Work of the NJR Committees

NJR Data Quality Committee (DQC) 
Chair’s report 2023/24 - Mr Derek Pegg 

During 2023/24, we have continued to focus on completing our annual data quality audit for the current audit year, alongside supporting hospitals to complete audits for any outstanding years. We continue to see the benefits of the automated data quality audit process, introduced in 2019, that has enabled hospitals to review their data more regularly and to complete audits in a timelier manner. 

There remain a few hospitals where compliance and engagement with the annual audit cycle has been consistently poor. There are often multiple issues within such hospitals and so the NJR will continue to support them as much as possible to achieve the data quality of many of their peers. We have reviewed our escalation process that is in place for poorly compliant trusts, to help clinicians access appropriate support. 

One of the main changes during 2023/24 has been the introduction of the new three-tiered data quality provider award scheme. This new scheme awards hospitals with a gold, silver or bronze award to further encourage them to aim to achieve high levels of compliance. From a total of 418 hospitals, 291 qualified for an award with 221 hospital teams receiving gold (52%), 42 receiving silver (10%) and 28 (7%) receiving bronze. Work is continuing to ensure that all hospitals fully understand the new award criteria and that there is NJR guidance and support for those hospitals that did not qualify for an award in the first three-tier award programme to enable them to meet the criteria for the current award cycle.

In August 2023, the NJR commenced an audit to retrospectively check and improve the volume and quality of the registry shoulder replacement data. Following a comparison of shoulder records between the NJR and HES data capture, approximately 15,000 procedures have been flagged as unmatched, and potentially missing from the registry. Work is ongoing and at May 2024 42 trusts and IS hospitals have completed the audit and 2,604 procedures have been added to the registry. Registration to participate in the audit closes in June 2024 with a deadline for hospitals to complete the audit and enter any missing procedures by 31 October 2024. We would like to thank Mr Jaime Candal-Couto, who is leading this work for the NJR, in collaboration with BESS and BOTA.

The NJR Data Quality Committee has developed a new strategy to cover the timeline of 2024 - 2027 which builds on the previous strategy published in 2020. Improving data quality is one of the key supporting themes of the NJR Strategic Plan and the new strategy focuses on four key areas: 

1.    Case ascertainment
2.    Data accuracy
3.    Minimum data set development
4.    Interfacing with other data sources

These four areas continue to develop the work of previous strategies, to work with hospitals to improve compliance with the core data quality audit and to conduct further spotlight audits to address specific areas of concern. This will include component data held within the NJR component database. The high-level strategic priorities developed will be used to inform the NJR Annual Plan over the coming three years.

Future plans

For the 2024/25 data quality audit year, additional OPCS codes will be included in the audit to identify DAIRs procedures and hip hemiarthroplasty procedures. 

Work will commence during 2024/25 to identify OPCS codes for periprosthetic fractures for inclusion in the data quality audit in future years.

Following completion of the shoulder audit, work will commence to plan a comparative audit of ankle procedures. 
 

NJR Regional Clinical Coordinators Committee (RCC)
Chair’s report 2023/24 - Mr Derek Pegg

The RCC Committee acts as a collaborative interface between the NJR and a diverse, active and regionally representative group of orthopaedic surgeons. Members provide useful observations and suggestions from their own regional community and act as a ‘sounding board’ for new ideas with NJR strategic policy direction. Members also highlight issues that may arise on a day-to-day basis and suggest potential constructive solutions.

Examples include the new Minimum Data Set version 8 (MDSv8) launched in Summer 2023; a particular development activity where RCC input has enabled hospitals to manage the system, upgrade changes and feedback to the NJR wider team on resolving local challenges. Improvements noted in poorly performing hospitals as regards achieving compliance and other quality indicators - consent and link-ability have often been due to the RCCs encouraging and supporting some non-compliant hospitals to improve and avoid advancing on the NJR’s newly updated escalation process. RCCs have provided support feeding into the design and advocating various data quality initiatives, including dual mobility hip, shoulder and debridement with implant retention (DAIRs) audits.

The RCC members provide excellent advice in their two-way communication with hospitals, providing feedback on any contemporary NJR activities and helping to facilitate remedial action where practice and performance may have been of concern. They have also raised several locally addressed topics that other members have then been able to offer greater clarity on and address suggested solutions to any challenges through an exchange of ideas and best practice examples; as well as continually supporting individual surgeons and hospitals in their regions who have faced challenges.

Most future meetings are likely to continue using online video conferencing facilities. However, as for other NJR committees, it is highly desirable to have at least one face-to-face meeting a year, to enable the opportunity for us all to meet any new RCC members and for extended, usefully engaging interaction, and this will take place for our committee once at least every twelve months.

Over the last twelve months, the RCC committee has seen three members complete their terms of appointment and one step down. We thank Mr Divya Prakash, Mr Sudheer Karlakki, Mr Koldo Azurza and Mr Michael O’Connor for their service and wish them well. We are very pleased to have had six new members join the committee in August 2023: Mr Sulaimann Alazzawi, Mr Rahij Anwar and Mr Jerome Davidson, who are representing the London region and Mr Murali Krishnan, Mr Kiran Singisetti and Lt Col Charlotte Tunstall, representing the North East and Yorkshire area, enabling further coverage across the NJR’s wide geographic regions. (This has been particularly useful for the London area). We are also looking forward to seeing some of the RCCs serve on other committees, across the NJR, in the future.

We continue to recruit to vacant positions and trust that we will fill these with enthusiastic and experienced surgeons who will also be a great support to the hospital staff in their respective regions. Finally, I am extremely grateful to all the RCCs, for their valuable input and their continued commitment to the NJR.
 

NJR Editorial Committee (EdCom)
Chair’s report 2023/24 - Professor Mike Reed

The NJR Editorial Committee brings together a range of contributors to plan and develop our report content collaboratively. This collective includes expert clinicians from the orthopaedic specialist societies for each joint, representatives from our experienced data collection and statistical analysis reporting teams, as well as valued input from our patient and industry representatives, alongside input from senior members of the NJR Management Team, to enable the considered development and subsequent publication of the report each year. We time our planning for the report publication to be the autumn of each year at the British Orthopaedic Association (BOA) Congress event, and it is launched within the NJR plenary session at that event within a programme of presentations showcasing the wide range and impact of our work. 

The Committee develops the report content development strategy and style with all members taking responsibility for producing a report that is rigorously edited and reviewed, taking almost a full year to consider and prepare the content, design the layout, write all of the numerous report sections and review all final content across the team. 

The Editorial Committee has always supported the NJR’s research study programme and is delighted to see the developments in the NJR’s approach to research with the strategic direction being shaped by NJR Research Committee Chair, Professor Mark Wilkinson. Summaries of some of the most recent NJR-supported research papers that have used the NJR data are published within the report and on the report website and we will also feature posters of some of this work in the NJR Session and on the NJR stand at the BOA Congress in Birmingham in September 2024. In addition, we would particularly encourage you to explore research using NJR data that has been published since the last annual report which you can find here.

Each year we aim to make new progress in reporting, using our rich data resource, making data easily accessible in our aim to help to improve patient outcomes. The analysis contains detailed information on implant performance and survivorship up to a maximum of 20.75 years. Details of implant and unit-level activity and performance can be found in more detail in the specific document in the Downloads area. 

This year, we have transitioned fully to the use of the new NJR component classification for the first time, therefore the time taken for our team to undertake the data analysis is taking longer than is usual. Adopting this new classification means that we will benefit from more granular data on joint replacement devices and also reduce the number of implants that we cannot analyse due to unvalidated construct data.

For this reason, we are publishing this year’s Annual Report as a series of sub-reports, each representing the joint sections that have previously formed chapters in the full NJR Annual Report. Following the complete publication of all of the sections of the report, we will canvass our stakeholders for feedback on how well this approach has worked, and thereafter the Editorial Committee will take a view on how best to publish subsequent Annual Reports. Analysis by the talented and committed team at the University of Bristol on each joint will be placed on the homepage of our dedicated website as each joint outcomes analysis becomes available, so we will be advising the schedule at the start and visitors can thereafter check the site for the date of publication of the analysis for each joint. 

Enhancing the online digital format

With the continued progress of development of the NJR Reports website, alongside the demise of printed publications more generally, the NJR Executive and Editorial committees previously made the ecological, cost-saving decision to only publish the Annual Report on our online website, so we do not now have any print copies available. Sharing the report online makes having each joint section of the report more easily navigable and accessible through the dedicated tiles on the report website or as downloadable files, which can all be found here.

Descriptive analysis of the NJR’s demographic data and activity trends can also be found by using the above link to the site. The data is filterable to enable user-driven enquiries and members of the Editorial Committee 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 and have been well-received by visitors to the NJR Reports website, and we will review and strengthen this report website further each year, as we work on the future introduction and enhancement of the report in an HTML format.

The 21st NJR Annual Report website will be formally launched at the BOA Annual Congress in Birmingham that takes place this year 17-19 September, during the NJR Session that will be held on Wednesday (18 September) morning from 8:30 - 10:30 am. We hope that you have been able to join us this year.
 

NJR Research Committee (RC)
Chair’s report 2023/24 - Professor J Mark Wilkinson

The Research Committee is responsible for delivering the research agenda of the NJR. The committee’s aim is to enhance the understanding of the science of joint replacement improve clinical practice and benefit public health. Research provides the route to improved treatments and keeping patients at the centre of what we do is a guiding principle for all of our research activity. My thanks go to all members of the committee for their efforts in the past year and for their hard work which makes it possible to facilitate data access and to support these high-quality research outputs. After nine years of service as health economics member of the committee, we thank James Mason for his years of service to the committee and wish him well for his retirement.

Whilst our business-as-usual activities continue throughout the year, including research application review, the data access portal, and publications outputs - please download the NJR Research Project Portfolio here that catalogues research projects, progress reports and NJR research updates, together with links to all publications related to NJR data, I would like to take this opportunity to highlight below some of this year’s particular highlights and developments.

Broadening data linkages

In 2022 the NJR was awarded £60,000 by Health Data Research UK to map our dataset to the Observational Medical Outcomes Partnership Common Data Model as part of the European Health Data Evidence Network. We are pleased to report that this mapping exercise is now almost complete and will allow the NJR dataset to be linked with over 180 data partners across 29 countries that are mapping their data to this common model. Closer to home, we continue working on agreements to allow greater value to be gained out of the NJR dataset through other data-sharing partnerships.

Research fellowship scheme

We are pleased to welcome Ben Gabbott in his appointment as the first Research Fellow to the joint NJR/ORUK/Royal College of Surgeons of England research fellowship programme. Ben is investigating the effect of mental health on knee replacement outcomes. 

In January 2023, the NJR Board also approved funding for the development of a Non-Clinical Researcher PhD fellowship. This award recognises the wealth of expertise within our specialty that lies with non-clinical scientists, without whom orthopaedics would have seen only a fraction of its current level of development over the decades. The award is aimed at non-clinicians who wish to study towards a PhD on any topic within the field of joint replacement providing the project has at its core use of the NJR dataset to address the question of interest. Elsa Marque has been awarded this year’s studentship and will be investigating incorporating socio-demographic and economic inequities in the clinical and cost-effectiveness evaluation of hip and knee replacement implants: outcomes, costs, and cost-effectiveness for different implants in primary elective total joint replacement.

NJR annual research programme

Building on many high-quality publications over the years, we continue to develop our annual research programme. Current projects include: inequalities in provision and outcomes; the development of a joint replacement morbidity index; examining factors associated with revision and its outcomes and an examination of the data quality of the national PROMs programme. As projects complete, new topics are brought on-stream. All projects are delivered in a collaboration between the NJR Research Committee and our statistical analysis partners.

Artificial Intelligence (AI) research

The NJR recognises the strengths, and limitations, that artificial intelligence brings to our field of study. We are pleased to announce that the NJR has recently appointed our second machine learning PhD studentship to address the limitations of current AI models in predicting implant and patient survival. We congratulate Naveen Bawan Muraleetharan on his appointment to his three-year PhD studentship on this topic.

NJR benefits

In our NJR 20th anniversary year, our patient representatives, the clinical leadership and NJR management team, together with the Lot 1 and Lot 2 contractors, reflected on the impact and value that the NJR dataset has brought to joint replacement healthcare, both within the UK and beyond. These benefits were summarised in a series of articles published in the Journal of Trauma and Orthopaedics (JTO), and covered the benefits to patients, hospitals, surgeons, industry, service commissioners, regulators, policy-makers, and broader society, and are also summarised on a dedicated page that can be found on the NJR website.

Submitting a research application

The Research Committee takes formal responsibility for the approval for the release of NJR data for research, through an impartial and objective process and has oversight of the use and reporting of this data by research groups. Its priority is to ensure that any research question justifies access to the data and offers potential benefits to patients. Research proposals should align with our 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 using registry data, in line with both national and international legislation. Therefore, all requests must also be approved by the Healthcare Quality Improvement Partnership (HQIP) Data Access Request Group for final authorisation of data release.

Further Information

If you would like to submit a research application, the first step in the process is to check whether the proposed topic is currently being examined by another research team by visiting the NJR Research Project Portfolio. If it is not, you can submit an expression of interest for consideration via research@njr.org.uk. Invited full applications are reviewed by the committee quarterly. Full details of the NJR’s research application pathway can be found here and please refer to the recording of our research webinar for full guidance.
 

NJR Surgical Performance Committee (SPC)
Chair’s report 2023/24 - Mr Peter Howard

The Surgical Performance Committee (SPC) comprises its Chair, Vice Chair, the NJR Medical Director, RCC Chair, surgeon representatives from the RCC committee, Care Quality Commission (CQC) representatives, a patient representative, representation from the NJR Management Team and representatives of both Lot 1 and 2 NJR contractors.

We have continued with the schedule of two data reviews each year, assessing performance over the previous five and ten years for both units and surgeons performing hip and knee joint replacement. 

NJR Annual Clinical Report and Consultant Level Report

Further changes and updates were made once again this year to the Annual Clinical Report (ACR) provided for all trusts, health boards and independent hospitals and to the Consultant Level Report (CLR) provided for consultant surgeons. These reports are accessible through the NJR Connect - Data Services portal. In addition, as part of NJR Connect hospitals are now able to access a wider range of information around hospital performance via management feedback. 

Clinician feedback now contains a tab for the Implant Library, where the Kaplan-Meier survival of all hips (currently shown separately for cups and stems), knees, ankles and shoulders are displayed in tabular form.

Implant mismatch, “never events”

We are continuing to alert surgeons and hospitals to the continuing but relatively rarely occurring mismatches. This alert process is well embedded and is monitored regularly by both the SPC and NJR Data Quality Committee. This currently covers side mismatch for knees, articulating size mismatch for hips and mixing of hip head and stems from different manufacturers. The implant scanning tool, available for hospitals to check implant compatibility in real time in theatre has been in use over the past year; as adoption by more hospitals increases, it is hoped this tool will help to reduce the overall numbers of “never events”. 

Future plans

During 2024/25 the NJR will start to introduce shoulder manufacture mix and match for primary procedures as part of the never event process. Also planned is some size mismatch alerts for knees Further work will be undertaken to roll out procedure outcomes at both trust and geographical level to help improve hospital performance. 

The NJR plans to expand our Accountability and Transparency model to include elbow, shoulder and ankle performance metrics for all hospitals and surgeons. Following completion of the shoulder audit, it is anticipated that this will commence with shoulder outlier analysis. 

The implant library will be expanded to show the KM survival graphically against the expected for the class of implant, and to include hip stem/cup combinations.

Finally, I will be stepping down as SPC Chair later in the year, with Mike Reed appointed to take over.
 

NJR Implant Scrutiny Committee (ISC) Chair’s report 2023/24 - Mr Peter Howard

The ISC comprises its Chair, Vice Chair, the NJR Medical Director, surgeon members from the RCCs committee, a patient representative, representatives from the NJR’s core contractors: University of Bristol (our Lot 2 providers), NEC Software Solutions (our Lot 1 providers), representatives of the Medicines and Healthcare products Regulatory Agency (MHRA), representatives from the NJR Management Team and from the Orthopaedic Data Evaluation Panel (ODEP)/Beyond Compliance. 

Examining the data

The registry data is refreshed and analysed every six months. The committee assesses potential outlier implant performance and notifies the MHRA when there are concerns. In addition, the committee also responds to any queries and concerns raised by surgeons and regulators, undertaking additional analysis to investigate and report on these where necessary.

To date, the Patient Time Incidence Rate (PTIR) method has been used by the NJR to identify poor performance, (in line with other registries) however it became apparent that this method alone was not sensitive enough to identify failure in sub-groups or in the longer-term, and in some cases missing out on relatively early poor performance. Over this year a new statistical methodology has been developed using Kaplan-Meier estimates and tested alongside the existing method with the aim for the NJR to move to this entirely by the end of 2025. An updated NJR Accountability and Transparency model for implant outlier monitoring will be published to reflect these changes, and engagement will take place with industry and key stakeholders.

A review of implant branding across the NJR continues, to ensure consistency across manufacturers and enable a more consistent stratification of implants as part of outlier analysis.

Future developments

A working group is currently developing the processes and methodology to enable us to monitor the performance of shoulder implants more closely, in line with the current processes for hip and knee implants. This key development will ensure the NJR’s commitment to deeper levels of scrutiny in relation to implant performance.   The committee will continue to work closely with EPRD (the German registry) and ISAR (International Society of Arthroplasty Registries) on the development of an international shoulder component classification, having now agreed and adopting a comprehensive classification for hips and knees.

NJR Medical Advisory Committee (MAC)
Chair’s report 2023/24 - Mr Tim Wilton

My thanks, as always, are due to all members of the committee who have continued to provide excellent and thoughtful advice about how the NJR can improve our analysis and information in order to maximise the benefit to both patients and surgeons in the field of joint replacement. The MAC provides a conduit for the exchange of information and opinion about what is working well, and what might be improved in all aspects of NJR work. In particular, I thank the presidents of the BOA and specialist society associations for their work and time attending the MAC meetings during the past year and providing this two-way channel of communication which is so vital if we are to keep fully up to date.

The committee has met three times in the past 12 months, with a combination of virtual and face-to-face meetings, as is now our usual practice. Matters forming important parts of our deliberations have included mechanisms for improving NJR data completeness and quality and how best to ensure that those hospitals which are not meeting the required data quality standards can best be helped to raise their game.

There has been an ongoing debate about how to improve the communication and responsiveness of our systems when individual implants or variants have been found to be performing less well than expected, and this has resulted in much better and more regular feedback of progress reports from MHRA to the NJR and the MAC members, and vice versa.

The main problem facing the NJR for the last two years has been the inability of NHSE to provide the access that we need and expect (and for which we have the necessary permissions and subscriptions) to other datasets such as HES data, Civil Registration data and national hip and knee PROMs data. This has become such an acute problem that it impacts our ability to provide routine comparative data about implants, hospitals and surgeons. It has been extremely helpful to have the help of the orthopaedic associations in MAC to support our representations about this issue to NHSE, as as it is of great concern in particular that we no longer have an understanding of the patients’ perspective of outcomes of their surgical procedures.

The MAC has been an important focus this year for informing the community about the developments of the Outcomes and Registries Programme (ORP) and the effects that may have on the way in which NJR is able to feedback information to the orthopaedic community. At present, we have the assurance of the leaders of that initiative that no changes will be taking place to the NJR in terms of moving our data collection and analysis systems into a more dependent physical or functional alliance with the ORP until the systems of the ORP itself have been shown to be as effective, complete and robust as the NJR systems that we already operate. I thank the MAC members for their continuing support in this regard as it will be clear to all that even a relatively brief hiatus in our ability to collect comprehensive data in the way we have been doing for many years would have a potentially devastating effect on our future reporting due to the long-term nature of the outcomes that we measure.

The position of SAS doctors who conduct an independent joint replacement practice was raised again due to concerns about whether these surgeons were being disadvantaged by having less good access to the data regarding their cases than is the case for consultants. The position was clarified following debate, and a formal position statement was produced and agreed, setting out the position of these surgeons and which surgeons are able to have their own surgeon-level reports reflecting their own practice, alongside emphasising the support of the BOA and the specialist societies for the policy regarding such reporting.

Useful feedback was received from members about difficulties with implementing some aspects of the new Minimum Data Set, for example with respect to dual consultant operating and the complexity scoring systems for cases which have been introduced. These discussions have enabled a greater degree of clarity in how the data should be entered, providing a consistent application across the country.

Concerns had been raised as to whether the issue of Field Safety Notices (FSNs) by the regulator was being achieved at a sufficiently early point in the lifetime of a device which was felt to be performing poorly. There were also concerns expressed by some members about whether the wording of those FSN documents always contained sufficiently explicit instructions about what advice should be given with regard to follow-up arrangements for those cases where such a device had already been used. Following the debate it was concluded that the type of alert, and the decision to issue such alerts (of which there are three distinct alert levels), was clearly a decision for the MHRA. It was agreed that closer liaison between the BOA, NJR and MHRA would be appropriate so as to ensure that the wording of FSNs could be agreed in advance, so that the possibility of confusion amongst surgeons and patients about how best to proceed would be minimised.

I believe that the deliberations and communication between the NJR and our important clinical stakeholders through the MAC is vital to the continuing improvement and utility of the NJR service. This will be further improved by our latest new recruits: the President of the UK Society for Computer Assisted Surgery (CAOS UK), Dinesh Nathwani, who we welcomed to the committee in November 2023; Rob Pollock, President of the British Orthopaedic Oncology Society (BOOS), from March 2024; and Alan Middleton, President of the British Orthopaedic Directors Society (BODS), who we will be welcoming at our July 2024 meeting.

My thanks to all involved.
 

NJR Executive Committee (NJREC) 
Chair’s report 2023/24 - Professor Sir Paul Curran 

The NJR Executive Committee (NJREC) meets quarterly to provide additional operational and financial capability to the NJR Board’s broader strategic and governance roles. As such it facilitates faster decision-making across the large and complex range of NJR business. The committee is led by Chair, Professor Sir Paul Curran and in 2023/24 four meetings of the NJREC were held.

The committee membership comprises the NJR Chair, NJR Medical Director and NJR Director of Operations, and additional representatives comprising the NJR Board committee chairs, senior representatives of the NJR Management Team, as required, and representatives from NJR contractors. Please see the online appendices for a record of members.

Importantly, the NJREC has delegated authority from the NJR Board for operational decisions that are under a financial threshold of £50,000 and for review and approval of proposed projects and developments that constitute a change in the strategic direction of individual workstreams and previously agreed project plans. 

Given the expansion of the NJR’s work in recent years, as set out in our NJR Strategic and Annual Plans, the committee has consistently provided invaluable support to the NJR Board.
 

NJR Board (Previously NJR Steering Committee)
Chair’s report 2023/24 - Professor Sir Paul Curran

This section provides a brief outline of the work undertaken by the NJR Board and our committees during 2023/24. Although brief, these sections are written with the intent of illustrating the ever-increasing scope and complexity of our work and the valuable commitment made by all NJR Board and committee members to ensure the work of the NJR meets the needs of our patient, clinical, regulatory and industry stakeholders.

NJR Board structure, governance and operating model

The NJR Board is designated as an NHS England (NHSE) ‘Expert Advisory Committee’ and is responsible for overseeing the strategic direction and management of the NJR. Oversight of the NJR and its funding arrangements, rests with the NHSE Medical Directorate who provide delegated authority to the Healthcare Quality Improvement Partnership (HQIP) to ‘host’ the NJR on their behalf and so provide the NJR with its legal identity, data controllership and governance arrangements. HQIP also acts as service provider to the NJR, providing operational services including finance, human resources and procurement.

A Scheme of Delegation between the HQIP Board of Trustees and NJR Board provides a framework for defining the relationship between both organisations and facilitating the effective separation of legal governance and clinical leadership.

Joint NHSE/NJR/HQIP accountability meetings are held quarterly; the NJR Chair, Medical Director and Director of Operations, represent the NJR and provide assurance, primarily on strategic matters relating to its advice. The NJR Chair also meets with the NHSE National Medical Director for strategic level discussions at least twice yearly. 

Meetings between the NJR and NHSE Outcomes and Registry Programme [ORP] are held on a bi-monthly basis, to discuss issues of alignment and partnership between both parties, related to the national outcome registry platform and data development. The NJR Chair, Medical Director and Director of Operations represent the NJR.

The NJR Board meets quarterly and is responsible for setting our strategic direction and for overseeing the successful delivery of our work and closely managing the associated budget. The Board also oversees a supporting structure of our eight committees, each responsible for a dedicated area of NJR work and ensuring the delivery of work plans and development of activities against agreed objectives. All committees are accountable to the NJR Board.

Key responsibilities of the NJR Board are to ensure that:

•    Advice is provided to NHSE Medical Directorate and HQIP, as appropriate, on the NJR’s strategic direction, annual  operational plan, work activity and financial position (including annual review of subscription charges and any proposed change).
•    Appropriate advice is provided to NHSE Medical Directorate and HQIP on any financial and/or intellectual property implications associated with licensing of the ‘NJR’ brand, particularly related to international collaboration with other national orthopaedic joint registries.
•    Accurate, relevant and timely data collected by the NJR, is made available to relevant stakeholders (regulators, commissioners/providers of orthopaedic healthcare) in an appropriate format, in order to support clinical governance.
•    Appropriate stakeholders (regulators, professional societies and implant suppliers) are involved in and consulted on the work of the NJR as appropriate and informed of outcomes in joint replacement surgery.
•    The NJR budget is effectively managed and monitored.
•    The NJR committee structure is fit for purpose and all committees have clear terms of reference, agreed composition and defined purpose and responsibilities.
•    Outcomes achieved by brand of prostheses, hospital and surgeon, are monitored and, where they fall below expected performance, are highlighted to enable prompt investigation and follow-up by relevant stakeholders (implant suppliers, regulators, commissioners/ providers of orthopaedic healthcare).
•    Patient awareness of joint replacement outcomes is enhanced, to better inform patient choice and quality of experience, through engagement with patients, patient organisations and providers of care.
•    Evidence-based purchasing (quality and value) of joint replacement implants by healthcare providers is supported.
•    Post-market surveillance of implants by key stakeholders (implant suppliers, the Regulator, Beyond Compliance) is supported. 
•    Delivery and quality of work by NJR contractors and the codes of conduct applied to NJR contractors in their relationship with key stakeholders, are effectively managed and monitored by the NJR Management Team.
•    The Annual Report on the work of the NJR is published in English and Welsh (and languages appropriate to any future countries that may be incorporated into the NJR) using patient-friendly language.