Table 3

What is required to improve this?

Themes and subthemes	Theme content	Representative quotation
Reduced variability in practice Individual practice Unit-based practice	Could address individual and system-based factors Could reduce burden of decision-making	“Something that was standardised and structured could inform a multidisciplinary discussion.” (Neonatologist 7) “The whole department has signed up for it, and we will all (manage) these babies more or less the same now.” (Surgeon 8)
More specific recommendations at handover of care between surgeons	Improved handover might reduce impact of repeated handover Specific recommendations likely helpful	“If I’m handing over a baby with NEC to a colleague on a Thursday morning I tell them exactly what they’ve got to do. If this baby’s not better by this point in time you’re doing an operation.” (Surgeon 3)
Increased objectivity of referral and transfer process Referral from neonatologist Transfer to surgical unit	Set threshold for when to initiate discussion about potential referral likely useful Could protect individuals from criticism if deemed that referral was not required Risk of increasing number of unnecessary transfers	“It gives confidence to the parents that actually, somebody’s not tossing a coin between Tuesday and Wednesday as to how their child’s going to be protected. It protects you medicolegally years down the line if people question your decision-making. The neonatologists then know how to refer, when to refer patients. So I mean the benefits are enormous, actually, once you start down this road it really is transformational.” (Surgeon 2)
A simple, objective method to inform surgical decision-making would be most useable	Extensive previous study of biomarkers and scoring systems A new method should be simple and understandable for users Endpoints include multidisciplinary discussion	“And the only thing I would say is keep it as simple as you can, I think I’ve seen lots of decision-making tools for NEC which require you to have 20-odd physiological parameters and they do your head in just reading them, actually.” (Surgeon 2)
Understanding of clinician attitudes to a new method Desire to implement change Barriers to change	Outcomes so poor currently that some clinicians are willing to change practice without clear evidence New pathway or approach developed through a consensus process would be welcomed Risks of change include an increase in negative laparotomy and unnecessary transfer	“But if you're looking to change practice and what drives it, then I think it is just challenging the surgical dogma. But also in the context that current outcomes were pretty [poor] for that group of babies. And so, if one takes the view that doing something, at least challenging dogma and changing something is probably better than staying as you are, then that’s a step in the right direction.” (Surgeon 3) “I would be very worried that if you’ve set specific criteria that you might end up with…a huge uptick in the patients that’re being moved around the country.” (Surgeon 12)

NEC, necrotising enterocolitis.