91 Efforts to introduce a risk-stratified approach to bowel cancer screening in England have been welcomed by healthcare professionals, but new research reveals significant barriers remain before such changes can be implemented across the NHS. The findings were published in the journal BMC Health Services Research. The study, conducted by a team at the University of Cambridge, explored the views of clinicians, commissioners, researchers, and other key stakeholders. It found broad support for the idea of tailoring screening based on an individual’s risk profile, but uncertainty about how best to design and deliver such a programme is slowing progress. Under the current system, men and women aged 54 to 74 are invited for bowel cancer screening every two years using a faecal immunochemical test (FIT). The test detects blood in stool samples, and those with positive results are referred for further investigation. Risk stratification would add complexity by adjusting screening intervals, test types, or invitations based on additional factors such as medical history, genetics, and lifestyle. Although some elements of risk-based screening are already in place, such as different pathways for individuals with genetic syndromes like Lynch syndrome, the study highlighted a lack of consensus about how to build on this. Stakeholders expressed concern that multiple competing approaches are being discussed in isolation, creating a fragmented decision-making process. Participants in the study stressed the need for a unified approach, with agreement on which risk stratification strategies are most appropriate, feasible, and equitable. Some supported a phased rollout, beginning with basic data already available in NHS systems, while others preferred a single, comprehensive shift to more complex models. Whichever route is chosen, experts agreed that implementation must not widen existing health inequalities. Workforce capacity emerged as another key issue. Colonoscopy resources are already stretched, and while risk-based screening could in theory reduce pressure by targeting high-risk groups, it could also overwhelm the system if not managed carefully. Primary care involvement, staff training, and updates to digital infrastructure would also be required. Public and patient acceptability was also flagged as a potential obstacle. Changes to who is invited for screening or how often could be perceived as unfair or politically contentious. The researchers noted that strong communication strategies would be essential to explain the reasoning behind any changes and ensure public trust. Despite these challenges, the study pointed to opportunities. The digital system supporting bowel cancer screening is among the most modern in the NHS, which may make adaptation easier. Lessons from other targeted screening programmes, such as those for lung cancer and HPV, could also inform future implementation. The authors concluded that without agreement on a clear way forward, uncertainty will continue to hinder progress. They recommended bringing stakeholders together to establish consensus, clarify evidence needs, and develop a system that is not only effective, but acceptable, sustainable and scalable.