BACKGROUND: Improving bowel cancer screening programmes through the introduction of risk stratification has been discussed, but not widely implemented in many countries. This study aimed to gain an understanding of system and programmatic aspects that need to be addressed to enable a move towards implementation. METHODS: The Engineering Better Care Framework was used to support exploration and thematic analysis of the views of stakeholders involved in delivery of bowel cancer screening in England. Semi-structured interviews (n = 11) were conducted to gain a better understanding of the problem, and to identify elements that would contribute to a well-designed programme and anticipate barriers to delivery. RESULTS: There is enthusiasm for introducing risk stratification and it is considered to be beneficial to improving the current screening programme. A major barrier impacting implementation is a lack of consensus on the best approach for risk stratified screening. Many interviewees recognised this as a bottle-neck and were in favour of processes that would enable more joined up decision-making to enable balanced consideration of the differing, and often nuanced potential of different strategies for risk stratification. Several key considerations and design elements were identified: evidence demonstrating benefit of a particular strategy, feasibility of programme delivery (data availability, workforce capacity, public and patient acceptability, impact on equity), as well as changes to design of patient communication materials, the bowel cancer screening system, consent and follow-up services. CONCLUSIONS: System level issues and clarification of remaining uncertainties require resolution in order to move towards implementation. Moving this agenda forward requires consensus across different stakeholders in the first instance on the best use of risk. This will enable outlining key outstanding evidence gaps and establishing evidence thresholds for implementation. There are opportunities to design an optimal system based on harnessing existing infrastructure and learnings from other screening programmes.