SNN Q1 2021 Earnings Call
Operator: Ladies and gentlemen, welcome to the Smith & Nephew First Quarter Results 2021 Call. My name is Stephanie, and I'll be coordinating your call today. Certain statements in this presentation are forward-looking statements. These statements are based on management's current expectations and are subject to uncertainty and changes in circumstances. Actual results may differ materially from those included in these statements due to a variety of factors. More information about these factors is contained in the company's filings with the Securities and Exchange Commission. Now I would like to hand the conference over to your speakers today, Roland Diggelmann, Chief Executive Officer; and Ann-Francoise Nesmes, Chief Financial Officer. Whenever you're ready.
Roland Diggelmann: Thank you very much, operator. Good morning, everyone, and welcome to Smith & Nephew's trading update. As mentioned, with me on the call today is our CFO, Anne-Francoise Nesmes. I'd like to start with a few opening comments. Firstly, we're very encouraged by our progress in the first quarter of '21, and that's for a number of reasons. One, our markets are getting better. The rollout of vaccination programs and the resilience of health care systems are actually bringing back elective surgery volumes towards more normal levels and in an increasing number of regions. Our approach through the pandemic has been to maintain our commercial readiness for the recovery that is now underway. Second, we've made progress on the priorities and growth strategy that we set out in February at the time of the full year presentation. The evidence of better at commercial execution in our existing business is building. We're driving performance from our acquired assets, and we're delivering on our 2021 R&D pipeline and investment. And finally, of course, visibility has improved on the recovery from COVID. And with that, we're pleased to return to giving financial guidance. Now Anne-Francoise will take you through the numbers for the quarter, and I'll then talk about some of our strategic progress. And we'll finish with the details of our 2021 outlook. With that, over to you, Anne-Francoise.
Anne-Francoise Nesmes: Thank you, Roland, and good morning, everyone. I'll start by summarizing our revenue by region. So our first quarter revenue was $1.3 billion, which represented a 6.2% underlying growth and an 11.5% reported growth. This includes the effect of 2 extra trading days compared to the first quarter of 2021. As you can see on the chart in front of you, there was significant variation between regions. In part, that reflects the timing differences in lapping the first COVID impact in 2020. And we are also seeing different trajectories of growth and recovery between markets, particularly later in the quarter. But as Roland mentioned, though, the balance is an increasing proportion of our end markets are moving closer to normal. Now going into the detail of each region. The U.S. grew by 7.1% and strengthened as the quarter progressed with increasing vaccination rate and easing of restrictions, enabling the recovery in elective procedures. Other established markets were more of a mixed picture. Japan and Australia showed solid growth, but Europe varied by country. And while the U.K. strengthened in the quarter, most of the European markets slowed in March as infection rates rose. And we expect that trend to continue into the second quarter. In Emerging Markets, China sales reflected and maintained recovery. And as you may recall earlier, greater COVID impact in the first quarter of 2020. We've also seen in China some distributors changing ordering patterns in anticipation of the VBP for a subset of our reconstruction products. In other emerging markets, we saw signs of improvement, although again, there was significant variation between countries. Now looking at the picture from a franchise perspective. It's important to note that all 3 franchises grew and all improved over the fourth quarter of 2020. Sports Medicine and ENT grew the fastest at 10.4%, while Orthopedics were at 1.6% and Advanced Wound Management grew by 9.3%. Recovering elective surgery volumes, our initiatives to improve commercial execution, and the effects of starting to lap the initial COVID impact in some of the regions also contributed to the growth. I'll now go into the details of the franchises, starting with Orthopedics. As in 2020, our Hips business outperformed Knees in the quarter. And we've seen, throughout the pandemic, that surgeons have prioritized hip procedures, and that's continuing across all affected regions. Our Hip business has consistently grown above peers in recent quarters and continues to benefit from the rollout of our OR3O Dual Mobility system. In Knees, the dynamics were similar to 2020 as we reported before. We are, of course, working towards adding the cementless knee options for which we are on track to launch later this year. Pleasingly, our other Reconstruction grew by 17.7% driven by the U.S. robotic sales following the launch of CORI, our next-generation robotic systems. Our shipments are now increasingly to new customers after our early prioritization of upgrading our NAVIO customers in 2020. And we're continuing to develop additional surgical applications and regional rollout and we expect further launches over the course of 2021. Trauma growth reflected the continued success of the EVOS plating system and the growth of our INTERTAN nail. We're also progressing with the commercial integration of the Orthopedic business acquired from Integra. We have started -- we have combined the sales team. We've trained reps on the new portfolio. We've set new targets and we are making the instrument sets available. Now moving to Sports Medicine. Both joint repair and arthroscopic enabling technologies grew double digit. The recovery in Sports Medicine has been faster than the other markets we operate in. The significance of the outpatient setting, the younger patient mix, and the involvement of acute injury all contribute to the speed of the rebound. Only knee repairs remain a little slower with more exposure to competitive sports injury. And very much in line with our strategy, our acquired products such as REGENETEN and recent launches such as HEALICOIL KNOTLESS continued to make important contribution across the segments. And while ENT growth is still negative, it improved over the previous period, reflecting a rebound in the Asia Pacific region. And volumes of procedures in established markets remain slow as parents continue to be cautious and lower -- and we're continuing to see lower ENT infection rates. And finally, moving on to Advanced Wound Management, Advanced Wound Care grew by 4.5%, with a rebound in Asia Pacific after the region's slow finish to 2020. Importantly, these franchise has stayed focused on improving commercial execution, and Roland will cover this in more detail in a moment. Bioactives growth was helped by the timing of shipments with year-end orders that would have historically been shipped in December coming in January instead. But even without this effect, growth driven by demand has been double digit. Advanced Wound Devices largely recovered in line with the broader franchise in each region. The lower growth rate in AWD is driven by the geographic mix with a higher proportion of sales in Europe, and less in U.S. and China, our fastest-growing market. And now I'll hand back to Roland who will cover the progress on our strategy.
Roland Diggelmann: Thank you, Anne-Francoise. I'd like to spend some time on our progress against the priorities for '21 that we sent out to you in February. One of those priorities is the return to top line growth and to recapture the momentum from -- before the pandemic. As you know, organic growth is a key driver of shareholder returns and it is what enables positive operating leverage through our P&L. So the aim is to build on the new commercial model and the leadership from 2018 and '19 by maximizing the potential of our existing portfolio, then delivering value from the acquired assets and, of course, launching a new pipeline of innovation in '21 and beyond. One example here is the progress of the Wound franchise. It continues in the first quarter. It is a good example of the delivery against the first 2 components of our growth strategy. Firstly, an important driver of the improvement has been the detailed work done by the franchise team together with the regions. I'll just take you through a couple of examples of what they've been working on. So in our go-to-market strategy, the franchise leaders focus more on key account management and winning in bigger blocks of the businesses. We also allocated more of our sales force towards working with large hospital networks to C-level contact and major customers and to national tenders and processes outside the U.S. We've also established a new launch excellence process for wound management with a dedicated team and a more systematic end-to-end process that involves the regulatory sales training, product supply and regional rollout plans. The franchise has also renewed its focus on people, including on sales training, development and mentoring programs, and we're seeing good results from this with employee engagement scores up with a lower attrition by about 50% and also 40% of management positions recently filled by women. So secondly, the performance of bioactive shows us delivering on the value of the acquired assets, in this case, Osiris. And that's an important part of the business case was actually to sell skin substitute products, Grafix and Stravix through the Smith & Nephew sales force. And we're seeing the benefit of that coming through now. And there's more to come. We're planning for launches of new forms of Grafix and Stravix this year, and we're also preparing for geographic expansions beyond the United States for these products. Moving on to innovation, where there is early progress on delivering our expanded pipeline. Many of the highlights of this quarter have been the recently launched growth drivers, such as what Anne-Francoise touched on, OR3O, the continued success, the strong adoption of EVOS in trauma, for instance. And in addition, 4 of the projects we highlighted to you in February have now received their first regulatory clearances and are expected to launch in the coming months. In Orthopedics, the new instrument for hip and knee surgery are ready to be shipped in the U.S. EVOS large fragment and Periprosthetic plates should also help extend the success of our plates and screw business. And actually having the large fragment plays gives us access to a bigger part of this segment and makes the whole of the system a more complete solution for our customers, and it's been adopted very positively by our customer base. In Sports Medicine, the next generation of Fast Fix builds on our already leading meniscal repair portfolio. It's a smaller flexible device that gives access to parts of the meniscus that is hard to reach with existing devices. We plan to launch in the middle of the year. And we see a good opportunity from launching this as the new repair market recovers further from COVID. Double Flow is a further upgrade to the Arthroscopic Tower. It combines inflow, outflow pumps for better control and fluid management. And this actually follows the launches in visualization, in many mechanical resection and in radiofrequency. And so the INTELLIO Connected Tower really has been upgraded and enhanced with Double Flow, and it will continue to enhance our competitiveness of the tower. We have upgraded the tower now on all elements within 2 years. These first regulatory clearances are an exciting start to our pipeline delivery for the year. And as you can see from the slide, there's more to come across all of our franchises. Now driving operational improvement is another priority for the year. In February, we announced a new operations transformation program. It targets around $200 million of annualized cost savings by the end of 2023. Work is underway on the key work streams. And this slide shows 2 examples which are already well advanced. On the left, you can see we're making good progress with the new manufacturing facility in Malaysia. We expect the site to actually begin production next year, enabling us to support future growth from a lower-cost location. We're also in the process of outsourcing our global warehousing and distribution to single regional logistics hubs in Memphis, in the Netherlands and in Singapore, all of that managed by specialized third-party partners. The European and APAC projects are already significantly advanced. The Memphis outsourcing is underway, and when complete, we should benefit from the greater scale and from the expertise of our partners, including their automation technologies. Of course, our focus on efficiency goes beyond manufacturing and operations, and we continue to control discretionary costs across the entire organization. Finally, I'd like to cover the outlook for '21. As mentioned, the improved visibility means we're in a position to return to giving financial targets. We are targeting underlying revenue growth of 10% to 13% for the full year. With that, we continue to expect Hips to outperform Knees, Sports Medicine and ENT to rebound strongly and the trajectory of Advanced Wound Management to remain strong. As of April 23, foreign exchange will add around 3% growth and M&A around another 2%. For the trading profit margins, we have a range of between 18% and 19%. And consistent with our previous outlook, this includes some temporary negative operating leverage at the gross margin level relative to 2019 and as a result of COVID. Our efficiency programs will provide a partial offset to this. Also, we continue to expect dilution from investments in R&D of around 100 basis points, an initial dilution from M&A completed since the start of 2020 of around 150 basis points and the headwind from transactional foreign exchange of around 100 basis points. Finally, we expect the tax rate on trading results to be in the range of 18% to 19%. They're still unknowns, of course, and we've made some assumptions about the course of the pandemic. Our assumption assumes the improvement in conditions through the rest of the year with surgery volumes largely unconstrained by COVID in the second half of the year. So in summary, it's been a really encouraging start to the year. The impact of COVID, of course, isn't over, but it's good to see more of the world emerging from the pandemic that has been such a challenge for our societies and, of course, also to our industry. Our industry also is very resilient. And the first quarter also started to show the benefit of our approach and our strategy for growth, and we expect that to continue as the recovery progresses overall. And with that, I'm looking forward to take your questions. Thank you very much.
Operator: [Operator Instructions] The first question comes from Tom Jones of Berenberg.
Thomas Jones: I have three, if I may. The first was on the Knee business. I was wondering if you could try and help us sort of tease out how much of the weakness in that business is market related and how much of it is just due to your lack of cementless knee? I guess, what I'm intrigued by is what you think your volume performance is if you took cementless knees out of the equation. I'm just trying to get a sense for how much of an improvement we might be able to expect once you launch a cementless knee. The second question, I just wondered if you could give us a bit more detail on what's going on in China with the orthopedic tenders, timing, what you expect the impact to be, et cetera, et cetera. And then the last question for Anne-Francoise. I just wondered if -- I don't know it's a bit early to talk about 2022, but your hedging policy is a little difficult for us to kind of fathom out externally. So my kind of question would be, if FX rates stay where they are, what kind of margin impact would you expect in 2022 versus 2021 from transactional FX?
Roland Diggelmann: Thank you, Tom. I'll take the first 2 questions then. On the Knee side, I think what we expect is we continue to expect higher growth and path to recovery on the Hip side. I think 2 factors here, very good performance of the newly launched products with a pull-along effect OR3O to the entire hip franchises. And then secondly, of course, there is more acute injuries in hips. So physicians tend to favor or do hip surgeries before knee surgeries. Knee surgeries are easier to be deferred, and that's what we're seeing in our numbers. And then, of course, the other side of it is not offering a cementless knee in the U.S. This is a trend that -- in the U.S., not so much in the rest of the world. Difficult to assess the volumes and the numbers at this stage. We have -- we are going to see a recovery as the markets overall recover. I think that's also important to note. We're working full speed on providing a cementless option towards the second half of this year. And what we do expect to see then is, of course, a pickup of both the entire franchise and an ongoing shift to cementless. On the China situation, the value-based purchasing, we are preparing for that tender. The tender has been delayed a couple of times. We expect the tender to go through in the second half of the year, probably then first result in implementation towards the end of this year and then the impact in 2022. Just to put it in a broader context. So we don't know yet what an impact this will have on pricing, but what you should understand is, of course, those pricing numbers are end user or to hospital prices. This is from distributors to the hospital. This is not our prices to distributors. We have seen, as Anne-Francoise has mentioned, a certain slowdown in ordering from distributors ahead of this volume-based purchasing tenders. When I look at the impact, it only does cover a part of our portfolio in orthopedics, namely primary hips and primary knees. Even there, some categories are excluded. So when we look at it overall, it probably only accounts for about 1/3 of our business in China, and then you have to put that into the context of our overall China business as part of our global sales. So we are, of course, monitoring this very closely. We have a strong team, a very high brand recognition in China. So we feel we're well prepared for volume-based purchasing in China. And then for the third question, Anne-Francoise?
Anne-Francoise Nesmes: You don't want to take the question on hedging, Roland? Come on. Tom, you're right to say it is a complex matter on our hedging policies to hedge 12 months forward on a rolling basis. So as we see today or as we've seen in the past few years, the U.S. dollar was strengthening and, therefore, we had headwind both in 2020 and 2021. Now recently, the U.S. dollar has weakened and, therefore, the impact will reverse. And to your question, I don't have a crystal ball, but as we look at the exchange rate today and assuming that they stay around current level, we'd estimate that the benefit in 2022 would be around 50 basis points. And of course, we'll have more clarity throughout the year and as we progress towards our 2022 hedging activities and as they are put in place.
Thomas Jones: That's very helpful. Just even a rough idea, gives us something to work with at this stage. That's very useful.
Anne-Francoise Nesmes: No problem. I am not making exchange rate forecast, though, please.
Operator: The next question comes from Hassan Al-Wakeel from Barclays.
Hassan Al-Wakeel: I have three questions. Firstly, if I can follow up on China. Is your base case that we will see a similar cut to what was seen at the provincial level rather than what we've seen nationally with drug-eluting stents? Secondly, could you talk about the growth in robotics and how CORI installations are progressing and what the split here is between ASCs and hospitals? And then finally, can you talk a bit about the strength in Hip, which continues to outperform peers? What proportion of your implant sales in Hip today are from the OR for you?
Roland Diggelmann: Thank you, Hassan. Thanks for the questions. On China, it's very difficult to predict. But of course, as you mentioned, we have the experience from the provincial tenders that are now being expanded nationally. We would expect more of this in a similar range. The drug-eluting stent market is a very different market, very different dynamics than the orthopedics. So very difficult to predict at this stage, but we're optimistic that, a, we're going to be able to play an important role in this tendering and that we will be able to manage the impact on pricing. On CORI, we usually -- we don't disclose the numbers and the breakdown. I think what we mentioned is, of course, initially, we've seen -- we've worked with some existing customers. We're transitioning NAVIO to CORI. And now the next phase is really to go after new customers. And some of them will, of course, be in ASC, some of them will be in traditional settings. The opportunity that we have here with CORI we have a very versatile solution. We have a very flexible handheld and a very small footprint solution, which I think is very well suited to ASCs. Now that said, the majority of the customers will continue to be the traditional hospitals. And that, I think, is just also a function of where knee replacements for the most part are still being done. On the hip side, yes, great continued success from OR3O. I think it's a combined success of OR3O really meeting the market needs and the combination with a leading surface technology which was OXINIUM, which has been on the market for many years, has got great clinical data to support. And of course, the strong hip stem franchise overall and the ability to combine with great solutions there as well. We don't provide the breakdown in the subcategories, but I think it's fair to say that OR3O has been a great success and that has a pull-on effect on the entire franchise in hips.
Operator: The next question comes from Lisa Clive of Bernstein.
Lisa Clive: A few years ago, Smith & Nephew did a big reorganization of the European business. My understanding was it caused some disruption, a fair amount of attrition. Has this finally stabilized? And what can we expect from that particular division going forward? And then second, you mentioned bioactives in the longer term moving beyond the U.S. I thought historically, the clinical data was just not particularly robust enough for other payers to start using bioactives. Has this changed? Or sort of could you talk a little bit about the commercial strategy and how it may be different outside the U.S.? And then third, just on the growth of the uncemented knee procedures. Are uncemented knees really only being used in robotics? And do you have any estimates for what proportion of knee replacements today are using robotics, both within the Smith & Nephew portfolio, but also sort of more broadly for the market.
Roland Diggelmann: Thank you, Lisa. Quick question. You were talking about wound for Europe. Did I get that right?
Lisa Clive: Yes, yes.
Roland Diggelmann: Okay. Thank you. Yes, indeed, I think we have gone through a period earlier where we had high attrition rates. We have changed the leadership. We have changed the approach. We have changed some of the teams. This is particularly important because our Wound business in Europe is the largest. I think we've turned that corner. Very encouraged by the progress made, and it's a progress on many fronts. It's our go-to-market, it's leadership, it's really the processes and an improved capabilities around large deals, tenders and also not just selling to the clinical and the professional base, but also, of course, to the C-suite. So I feel that we've made really good progress in Wound in general and in Europe in particular. On the bioactives, we feel that we have the clinical data to certainly go outside the U.S. as well. I think what will -- it will take some time. Of course, this is human-derived product, and there is a very particular or distinctively different regulatory pathway in different geographies. So based on this, we've decided to go first to Japan. And then today to other markets. I don't think there will be a different adoption to bioactives than in the United States. I think what you will continue to see, of course, is a different price levels as is typically the case outside the U.S. But we're optimistic about bringing those bioactives to -- outside the U.S. market. Third question on the knees, on cementless and the share of robotics. I think cementless is being used, of course, in traditional surgery as well as in robotic surgery. I would say that it is within robotic surgery, cementless accounts for a higher proportion. But our goal has always been to pursue this dual strategy of offering cementless for both robotics, but then also, I would say, traditional surgery. The trend to cementless is more pronounced in the U.S., less so in Europe and in Asia for many different reasons. This is search and preference. This is the ability to markup higher prices in the U.S., which is less so in Europe. But indeed, cementless will continue to play an important role across the market, and particularly in the U.S. And of course, cementless surgery is faster because you do not need to wait for the cement to harden, and that offers a time advantage over cemented surgery.
Lisa Clive: Just one quick follow-up on that. I mean, cementless is not exactly a new concept. I mean it's pretty standard in hips, and my understanding was sort of 20 years ago it was used in knees quite a lot and just the outcomes weren't very good because of the initial instability. So what has changed? Has there been a sort of technology change that makes cementless better today? Or am -- I'm just wondering why this has roared back, particularly in the U.S. in the last sort of year or 2?
Roland Diggelmann: Well, I think also originally, I think we had some good results in cementless knees. I wouldn't say that overall the concept didn't work. I think we've seen different designs. We've seen different rates of success. But overall, there has always been this notion that if you have a better fit and if you have really accurate cut, of course, cementless offers bond preserving opportunities initially. And hopefully, in the event of a revision, you would also have a higher bone stock that would be preserved. So I think we've made a lot of progress around designs, around surgical time that is important. That's a huge trigger, of course. We're also talking about the blood barrier and the blood loss. And designs, cuts, technology advantages, bearing surfaces, everything playing together. I think cementless has a strong role to play. And they are part of what the physician should expect as having choices between both cemented and cementless, depending on the patient and not the anatomy and on the patient needs.
Operator: The next question comes from David Adlington of JPMorgan.
David Adlington: A couple of questions. Firstly, just on margins, you still look towards that negative operating leverage. Now I know that's relative to 2019, but given the stronger growth in the first quarter that a lot of us were expecting, maybe you could just talk about whether there's upside risk to that margin guidance or whether you would plan to reinvest. Any upside coming through the margins? And then secondly, on Wound Care, just interested to see who you think you're taking share from and whether you're using price as a lever to do so.
Roland Diggelmann: Thank you, David. Anne-Francoise, do you want to go ahead with the margin question?
Anne-Francoise Nesmes: Yes. So I take the margin. So David, when we look at the margin and as we -- consistent with what we said during the full year results, there's a number of dilution items which are not dependent on revenue. So when we talk about the FX dilution, our investment behind growth levers like R&D and the M&A, that has a dilutive component that will not be driven by volume. And as where we sit today, there's still a negative operating leverage at gross margin given our production volumes are not quite back to 2019 levels, hence the dilutive effect. Also, if you take the organization as a whole, and we should not underestimate that, there's effectively 2 years of price erosion, 2 years of cost inflation, which were partially offsetting with our restructuring, with our process efficiencies, activity and process improvement. But that's where you've got to bear in mind when you look at the margin. Now having said all this, we are managing our cost base carefully, but importantly, what will drive the margin is the return to growth. And that, as you've heard us say before, it's finding that revenue growth that will drive margin over time.
Roland Diggelmann: I'll go with the one question then, David. We haven't seen any price impact. Actually, it's been relatively remarkably stable. So to date, I think it really comes down to better commercial execution. Some of it is also due to the timing of certain contract renewals. When I then look at the breakdown between Wound Care, bioactives and devices. On the bioactives, we mentioned we've also had some of the timing impact between late 2020 and beginning of '21 that has helped us. But overall, I think we just continue to execute better on the basis of having really great and differentiating products. On devices, I would say that this is still, as you can see, the numbers are still negative, but also a function of elective surgeries and still lower levels. That has had an impact. But there too, very confident that with our PICO line, we'll continue to grab share. It's difficult to really extract where from we win share. We haven't seen all the market data yet, but we'll certainly follow up on that.
David Adlington: Perfect. And then maybe just one follow-up. In terms of your expectations for the second half, are you expecting just a return as kind of normal market conditions? Or are you baking anything in for what we think is posting heads-up demand out there?
Roland Diggelmann: We definitely see a pent-up demand. What is very difficult to actually assess is how big that pent-up demand is. What we're seeing, though, is that typically, when restrictions are eased, there is a pretty quick recovery in the markets that can absorb higher volumes. And that's more a question of the health care system and of the readiness of the health care system and of the capacity. Some markets like the U.S. are responding quicker and some others like the U.K. with a more centralized system are responding more slowly. And I think that's how we will have to continue to monitor and be very close to these markets and see how we can actually also support the restart. So that's how I would qualify it. And the assumption that we've made is, of course, is a return to more normal levels or volumes of surgery, especially in the large markets. But we do expect, of course, continued weakness in some of the markets that are struggling today. And unfortunately, we've just seen the news from India, albeit a small market for us. Latin America continues to struggle. And in general, hopefully, on the Northern Hemisphere with the continued rollout of the vaccine programs and the better weather and the higher activity levels, this should help us.
Operator: The next question comes from Michael Jungling from Morgan Stanley.
Michael Jungling: I would like to ask 3 questions. Firstly, on U.S. Knees. Can you comment to the degree your cementless knee has now been gone -- how it's going through testing. Have you completed testing? And does the surgeon need an entirely new instrumentation kit? Or can you use the existing kits that you have on other needs. Question #2 is on the U.S. sales force. To what degree has that sales force now returned to pre-COVID customer engagement? I'm referring you to travel, physical hospital visits, and helping in the OR. And then question #3 is on CORI. Can you comment how high up the priority list selling CORI is for your orthopedic sales force this year? Do you have a specific target of robots that you must sell in 2021?
Roland Diggelmann: Thank you, Michael. U.S. Knees, we're on track. We're obviously not going to go into details of where we are with the program, but we're on track for delivery in the second half. On the instrument side, some of the instruments, of course, are both on LEGION and JOURNEY will be able to be used. And some components will have to be adjusted, of course, for the cementless application. But overall, this is going well. We also have just -- we find our instruments program to actually upgrade the instrument, simplify, and this is also ready for rollout as we speak. So invested in parallel in the instrumentation, which will make it easier to use for our customers. On the U.S. customer visits, indeed, the commercial team is going to visit and assisting in surgeries wherever they can. But the U.S. market, of course, is pretty heterogenic. So there is areas where everything is back to normal activity levels, and then there are some states and regions where we continue to see constraints. I would say, in general, of course, The access to hospital is still somewhat less than before COVID. And then also hospitals have adopted some different protocols, of course, in looking to protect health care workers and the patients from COVID. So what I would also say is that we continue to see a shift towards decentral, towards ASCs for the obvious reasons, being more flexible closer to the patient in providing care. On your third question, on CORI. Yes, of course, we have targets. We have internal targets, the number of instruments that -- the number of CORI that we want to bring to the market. We're not going to disclose these publicly, but we have those targets. And as I mentioned, the first phase was, of course, to upgrade from NAVIO to CORI with existing with good customers. We're ready now to roll out to new customers. And we're seeing actually a very good reception of CORI overall.
Michael Jungling: Great. Can I briefly follow up on the U.S. Knee? Maybe I should have asked the question slightly different. Will the surgeon require additional training to do the new porous cementless knee, i.e., can it be done very quickly to roll out or is there an extensive training program that these surgeons need before they can start to operate?
Roland Diggelmann: Yes. Thank you. Great question. I mean, typically, surgeons are used to doing both cemented and cementless knees through their training. They've grown up to do both. Some have preferences for one or the other. Some have more an approach around patient conditions, patient anatomy and other factors. So I think the training requirements typically will be limited. Certainly, physicians will be already familiar with the different features of both LEGION or JOURNEY, so they will be familiar with the implant, they will be familiar with the instrumentation. And so I would expect the training requirements to be very limited both because of the familiarity with the system, and familiarity with cementless surgery overall.
Operator: The next question comes from Veronika Dubajova from Goldman Sachs.
Veronika Dubajova: Excellent. I will keep it to 2, please. One is, I just want to kind of follow up on some of the CORI conversation, Roland. Just get your perspective on how much you think the robot as a lead for the implants versus the implants are a lead for the robot. And I think there's been quite a lot of discussion about this in the industry more broadly. And I guess in your case, in particular, you are using a slightly different technique versus your peers. Is that something that you think is a differentiator that is driving placements and then following through to the implant sales? Or is it more the other way around? And I guess, Zimmer in particular, have become a bit more aggressive in terms of giving the robot away free in return for higher prices and greater volume commitment, it would be great to get a sense for kind of the placements that you're putting out there into the market, how they break down between lease agreements versus outright sales, if you can share that. So I know it's a very big question, but lots in there. And then my second question is just following up on the China tender question. And from memory, I do recall China being an extremely profitable market for you guys. And just kind of curious if there are offsets should the worst case materialize that you do see a fairly aggressive price reduction and some of that is passed on to you. What is the flexibility that you have in the rest of the P&L to protect the margin that you are currently earning in China? Or should we be assuming that in that worst-case scenario that does indeed drop through to the bottom line fairly -- on a fairly straight forward line?
Roland Diggelmann: Okay. Thank you, Veronika. I'll try to give some color on CORI. And I think, in general, I think when we look at procedures, we'll continue to see a shift from implant to the overall procedure. I think that's something that we continue to foster as well. We're looking at this more as a real experience rather than just implant features that goes from preoperative to postoperative. Different elements here play a role. We also have -- we're offering remote physiotherapy for instance, for patients that, for instance, are going through ASCs and return to home quicker. So we are looking at the entirety of the delivery of a surgical experience. So I think the shift that you're seeing is not just robotic specific, but really specific to the experience that a customer is going through. Robotics play an important role here, such as instruments, traditional instruments do. And I think we've recognized that. I think the robot can be a lead. It doesn't have to be a lead, but it can be a lead. And I believe here with our handheld, we have 2 differentiated. And we certainly have a differentiator when it comes to very flexible approaches, small footprints, not requiring a CT scan. So there's quite a few advantages here that lead to that differentiation. Now with regards to the different models, yes, so far, we've been -- we're seeing good selling of CORI, but I believe we have exactly the same opportunities and flexibility in our commercial models than other companies in the marketplace. Again, I don't see robots being very different from what we had traditionally here. This industry was one that, at some time, very long time ago, sold instruments. Then instruments became an element that was being placed. And we're seeing similar patterns here. Altogether, I would say we have the flexibility like everyone else in the industry. On China, volume-based pricing. We'll have to wait and see where the real prices come out. I think there is always an opportunity through higher volumes to compensate some of that. Obviously, yes, China is important to us, but we've never said that China is extremely profitable, but we believe that we have the ability in China to continue to grow. We have the ability to also look into our business model altogether to react. It's too early to tell where exactly this will be. But then if I just take you to the overall numbers, I would say, right now, as we said, this is primary hips, primary knees that are part of the national volume-based pricing tenders. Some categories are even excluded from primary hip and primary knee. So it accounts for a smaller part of our overall business in China. And I don't think this will have an immediate effect on our global P&L.
Operator: The next question comes from Kate Kalashnikova from Citi.
Kateryna Kalashnikova: Yes, this is Kate Kalashnikova from Citi. I got 2 questions. First one on REGENETEN, REGENETEN is a key growth driver. But what we hear from surgeons is that while it is a great product there are more synthetic options available in the market that are cheaper than REGENETEN, I think more competition for REGENETEN. And how concerned are you about those cheaper synthetic options, that's the first one. And then secondly, again, speaking to surgeons they say that in quite a few cases lower endorsement for procedures in ambulatory surgery centers compared to hospitals means that some procedures can be actually done in ASC are still only done in hospitals. Do you see the slower endorsement as a meaningful limiter to growth of ambulatory surgery center.
Roland Diggelmann: Thank you, Kate. The line was a bit breaking there. So hopefully, I got the questions right. So on REGENETEN and alternatives and then on ASCs and the reimbursement. Let me start with REGENETEN. I'm not at all concerned about synthetic options. I think what REGENETEN brings is actually a huge advantage in the clinical results over synthetic options. We have a lot of clinical results published that actually demonstrate that. We continue to improve the instruments for better delivery, and I'm very encouraged by the growth patterns that we see. I think we continue to see a really good runway here. And I think the differentiator is actually just that REGENETEN is not the synthetic option, but that ideally delivers truly a better clinical outcome. So I think it's a huge progress for patients with rotator cuff injuries and deficiencies. On ASCs. I think, again, we continue to see a shift to ASCs. This is driven by different factors, technological advances, surgical improvement in surgical procedures, the proximity to patients, of course, same-day surgery and all of this has been enhanced by COVID where decentral and specialized care has been accelerated. Indeed, there is lower reimbursement overall. But what is, of course, also fueling the shift is the fact that we now do have reimbursement, and we do have CMS codes for total knee, uni knee, total hip, and that will continue to accelerate that shift. The lower prices means that we have opportunities to also improve our delivery, the model, the support we provide to ASCs. So we see this as an ongoing trend, and we believe that we're well positioned, especially because we call on ASCs with our Sports Medicine franchise already. So we are a known entity or a known brand in ASCs. And I hope this answers your question, Kate.
Operator: The next question comes from Julien Dormois from Exane.
Julien Dormois: I have three. The first one is a follow-up to Michael's question on the launch of the cementless knee, and you alluded to the fact that there should be limited training necessary for the launch of the product. So would that mean that we should expect a return to market growth for the knee franchise already in full year 2022. So that would be the first question. Second question is probably more for Anne-Francoise, but it comes to the phasing of margin in 2021. Usually Smith & Nephew is having quite a higher margin in the second half versus the first half. But given the magnitude of the growth we will have in H1 compared with H2, should that be different and should we expect something more balanced this year? And the last question is a broader one. With the situation now normalizing and probably having less time dedicated to manage the pandemic, do you believe you will be in a position to come up with long-term or midterm financial targets at a later point in 2021 or early 2022?
Roland Diggelmann: Thank you, Julien. I'll take the first question and then maybe Anne-Francoise, you can speak about the margins and then the long-term targets. On the cementless launch, as I mentioned, we're looking for a limited launch in 2021 towards the second half of the year. You need to think of this as a longer-term process. There is many different components on 2 main knee brands, LEGION and on JOURNEY. But then within those categories or within those brands, there is different components that need to be brought on to a cementless platform. So the rollout will be in 2022 and beyond. This is an ongoing process there. I would say the one important factor is the scale of the launch. And we're talking about hundreds of instruments, of course, that need to be delivered. And I'm talking about the specific instrument components for cementless. So it's a big exercise. But it's a great opportunity for us indeed because we do very much need the cementless options in the market to complement our cemented options.
Anne-Francoise Nesmes: And then the -- so on margin, you're right that there's, I guess, a historical pattern of certainly we see higher margin in the second half particularly linked to the revenue pattern. So really, what will be important for the margin is the absolute sales level as we go through the second half and when we were looking at assumptions. So there is a pattern. However, when we were looking at our assumptions, some expenses are normally weighted towards H1, like big conferences or event or meeting probably will move towards H2 to the extent they can. So that may mean shift a little bit the historical pattern we've seen. But other than that, we don't have much more to add. And then in terms -- before I move to the long-term outlook or guidance, I just want to reiterate, for 2021, clearly, our focus is to return to growth, deliver on our optimization on process efficiency and, of course, recover to COVID. So that's priority #1. And then the focus, midterm, is the growth, as we talked about, and delivering the 4% weighted average market growth. That is our ambition. And that will come through the delivery of the pipeline, excellent commercial execution and our continued focus on landing in tuck-in M&A.
Operator: This concludes today's questions. So I'll hand it back to yourselves, Roland and Anne-Francoise.
Roland Diggelmann: Thank you very much. Thank you all for your interest in Smith & Nephew, and I wish you a good day, and all the best. Stay safe. Thank you.
Anne-Francoise Nesmes: Thank you, everyone.