Work of the NJR Committees

2018/19 Regional Clinical Co-ordinators (RCC) Committee Chairman’s report - Mr Matthew Porteous

The RCC committee continues to serve in its role as the link between the NJR management team and the surgeons and hospitals on whom the NJR depends for acquiring its data and to whom it reports back on performance. Over the past decade the role has evolved from one that required much assistance to local hospitals struggling with data input, to a lighter touch as the volume and proportion of joint replacements entered has risen to close to 100% with the data quality audit initiative.  RCC’s continue to play an important role in those relatively few hospitals that do have issues and have been exceptionally helpful in assisting individual surgeons and units who have become alarm level outliers.

The committee has served as a useful sounding board on policy and development, and many of their suggestions have been incorporated into the feedback we provide to surgeons and units.  This also works in two directions as they are able to feed this back to their regions, both at local meetings and by participating in the rolling series of regional meetings run by the NJR on a six-monthly basis.

Recently, with an eye to succession planning, additional surgeon members have been recruited from the RCC committee to other NJR sub-committees including Surgical Performance, Implant Scrutiny and Data Quality.  Members have also been involved in the scan for safety project. 

The gradual evolving role the RCC committee has meant that it has been restructured, reducing the number of representatives for each region from two to one (by natural wastage) though job sharing by two surgeons from one region is welcomed, particularly where they have different specialist interests.  This reduction has been partially offset by each of the specialist societies (BHS, BASK, BESS and BOFAS) being asked to nominate an appointee to the committee in order to ensure that specialist representation is more evenly spread than it has sometimes been in the past.

2018/19 Data Quality Committee Chairman’s report - Mr Matthew Porteous

2018/19 has been a busy year for the data quality committee.  At the time of writing we are very close to completing our audit of data for 2016/17 and the audit of 2017/18 data is also now well underway.  It is gratifying to see that with each round of the data audit the process has speeded up as hospitals have become accustomed to the process, and the number of anomalies has fallen as they put in place lessons learnt from the previous round.  With the time lags involved only now are we seeing substantial benefit from this process.

The audit shows that we are collecting about 95% of primary hip and knee replacements which is excellent, though the fact that about 10% of revisions are missing is of more concern as it is these that determine the failure rate of any implant.  However, this is offset by the fact that part of the audit process includes entering any missing data, so all these ‘missing’ cases are now entered into the NJR and we can reasonably claim that from 2014 when we started this process we have almost 100% data collection, only failing to capture cases not entered into either the NJR or onto the hospital PAS system. 

The ability to analyse three years of audit data has enabled us to identify individuals and units where a selective approach to data submission gives rise to concern.   Those identified have been discussed as part of the surgical performance process and we have written to them expressing our concern.  More common are units whose data entry is simply poor.  Going forward these will be identified in the annual report as ‘outliers for data quality’.  This will mean that their reported surgical performance will be qualified as being unreliable because of their poor compliance.

We have recently conducted a pilot audit of shoulder replacement data entry in the North East. This has shown the feasibility of using this same technique for collection of shoulder replacement data.  My thanks to Mr Jaime Candal-Couto and the support of BESS for organising this audit.

We have also just started to pilot our Data Quality Audit Automation Project with selected hospitals.  Instead of an annual data upload, hospitals will be able to upload their PAS data at self-determined intervals (monthly or quarterly is recommended) and have this data computer-matched and returned in 48 hours, eliminating the manual process.  Close but not exact matches of cases (for example a unit number or date of birth that is close but not exact) are highlighted as probable matches.  Early feedback has been positive.  Hospitals will be able to build this almost real time process into their work cycles, with much earlier recognition of unmatched cases, hopefully making data submission more than a year after the event (which is very time consuming) a thing of the past.  It is intended that this process will roll out next year and include shoulder replacement.

While our focus has been on making sure that no joint replacements are missed, we have also been working hard on trying to ensure that the data in each submission is accurate.  We now have a process in place for identifying any implant mis-matches (wrong sided knee replacements, and head/cup and head/stem mis-matched hip replacements) and following these up as potential ‘Never Events’.  Alerts appear if entries of this type are made into the NJR and we follow these up. Fortunately, the majority of these are data entry errors.  In 2018 we identified 1,940 potential Never Events of which on investigation only 14 were found to be genuine.

I would like to thank the hard work of the members of the Data Quality Committee, as well as the NJR Regional Co-ordinators led by Carol Harrison, whose hard work has made this all possible.

2018/19 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 two new members to the research committee team, Mr Jitendra Mangwani who brings expertise in foot and ankle surgery and Mr Tim Wilton, the new NJR Medical Director. We would like to express our thanks to Mr David Macdonald and Mr Andy Goldberg who have demitted from the research committee this year.

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 2018/19 the research committee has overseen a number of major projects. 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 Support Tool

We were delighted to launch the NJR Patient Decision Support Tool during 2019. This is a web-enabled personalised patient decision-making tool for patients considering hip or knee replacement. This simple tool, whose development was 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 tools 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 also benefit healthcare economies through improved clinical outcomes and better resource utilisation.  

Having now launched this tool (available at: http://www.njrcentre.org.uk/njrcentre/Patients/Patient-Decision-Support-Tool), we are continuing our collaboration with the University of Sheffield to further develop it. This will involve developing algorithms that will allow the most up-to-date NJR data to be used to calculate projected risks and benefits of joint replacement surgery.

Research Ready Dataset and Data Access Portal  

Building upon our development of the NJR ‘research ready’ dataset last year, we are now continuing to improve the NJR’s data access systems to make the process of applying for, and working on, NJR data more straightforward for researchers.

The NJR Data Access Portal represents a secure data access platform that houses registry data in a secure area that researchers can access, reducing the burden of legal permissions that would be required if data were to be released to them directly. We have also made progress with entering into a sub-licensing agreement with NHS Digital that would allow applications for linked NJR, HES, PROMs and mortality data to be managed under a single application to NJR.

NJR PROMs Strategy

PROMs remains a major strategic priority for NJR and in 2018/19, an NJR PROMs working group was established to develop an operational plan for how NJR develops our PROMs activity.

This multidisciplinary group – consisting of clinicians, academics, information management specialists and patient representatives – has undertaken a review of ongoing PROMs activity in the area of arthroplasty surgery across the UK, and has engaged with multiple key stakeholders who are involved with the delivery of orthopaedic PROMs – including NHS Digital, NHS Wales and the National Orthopaedic Alliance.

NJR Annual Research Programme

Building on a number of high-quality publications over a number of years, the NJR continues to develop our annual research programme. Current projects include: inequalities in provision and outcomes; surgical approach; development of an arthroplasty morbidity index; and examining factors associated with revision and its outcomes. As projects complete, new topics are brought on-stream.

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.

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

Please see the NJR Research Project Portfolio here 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 Toby Jennison, our 9th appointed Research Fellow, who will be investigating five year survival of total ankle replacements. 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.

Richard Craig, outgoing Research Fellow, completed a study looking at improving outcomes after shoulder joint replacement surgery. This is the first examination by the NJR to determine the characteristics of patients who benefit from shoulder replacements. Study findings indicate that five out of six patients improve with surgery for shoulder arthritis, but one out of six may not notice any benefit. Computer-based regression modelling methods were used to generate individual predictions of those patients most and least likely to benefit. The project was also able to recommend a number of changes to improve the reproducibility, efficiency and validity of NJR shoulder data for future annual reports and research studies.

Research is also underway by our two current Research Fellows, Robert Middleton, who is investigating the association between frailty and outcome in joint replacement surgery; and Jonathan Evans, whose work focuses on benchmarking of hip prostheses. 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 process 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 benefits 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 using 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 here.

Please see the NJR Research Project Portfolio. A full list of publications related to NJR data is included in Appendix 4.

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2018/19 Surgical Performance Committee Chairman’s report – Mr Peter Howard

The SPC is comprised of its chair, deputy chair (Matthew Porteous), Medical Director, patient representative, and with representation from HQIP and both lot 1 & 2 contractors. From March this year it has welcomed three further surgeon representatives from the RCC committee.

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 were 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 March 2019 we moved 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.

In the latest refresh of data on Clinician Feedback it is not currently possible to see the outcomes of cases >10 years on the funnel plots. It is intended in the future to portray the long term results in a different manner, probably in the Kaplan-Meier format.

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 Surgeon Level Report report (intended for use in appraisal) via Clinician Feedback. The funnel plots also show the surgeon identifiers to facilitate unit based data scrutiny. We will be contacting active surgeons who have not downloaded their reports to emphasise this utility, and how to use it. We plan in the future to draw the attention of responsible officers to those surgeons who have not been accessing their data and hence not using it for appraisal purposes.

BOA external reviews

Several units where long term performance showed persistently higher than expected revision rates (above 99.8%, alarm/outlier status at both five years and long term), have already undergone reviews through a BOA mechanism closely supported by the NJR. One further unit has been recommended for such a review in the last 12 months.

Implant Mismatch

The process for alerting surgeons and units to mismatches in size and side is now firmly embedded. Several presentations at the BOA, BASK, BHS and other major meetings have been carried out to inform about this process and to emphasise the need for a thorough check of implants at the time of surgery. A fall has been seen in the incidence in both hip and knee replacement surgery over the last two years, and also a fall in the data inaccuracies (the latter due to the alert system which allows cases to be placed temporarily in the edit stack).

The system has been recently modified to include mismatches between manufacturers, this mainly relates to the use of hip femoral stems and heads.

2018/19 Implant Scrutiny Committee Chairman’s report – Mr Peter Howard

The implant scrutiny committee meets formally four times a year. The committee is comprised of surgeons, the NJR Medical Director, and representatives of University of Bristol (lot 2 providers), Northgate (lot 1 providers), MHRA, HQIP and ODEP/Beyond Compliance. In addition to this there have been informal meetings to discuss data analysis methodology.

Examining the data

The NJR data is refreshed and analysed every six months. The Implant Scrutiny Committee 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 (Level 1) when there are more than 100 cases and the overall revision rate (based on the prosthesis-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. Once an implant (or implant combination) has more than 1.5 times its expected revision rate (Level 2), the manufacturer is alerted and required to investigate.

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.

We have been looking closely at our assessment methods, in particular how these might be refined to give greater sensitivity and whether lower thresholds might be more appropriate.

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. Since the 2018 report there have been no new notifications to the MHRA in knee replacements (Level 1), three implants have been reported at level 2. In hips there was one notification to the MHRA (Level 1), the Exeter/Mitch stem/cup combination – metal on metal and discontinued in 2010. At Level 2 there were two hip acetabular component, two hip stems, and three hip stem/cup combinations.

2018/19 Editorial Board Chairman’s report – Professor Mike Reed

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 to and reports 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. Part 4 is on implant performance, and unit-level activity and performance.

The Editorial Board develops 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. Once the annual report is published NJR’s Public and Patient Guides to joint replacement surgery will be developed and will be thereafter also available on the NJR reports website. These reference guides provide information from the annual report that is useful and easy to digest for patients who are considering a joint replacement.

Promoting the 16th Annual Report findings

The 16th Annual Report will be formally launched at the BOA Congress in Liverpool in September 2019.

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. 

Analysis 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 continue to grow as the demographic requiring joint replacement also grows. Each hospital who reports data to the NJR is sent one copy of each relevant PPG with an enclosed cover letter encouraging units to contact the NJR Service Centre for further copies.

There will be further development of and engagement with Patient Network members throughout 2019/2020, to ensure the patients’ perspective is represented in the development of NJR patient focused resources and activities, for example, the Patient Network have significantly contributed to the development of the online Patient Decision Support Tool which can be found in the ‘Patient’ menu on the NJR website.

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 with 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 in Appendix 4. Highlights have been summarised in the printed report.

The NJR Reports Website

The website is reviewed and updated annually at the same time as the publication of the printed report to reflect the requirements of NJR reporting and share information about NJR’s committees, highlights of the year and wider activities. We will be reviewing and assessing the potential to develop this website further for next year’s report.

2018/19 NJR Medical Advisory Committee Chairman’s report - Mr Timothy Wilton

The MAC is chaired by the NJR Medical Director and is the channel for exchange of professional views and advice between the NJR and the associations whose members deal with the procedures of interest to the NJR.  The associations’ presidents are invited to attend the committee and in addition, we gain valuable input from members of the GIRFT team and senior NJR clinicians alongside occasional input from members of our data management and data analysis providers.  I am most grateful to all of the members for their hard work and input over the last 12 months and in particular to my predecessor Mr Martyn Porter who has started us on the way to many of the changes and advances outlined below and who chaired the MAC for the past five years.

The committee meets four times a year and there have been some important achievements in the last year.

Elective Care Reviews

This was an initiative set up between the NJR and the BOA in order to address the problems of outlier units in particular those who have persistently high revision rates.  The BOA sends a team at the request of such a unit, and after a rigorous examination of the outcomes data, and multiple interviews with all levels of staff, the team give advice to the unit on where there may be issues either with the Trust, the facilities, or surgical teams.  A review is taken on what has already been changed and advice is given on other processes that could be changed in the future to achieve better outcomes.

This process is still developing with the valuable feedback of the society presidents and gives the opportunity to feed back to the NJR about matters where data could be utilised or analysed differently, or where the current reports may be improved to avoid misunderstandings.

This review process has been designed to be constructive and has in fact been regarded as such by all of the hospitals that have so far commissioned a review.

GIRFT

A development from NHS England and the GIRFT team this year to introduce a Best Practice Tariff attached to the use of higher proportions of cemented implants for THR in patients over the age of 70, has produced some controversy and misunderstanding.  Working through the MAC, the BOA, BHS and NJR have developed different metrics and new ways to present the data which can be used to feed back to the Trusts on the outcomes of surgery performed with the various types of THR implants within their own Trust. This can inform the Trusts and CCGs of the relative performance of different implants in the hands of the local surgical team, rather than solely comparing them to standards achieved by other teams, perhaps with different devices and in different circumstances.

This is a crucial distinction as we currently do not have detailed information about the impact upon outcomes when surgeons are directed to change to new implants and techniques contrary to their wishes and training. The MAC anticipates that the new forms of data we are providing will inform trusts and surgeons so that an appropriate decision can be made locally on these matters.

PROMs and other alternative metrics

The NJR has been aware for a long time that revision rates and mortality rates by no means give the whole picture when seeking to assess the quality of care and outcomes in arthroplasty. Through the MAC we have been discussing various metrics which can give a more nuanced and comprehensive assessment of the outcomes in a unit or in a surgeon’s practice.

PROMs have been collected specifically for the original NJR PROMs study and also more recently for the shoulder arthroplasty cohort.  These have previously been fed back at unit level but have not been analysed by surgeons.  Clearly, allowing the surgeon to have PROMs data about their own procedures and patients would add considerably to the value of outcomes data we can provide for appraisal and other audit purposes.  This will apply particularly when one metric is consistently less good for one procedure compared with another, but when there are other metrics which give the reverse ranking of those procedures.  The provision of this data to the surgeon was a project initiated through MAC last year and after detailed discussion this year we anticipate that such information will be made available to the surgeons in their Consultant Level Report shortly. 

The MAC is also discussing other measurements which may be made available to consultants and units from our routinely collected data.

Component Database

The Component Database project with EPRD (the German Registry) has been going on for some years and has now been completed.  Detailed implant criteria are now being uploaded by the industry to provide us with a much richer and more precise means of classifying implant characteristics in the future.  The input from various associations and members of the MAC has been of great value in achieving what is now the most comprehensive and detailed implant database in the world.  My particular thanks go to Mr Keith Tucker for his considerable work on the database project.

NJR-TORUS development

This concept, mentioned in last year’s report as a potential significant change to the Registry, has been a major NJR project during the year, with collaboration and support from the BOA and NHS England.  The purpose of the initiative was to undertake a fully researched feasibility assessment of developing an operating model that would facilitate a closer working relationship between the NJR and the seven orthopaedic registries forming the BOA TORUS programme.

This has involved investigating the possibility of providing an umbrella organisation to achieve proper governance of the developing orthopaedic registries in specialities other than arthroplasty. These various registries are at very different stages of development and mostly collect a small fraction of the numbers of cases which might be available for audit. The project has seen intense activity and work by a whole raft of people from the NJR and all of the sub-speciality organisations and it is most gratifying to see engagement from all of the societies concerned, through their Presidents and also the individual champions of each of the registries.  The willingness to modify their approaches towards the proposed creation of an over-arching ‘National Musculoskeletal Registry’ has resulted in considerable forward progress such that the concept has gained acceptance by HQIP, GIRFT and the NHSE Medical Director.  The challenge for the coming year will be to consider in more detail the associated implementation arrangements, including operational and resource implications, while maintaining the impetus that has been achieved.

2018/19 NJR Executive Committee report - Laurel Powers-Freeling

The NJR Executive committee meets on a circa monthly basis to provide additional operational and financial capability to the NJR Steering Committee’s broader strategic and governance role.

The committee membership alternates on a bi-monthly basis between a ‘core group’, comprising of the NJRSC Chairman, NJR Medical Director and NJR Director of Operations; and an ‘extended group’,  with additional representatives comprising of the NJRSC Sub-committee Chairmen, and senior representatives of the NJR Management team and NJR Contractors as required. (Please see the online appendices for a record of members.)

Importantly, the Executive Committee has delegated authority from the NJRSC for operational decisions under a financial threshold of £50,000 and for review and approval of proposed projects that constitute a change in the strategic direction of individual work streams and previously agreed project plans.

Given the expansion of the NJR’s work in recent years, as set out in the NJR Strategic Plan for 2018/21, this committee has already provided invaluable support. It is essential that the registry’s structure enables flexibility and responsiveness as stakeholder needs and requirements of NJR demand change.

2018/19 NJR Steering Committee - Laurel Powers-Freeling
 

This section provides brief outlines of the work undertaken by the NJR Steering Committee (NJRSC) and its sub-committees during 2018/19. Although brief, these sections are written with the intent of demonstrating the ever-increasing scope of the registry’s work and the valuable commitment made by all committee members to meet the needs of orthopaedic and patient stakeholders.

Structure, Governance and Operating Model:

The NJRSC is designated as a NHS England ‘Committee of Experts’  and is responsible for setting the strategic direction of the NJR and overseeing its work. It also oversees a supporting structure of 9 standing sub-committees, ensuring delivery of objectives and work plans from each. Key responsibilities of the NJRSC are to ensure that:

• The NJR budget is effectively managed/monitored;

• NJR work is appropriately aligned to the NJR Strategic and Annual Plan objectives;

• Outcomes achieved by brand of prostheses, hospital and surgeon are monitored and if  these fall below expected performance,  are highlighted to enable prompt investigation and follow-up by relevant manufacturers, regulators, commissioners and providers of orthopaedic care;

• Appropriate stakeholders, for example patients, clinicians, providers and commissioners of healthcare, regulators and implant suppliers, are involved in and consulted on the work of the NJR as appropriate and are informed of the outcomes achieved in joint replacement surgery;

• Patient awareness of joint replacement outcomes is enhanced to better inform patient choice and patient’s quality of experience, through engagement with patients, patient organisations and providers of care; and

• Appropriate governance and monitoring arrangements are in place to facilitate the use of NJR data to support and enable related research.

Membership 2018/19

During this reporting period, the following changes to the membership of the NJRSC can be reported:

Mr Martyn Porter, NJR Medical Director and Vice Chairman, left at the end of December 2018 and was succeeded by Mr Tim Wilton from 1st January 2019.

Ananda Nanu completed his annual co-opted membership as BOA President in September 2018 and was succeeded by incoming BOA President Professor Philip Turner.

Robin Brittain joined as the new patient representative member, joining the current patient member Gillian Coward from 1st January 2019.

NJR is thankful to all of its members, past and present, for their considerable contribution to the registry. Details of the membership of the NJRSC and each of its sub-committees for 2018/19 can be found in online appendices. Further information on any changes this year can also be found in the Chairman’s introduction.