Annual progress: Work of NJR Committees

2017/18 Regional Clinical Co-ordinators (RCC) Sub-committee Chairman’s report - Mr Matthew Porteous

The Regional Clinical Co-ordinator (RCC) Committee sat three times in 2017.  The committee is made up of representative surgeons from each region of England, Wales and Northern Ireland.  It represents a key link between the NJR team and the surgeons and hospitals who contribute data to the NJR.  RCC members are the first port of call for the Regional Co-ordinators when they are struggling to resolve issues with individuals or units.  In the vast majority of cases they are able to sort out the problem without the need for further escalation.  RCCs also act as a sounding board on matters of NJR policy and its impact on units at grass roots level, as well as feeding back where there are issues that are or might in the future cause problems.

The past year has seen the finalisation of the new Minimum Data Set (MDS) version 7 which has recently cleared its regulatory hurdles and is due for introduction in June 2018.  The majority of the changes came about as a result of feedback and suggestions by the RCCs, and brings the NJR into line with contemporary practice.  It is envisaged that a revision of the data set every 3 years is inevitable given the way that some areas of joint replacement are evolving.

The RCCs have been consulted and have contributed to both the broad scope and the finer detail of the Accountability and Transparency Agenda details of which can be found here.

As a result of problems obtaining urgent access to data on individual patients’ implants raised by the RCCs (for example the need for details where a periprosthetic fracture has occurred and urgent surgery is required) , a mechanism has been set up to permit this.  

The past year has seen increasing numbers of RCC members co-opted onto other NJR committees, including the Editorial Board and the Data Quality Committee.  Derek Pegg who has been appointed as the Vice Chair of the RCC committee.  As usual a number of committee members have left at the end of their terms of office and I would like to take the opportunity to thank them for their contribution over the past years, and to welcome their replacements. 

RCC posts falling vacant at the end of 2018 and details of how to apply for these (which are made on a regional basis) can be found here on the NJR Website.

2017/18 Data Quality Sub-committee Chairman’s report - Mr Matthew Porteous

Read ‘Supporting data quality – NJR strategy 2014/16’

The audit process, which is focused on identifying missing NJR records, involved asking Trusts for a file of patients for whom they have recorded an OPCS4 code that should correspond to an NJR entry.  (i.e. primary and revision hip or knee replacement).  

This is then compared to the NJR return from that hospital and there are three possible outcomes:

a) PAS return and NJR entry match for operation, date and patient number

b) Patient is on hospital PAS but not on NJR

c) Patient is on NJR but there is not a suitably OPCS4 coded PAS entry

The output is then returned to the relevant Trust who is asked to reconcile all the mismatches, inform the NJR of the reason for the mismatch, and correct or enter any missing data on the NJR. 

The 2014/15 audit only involved NHS Trusts and Health Boards in England and Wales and has now been completed by all the Trusts and Health Boards involved with the exception of King’s NHS Trust in London (King’s College Hospital, Princess Royal University Hospital (Farnborough) and Queen Mary’s Hospital Sidcup ).  

Results:

149 trusts completed the audit and one has not yet done so, 95% of eligible records had been submitted by the trusts (and the majority of the remainder were submitted after completion of the audit process).  

122,803 records were matched being in both the NJR and in the hospital PAS.  20,816 were on PAS but not in the NJR, 37% of these should have been in the NJR but no record had been submitted (though this has now been rectified).  The remaining 63% were either not eligible to be entered into the NJR (i.e. not an NJR procedure), had been subcontracted to a local private hospital, or were not matched due to a clerical error (e.g. incorrect hospital number).

10,613 cases were on the NJR but not in PAS.  A third of these were clerical errors (e.g. wrong hospital number, the majority of the remainder were local coding issues for the trusts concerned.  This could have led to a significant shortfall in trust income.

The 2015/16 audit was expanded to include all private hospitals in England and Wales and has, on the basis of lessons learnt in the previous audit, asked for returns at Hospital rather than Trust level (some trusts comprise more than one hospital).  

Results:

413 units were asked to return data (237 NHS hospitals and 176 independent sector hospitals).  At the time of writing 250 hospitals have completed the audit, 2 hospitals have failed to return any data and the remainder are reconciling their results.  Hospitals completing the audit to date returned 94% of eligible records to the NJR.

Comparisons with the previous years audit are difficult because of the inclusion of the independent sector, and the fact that returns are still being received.

The 2016/17 audit has requested data from NHS and private hospitals in England and Wales and the Isle of Man.  It is too early to report any meaningful results from this audit. 

Audit Conclusions:

The 2014/15 audit has reported 95% of all eligible hips and knees had been entered into the NJR at the time it was undertaken, but any missed entries were identified and subsequently entered, giving a patient entry rate of  more than 99%. 

It is inevitable that given the large numbers involved there will be a few patients missed who are neither appropriately coded on a hospital PAS system nor on the NJR. 

It was of some concern that the rate of failure to submit revision cases was almost twice that of primaries.  However, the fact that this has been picked up on and the missing cases entered retrospectively is encouraging.  

The process of carrying out the audits has bought the NJR to focus in some units with previously poor performance and allowed the NJR to forge closer links with individual hospitals.  We have seen a marked improvement in some units’ submission rate, and the process has helped a number of NHS trusts identify internal coding issues which will have had an effect on their income.  None the less the health care environment remains challenging and some trusts have more generalised systemic and financial problems, one manifestation of which is poor NJR compliance.

Looking forward

The Data Quality Committee has recognised that among its more than 2,000,000 records there are inevitably some errors.  A retrospective clean-up of data has been undertaken specifically identifying:

• 2nd primary joint replacement performed on the same side 

• Revision joints performed before a primary

• Incorrectly sided knee implants used 

• Mismatches between hip femoral head size and acetabular cup or cup liner size

• Date of joint replacement after date of death

• Joint replacement in patients ASA grade 5 (expected to die of medical problems)

• Revision on the same day as the primary joint replacement

Where possible, hospitals are being contacted (some hospitals have close in the lifetime of the NJR) and asked to investigate and report on, and where required, correct any entries.  As can be seen from Table 1 the vast majority of cases are errors in data entry, however a small number of head/cup mismatches and incorrectly sided knee implants have been identified and hospitals have been asked to investigate and resolve these.   

*Untraceable records (including those in hospitals that have closed, or patients who are known to have died) are considered resolved and are included in the Other category.

From June 2017 the most serious cases (head/cup mismatch and incorrectly sided knee replacements) are now identified at the time of data entry onto the NJR and an alert message emphasising the serious nature of the issue is flashed on the data entry screen.  All such cases are then followed up by the Regional Co-ordinators using an established pathway to ensure that any genuine mismatches (which are potential Never Events) are not overlooked by either the NJR or the hospital concerned.  Less serious issues are identified in regular data reviews and hospitals asked to review and correct them. 

Members of the committee have also been assisting the Healthcare Safety Investigation Branch in their investigation into the causes of the use of incorrect sided or sized implants in surgery.

The Committee recognised that although the data quality audits have been exceptionally useful in identifying the level of data entry compliance, and bring this up to close to 100%, the effort required to achieve this by both NJR and hospital staff is costly and unsustainable in the long run.  A Data Quality Review Group was established in 2017 and has come up with a number of recommendations to:

a) Streamline and largely automate the current audit process by automatically providing each hospital with a list of patients not entered into the NJR and possible data quality issues on a quarterly basis. 

b) Make it much easier for data entry staff to correct data without compromising the integrity of the database. 

c) In the longer term work on being able to check not just on the fact that an entry has been made onto the NJR but also the quality of the data within each submission. 

The output from this review is now being refined and the details finessed but it is intended that implementation of an automated audit process will start in the second half of 2018 with a gradual roll out over two years.

Data Quality Awards

These are given to those trusts who achieve better than 95% compliance with data entry, participate in the data quality audit in a timely manner and have paid their subscription to the NJR.  Introduced in 2016, these allow trusts to use the Data Quality provider logo and from this year trusts are also provided with a framed certificate.  In the last year X % of trust received the Quality Data Provider Awards, up from Y % the previous year.  The scheme has not only provided trusts with something to show for their efforts but has also proved to be an incentive for those who just failed to qualify last year to improve their performance.

2017/18 Research Chairman’s report - Professor J Mark Wilkinson

NJR Research Committee                                                              

The research committee is responsible for delivering the research agenda of the National Joint Registry. Our aim is to enhance the understanding of the science of arthroplasty, improve clinical practice and benefit public health. This year we are delighted to welcome three new members to the research committee team, Mr Andrew Goldberg who brings expertise in foot and ankle surgery, Dr Jonathan Jeffers contributing his expertise in musculoskeletal biomechanics, and Mr Mike Reed who brings further expertise in lower limb arthroplasty.                                                                                             

Research is the route to improved treatments, and keeping patients at the centre of what we do is a guiding principle for all NJR research activity. In 2017/18 the research committee has overseen a number of significant projects which are nearing completion. Below are details of a small selection of projects amongst a varied programme of work underway.  These projects represent key achievements for the NJR in meeting its aim to maximise the value of the NJR dataset to patients and the wider healthcare community. My thanks to all members of the research committee for their efforts in the past year, whose hard work makes it possible to facilitate data access and support these high quality research outputs.

Patient Decision Aid                                                                        

We are pleased to announce that plans are well established to launch a web-enabled personalised Patient Decision Aid (PDA) for patients considering hip or knee replacement. This simple tool, supported by the charity Versus Arthritis, will help patients considering joint replacement make evidence-based choices about their treatment and share decision-making with their clinicians when considering the benefits and risks of undergoing joint replacement.                                                                                            

This project represents a substantial initiative on the part of NJR members to meet one of our core objectives to improve accessibility of the NJR resource to patients and promote shared, informed and value-based decision-making. Decision aids fill the gap between population level data and its application to the patients’ individual circumstances, to better inform patients making choices about healthcare interventions, enhance patient participation in the process, reduce decisional conflict, and benefit healthcare economies through improved clinical outcomes and better resource utilisation.               

The development and validation of this decision aid has been undertaken in collaboration with arthritis patient groups who have been involved in every stage of the PDA development process, including the focus of the project, selection of input variables, presentation of the output results, and the appearance of the web-based dashboard interface. We have presented interim versions of the models to local and national patient groups and professional forums and received very positive responses. Our goal is that this work translates into a widely-utilised web-based patient resource accessible directly from the NJR and other relevant websites.

Research ready dataset and Data Access Portal                    

Another important milestone for the NJR is the delivery of our ‘research-ready’ dataset and online Data Access Portal which will launch later this year. These resources will enable researchers to utilise the NJR Annual Report dataset more effectively as a research source by providing a cumulative dataset that is annually updated. This approach will foster timely remote access to the dataset for researchers with approved projects. The portal will also enhance the security of the NJR dataset and transparency of published work based on the NJR dataset. We have developed user guidance, which will available on the website when the portal is launched, to aid researchers using NJR data. This guidance also contains a useful list of online tutorials, reading materials and other resources to help researchers analysing more complex datasets for the first time.

Findings of 5-year PROMs analysis                                            

Analysis of the 5-year PROMS data related to serial outcomes is currently taking place. An earlier analysis of the NJR Extended PROMS study was prepared using data collected for 3 years postoperatively and included in the 12th NJR Annual Report (2015). This forms part of the work of the NJR Extended PROMS Working Group, a collaboration between teams at the University of East Anglia, the University of Bristol and the University of Oxford.                                                                                                    

Findings demonstrate the feasibility of collecting long term PROMS data, with an excellent response rate over 5 years in a representative sample. Serial measures of PROMS have been recorded in a cohort of 21,449 THR and 17,849 TKR with assessment taken preoperatively, at six months, 1 year, 3 years and 5 years.  Examining the pattern of joint pain reported by individuals over time suggests that while the majority show a rapid improvement in outcome, around a fifth of patients experience their maximal improvement only after three years postoperatively. By the end of the five-year interval, around a third of patients receiving implants experiences either a relapse or show no improvement. Advancing age, high BMI, depression, multiple morbidity and social deprivation are the main factors that predict a poor outcome. 

There are clear indications from this preliminary analysis that the long-term PROMS provide important information relating to implant performance that is not captured in 6-month National PROMs data. In keeping with other work in this area it is noteworthy that patient related factors (age, BMI, depression and social deprivation) appear to be the main determinants of patient outcome. This will need to be considered if the aim of the register is to equate these outcomes to surgeon, hospital or implant performance. The results justify the value in measuring long term PROMS in evaluating the patient experience following arthroplasty and further follow up of this sample to establish how these trajectories project forward and relate to the need for revision.

Use of NJR data this year

The research committee encourages external use of the NJR dataset to answer questions of clinical relevance and the NJR dataset has provided opportunities for a number of external researchers this year to develop innovative projects. Several of these independent research projects were showcased at the BOA 2017 Annual Congress. During the period 2017/18, the committee sanctioned the release of data to 20 research projects, 10 of which are externally-led projects.

The NJR dataset has been used as the key resource in 11 research papers published during this same time period, of which 8 were conducted or led by external, independent researchers.

Our internal research programme is currently addressing in depth several topics that relate to NJR priorities. In a large scale collaborative national linkage study receiving wide media coverage and published in The Bone and Joint Journal, it was possible to demonstrate the reassuring finding that the risk of cardiac failure following total hip arthroplasty was not increased in patients for who metal-on-metal implants were used, in the first seven years after surgery.

Other topics of focus include a study published in The Journal of Bone and Joint Surgery looking at the implications of introducing new technologies, often used widely without adequate supporting data, a practice that can lead to widespread catastrophic failure such as occurred with metal-on-metal (MoM) hip replacements. We determined both how revision rates would have differed if, instead of receiving MoM hip replacements, patients had received existing alternatives and the subsequent cumulative re-revision rates of the patients who did receive MoM hip replacements compared with alternatives. This study highlights the consequences of widespread and poorly monitored adoption of medical technology and why adopting new technologies without adequate supporting data must not be repeated.

A retrospective observational study was published in The Journal of Arthroplasty, investigating Trabecular metal (TM)-coated acetabular components which are increasingly used in both primary and revision total hip arthroplasty (THA). However, previous studies assessing TM acetabular components have been small single-center cohorts with most lacking a control group. This study compared revision rates following primary THA between TM and non-TM-coated acetabular components. Following primary THA, TM-coated acetabular implants had a reduced risk of revision compared with non-TM implants. Although absolute differences in revision risk were small, they may be clinically significant if TM designs were implanted in more complex cases.

Please see the NJR Research Project Portfolio here on the NJR website which catalogues all sanctioned research projects, progress reports and NJR updates in relation to research using the NJR dataset together with links to all publications related to NJR data.

Research Fellowship Scheme
 
We are pleased to welcome Robert Middleton our 8th appointed Research Fellow who will be investigating the association between frailty and outcomes after primary knee replacement.  This programme is part of our Joint Clinical Research Fellowship scheme run in partnership with the Royal College of Surgeons of England, helping us to support high quality research in orthopaedics. Prospective fellows are encouraged to apply to our rolling programme. We encourage a diverse pool of applicants, including those from the allied health professions and non-clinical backgrounds, to apply. Look out for current opportunities on the NJR website.                                          

Tanvir Khan, outgoing Research Fellow, completed a study looking at periprosthetic fracture and joint replacement. This is the first study to demonstrate the ‘real world’ probabilities of revision for periprosthetic fracture accounting for two competing risks; death and revisions for other indications. Study findings indicate if choosing a cementless stem, for patient groups with a higher risk of periprosthetic fracture the preferential use of stems with a collared design is advocated and caution advised in using anatomic, curved or short stems.

Research is also underway by our two current Research Fellows Jonathan Evans, whose work focuses on benchmarking of hip prostheses, and Richard Craig who is investigating improving outcomes after shoulder joint replacement surgery. To find out more about the Research Fellowship programme and links to current and published work, please see the NJR website.

Submitting a research application

The research committee takes formal responsibility for the release of data for research through an impartial and objective protocol and has oversight of the use and reporting of NJR data by research groups. Our priority is to ensure that any research question justifies access to the data and offers potential benefit to patients. Research should align to the NJR’s priority framework and be feasible, ethical, relevant and methodologically sound.

We have a commitment to uphold the standard and consistency of work that is carried out on NJR data in line with national and international legislation.  Therefore, all requests must also be approved by the HQIP Data Access Review Group for final authorisation of data release. If you would like to submit a research application, the first step in this process is to submit an expression of interest. Invited applications are reviewed by the committee quarterly.

Further information

Full details of the NJR’s research application pathway, together with detailed guidance notes for applicants, can be found at www.njrcentre.org.uk.

Please see the NJR Research Project Portfolio, which catalogues all sanctioned research projects, progress reports and NJR updates in relation to research using the NJR dataset together with links to all publications related to NJR data.

A full list of publications related to NJR data is included in Appendix 4.

2017/18 Surgical Performance Chairman’s report – Mr Peter Howard

Committee name and work

The analysis of the registry data has continued on a six-monthly basis. The sub-committee meets soon after the production of each report, and then again three months later to monitor responses. Each report has seen the identification of further potential outliers based on the NJR’s funnel plot analyses.

From March 2015 the last five years of data was added as an additional analysis. This is examined on a rolling basis, allowing more contemporary practice to be observed, and also offering a reflection of greater data accuracy. It is particularly useful where a surgeon/unit has made a significant change in their implant usage and/or practice.

From September 2018 it is planned to move to using 10 year data, rather than the whole 15+ years, for surgeon and unit analysis. This is in recognition of the greater data accuracy as the registry matures, and again the greater relevance of more contemporary practice.

Annual Clinical Report 

The Annual Clinical Report (ACR) issued to Trusts, Health Boards, independent organisations and units, and to surgeons has been further refined this year. This now shows which surgeons in a unit have accessed their own annual report (intended for use in appraisal) via Clinician Feedback. The funnel plots also show the surgeon identifiers to facilitate unit based data scrutiny.

Management process of potential Surgeon Outliers

The process for managing surgeons whose data shows a standardised revision or mortality ratio significantly greater than the expected has evolved over the last six years. It has been formally reviewed and documented this year, and agreed through the Medical Advisory Committee.

BOA external reviews

The NJR SPC has identified several units where long term performance has persistently shown higher than expected revision rates (above 99.8%, alarm or outlier status).  Some of these units have also subsequently shown to be at alarm level on the last 5 years’ data as well, indicating that any remedial action that might have been taken has not been effective.

Any such units have received a recommendation from the NJR SPC, to their Medical Director, that they seek a review from the BOA, which now has an established mechanism for this. The SPC chair liaises closely with the BOA over this with regard to the data, but is independent of the review process.

2017/18 Implant Performance Chairman’s report – Mr Peter Howard

The Implant Performance Committee comprises members of the Scrutiny Group together with representatives from industry. The Scrutiny Group includes surgeons, representatives from the MHRA, Northgate Public Services, the University of Bristol and the NJRSC Chair. Both groups are supported by the NJR management team based at HQIP.

Examining the data

The NJR data is refreshed and analysed every six months. The Scrutiny Group assesses potential outlier implant performance and notifies the MHRA when there are concerns. This process is refined constantly and, as a result of recent reviews, it is likely that more comprehensive reports will be developed for the future.

An implant (and implant combinations in hips) is considered as a potential outlier when there are more than 100 cases and the overall revision rate (based on the patient-time incidence-rates (PTIR) is more than twice the expected rate, using non-overlapping confidence intervals for statistical significance. When an implant has been notified to the MHRA because of its poor performance, once a period of three years has elapsed then data for the whole NJR is analysed to give baseline PTIRs with the outlier data excluded. This is similar to the method used in assessing surgeon performance.

Notification from surgeons of poor implant performance

We continue to encourage surgeons who have concerns about any implant brand or a particular range within a brand to contact us directly. This enables us to focus on a specific area that might otherwise be camouflaged by the overall brand if the remainder is performing well.

Data from the other major joint replacement registries is always monitored and used to provide areas of focus for our analyses.

Future development

As always, we are looking to improve our skills at identifying poor performance, whilst at the same time identifying excellent performance.  The development of the international database of implant attributes is now established and is being populated with data from the implant companies. The greater granularity of the data will facilitate closer scrutiny of the implants and their sub-types.

Implants and combinations identified as outliers

Details of implants and combinations identified as outliers are again included in Part 4 of this year’s report. There have been two new notifications to the MHRA in knee replacements in the last year, two hip acetabular component, one hip stem, and three hip stem/cup combinations. Two of these were largely metal-on-metal.

2017/18 Editorial Board Chairman’s report - Mr Martyn Porter

The role of the Editorial Board is to facilitate NJR communications and dissemination of key findings. The main outputs are the annual report, Public and Patient Guides and the NJR website.The Editorial Board is accountable and report to the NJR Steering Committee. 

Over the years the format of the annual report has changed. Part 1 is the formal account of the process and activities of the NJR and its various sub-committees within the last financial year. Most of this material is now available online. Part 2 is a descriptive analysis of NJR data demonstrating demographic data and activity trends. This is wholly available online. The data is filterable to allow end user based enquiries. Part 3 is the analysis by the University of Bristol and contains detailed information on implant performance and survivorship.

The Editorial Board develop the strategy and style of the report and all members take responsibility for producing a report that is rigorously edited and reviewed.  The continual development of the interactive NJR Reports website has enabled users to interrogate the data to produce tailored reports for clinical activity. This has reduced demand on the published report and created more interaction from the public, as well as offering the potential for more detailed data to be available electronically. 

Enhancing the digital format 

With the continued development of the NJR Reports website, members of the Editorial Board provided invaluable contributions towards the interactive filter options offered in the presentation of clinical activity data for all joint types. The intuitive, flexible options help readers to engage with the data presented and have been well received by users of the NJR Reports website. Years 2015/16 also saw the inclusion of the interactive NJR’s Public and Patient Guides to joint replacement surgery on the website (see below).

Promoting the 15th Annual Report findings

Other achievements for this year included the launch of the 15th Annual Report at the BOA Congress in Birmingham in September 2018 and securing coverage in the relevant key trade magazines/ news outlets about the report's findings. 

Public and Patient Guide progress

The Editorial Board has been particularly pleased to see the continued development of the NJR’s Public and Patient Guides to joint replacement surgery (PPGs) in conjunction with the NJR Patient Network. With input from the Patient Network, five editions of the public and patient guide (PPG) have been produced, which continue to offer the NJR the ability to tailor the information provided to address differences by surgery type.  This remains particularly important as the data grows for ankle, elbow and shoulder replacements by allowing the patient guides to remain manageable in terms of size and format for the years to come. 

The Editorial Board acknowledges that the guides’ readership still only represents a small proportion of pre-operative patients annually. However, anaylsis of the number of downloads and views of the interactive PDFs to the PPGs show that they are a popular resource which we can expect to grow as the demographic requiring joint replacement becomes even more technology literate. Each hospital who reports to the NJR is sent one copy of each relevant PPG with an enclosed cover letter encouraging units to contact the NJR Centre for further copies.

There will be engagement with Patient Network members throughout 2018/19, most specifically to ensure that additional NJR patient focused resources are appropriate.  For example, the Patient Network helped to redesign the NJR’s patient information leaflet. 

Aligning in-depth studies and research interests

The Editorial Board has always supported an in-depth research study programme and is delighted to see the developments in the NJR’s approach to research and the strategic direction being shaped by NJR Research Sub-committee Chairman, Professor Mark Wilkinson. I would particularly encourage you to explore the research published since the last annual report on ethnicity and joint replacement  and the main cause of death following primary total hip and knee replacement for osteoarthritis.

The NJR Reports Website

The website is continually reviewed and updated to reflect the requirements of NJR reporting.

2017/18 NJR Medical Advisory Committee Chairman’s report - Mr Martyn Porter

The NJR’s Medical Advisory Committee meets quarterly to provide clinical leadership and oversight to the registry’s work and provide a forum for discussion and engagement with the profession through specialist orthopaedic societies.

In addition to the NJR Steering Committee and NJR Regional Clinical Coordinator Sub-committee, surgeon members, representatives from industry, and representatives from the British Hip Society, British Association for Surgery of the Knee, British Foot and Ankle Society and the British Elbow and Shoulder Society also attend.

Key areas of consultation with the Medical Advisory Committee in 2017/18 have included:

• Development of the NJR accountability and transparency model

• Continued initiatives to improve NJR data quality

• Minimum dataset changes

• GIRFT 

• Model hospital

• PHIN

• NJR component database changes

• MHRA expert advisory group activities

• Consultant outcome publication

• Using NJR data as part of annual appraisal

• Supporting regulation and service review

• Other orthopaedic registries (TORUS)

2017/18 NJR Executive Committee report - Laurel Powers-Freeling 

The NJR Executive committee meets monthly to provide additional operational capability to the NJR Steering Committee’s strategic and governance role. The committee membership alternates on a bi-monthly basis between a ‘core group’, comprising the NJRSC Chairman, NJR Medical Director and NJR Director of Operations, and an ‘extended group’ with additional representatives comprising Chairman of the Sub-committees and main contractors, as required. Please see the online appendices for a record of members.

Importantly, the Executive Committee has delegated authority from the NJRSC on operational decisions under a financial threshold of £50,000 and where projects constitute a change in the strategic direction of individual work streams and projects. 

Given the expansion of the NJR’s work in recent years, as set out in the refreshed NJR Strategic Plan for 2015/18, this committee has already provided invaluable support. It is essential that the registry can remain flexible and responsive as stakeholder requirements and demands change.

2017/18 NJR Steering Committee

This section provides brief outlines of the work undertaken by the NJR Steering Committee (NJRSC) and its sub-committees during 2017/18. Although brief, these sections intend to demonstrate the ever-increasing scope of the registry’s work and the commitment required by its members to meet the needs of its orthopaedic stakeholders.

Structure, governance and operating model

The NJR Steering Committee is a NHS England Committee of Experts and is responsible for the work and progress of the NJR.

Membership 2017/18

During this reporting period, there have been some changes to the membership of the NJRSC. Members leaving the NRJSC included patient representative member Sue Musson and industry representatives, Nick Wishart and Michael Green. Members who were granted extensions to their membership of the NJRSC included Mr Peter Howard and Professor Amar Rangan, surgeon members, until May 2020 and May 2021 respectively; Mr Rob Hurd, NHS Trust management representative until June 2020; Professor Mark Wilkinson, public health and epidemiology representative to January 2022 and Gillian Coward, patient representative to September 2022.

Also Mr Martyn Porter, NJR Vice Chairman and Medical Director, was granted an extension to his membership until December 2018, when his final term will come up. Work is now underway with the Department of Health’s Appointments Team to recruit Martyn's successor, as well as a new patient member to replace Sue Musson.

New member appointments included Professor Mike Reed as a surgeon representative, Professor Karen Barker as Practitioner with a special interest in Orthopaedics representative; and Sandra Lawrence and Jeff Stonadge as Orthopaedic Implant Manufacturer representatives.

NJR is thankful to all of its members, past and present, for their considerable contribution to the registry. 

The membership of the NJR Steering Committee and membership of all sub-committees for 2017/18 can be found in online appendices. Further information can also be found in the Chairman’s introduction.