones are invariant. If you have no Front-Cover Texts, write "no Front-Cover Texts" instead of

"Front-Cover Texts being LIST"; likewise for Back-Cover Texts.

If your document contains nontrivial examples of program code, we recommend releasing these examples in parallel under your choice of free software license, such as the GNU General Public License, to permit their use in free software.