Smith & Nephew PLC

LSE:SN

Earnings Call Transcript 2018-Q4

[Namal Nawana, Chief Executive Officer]

Good morning, everyone. And welcome to Smith & Nephew's Full Year Results Presentation. With me is Graham Baker, our Chief Financial Officer and Phil Cowdy, our Head of Business Development and Corporate Affairs.

Really pleased to report 2018 results have delivered on our guidance. We had $4.9 billion of revenue, increasing by 140 million. We accelerated the business in the second half with two consecutive quarters of 3% underlying growth, taking us to 2% full year growth. Our trading profit was $1.1 billion, and the 22.9% trading margin was significantly above the 2017 level. Trading cash flow was $951 million, so a strong 85% trading cash conversion. Adjusted earnings per share of $1.01 was 7% improvement over the prior year. The second half of 2018 was a solid start towards our goal to accelerate our top line growth and deliver that growth sustainably with consistent margin expansion.

After I take you through the highlights of Q4, I'll summarize the changes we've made and the new strategic imperatives for value creation that we announced last month at the J.P. Morgan Healthcare Conference. Then Graham will cover the details of our full year results and our 2019 financial outlook.

Let me start with our Q4 performance by geography on Slide 5. We again had a solid quarter in the U.S. The U.S. represents about half of our business and grew by 3%, well above what we saw in the first half. Emerging Markets are now 17% of our sales and grew 8% in the quarter. China again stood out with growth in the teens across all 3 core franchises. And Latin America grew 8%. Other Established Markets improved to flat after negative growth in Q3. As you know, Europe has been an area of weakness for some time and was minus 1% in Q4, after minus 2% in Q3. The decline in our UK business moderated in the quarter, and we've now appointed new leadership in Germany, which is another market that we've highlighted as a challenge.

Now moving on to performance by franchise. We grew by 3% globally in Reconstruction. Knees grew 3% again, and that was driven by double-digit growth from JOURNEY II, ANTHEM and the LEGION Revision System. Growth in the U.S. was 1%. This quarter-on-quarter trend is similar to that reported by our competitors. Pleasingly, the annual annual sales of our Knee franchise passed $1 billion globally for the first time.

In Hips, we saw continued momentum from Q3 with a second quarter of plus 4%. This market-leading performance comes from the increased focus from the commercial teams around POLAR3 and our REDAPT Revision System. I also want to highlight our pipeline of new products still to come in Hips. I'm very excited about our dual mobility product with its OXINIUM bearing services. Dual mobility is a technology that protects against dislocation and without compromising the range of motion of the device. And it's another product that allows us to access one of those faster-growing product segments in hip replacement.

Moving on now to our Sports Medicine franchise. Sports Medicine and Trauma grew at 3% in the quarter. Our highlight continues to be our Joint Repair business, which grew at 9%. REGENETEN for rotator cuff repair more than doubled for the full year, well ahead of our deal plan, as customers recognize what the technology can do for their patients. Our U.S. Sports Medicine sales force is fully trained now on REGENETEN, and that's happened during the course of last year. And we're beginning to launch outside of the U.S. during the course of this year. In December, we added another exciting product to our franchise with the acquisition of Ceterix. That's a deal that is now fully closed. And the lead product, NovoStitch Pro, is a unique technology that enables surgeons to repair a broader range of meniscal tears. And as a market leader in meniscal repair, we're really well positioned to sell it through our existing sales force.

Arthroscopic Enabling Technologies declined by 4%. The team is focused on remediating the performance, and product launches in 2019 are a key part of that. We've been waiting for these for a while, but I am very pleased to say that our FLOW 90 Wand is already beginning to launch in select markets outside of the U.S. And we just last week received the 510k approval to enable us to begin our launch in the U.S. in Q2. So FLOW 90 will enable our WEREWOLF technology to expand to the shoulder, and that is, of course, the largest area of use for COBLATION technology. We also have a new range of PLATINUM resection wands, and that's a workhorse in our Sports Medicine business which will launch in Q2.

Our current views and plans point towards AET, therefore, returning to growth during the second half of the year. Trauma & Extremities grew at 1% in the quarter. The U.S. is growing well for us. And that's on the back of our -- not only our EVOS launch but our INTERTAN product group in nailing. And we are now bringing our EVOS SMALL plating to more countries in 2019, having fully launched in the U.S. And Other Surgical Businesses grew again at 11%, including a very strong quarter for our NAVIO robot and capital sales. The number of units sold for the full year was more than double that of 2017.

Finally, on to our Wound business, which grew 2% overall in the quarter, up from 1% in Q3. Within that, we grew our Advanced Wound Care business 2% but relied on the second quarter -- which relied on the second quarter of consecutive double-digit growth in the U.S. Our pressure injury prevention strategy has been a primary driver within that. And reduction of hospital-acquired pressure injuries is a priority in the U.S. hospital market. And we've been able to meet this need with a broad range of solutions from our portfolio, including ALLEVYN Life and our skin products.

Advanced Wound Bioactives was down 3% in the quarter due to a reduction in the rate of decline of SANTYL volumes. And looking into 2019, we have a new opportunity with the relaunch of REGRANEX, our platelet-derived growth factor. REGRANEX is an important medicine for a serious condition, and the FDA removed the boxed warning and the associated warnings from the REGRANEX label during the quarter. Our regulatory team has done a fantastic job in bringing the appropriate data to document REGRANEX' historical safety and providing the FDA with the evidence it needed to support this change. Now our understanding is that this is only the fifth occasion in which a boxed warning has been completely removed from a pharmaceutical product in the U.S., so we're very pleased with the work of our regulatory team and confident in our product.

Finally, Advanced Wound Devices grew 14%. Our single-use negative pressure device PICO was again the main growth driver for the franchise. And RENASYS also had a good quarter in the U.S. We've been gradually building customer confidence in the product since its return to the market, and we're starting to win contract business again. So with our Q4 performance, we've had a really solid finish to 2018. We're moving in the right direction, but there's still more work needed to get business areas growing at or above their markets and to get our overall growth rate, firstly, to the 4% aggregate market growth that we've called out and then, of course, beyond that.

And we announced an important move towards improving our commercial execution at our Q3 results with a shift to a global franchise structure. I have appointed dedicated presidents of Orthopaedics, Sports Medicine and ENT as well as Wound Management, alongside regional presidents for Europe, Middle East and Africa and Asia Pacific. We now have a less complex and more customer-centric model than in the past.

We also announced our new strategic imperatives, which are in front of you. And I'm just going to go through those briefly now. So three of the five imperatives are focused on growth, the first of which is to achieve the full potential of our portfolio and, with that, really improve how we launch new products and ensure that we're well positioned in fast-growing segments in the market, like ambulatory surgery centers in the United States in particular, and also focus on Emerging Markets. I've already mentioned some important launches we have coming in 2019, and our franchise-focused commercial model should enable better commercial execution than in the past.

The second imperative is to transform our business through enabling technologies. NAVIO is an important part of that, and we plan to talk more about the specifics of our development plan for robotics at the American Academy of Orthopaedic Surgeons Annual Meeting.

Third is to expand in high-growth segments, and that's through our internal product development and R&D and also more M&A. The value-creation potential from bolt-on deals, like Rotation Medical and our REGENETEN product and now also Ceterix, is very clear. And we want to find -- continue to find similar acquisitions. I'm pleased to report that -- as I just mentioned, that we have completed the Ceterix acquisition in January, and that's going well. And we're now scaling up our manufacturing and in the process of rolling out NovoStitch Pro firstly to our U.S. sales force and then beyond.

We're also looking at deals to get access to adjacent markets, and there's -- where there's a good strategic fit for Smith & Nephew. And that's been a very big part of the exercise of my team, mapping out the full universe of our possibilities. At net debt to EBITDA of 0.8 times at the end of 2018, together with our strong ongoing cash conversion capacity, we certainly have the capacity and capability to do more.

The fourth imperative is to strengthen talent and capabilities. We've already brought in many new leaders, and over half of the Executive Committee of Smith & Nephew is new in role in the last 12 months. The work we've been doing to create a purpose-driven culture is another component. Employees all around the world and our company have contributed to what you saw at the beginning of this presentation in our new brand purpose, Life Unlimited. And Life Unlimited really does strive to and does capture what we aim to do at Smith & Nephew and what we aim to do for the world, which is ensure that we're meaningfully addressing the health issues that hinder people from living their lives to the fullest. We also have new culture pillars: care, collaboration and courage. And they are simple pillars that are being embedded in the way we work every day around the world.

Finally and our last imperative here, which is to become the best owner of our business, speaks to our opportunity to meaningfully improve our margins at Smith & Nephew. There's still more scope for us to simplify and improve the efficiency of our manufacturing, and there's significant potential for us to deploy lean methodology across our organization. And the improvements in trading margins that we saw at the end of last year will continue into this year, and Graham will update you in a moment on our guidance, which demonstrates our commitment not only to our revenue growth but also to trading margin expansion over time.

The franchise presidents were in place to launch 2019 with specific plans for each area based on those 5 strategic imperatives I presented. We announced in November the appointments of Skip Kiil, Brad Cannon and Max Colella. And Simon Fraser joined us just in January as our President of Advanced Wound Management. Rodrigo Bianchi is our current President of Asia Pacific, and he'll remain in place until the appointment of our new Asia-Pacific President, which we anticipate being announced shortly. There will be an opportunity to meet some of our leaders at the American Academy of Orthopaedic Surgeons, and that's in March. We'd also like to announce today that we'll include a presentation from each of our franchise presidents in the remaining trading updates for 2019, so one of them will attend each of the trading updates.

I now hand you over to Graham, who is going to take you through a detailed look at our full year financials. Thank you.

[Graham Baker, Chief Financial Officer]

Thanks, Namal. Good morning, everyone. I'll start with the P&L. Full year 2018 revenue grew 3% on a reported basis and 2% on an underlying basis, excluding the impact of foreign exchange and acquisitions. Trading profit grew by 7% to $1.1 billion, and the trading profit margin rose to 22.9%. That's an increase of 90 basis points over 2017, reflecting both the 50 basis point nonrecurring gain from the legal settlement with Hologic that we disclosed at Q3 and operational margin expansion of 40 basis points. The operational improvement reflects savings realized under the APEX program, partly offset by negative leverage effects in the P&L.

APEX is progressing well and contributed around $60 million of savings to the P&L in 2018. Our guidance for 2019, which I'll turn to shortly, reflects continued confidence in our ability to grow both sales and margins into the midterm. Gross margins and our R&D cost-to-sales ratio remained broadly stable in the year.

And moving further down the P&L, adjusted earnings per share growth at 7% was in line with the growth in trading profit. Basic earnings per share declined by 13%, reflecting the expected restructuring charges of $120 million and the $72 million increase to our metal-on-metal legal provision as we saw an increased volume of claims in 2018, principally in the U.S. The tax rate on the trading result was lower than guided at 16%, mainly due to a onetime benefit in the second half from a tax provision release. We propose to increase our full year dividend by 3%, which continues to reflect our progressive dividend policy while recognizing that the Hologic settlement gain is non-recurring.

We generated trading cash flow of more than $950 million in 2018, an increase of 1% from the prior year and representing trading cash conversion of 85%. Lower capital expenditure in 2018 reflects careful project prioritization and a review of manufacturing effectiveness by the new operations leadership team brought in under Namal, which is still ongoing.

We expect 2019 CapEx to be around 8% of sales compared to our previous indication of 8% to 9%. Working capital outflows were, however, higher than in the prior year at $195 million, including increased inventory supporting sales growth, new product launches and an increase in safety stock levels, in part in preparation for Brexit. Overall, free cash flow was $584 million, $130 million lower than the prior year, reflecting higher restructuring acquisition, legal and other costs of $190 million. Of these, around $80 million was cash restructuring cost.

Our continued solid free cash flow generation saw net debt fall during 2018 by nearly $180 million to $1.1 billion, which represents 0.8x EBITDA. As Namal mentioned, we intend to become more active in M&A going forwards. Our policy to maintain investment-grade credit metrics remains unchanged, but you should expect our net debt levels to rise from current levels to typically be between 2x and 2.5x EBITDA in future. Of course, we may be below that for a while and may also be above that range for limited periods for the right value-creating opportunities consistent with maintaining the investment-grade metrics.

To conclude the financial section, I'll now turn to guidance. In 2019, we expect underlying revenue growth of 2.5% to 3.5%. Based on the prevailing FX rates on the 1st of February, foreign exchange, offset by the acquisition of Ceterix Orthopaedics, will reduce growth by around 70 basis points. So we expect reported revenue growth to be around 1.8% to 2.8%.

For your modeling, I'd highlight that at those rates, the currency headwind on reported revenue growth will be concentrated in the first quarter of the year before returning to being a small tailwind in the second half. Our guidance for trading profit in 2019 is for margin to be between 22.8% and 23.2%. This represents 40 to 80 basis points of underlying expansion above the realized 2018 trading margin of 22.4%, which excludes the nonrecurring legal settlement gain. Also, we expect the tax rate on trading results to be in the range of 19% to 21%. This excludes the impact of any further changes to tax legislation or one-off items. Beyond 2019, our medium-term revenue and margin guidance is unchanged.

Finally, we'll be making some adjustments to the way we report from 2019. You'll notice that our revenue growth guidance is now to 1 decimal place, and I hope you'll be pleased that we intend to also report our actual results with this additional level of precision. I can see one or two smiles around the room. Also, in line with our management changes, we'll be making some adjustments to our franchise reporting. We'll give you good notice of the details, which represent relatively modest adjustments just to align to the new operating structure ahead of our Q1 trading update.

And with that, I'll hand back to Namal.

[Namal Nawana, Chief Executive Officer]

Thanks.

[Graham Baker, Chief Financial Officer]

I meant to put your slides up.

[Namal Nawana, Chief Executive Officer]

That's okay, we're fine. Thanks, Graham. I'm encouraged by the way we closed out the year and our 2019 guidance is for more progress, higher underlying growth than in 2018, getting us closer to the market rate and with continued meaningful margin expansion at the same time. The team is working hard to execute on our strategy, and I'm really grateful for the energy they're putting behind our plans for Smith & Nephew.

So I look forward to updating you as the year progresses. And I'll be very happy with Graham to take your questions now.

[Veronika Dubajova, Goldman Sachs]

Veronika Dubajova from Goldman Sachs. I have two questions: one for you, Namal and one for Graham. My question is on M&A for you, Namal. I think a number of your peers have stated that asset valuation seemed pretty elevated in the space, so I'm curious to get your thoughts. And as you think about the target to try to accelerate the pace of capital deployment at Smith & Nephew, do you see the current environment as favorable towards that? And just maybe remind us what the key priorities are for potential M&A in terms of technology or white spaces in the business. And then for Graham, on the APEX program, I'm a little surprised not to see an increase to the target that you've communicated. I know you generated $60 million in the year, but I suspect the run rate is actually maybe towards $80 million, so you're kind of halfway of the way there towards the $160 million. So maybe comment on what's gone well versus the plan, how you're thinking about the opportunity to go beyond the $160 million as well.

[Namal Nawana, Chief Executive Officer]

So Veronika, let me start and just say thank you for the questions. First of all, we think that as a portfolio medical device company, our job is to make sure that we are getting the best technologies for Smith & Nephew. And that happens both through our internal R&D as well as looking externally. In terms of the environment, we have to work hard to find the right assets at the right price. And the first part is really around strategy. And what I can tell you is that my leadership team and I have spent a lot of time mapping out our full environment. We're very confident that we know what is -- what are good technologies and businesses for us to be the owners of. And then we'll really pressure test the valuations. And as Graham said, in how we intend to deploy capital, very strong balance sheet, we will maintain investment-grade ratings, but we will look for attractive acquisitions throughout this year and an ongoing part of how we run the company. So I think there's always good opportunities. You just have to work hard to find which ones at which time and have an order to what you do.

[Graham Baker, Chief Financial Officer]

And on APEX, thanks, you're right. The program is running well, and you're also right that the run rate benefits are ahead of what we realized in P&L in 2018. Obviously, programs like that, we're continuously reviewing the progress, and new leadership has joined the organization, particularly in our manufacturing operations arena. That, of course, is one of the important legs of the program. So we're in the middle of reviewing the opportunities. We're not yet at a point where we're ready to release a full update. But directionally, I think you're thinking in the right sort of place, Veronika.

[Kyle Rose, Canaccord Genuity]

So this is Kyle Rose at Canaccord Genuity. A question for Namal. When you think about just the puts and takes of the guidance this year, when I go back to the half year results, you talked about the percentage of business units underperforming relative to the market rate. When you think about the 2019 guidance for reported revenue growth, which business units do you see really improving this year and bridging the gap? Maybe just give us a little more clarity there.

[Namal Nawana, Chief Executive Officer]

First of all, it's an important way we analyze our performance, and we go segment by segment. We don't comment on each of those segments. And the first thing I'd say is, since I made that statement when I first joined, we have seen improvement, and that's very important. Our team looks at that basically very regularly. And irrespective of the sector, whether it's Orthopaedics, Sports Medicine or Wound Management, we're looking at that category-by-category analysis, and we do feel that we have lots of opportunities in each of our businesses. Some of the things we've highlighted in my presentation, one is Hips.

And again, when I joined the company, I guess, Smith & Nephew had basically a decade of flat growth in Hips. And I called out and said, hey, we've got a great Hip portfolio, and we're going to grow it. We've had two quarters at 4% growth. Out of the majors, that is market-leading growth. And with the products that we have coming, you can expect us to continuously focus on that segment. Joint Repair, 9% growth. And a great product like REGENETEN, what that great product does, it means that we are present in shoulder repair, and we are really bringing value in what are difficult cases for doctors.

And so when we bring that value, we have the opportunity to really talk about our full portfolio. And so when we have a product like a FLOW 90 coming in for COBLATION now available in the shoulder, we're going behind that strong performance in REGENETEN already. If we think about wound care, 14% growth in PICO in Q4. You've heard me talk about PICO a few times. I love this product. I think it's -- very rarely do you get a product which not only has obvious clinical benefits, but it actually reduces the overall health care costs for health care systems, like the UK here, where NICE has recognized that and published why they think PICO should be used broadly.

So across the board, I think that we have opportunities in each of our segments. And importantly, we measured and made performance improvements in 2018, and I expect those to continue in 2019.

[Kyle Rose, Canaccord Genuity]

And then maybe just one quick follow-up on Knees. When I think about the market share, specifically in the U.S., it held relatively flat over the last two years. But you've got one major competitor who's been donating share to the market. Stryker has obviously been taking share. And part of that is coming from MAKO, but a large majority is also coming from the cementless market. Now how do you view your Knee platform into 2019 with a backdrop of new products, potentially a cementless product, but then also with another competitor reemerging as less of a share donator?

[Namal Nawana, Chief Executive Officer]

First of all, it is clear that Stryker has posted some good numbers and for a good period of time on their knee portfolio, and I do attribute a lot of that to the robot. I also said that we had good performance with our robot. And in the course of 2018, we are now training our workforce better with why this is important. And equally, I've said a couple of times, I'll be coming out at the American Academy with our plans, and I -- we've been working very hard in that field, and I feel very excited about where we can take that. It's an important part not just in knee replacement but more broadly in surgery. And I think that for knee replacement specifically, Stryker is number one, and we've also been a very consistent number two, and we've been growing above market overall.

We have some strong products. JOURNEY II is a strong product, double-digit growth. ANTHEM is a strong and relevant product in Emerging Markets. And our Revision System got enhanced last year with some of our conical sleeves, which I think is a good add and helps us really deal -- helps our customers really deal with more challenging procedures. So look, we feel good about the portfolio. We still have some improvement to make on how we operate and how we serve our customers, and I expect our teams to lift in that area as well as gaining their understanding of how robotics can help their customers. And that takes time, and we've only been playing with the toys for a little bit of time, so...

[Michael Jungling, Morgan Stanley]

It's Michael Jungling, Morgan Stanley. I'm here. I'm here. I have three questions, please. I'm a bit late. That's why I'm in the back. Firstly, on organic sales growth guidance of 2.5% to 3.5%, it's a slowdown in terms of comp-adjusted growth and probably is the weakest read that we've seen in the last five years. And in a way it doesn't reconcile with the level of optimism I see from you and I saw from you over the prior six months, how should one view the comp-adjusted slowdown that you're guiding to? Is it a conservatism, or is there are changes in the marketplace that makes you feel a little bit more -- a bit more less excited, let's say, in terms of guidance? Secondly, on Arthroscopic Enabling Technologies, when can we expect that business to turn around? We've had several promises over the years that things will change, and the numbers just don't look any better. And then thirdly, on NAVIO, I recognize you're going to give us some more details at AAOS, but I'm just curious at -- today with respect to the investments needed and the urgency to drive some similar results in the Knee business. I'm just curious what can we expect here in 2019.

[Namal Nawana, Chief Executive Officer]

So there's a few questions. Let me start with your guidance question, Michael. It's a range, okay? We provided a range, which we think is an appropriate range based on our performance and based on our business plans. And so what we want to do is consistently improve our business, make ourselves a stronger company as we go forward, and we're going to do that. We've got some good momentum in a lot of our businesses, and we've got some things to address as a company. And you highlighted one of them later, which is AET.

And so I'm encouraged by what we have as a medical device portfolio company. We have a great range of products. We still have work to do. We have an organization that's lifting. And I'm really, really grateful to the energy that I see in the company and the support that we're getting to turn and to do things in a different way as things take time. But I think solid 2 quarters, 3% growth in each of the final two quarters, obviously, when I joined the company, that wasn't the growth rate. And so for my new management team, I'm pleased with the progress so far; still got work to do.

In terms of AET and when does that turn, I did say when that's going to turn. We anticipate that we'll be growing by that in the second half of this year, and that's on the back of actually fundamentally launching new products. We have FLOW 90 now available in the U.S. We got regulatory approval for that last week. I'm pretty happy about that because it's the most relevant part of surgery. I mean, we get to access shoulder surgery. FLOW 50, our other one, is for the knee, and actually, we had some good performance in that, just not enough to really cater with the headwinds the company is seeing. Also, something we've talked less about is our LENS portfolio for visualization.

And our lens product development has been ongoing for 4K, and that's a program that we've accelerated. The team's focused on it. Very pleased with the R&D team. And we look to actually bring that to market during the course of 2019. So that's a component of what will help with AET as well. And then finally, NAVIO, what investments to expect in 2019, we'll talk about that at the American Academy when we've got through a few more of the things that we had planned. I love this platform. We're the only CT-free platform in robotics. That's important. And what we can do with -- the technology we have is extensive, and the teams have been working hard on that. So we're looking forward to sharing with you all our plans and progress in NAVIO and robotics.

[Tom Jones, Berenberg]

It's Tom Jones from Berenberg. I have two questions. One, on China, different corporates are bringing out very mixed messages about China, but you seem reasonably happy with your Chinese business. Are you just not seeing any kind of wobble in the market, or is there something different about your business, which means it's performing better than the last time China had a wobble, and the wheels, frankly, came off? And then the second question is a bit of more of a structural one. Over the last 10 or 15 years, one of the sort of big problems at Smith & Nephew regarding M&A is that there are other players out there bidding for the same assets who tend to have less of a focus on returns and more of a focus on EPS accretion. And Smith & Nephew, quite rightly, has always focused on returns, but that's always hampered you to some degree. So you've been limited to doing M&A where you have the scale, where you have the market presence to kind of generate returns at the same prices or better prices than other people. So that's been limited kind of really to Sports Med in a degree. Wound and everything else has been a bit mixed. So going forward, your guidance implies you're willing to spend $2.5 billion, $3 billion before touching the equity side of things on M&A, which is quite a lot of spending. Have you got enough places in your business where you have the scale to generate the kind of returns that your board demands? Or are we going to struggle over the next two or three years to find the assets at the right prices where you can generate returns that keep the board happy, the EPS accretion that keeps us happy and don't do bad M&A which upsets everyone?

[Namal Nawana, Chief Executive Officer]

Let me take the first one first, which is China. And look, I think there are macro issues in the world, and that has -- obviously, we pay some attention to that. Our outlook for China is fantastic. We have a great team there, that's the first part; and we have relevant products. We have -- our Wound Management business has broad really needs in that marketplace, so that's where we're very relevant. And as orthopaedic surgeons have been trained more and more in joint replacement and sports medicine surgery, and we're seeing expansion in the volumes. And being one of the companies that has invested and stayed -- continuously invested in China, I think it served us well. So I actually looked at that as an area that we could lean on and support our team more. And I see us doing even better going forward in China, so it's a great opportunity for us.

And similarly, in Emerging Markets, Smith & Nephew is relatively strong. 17% of our revenue comes from Emerging Markets today. We've been growing well. And again, a lot of it relates to leaders that understand our business and portfolios which are relevant for the marketplaces they serve. And we have both of those, so that's good.

In terms of M&A and doing M&A well, look, I think the most important thing that I think we should communicate is that Smith & Nephew currently operates in about a $40 billion market, and that's a good-sized market to play in. But the med device industry is a $400 billion market, and so there's a big, big world out there, and there's lots of segments in that market that are growing faster than our end growth rates that we enjoy today. And we've got good markets, obviously, about 4% growth rates. So we have to work hard, I'm not pretending we don't have to work hard in this environment and to find the right strategic fit as well as the right financial outcomes, but we're very prepared to work hard. And that's what we've been doing.

And what does that actually look like? What does that look like from a management team? That looks like looking at a lot of things before you move on something. And I'm pleased with finding an asset like Ceterix. That was perfect for us. We're the leader in meniscal repair. And here, we have a product that allows our physicians to treat more types of meniscal tears. So we have a workforce that's there every day, and basically, we just expand what they can do and how they can help people leave with their meniscus intact. And so the team always cries out save the meniscus. It's amazing. But what I can tell you more broadly is that there are really some very good opportunities out there for us, and we're going to be disciplined. And we have really excellent support from our board for our overall strategic plan, which we presented to them and they approved, and that includes these comments that we've made around how we intend to move on M&A.

[Graham Baker, Chief Financial Officer]

If I may, I'll just add one further thought and reminder, that last time the market did see a small wobble in China, we went into that back in 2015 with very significantly higher channel inventories than we're sitting on today. And we've been working those down over the last three to four years. So I think the business is healthier, quite frankly, in its current state.

[Tom Jones, Berenberg]

And maybe just a quick follow-up on the board, seeing as you mentioned, I mean the returns question. My suspicion is a lot of your predecessors were a bit hamstrung, by a kind of return threshold that the board demanded. In your discussions with them, have they kind of reined in their expectations a little bit to give you a little bit more flexibility to do strategically sensible stuff that might not have the sort of one, two, three year return profile? Or has just the kind of dynamic not really changed very much?

[Namal Nawana, Chief Executive Officer]

Look, I don't know what the history is. We probably could've learned more about what it is, but it's not the important factor. The important factor is our conversations now. We have a great strategy. We have, I think, a really good understanding of what we want to do with the company. And there's very strong support for what we want to do with the company. And in terms of returns, I think you only need to look at management to say what kind of financial returns we want. We want strong financial returns. We don't need to have someone else kind of put a threshold for us. We want to get good returns.

[Unidentified Company Representative]

Over the phone?

[Namal Nawana, Chief Executive Officer]

Yes, we need to do some phone line calls. Just it's what I've been told. We'll come back to you in a second. Don't worry, we got plenty of time. Go ahead on the phone.

[Operator]

Questions from Chris Gretler of Crédit Suisse. Thank you, your line is open.

[Chris Gretler, Crédit Suisse]

Namal and Graham, I have actually two questions. The first relates to NAVIO, and actually, can you remind us now how many units now have been placed in the market? And if I look at your Knee growth over time in the U.S., I basically don't see any real acceleration in your growth rate. Can you explain to us why there is not such a big pull-through on that business? And then the second question relates to your choice between growth and margins. I noticed that, basically, I mean, of course, you're making a lot of efforts to improve growth but, at the same time, basically also delivering on margin improvement, which is great. However, is there an opportunity kind of to spend more aggressively in order to accelerate top line growth in your portfolio?

[Namal Nawana, Chief Executive Officer]

First of all, what I can remind you about NAVIO is that we don't report how many units we sell out there, but I did say that we doubled our units in 2018, and we are a very relevant part of the overall robotic placements and units in the world today. In terms of Knees, again, we're above-market growth in Knees. We're second behind Stryker, if you like, in terms of that knee growth. We want to accelerate further for sure. And there is some correlation between Knees and robotics, but overall, I think our Knees business is strong. In terms of growth versus margins and is there an opportunity to invest more aggressively to accelerate growth, I've said this a couple of quarters ago, and I'm going to just continue to say it, is that we have a wonderful opportunity to do both. And we want to go step by step here. And so we showed we can do that in the second half of the year, 2 quarters in a row with 3% growth, and we expanded our trading margin with good cost control and good execution of our APEX plan. So we have the management team now to continue along that vein as we go forward. Maybe in the room again.

[Yi-Dan Wang, Deutsche Bank]

It's Yi-Dan Wang from Deutsche Bank. A question for Phil. Clearly, the management team is willing to commit a lot more capital to M&A. Can you comment on the availability of assets and valuations in the segment that you're competing already and then those in the adjacencies that the company could look at? And then the -- a question on guidance to Namal. In the second half of the year, you've done very well, 3% growth, so somewhat surprised that the 2019 guidance starts with a 2.5%, at the lower end. So what are the considerations there that would cause you to provide that kind of a range? I would have thought it would start with a 3 rather than a 2. And then question to Graham. The associate line in the second half went into rather negative territory. So what's causing that? And what sort of run rate should we get? And then a comment on the financials guidance for '19.

[Namal Nawana, Chief Executive Officer]

Phil, go ahead.

[Philip Cowdy]

Okay, I'll go first. So exactly the idea. So availability of assets, I would have said there are plenty of things to look at. I think if you look at the private space, we're very lucky in medical devices that there's a lot of innovation, and it is relatively -- it's not like pharma, where it's very expensive to invent a new product and develop a new product and get it through trials. And therefore, there are a lot of companies of a variety of sizes, and we evaluate those. What stage are they in the approval? Have they started to commercialize? And then what are their value aspirations? And at the end of the day, it's -- as Namal said, it's about us looking strategically at that asset. Does it fit? Can we be a better owner? And then it's about looking at the value. And again, as Namal said and Graham said, we are going to be disciplined. Some, like Ceterix, it worked for us. There are other assets where we say it doesn't work for us. So it's not about availability. I think it's more about choice.

[Namal Nawana, Chief Executive Officer]

Moving on to the question on guidance, first of all, again, I'd highlight that is a range. Yes, we're really pleased with 3% growth in each of the two final quarters. We don't control everything in the world. And I think it's important to be prudent given we have our own plans, and the world does what it does, right? So our plans are to continue to work on accelerating our growth and, firstly, get to that end market growth rate of 4% and then beyond that. And I'm not trying to say that we don't -- we want to do that slowly. I guess we're going to go steadily and actually execute on our commercial plans. So some of these launches take time. All of these things that -- commercial actions that we have to improve our business take a little time.

And equally, in the new franchise model, giving my new presidents the opportunity to now lead their teams and get the workforce moving in exactly the direction we want. But I think this is good progress for Smith & Nephew to -- with that range that we've provided and also margin improvement during the course of the year, will be a good year for us. And we want to get there as fast as we can, but that's -- I think we've put in a very appropriate range in place based on those multiple inputs.

[Graham Baker, Chief Financial Officer]

And on the associates line, as you know, that reflects our -- principally reflects our investment in the Bioventus asset. There were a couple of things that went through in the second half: a provision for a legal matter and a write-down on some intangibles. I'd obviously be disappointed if those were to recur and continue, so I treat them as one-offs.

[Yi-Dan Wang, Deutsche Bank]

And what's the ongoing?

[Graham Baker, Chief Financial Officer]

The ongoing was pretty flat, so pretty much all of that loss was reflected by those two matters.

[Yi-Dan Wang, Deutsche Bank]

Financial costs?

[Graham Baker, Chief Financial Officer]

Sorry?

[Yi-Dan Wang, Deutsche Bank]

Financial costs?

[Graham Baker, Chief Financial Officer]

So financial costs, sorry, forgive me that I missed that one. Sorry.

[Yi-Dan Wang, Deutsche Bank]

For financial costs, have you set your guidance for '19 [indiscernible]…

[Graham Baker, Chief Financial Officer]

Yes, as I say, the two things that led to the loss were pretty much nonrecurring items. So if you strip those out, it was pretty flat. And therefore, I'm not giving a detailed line-by-line guidance on that, but I'm not expecting those to recur.

[Yi-Dan Wang, Deutsche Bank]

Graham, I'm not expecting line-by-line guidance, but [indiscernible].

[Graham Baker, Chief Financial Officer]

So it's about $5 million. I think it's in the detailed technical guidance in the back of the presentation.

[Namal Nawana, Chief Executive Officer]

Yes, go ahead.

[Ian Douglas-Pennant, UBS]

It's Ian Douglas-Pennant at UBS. So a question on the tax rate first, please. You continue to see a decline there. Given the changes that you're seeing in your business going forward, do you think that, that can continue to decrease from here? And obviously, I've seen your guidance for next year. I'm thinking longer term than that. And secondly, on the M&A side, do you have a preference for Ortho versus Wound when you're thinking about targets?

[Graham Baker, Chief Financial Officer]

As you saw, we nudged down the guidance both for next year and the medium term to go into the 19% to 21% range. Obviously, there's a little bit of uncertainty about some of the things that are still out there from some of the legislative changes. We're working through those. And as we saw in 2018, they seem to be working out together with the mix of our profits in a favorable way. So at the moment, our medium-term range as well as our range for next year is in the 19% to 21% range.

And that ultimately reflects the mix of the markets that we operate in and our commitment to being obviously a good business that's run effectively but also being a responsible stakeholder in all the communities that we participate in. So I think that's a lot closer to where many of our competitors have been as we've seen their rates nudge up a little bit and ours nudge down. So I think that's about the right range to be thinking of.

[Namal Nawana, Chief Executive Officer]

And in terms of M&A, again, preference for Ortho versus Wound was the question. There are no favored children. In our portfolio of medical device companies, we look at all of our business areas for opportunities, I would say that the market structures are very different in the areas that we operate. So the kinds of assets, the size of assets are different. And I would also say that we operate in a $40 billion marketplace and with the current businesses, but it's a $400 billion world out there for med device, so we're not just looking inside of these sectors. Another one from the phone, and then we're going to get there.

[Operator]

Next question is from Julien Dormois from Exane. Your line is open.

[Julien Dormois, Exane]

I will have three questions, please. The first one relates to Bioactives. I think you mentioned that there's been a slight improvement in the growth trajectory for SANTYL, and you also alluded to the relaunch of REGRANEX. So should that be not in your view to return to growth in 2019 in that segment? The second question is related to Trauma. It's now like four years that this business has been virtually flat. So is that a problem of your -- how the portfolio is being structured? And do you plan to address that through M&A? Or is there something you can do organically? And the last question relates to the potential Brexit plans that you have put in place. I know you've put a bit more details in the press release, but I would just be curious if you could give us the share of your costs that you labeled in pounds and maybe elaborate a little bit on what are your plans on that side.

[Namal Nawana, Chief Executive Officer]

So thanks very much for those questions. On Bioactives, the first part, we don't go down to the segment level to kind of like forecast for you what the performance will be. It's been an area of strong focus for me just to firstly learn about the area and understand what we can do to remediate our performance, which has not been good in that area. So I'm kind of pleased that we're seeing some progress. That's the first thing. And a lot of that has got to do with how we manage our current products. I think we've got a lot more that we can do. Overall, our forecast for Wound is for good growth in 2019, and we've got really strong momentum with our negative pressure technologies and in the U.S. in particular with our consumables also, where we've seen double-digit growth in the U.S. for our consumables business. So overall Wound, good Bioactives, still more work to get that portfolio where I'd like it to be, but some progress.

In terms of Trauma, it has been flat, and it's not an issue of our portfolio. Our range of nailing is fantastic, and our EVOS platform is fantastic. It hasn't been the historical case that Smith & Nephew has necessarily had a strong plating system. And so EVOS is important to us in completing how we can show up for some of the bigger hospitals with a complete portfolio. And it's also the case that we haven't had the scale in International Markets for our business leaders to really choose to focus on Trauma. And as I go around the world and I work with our teams and we have this new franchise model, we do aim to improve our performance in Trauma, and we do have the products to do that. And I think the U.S. has shown that with the EVOS plating system that they can accelerate growth, and I'm pleased with the work that they've done. Our International Markets haven't had access to EVOS SMALL, and they're now getting access this year to that. And with that access, we're increasing the accountability that they improve their performance with it.

So I think there's work to do in Trauma. I think, again, we have to make the turn of how we run our company and actually have focus in each of the areas of business, each of the segments we operate. In terms of Brexit plans, I mean, we are well prepared for Brexit. We see no disruption to our business. We had some work to do, like most companies. In med device, we had to shift our registrations. We're a British company, and we had British registrations, and we've covered that base. And with that base being covered, we obviously manufacture in many parts of the world, also including the U.K., but many parts of the world. And we have no issues with the make side or the supply side or the registration side, so no issues for us. Ed?

[Edward Ridley-Day]

Ed Ridley-Day at Redburn. A couple of follow-ups on the M&A. It's great to hear you talking about how you could perhaps look at some faster-growing areas. One interesting area for me would be minimally invasive surgery. You have a great expertise there. It was always, I found, a little odd that a couple of years ago, you sold a fast-growing OB-GYN business to Medtronic. Despite that, is that an area that you would consider again given the leverage you have from arthroscopy? That will be my first question. And secondly, just quite simply, for the right acquisition, would you issue equity?

[Namal Nawana, Chief Executive Officer]

Yes. So first question regarding M&A, look, I'm very excited about our current portfolio and what we can do with that. And I'm also excited to be in med device, where the opportunities are so good to get good assets that make great financial returns. And I think that as a business, we need to take up our opportunity by being an owner of some of these great businesses. In terms of the specific areas, we are a good company in minimally invasive surgery. We are the folks that actually brought these arthroscopic techniques to the world. We have deep knowledge on how to do this well. So that's a good area for us to be in. The competition profiles in the specific areas that you talked about are pretty obvious at this stage, and the vectors for success rely on that -- on certain scale as well as on access to robotics and specific forms of robotics. And so we look at each of the sectors based on the -- our ability to manage the business, the financial returns as well as the market dynamic structures, etcetera, so we're looking more broadly.

In terms of issuing equity for the right deal, now look, we are -- the guidance we've put out there is pretty clear, which is we feel that at 0.8x leverage ratio, we have an opportunity to deploy more. We will maintain investment-grade rating. And I'm not making further comments beyond that, but thank you for the question all the same.

[Namal Nawana, Chief Executive Officer]

Yes, one more question in the room perhaps. Okay, any more questions on the phone? I've worn you out. This is awesome.

[Operator]

We have our last questions from the phone line, from the line of Virendra Chauhan of AlphaValue.

[Virendra Chauhan, AlphaValue]

So I have one on wound care. So I mean, the commentary of weakness in Europe has been pretty steady over the last at least two or three quarters. And so any actions that you've broadly taken to counter this and results that you have seen?

[Namal Nawana, Chief Executive Officer]

I'll try again. So thank you for the question. So I think it related to weakness in Wound in Europe. Yes, the actions that we've taken -- that we took actually about the time when I joined, we did make management changes in certain of our geographies related to Wound. In places where we saw that management change earlier, we've seen improvement. And we've made further management changes in the last couple of months that I think will, in time, pay. And look, what I want to acknowledge is it's not just the market, the historical performance, some of it related to our management of and understanding of how we should succeed in the European wound market space. So I think it's an area where I feel that we should improve this year with now the team in place and a little bit of time and better focus on what are great products and a great portfolio and also great lead assets like PICO. I had to get that in. So overall, still more work for us in Europe, full stop, but there's still more work for us in Europe in Wound.

So I think we're going to end questions there. Thank you for your interest. And also pleased with the progress so far, and looking forward to 2019. Thank you.