Smith & Nephew - Q3 2024 TU

Transcript

Operator (participant)

Hello everyone, and thank you for joining the Smith & Nephew Q3 2024 Trading Report. My name is Marie, and I will be coordinating your call today. During the presentation, you can register a question by pressing star followed by one on your telephone keypad. If you change your mind, please press star followed by two. I will now hand it over to your host, Deepak Nath, Chief Executive Officer, to begin. Deepak, please go ahead.

Deepak Nath (CEO)

Good morning, and welcome to the Smith & Nephew third quarter trading update. As mentioned, I'm Deepak Nath. I'm the Chief Executive Officer, and joining me is Chief Financial Officer, John Rogers. We announced underlying revenue growth of 4% in the quarter. When we get into the detail, you'll see that there were several moving parts, but I'd like to call out two major components. Firstly, we've continued to make good progress on our strategic growth priorities under the 12-Point Plan. As part of fixing Orthopedics, returning our U.S. Recon business to growth is an important milestone for us. We've made significant operational improvements around product supply and commercial execution over the last year, and these are now starting to come through in revenue.

Although our Orthopedics performance across the world as a whole was slower, our recon business still maintained its momentum in the other established markets, with growth accelerating over the first half. Aside from the effects of VBP, Sports Medicine also continued to perform well, and Advanced Wound Management delivered its best growth quarter this year. Both were further focus areas under the 12-Point Plan. The second component was a weaker-than-expected quarter across our surgical businesses in China, costing almost two points of growth at group level. In sports, we saw the expected price impact of VBP, but with the related volume benefits yet to come through. And in Orthopedics, there was a further headwind from slower in-market demand, with consequent channel adjustments, particularly late in the quarter. Our assumption today is that both of these headwinds will continue for the rest of 2024 and into 2025.

As a result, we now expect to finish the year with underlying revenue growth of 4.5% and trading margin expansion of up to 50 basis points. The slower development of the VBP volume benefits also means it's likely to contribute more margin pressure in 2025 than we previously assumed. More broadly, we still see very significant margin expansion from the operating leverage, productivity improvements, and cost reductions that we're driving through throughout the business. But this additional pressure will have an effect, and we now expect to reach a level of between 19% and 20%. While it's disappointing to be making this change, I feel positive about our strategic progress. The growth headwinds from China will roll off, given we will lap Sports Medicine VBP as we move through 2025, and China Recon sales will align with end-market demand.

In contrast, our better performance in the established markets is more structural, driven by improvements under the 12-Point Plan. Operational metrics from product availability and capital have remained strong. Commercial execution improvements in U.S. Recon have brought customer churn down, and we continue to deliver on longer-term growth drivers such as robotics adoption and innovation delivery. Putting all of that together, our transformation to a higher growth company with the ability to drive productivity and operating leverage throughout the P&L remains on track. I'll come back to that later, but for now, I'll hand over to John to take you through the detail of the quarter. John.

John Rogers (CFO)

Thanks, Deepak, and good morning, everyone. Revenue in the quarter was $1.4 billion, with 4% underlying growth. Foreign exchange was neutral overall, so reported growth was also 4%, with trading days unchanged from the prior year. I'll come to the business detail of the business units in a moment, but as you can see, geographic differences were an important factor in the quarter. Our established markets business remained strong and accelerated sequentially, with 4% growth in the U.S. and 6.8% in the other established markets. However, the emerging markets were broadly flat, as Deepak mentioned, with a disappointing quarter in China. For the business unit performance, I'll start with Orthopaedics, which grew 2.3% underlying. A highlight of the quarter was positive growth, both of U.S. knees and hips, at 0.7% and 3.2%, respectively.

U.S. Recon has been later to improve than other areas of Orthopedics, so this is an important step following the operational and commercial improvements in recent quarters. It's taken longer than we initially wanted, and there are still further improvements to be made, but the customer churn of recent quarters has reduced, and we're on an improving trajectory. Recon growth outside of the U.S. was slower overall than in recent quarters, but with significantly different trends by regions. On the positive side, Europe and the other established markets continued their recent momentum, with growth ahead of the first half. However, China lowered overall U.S. growth by around 5 percentage points in each of knees and hips.

There's been a spell of reduced end customer demand, and as a result, sales to our distribution partners significantly slowed as they reduced their holdings of implants in response, particularly towards the end of the quarter. This is ultimately, of course, a temporary effect, but our expectation is that orders will remain low through the fourth quarter and into 2025. Other Reconstruction grew by 13.7%, reflecting the ongoing growth of robotics, capital, and consumables. Utilization continued to rise during the quarter and reached almost a third of our U.S. knees being placed with CORI. Trauma and Extremities grew by 3.3%. The EVOS Plating System has been a key growth driver for some time now, and that continued with strong double-digit growth and acceleration over Q2. Offsetting that was a slower quarter for some of our legacy systems, and in particular, lower sales of whole surgical sets.

This is a dynamic that can drive variability in trauma growth, given high values of single transactions, and was a large swing factor in the quarter. We expect higher growth to return in the fourth quarter as we continue to drive EVOS and roll out the AETOS shoulder. Sports Medicine and ENT grew 3.9% underlying in the quarter. Within that, Joint Repair growth was 0.1%, reflecting the headwind from VBP in China. Excluding China, Joint Repair growth would have been plus 9.4%. Q3 was the first full quarter since VBP implementation, and the new pricing is now in place across all provinces. The scale of the headwind reflects the price impact that was already known, and also that the anticipated volume benefits from higher utilization are yet to come through.

Growth was strong across all other regions, with REGENETEN again a major driver, primarily from increased adoption in rotator cuff procedures. There remains a very significant opportunity from global penetration, which was still an estimated single-digit % of procedures in 2023. In addition, we see expansion into new procedures such as foot and ankle. Arthroscopic Enabling Technologies grew by 15% in the quarter, with robust growth across all categories of the arthroscopic tower and from where we were a year ago. The quarter also benefited from a relatively soft prior year comparator. The minus 6.8% decline in ENT was more than expected, although also primarily reflecting prior year effects as we lapped an unusually strong Q3 2023, which had benefited from one-time backorder clearances. We expect Q4 to return to more normalized growth for both AET and ENT.

Looking now at Advanced Wound Management, which grew plus 6.5% in the quarter, that represents a significant improvement over the first half and our strongest quarter this year, with broad-based strength across regions and categories. Advanced Wound Care grew plus 3.4%. The largest driver was our ALLEVYN range of foam dressings, and also with good growth coming from our anti-infective portfolio. Bioactives' growth of plus 8% included double-digit growth in skin substitutes. This follows the launch of GRAFIX PLUS in the second quarter, which is a new, easier-to-handle version in our lead product family, targeting the growing post-acute market. Clearly, there's a lot of interest in the Medicare local coverage determinations for the category, but as yet, we've not seen market behavior noticeably changing in anticipation. Finally, Advanced Wound Devices grew plus 11%.

We had a strong growth from both PICO and RENASYS and a good quarter from the LEAF Patient Monitoring System, as we continue to expand the market in pressure injury prevention. So I'll finish with our updated outlook. For 2024, we continue to expect growth acceleration into the end of the year. That should come from the ongoing improvements in established markets Recon through the 12-Point Plan, a return to higher growth of Trauma and Extremities in the fourth quarter, and the benefit, of course, of two extra trading days, although we expect the effect to be less than proportional given the day's fall in the lower volume holiday season. However, we also see our China business remaining a headwind in Q4 due to the slow development of volume benefits in Sports Medicine VBP and continued slow shipments to our Recon distribution partners.

As a result, we expect underlying revenue growth of around 4.5% for the full year, which is below our previous guidance range of 5%-6%. This also feeds into our trading margin outlook. As I set out with our half-year results, margin expansion for 2024 should come from the combination of productivity gains under the 12-Point Plan, operational leverage, which together should more than offset the headwinds from input cost inflation and VBP. These same moving parts still apply, but with a reduced tailwind from the operational leverage, reflecting our updated growth outlook and an increased VBP headwind. We now expect year-on-year trading margin expansion of up to 50 basis points. Our target of improving trading cash conversion is unchanged at around 85%. We also expect the China headwinds to spill over into next year.

Our expectation was that the 2025 margin impact of sports VBP could be largely mitigated, but the slower development of offsetting volume benefits to the known price impact means VBP is now likely to be a more meaningful incremental headwind. More broadly, we still see the same margin tailwinds that we previously set out from the operational leverage, productivity improvements, and the cost reductions that we're driving throughout the business, but the combination of the 2024 baseline and this additional headwind in particular would also have an effect. As a result, while we still see significant expansion in 2025, we now expect a trading margin of 19%-20%. And with that, I'll hand back to Deepak.

Deepak Nath (CEO)

Thanks, John. As I mentioned in my opening remarks, the quarter has been a story of two opposing factors. One is that we're working through significant growth headwinds in China in both Sports Medicine and Orthopaedics. However, outside of China, the rest of the business is showing the higher growth profile we were aiming for when we initiated the 12-Point Plan. To put some numbers around that, in the last four quarters, China has gone from being broadly neutral to group growth to an almost two percentage point headwind in Q3. Growth ex-China of 5.9% in the quarter and 5.1% year-to-date is well above Smith & Nephew's pre-COVID group average of around 3%. Importantly, that's also a level that can typically drive operating leverage throughout the P&L. Just putting China in context, it's still 4% of group sales and one of our largest markets.

As with many other companies in the med tech sector, we are dealing with a rapidly changing market. The aim is to adapt and to build a sustainable business there. However, it's also important to recognize that the current growth headwinds should unwind as we move through 2025. In Orthopedics, our sales to our channel will have to converge with end-user demand over time. And in Sports Medicine, we'll fully annualize the VBP impact after the second quarter. In contrast, our better growth story in the rest of the business is more structural. And what's behind that is the 12-Point Plan.

I'm sure this slide is familiar to you by now, but it's a reminder of what we've done on both growth and productivity. Specifically for orthopedics, we've rewired our commercial delivery, including better connecting supply and demand, better asset utilization with our instrument sets, and driving our key innovating products.

The return to growth of U.S. Recon in Q3 is another example of the 12-Point Plan initiatives converting into commercial outcomes. We've talked in previous quarters about the gradual improvements in operational KPIs as lead indicators of improved growth. Availability of implants and capital had mostly reached our goals by the end of 2023, with knee capital availability the remaining item that got to target in the second quarter of 2024. Improved product availability and capital deployments has been a repeating roadmap for performance improvement. Even so, it was important to show that we could also apply this to the largest area of Orthopedics, as well as the earlier improvements outside the U.S. and in trauma. These improvements need to be sustained for the long term, and that means the new ways of working under the 12-Point Plan have to become lasting changes to the way we do business.

We're starting to see evidence of that in our operational metrics. Key KPIs that we've used to measure progress and drive accountability in the 12-Point Plan have remained strong after reaching their targets, and many have continued to progress beyond the original goals as a culture of continuous improvements starts to become embedded in the company. Some examples are shown on the slide. For implant availability, U.S. non-set LIF for key products reached our target level at the end of 2023. For the third quarter of this year, we had not just held on to those gains, but had even improved further with the KPI more than 3 percentage points above an already high target level. The picture is similar outside the U.S., with international metrics of product availability also showing further improvement in 2024.

Overdue orders have shown a similar pattern, falling by 85% for U.S. knees in 2023, and then another 30% so far in 2024, and on capital, our kit health, which is the percentage of sets that are available for use, reached our target level at the start of the year and has improved by another 5 points since. There is more to do in the U.S., and it will take time, but I've set the team the realistic target of being at least at market growth by the end of 2025. Another key element of a growth story is innovation. Through consistent delivery and good launch execution, new products from the last five years provided almost half of the total revenue growth in 2023. We continued with a good cadence of delivery in Q3 across implants, instruments, and evidence generation, and in a range of high-growth categories.

In Recon, we had the first procedures of CATALYSTEM. This is our new shorter hip stem suited to the direct anterior approach, which represents now around 50% of the U.S. market. That's growing at double digit. Initial feedback has been positive on the precision placement of procedural efficiency and reproducibility. In Extremities, we've launched patient-specific instrumentation for total ankle replacements. This strengthens our position in another high-growth market, which is expected to grow at around 7% CAGR. In Sports Medicine, we've continued the stream of incremental innovation with 510(k) clearance for Q-FIX Nautilus, a new version in our established Q-FIX range of suture anchors, and we've continued to generate clinical evidence to support our earlier launches. In August, we presented new data for our cementless knee at the International Society for Technology in Arthroplasty.

A 153-patient study found 100% survivorship of the tibial and femoral components at one year, with supportive patient-reported outcomes. Radiographic data also indicated stable fixation one year after implantation, which is known to be predictive of long-term stability. Overall, this was a somewhat complex quarter with a number of moving parts. It is disappointing that the headwinds in China have offset a lot of good work in the rest of the business, and that will have an impact as we go into 2025. Coming off of our 2025 target is not what we wanted, but it's the right thing to do, balancing investment in the business for sustainably higher growth and returns, but delivering meaningful improvement year-on-year. We're still making good progress in the fundamental transformation of Smith & Nephew.

Over the last year, the 12-Point Plan has enabled us to turn around the performance of most of our Orthopedics business, and although there's further still to go, the last trailing area of U.S. Recon has now also started to grow. VBP aside, Sports Medicine and Wound Management continue to perform well. Our innovation investments are delivering growth, and we're seeing signs that the culture of focus and accountability in the 12-Point Plan is becoming embedded as a new way of working at Smith & Nephew, helped by the move to the global business unit structure. Today was a sales update, but our productivity initiatives, including manufacturing optimization and our work to improve cash generation and to focus our investments for higher returns, are also continuing. I'll look forward to updating you on the progress in the new year. Now we'll take questions.

Operator (participant)

Thank you, Deepak. To ask a question, please press star followed by one on your telephone keypad now. If you change your mind, please press star followed by two. When preparing to ask your question, please ensure that your device is unmuted locally. Our first question is from Jack Reynolds-Clark of RBC Capital Markets. Jack, your line is open. Please go ahead.

Jack Reynolds-Clark (VP of European MedTech Equity Research)

Hi, thank you for taking the questions. Three for me, please. First, on China Orthopedics, can you just kind of talk about what the drivers were that lower end market demand? Was this unexpected, and do you expect a rebound, or are they kind of lost volumes? Then on the China sports, VBP, kind of what gives you confidence that the volumes kind of will expand, and kind of can you give a rough estimate of what your expectations are around timing for that? And then just on the margin downgrade for next year, and I guess to a degree for this year, you said that this is mostly the results of China. I guess how much of the downgrade is from other sources, and how much is from China? Thank you.

Deepak Nath (CEO)

Good. Thanks, Jack. Thanks for the questions. On China Recon, what we're seeing is the VBP component of the market, and there's an off-VBP component of the market. What we're finding is the component of the market that's not covered by VBP. The in-market demand has been much, much weaker than expected, and that had an impact on top line, especially. Secondly, the adoption of robotics, there's a lot of uncertainty around that, and we're continuing to see that adoption of robotics has been quite muted at best. On the sports side, what we had assumed was, with the implementation of VBP, that there was going to be growth in the market that would translate into higher volumes for us, for our business. And we didn't see that across the market, and we didn't see the volume uplift in terms of demand for our products.

As we go into 2025, the current outlook assumes that we won't see that as we go into 2025. In other words, in Joint Repair, we'll see the impact of price, but not the increased demand for our products. And that translation of those two things is what results in the downgrade. So when you bridge over into the impact of that, the majority of the margin delta comes from the combination of these two factors. The U.S. Recon business did turn positive. It's a bit slower than we had expected. That impacts the outturn a little bit, but that is a smaller effect in all of this. So by and large, the impact from 20+ into what we're guiding for today is China and China sports.

John Rogers (CFO)

Jack, maybe if I can just build on Deepak's comments there and give you some indications as to the movements in the margin bridges that I set out in the first half interims. Obviously, we'll provide a lot more detail at our prelims, but just to give you a little bit of a flavor, if you remember the margin bridge that we gave at the half one on half two 23 to half two 24, had a number of different components to it. The input cost inflation and merit component, we expect to be the same. The FX component that we said at the half would be a drag of about 50 basis points. We actually think that will be favorable. That will move to a drag of 30 basis points. So it's like a 20-basis point improvement versus what we said at the half one.

Then when you look at the impact of China VBP pricing and also the impact on the revenue leverage that Deepak's just described, we think that could be somewhere in the order of 30-50 basis points or so, something like that. That's a directional number. Then when we see the manufacturing and distribution and expense savings being exactly the same, so as we said at the half, when you add all that together, that's a little bit of a drag on the half two margin, hence why we're now saying margin accretion of up to 50 basis points for the year. Coming now to the bridge for 2024 to 2025, again, I can take you through the different component parts.

Again, the input cost inflation and merit, we didn't give the exact numbers, but we think that's probably going to be actually 10 basis points worse than we said at the half. You've got the combined benefits of the China VBP and the revenue leverage that Deepak just described. We think that could be in the order of 40 basis points or so. Of course, I mean, these are broad and rough numbers, but giving you a little bit of a flavor. Of course, the savings we think will be exactly in line with what we guided at the half. When you take that, you sort of got a bit of a headwind of around a range of sort of 50 basis points or so versus where we were, hence why we've moved from the target of plus 20% to 19%-20%.

So hopefully that gives you a little bit of a flavor as to the margin bridges, both for the second half and also for the next financial year. And the vast majority of the delta, notwithstanding Deepak's comments on U.S. ortho, the vast majority of the delta is driven through China. And that's a combination, just to be clear, of both sports VBP and also ortho volumes.

Jack Reynolds-Clark (VP of European MedTech Equity Research)

That's it for today. Thanks very much.

Operator (participant)

Our next question is from David Adlington of JPMorgan. David, your line is now open. Please go ahead.

David Adlington (Managing Director)

Yeah. Morning, guys. Thanks for the updated margin targets for 2025. Just wondered if you could help us think how you're thinking about revenue growth for 25, and then more broadly, just in terms of the margins, the more than 20% that you've walked away from for 25, is that still a valid target, and do you expect still to be able to generate some operating leverage beyond 2025 to see further margin progression? Thanks.

Deepak Nath (CEO)

Yeah. So on the top line, David, thanks for the question. So we'll give detailed guidance when we come back in prelims, but revenue growth is broadly in line with what we had indicated around 5%, and so that remains in place. As far as the margin is concerned, so as John mentioned, the delta really comes down to the impact of sports and the volume uplift not coming through in the back half of 2024 and as we go into 2025.

But just to be clear, David, in terms of your question on the 20%, we do expect to get to 20% margin. If you remember last, I think of the half, we talked about margin accretion coming through in 2026 and 2027. We expect that to continue to be the case as a consequence of annualization of cost savings and also additional cost savings coming through. So obviously, we're not going to set out guidance at this stage for 2026 and 2027, but we do expect to get to the 20%, and we do expect to see continued margin accretion through both 2026 and 2027.

David Adlington (Managing Director)

Perfect. And then maybe just to follow up on VBP in China, the lack of volume growth coming through, is that a market phenomenon, or do you think you're losing share?

Deepak Nath (CEO)

It's a bit hard to parse. There's definitely a market effect of what we had anticipated is that on the back of price implementation, that more and more patients would be treated with these procedures. So we're not seeing evidence of that. There is some evidence that there's local products. There's an uptake of local products that are expensive. There's a little bit of share loss that we see, but it's hard to parse that at this early stage. The big effect is market, but we are seeing some level of local companies coming into a space that we previously occupied.

David Adlington (Managing Director)

Perfect. Thank you.

Operator (participant)

Our next question is from Hassan Al-Wakil from Barclays. Hassan, please go ahead.

Hassan Al-Wakeel (Managing Director of European MedTech & Services Research)

Hi, good morning. Thank you for taking my questions. Three for me, please. So firstly, just following up on the 25 revenue point that you talked to Deepak and your comment of around 5% in line with your midterm outlook, could China continue to have an impact, and how do you think about U.S. backlogs coming down and utilization, given hip and knee growth is considerably higher than pre-COVID levels? Secondly, even after adjusting for China, you look to be losing considerable share OUS in knees based on peer reporting. If you could talk to this and what you're seeing on the ground. And then finally, if you can talk to the trauma franchise and the strength here and what you're seeing from a competitive standpoint, given some launches, and whether you expect any impact here going forward. Thank you.

Deepak Nath (CEO)

Sure. So, China impact, as you mentioned, we expect that to continue into 2025. In the U.S., as I've said previously, I've been a little loath to comment on ortho market or recon market in the U.S. from our vantage point, and that's because we've had performance challenges, and it could be difficult for us to parse what's market and what's us, so it is a bit tough to call right now. We're focused on operational improvements in-house, and as I indicated, there's quite a bit of progress that are underneath these numbers, and one proof point is, of course, the U.S. starting to return to growth against reasonable comps, so for us, on the back of those operational improvements, we expect to participate better in a market than we have.

Our assumptions are, in terms of our modeling, don't expect a continued frothy market in the U.S. for us to deliver what we've said we're going to deliver. So we're expecting normalized markets for us to be able to operate and on the back of operational improvements to participate in that market. As far as the backlog in the U.S., like I said, it could be hard to parse that given our position in that market today. In terms of our share in knees, in general, our product availability in knees has lacked. Improvement has lagged that of hips, and OUS came first, as I've indicated, the SKUs that are mostly relevant outside the U.S. improved before those SKUs that are relevant to the U.S., particularly OXINIUM-related U.S. and certain OUS markets, Japan, Australia being key among them.

So on the back of improved availability and OXINIUM-related products, we expect knees to kind of follow the course that hips have. It's the same organization by and large that represents both the knees and the hips portfolio. So we expect knees to also recover in the way that hips have. So knees are just lagging, I would say, a quarter or two behind hips in terms of performance. So I expect that to recover OUS as well. In terms of trauma, we're very encouraged by the progress we're making with EVOS, as we called out in our release, double-digit growth with EVOS. We believe we've got a great system there. We're not blind to competitive activity. We do expect particularly the launch of a competitive system. We don't underestimate that competitor, but we do feel good about EVOS and the traction we've gotten so far.

There are some set sales-related activity that introduces volatility into the trauma numbers from one quarter to the next. So we had relatively high set sales in Q3 of 2023 and not so much in 2024. So that impacted numerically the numbers, along with some of the legacy trauma products for which we had a slow quarter in Q3. But by and large, though, we're very encouraged by how EVOS is doing, and we believe we're poised to take share in the core trauma segment.

John Rogers (CFO)

And Hassan, maybe if I can just build on Deepak's comments on your question around knees outside the U.S. Actually, if you look at our overall knee performance, and I mean, across the entire group, and you strip out China, the Q3 growth was not dissimilar to the half one growth on knees. So I would argue that the bulk of the dynamic that you're seeing outside of U.S. knees is all coming through from China. We're continuing to see the positive trajectory on our U.S. knees across the other markets that we saw in the first half.

Hassan Al-Wakeel (Managing Director of European MedTech & Services Research)

That's very helpful. If I can just follow up on that competitor, that competitor is also talking about record installations on robotics. So very interested to hear how CORI installations are trending through the quarter, both in hospitals and ASCs, please.

Deepak Nath (CEO)

Yeah, sure. So we don't give specific numbers every quarter, and just to reiterate what I've said on previous calls, for us, we're looking at placements and utilization, and I'm pleased to report that we're doing well. We're continuing to place, and where we're placing, we're continuing to see nice uptake, so today, we're up to roughly a third of our knees going through CORI. So it's a pretty healthy number, and that's an increase over where we were at this point last year, very encouraged by the traction we're getting across a range of healthcare settings and hospitals, teaching institutions, and in ASCs. The proportion of our placements in ASCs are slightly above our overall market share, so we're actually getting more traction, relatively speaking, in ASCs than elsewhere, so overall, very encouraged by the uptake.

We'll come back at the full year of the prelims to give you a picture of how we did in 2024 versus 2023.

Hassan Al-Wakeel (Managing Director of European MedTech & Services Research)

Perfect. Thank you very much.

Deepak Nath (CEO)

Sure.

Operator (participant)

Our next question is from Robert Davies of Morgan Stanley. Robert, please go ahead.

Robert Davies (Executive Director)

Yes. Morning. Thanks for taking my question. My question was just circling back on that OUS knee performance. You mentioned, I think, sort of ex-China, you were in the same ballpark territory as you were in the first half of the year. But just looking at the sort of performance relative to your peers globally, everyone else seems to be in sort of a high single-digit or double-digit territory versus you guys in sort of low single-digit negative. I'm not entirely clear why the performance differential has showed up in this quarter because I think over the last couple of years, you've clearly been making pretty good progress in the OUS knee business. So that was my first question.

Deepak Nath (CEO)

Yeah, Robert. So overall, just to build on what I've said and what John indicated, OUS, by and large, the factor that's different is China. When you take China out of it, there are some markets on a smaller scale where there's ins and outs. But overall, if you look at our performance over the last couple of years, several quarters, I would say, we are in a fairly robust place with Recon OUS ex-China. With knees, in particular, knees and hips, as I mentioned, when you double-click on markets and specific SKUs, the recovery from a supply standpoint that had been hampering us right in 2022 and 2023 was not created equal. As I mentioned, hips recovered before knees did. But within knees, as I said, OXINIUM was slow to recover. It looks like markets where OXINIUM is relevant.

It's the U.S., it's Japan, and it's Australia, and to some extent, Korea. So when you double-click on that, you'll see a little bit of differences in performance by market and by SKU. So that's the real, I guess, high-level explanation for differences in market. But overall, though, when you strip out China out of it, I am encouraged by the translation of product availability on the back of improved commercial performance translating into a reasonable set of numbers OUS. And like I said, with the U.S., we've got one data point, a little bit of a green shoot, and we expect to build on that as we go into Q4 and beyond.

Robert Davies (Executive Director)

Thank you. And then my second question was just around, I guess.

Deepak Nath (CEO)

And one other thing, just real quick, Robert, one other thing as you parse our performance, we do talk about our robotics separately, right? So in terms of like-for-like performance, you do have to do a bit of work to arrive at an apples-to-apples comparison. So that could be another thing that got you to not to say that you're not doing that, but it is something that it's a little bit of a difference in terms of how we report versus our competitors.

Robert Davies (Executive Director)

Thank you. Yeah, my follow-up question was just in terms of the elements of the 12-Point Plan and where we are on the kind of medium-term outlook, what are the biggest elements in terms of moving the numbers, I guess, over the next one to two years that you still feel like you're not making as much progress on as you maybe thought before? Is there anything above and beyond China that you still feel is kind of options to sort of move the needle, really?

Deepak Nath (CEO)

Yeah. So the buckets, I mean, John took you through. I won't repeat what John said because he essentially was referencing the bridge that we put forward at midterms that was literally going off of the charts that we had there, right? And so he gave you the 2023 - 2024 bridge and the 2024 - 2025 bridge. The building blocks are all the same. The biggest delta there is the China effect. I called out U.S. Recon, but it's in the noise in terms of where we are relative to where we expect it to be around this period of time. So bottom line, the productivity measures that we have put in place, not only on the recon on the orthopedic side, but writ large, those are coming through just as expected.

The steps we've taken in Recon to optimize our network to bring capacity into line. We expected an uplift in terms of the impact of those actions that have already happened into 2025. Those we expect to come through just as we had laid out. Operating leverage is another part on the back of improved supply and all of the rewiring improvements that we've made in connecting supply and demand and all of the commercial process improvements that we've made will come through, has come through, and we'll continue to build on that and those are very much in line with where we expected. Yeah, I mean, am I 100% pleased with the pace of recovery in the U.S.? No. But it's within the zone of what we had assumed when we provided the guide.

So in very real terms, the building blocks really are just as we had laid out at the midterm, which was in fact in itself a build on what we had said the year before. And those all remain intact.

John Rogers (CFO)

And maybe two builds from my side. As Deepak said, the recovery in our U.S. recon may not be quite as strong as we would have liked to see. But what's, I think, really encouraging is the progress that's being made quarter-on-quarter. So just to remind you, U.S. knees, Q1 minus 5%, Q2 minus 1.7%. Q3, we're now at plus 0.7%. And we expect to make further continued progress in Q4. So that's encouraging. If you look at the hips, minus 1.9% in Q1, 1% positive in Q2, plus 3.2% positive in Q3. And then we expect to be, again, another uptick in growth in Q4. So we're very much encouraged by the progress we're making in terms of U.S. performance. And then I think a second build is, obviously, we set out the savings that we expect to deliver in 2025 at the half one interims.

Obviously, as we now go through our detailed bottom-up budgeting process, I'm pleased to say we've got better and better visibility of those savings and how they're being baked into our plans, and so again, we can feel reasonably confident in our ability to deliver that cost improvement year-on-year as we progress through 2025.

Deepak Nath (CEO)

Just again, just to go back to the point that I made in answer to the last question, Robert, the numbers that John recited for knees. You've got to add the robotics component that primarily impacts knees. When you put that on and you compare ourselves to competitors, what you see is clear evidence of us gaining ground OUS, narrowing the gap in the US. We're kind of flattish this year relative to competitors. When we talk about all of the KPIs, all the operation improvements translating into financial benefit, that's kind of what we're really looking at. In Q4, we expect to further build on that.

Robert Davies (Executive Director)

Sorry, just to finish off, the OUS knees business, are you still expecting that to be negative now for the next sort of year or so? Because, I mean, you have some pretty difficult comps there for at least the next three or four quarters, no?

Deepak Nath (CEO)

No, we're not expecting that to be negative. We expect to go into positive territory.

Robert Davies (Executive Director)

Okay. Okay. That's all my questions. Thank you.

Deepak Nath (CEO)

Yep.

Operator (participant)

Our next question is from Richard Felton of Goldman Sachs. Richard, please go ahead.

Richard Felton (Equity Research Analyst)

Thank you. Good morning. Just one question for me. And it's following on the destocking impact in China. My question is, how much visibility do you have on the inventory that's being held by your distributors? Is there more adjustment of that inventory to come? And if so, how many more quarters can we expect that destocking impact to affect your performance? Thank you.

Deepak Nath (CEO)

Yeah. So we've got, I'd say, reasonable visibility. We've taken steps over the last couple of years to get better and better line of sight into that inventory. So we closely monitor in-market sales and our shipments into distributors, right? So we've got a reasonable line of sight. Bottom line, in terms of how long it takes for us to kind of for our distributors to work through the inventory, it really depends on in-market sales. So what we're seeing is the dynamic around local competitors versus demand for multinational product and the relative incentives of one versus the other, right? So it depends a bit on how the demand for multinational products, including ours, shapes over the course of the next couple of quarters.

So in the outlook that we've provided, we certainly expect Q4 to be as it was in Q3, in other words, for distributors to work through the inventory that they've got. And we expect in the first half of 2025 for that to persist and beyond that, so the days of inventory to go down from that point and then to recover back up towards the end of 2025. So bottom line, we expect this mismatch to be in place for the next couple of quarters because a lot of things about China are uncertain, as you know, Richard. And so we've taken a call on this and providing outlook.

Richard Felton (Equity Research Analyst)

Thank you very much.

Operator (participant)

Our next question is from Graham Doyle of UBS. Graham, your line is now open. Please go ahead.

Graham Doyle (Executive Director of Equity Research)

Morning. Thanks for taking my question. It's just one, but it's a slightly more bigger picture one of the strategy, which is ultimately this 12-Point Plan has been in place now for two years, and a lot of money has gone through the P&L to execute it. And there's lots of slides showing progress on supply meeting demand and things like that, but margins are flat and revenue, as we can see now, is slowing. So I suppose from your perspective, when do you assess this plan and decide it doesn't work if it continues to not work? And if it continues to not work and deliver the financial results, would you look at doing things like releasing value through asset sales, shutting down businesses that don't generate cash?

I mean, just because we're at a point now where at some point there needs to be a pivot unless we see tangible results from the financial markets pretty soon, I would have thought. Thank you.

Deepak Nath (CEO)

Yeah. No, Graham, thanks for the question. So yes, we had indicated kind of a two-year kind of timescale to the 12-Point Plan. We're coming up on that, and we had indicated 2025 was to be a pivotal year where we were expecting to see a step up in margin. Obviously, the level to which we expected was a 20%, and we're coming off of that. But the range that we've provided here still implies a significant step up relative to where we are today, and we believe that. We believe that strongly in terms of every indicator that we've got. Absent the China effect, we would have been rather more bullish on that, so we do have to parse things. As we said, there are a number of moving pieces.

When we look at outside of the China effect, generally speaking, we are on track relative to what we set out to do. 2025 will be the pivotal year for all of the operational metrics, some of which you've called out to translate into margin impact, and we are geared up to do that. The question of at what point we would take more fundamental actions relative to strategy, as you can imagine, we regularly review our strategy, our portfolio strategy. We are somewhat dispassionate about it. There's no emotions here in terms of what the constituent parts of our group are, but we firmly believe that there is value to the businesses being here together.

We do believe that with the 12-Point Plan and the benefits of that coming through, as expected, we will be well positioned to start to get back into a better place and continue to expand margins even further beyond what we've indicated for 2025. Short answer, at this stage, fundamentally, we're on track to what we've set out to do from a 12-Point Plan standpoint. We do regularly review our strategy, including the components of our portfolio. Right now, we believe that the value of the portfolio is greater together than apart. In 2025, we expect to deliver more hard improvements also in margin. As I indicated in response to another question earlier today, in terms of sales, we didn't guide to sales. We'll come back with detailed guidance.

But we do expect to be around 5%, which would be structurally higher than where we were relative to our pre-COVID average. So top line higher, bottom line margin expansion, very significant margin expansion from where we are as we get into 2025, and position the business in a better place than it was.

Also not forgetting also, of course, cash and cash conversion. We're forecasting our cash conversion to be 85% for the full year and expect that to continue in 2025. I think to Deepak's point, if you looked at our average growth over the last couple of years, it would be north of the 5%, which is a step up from our pre-COVID growth. If you look at our margin target, we actually set the margin target of 20% plus pre-China VBP. We held on to it for a while, but obviously, the impact of China you now see coming through. Absent that China effect, as we talked through on the call today, we'd be pretty much there or thereabouts on that. The cash conversion is significantly stepping up.

I think there's a lot of positives regarding our 12-Point Plan, a lot of good progress being made. Of course, 2025 is a critical year, particularly in terms of seeing some of the cost savings start to drop through into our margin.

Graham Doyle (Executive Director of Equity Research)

Okay. Thank you. Maybe just a follow-up then, John, as this will be I suppose you've had a hand in this guide in a way maybe you didn't in the previous guide. Would you have put the volume expansion in VBP? Because that seems to me like a risk that was a pretty firm risk. We see other companies where they have the advantage of winning VBP tenders, and they don't stick it in the guide. So having had a price cut, I'm surprised that you put the volume in. I mean, when we think about next year, how cautious do you stack this guide up versus the last three years of guidances? Just to give people on the call a little bit more comfort that you can really do somewhere between 19%-20% next year.

Deepak Nath (CEO)

Look, I can't comment on previous sets of guidance because I clearly wasn't here. I can comment on the guidance that we're giving for this year and the guidance that we're giving for next year. And we'll set that out very, very clearly at our prelims in terms of the bridges. But I've given you a flavor on the call today. I think we are sensibly balanced in the way that we provide that guidance. So we reflect risks and opportunities against the market, and we use that to give us a feel as to how we set and guide the market. And that's the basis on which we set the guidance for both this year and going into next year.

Graham Doyle (Executive Director of Equity Research)

Okay. Thank you. I appreciate that.

John Rogers (CFO)

I'm very comfortable that we've taken a sensibly prudent view.

Graham Doyle (Executive Director of Equity Research)

Okay. I appreciate that. Thank you.

Deepak Nath (CEO)

I just wanted to come back to just a response to a previous question, if I may, just on I think there was a question asked feedback on the OUS knees business and whether or not it would be negative going forwards. I just want to make clear that when we talk about the China effect, as it were, we expect that effect to continue to flow through into Q4 and into the start of next year. So it may well be the case that our knees business, OUS, continues to be slightly negative into Q4 and into the start of next year. However, I want to make very clear that outside of China, in our OUS business, we expect to see the continuation of the progress that's already been made through Q1, Q2, and Q3.

Operator (participant)

Our next question is from Lisa Bedell Clive of Bernstein. Lisa, please go ahead.

Lisa Bedell Clive (Senior Research Analyst)

Great. Thank you. First question, you mentioned you're doing fairly well in ASCs in the U.S. Could you give us just any estimate of the percentage of U.S. knees that are being done in the surgery centers today? And also, could you comment on pricing? I think one of the concerns about the shift to ASCs is that with surgeons sort of more financially involved, that they're more focused on price and that the ASC prices may end up being sort of a step down from what is sold into the hospital. So just any commentary on that would be helpful. And then second, one of the things that you've mentioned in the past around the Orthopedics business, which has contributed to the complexity and perhaps the excess costs, is the number of SKUs and basically the number of product families.

Can you give us just a reminder of where you are in terms of number of product families in hips and knees and where you should get to in, say, the next three, four years, and how we should think about the phasing of that and whether that can help us give some comfort that as that complexity reduces, you can get more operating leverage? Thanks.

Deepak Nath (CEO)

Sure. Thanks, Lisa. So overall, in terms of ASC volume, we're kind of in the low double-digit proportion of our business going into ASCs, right? So I mean, that's not saying a lot.

Lisa Bedell Clive (Senior Research Analyst)

Is that low double-digit of just knee sales, just to be clear?

Deepak Nath (CEO)

Yes. Yes.

Lisa Bedell Clive (Senior Research Analyst)

Yeah. Great.

Deepak Nath (CEO)

I mean, hips are a little bit further behind than knees in terms of what we see in the ASC in our business, but low double-digit overall. I mean, to put that into perspective, about a little over 40% of our sports business goes through ASCs versus hospitals, right? So it's a lower number than that, significantly lower number than that in terms of knees today. We obviously see significant growth in that, as other market participants have commented. So we see growth overall. But today, when you compare that to where our sports business is, it's significantly lower still. In terms of pricing, as you know, Lisa, there are different models of ASC. There are physician-owned ASCs that are part of IDNs or what have you. So there are different kind of dynamics there.

In general, as you well know, the reimbursement level for procedures in the ASC are significantly lower than they are in the hospital. The translation of that into pricing very much depends on what type of ASC you're talking about, if it's a physician-owned versus others. So I think it's fair to say that there's more price sensitivity in the ASC channel than there is elsewhere. And we're in the throes of kind of adapting to that and also adapting our business model to best serve that segment. As far as your second question, we do have a more complex portfolio. We have a relatively large number of products within hips. We've got four knee platforms all around the world. So there's complexity that's driven by number of families of product, and then there's complexity that's driven by the number of SKUs within a family.

We're making really good progress on SKU rationalization within families. I think the last time I gave a number to that was, so I think about a year ago. I'll look to my colleagues for that. But about a year ago, we said something like 40% or 45% reduction in the number of SKUs, largely in our OUS markets. And we've built off of that number over the last year. So that program of SKU rationalization remains in place. In terms of the progress in reducing the number of families, ultimately, we want to consolidate into a smaller number of product families and knees. Our lead products are JOURNEY and LEGION. And over time, we want to consolidate to one platform. The pace at which you do that, of course, depends on a lot of factors, a high level of physician preference here.

We want to migrate physicians in a thoughtful way. So this is going to take several years before we're able to bring about the rationalization in terms of families. Again, balance here in terms of not putting top line further at risk as we manage through our complexity. That said, the bigger driver really for us is bringing our capacity in line with demand. We've got excess capacity within our factory network. The steps we've taken will bear fruit in 2025. We've talked about the number of factories that we have closed in 2023. That really is the bigger driver in terms of our cost position. Hopefully, it gives you a bit of color that you're looking for. Just to give you a number, one in three legacy hip and knee brands have been phased out already.

So just to give you another metric where we're going with that.

Lisa Bedell Clive (Senior Research Analyst)

Super. Thanks.

Deepak Nath (CEO)

Sure.

Operator (participant)

Our next question is from Julien Dormois of Jefferies. Julien, your line is now open. Please go ahead.

Julien Dormois (Managing Director of European MedTech and Equity Research)

Hey. Good morning, Deepak. Good morning, John. Thanks for taking my questions. I had three. The first one is just making sure that I got you right in terms of the knee business going back to market growth in the back half of 2025. Just wondering whether that's a global assumption or whether that's specifically for the US. So that would be the first question. Second question is that the hip business has been growing at a pretty consistent pace of around 4% in the past seven quarters now. So anything that could derail the story in 2025? And the last question is just for some sense of an early feedback on the rollout of RENASYS EDGE and the potential contribution that we could see next year for wound device.

Deepak Nath (CEO)

Sure. I'll take those in turn. Just to clarify, what I meant is the U.S. in the first part is getting to U.S. growth. Obviously, we're doing better OUS ex-China, as we've kind of detailed that in response to other questions. Second, with hips, with the launch of CATALYSTEM, in fact, we've got even further catalysts for growth, no pun intended, than we've had before. So we're in the early stages of launch. Further, we're going to be bringing forward additional functionality on CORI related to hip over the next, call it, 12 months - 18 months. So we actually are rather bullish on our prospects in hip on the back of new launches that's coming. So the launch really of CATALYSTEM really taking off for us to participate in a rapidly growing segment of direct anterior approach. It's more relevant in the U.S. than it is in OUS.

But obviously, there's changes happening in OUS as well. And then CORI functionality should only enhance our value proposition in hip. In terms of RENASYS EDGE, early feedback has been pretty good. We're in the very early stages of launching. Of course, we announced the CE Mark, I think, now about two quarters ago. And so those are progressing well. We talked about a double-digit growth we're seeing in negative pressure overall, right, both in the traditional segment of RENASYS and also the single-use segment. So we expect that this will continue. And we are optimistic about what lies ahead in 2025 and beyond.

Julien Dormois (Managing Director of European MedTech and Equity Research)

Thank you very much.

Deepak Nath (CEO)

Thanks, Julian.

Operator (participant)

I will now hand back to Deepak Nath for closing remarks.

Deepak Nath (CEO)

Great. So thank you so much. I appreciate the attention here. As I indicated, a complex quarter with a number of moving parts here. But the China commentary aside, we're making good progress in the fundamental transformation of Smith & Nephew over the last year or so. The 12-Point Plan has enabled us to turn around the performance of most of our Orthopedics business. So although there is further still to go, I do call out the green shoots that we're seeing in recon and U.S. Recon in particular. I look forward to coming back in the new year to update you on progress. Thank you very much.

Operator (participant)

This concludes today's call. Thank you for joining. You may now disconnect your lines.