Two major reports from the Flexible Approach to Training in Expanded Settings (FATES) program set out a practical pathway to expand rural training, strengthen accreditation and build a specialist workforce that better reflects community needs.

The Royal Australasian College of Surgeons (RACS) is pleased to announce the release of two landmark reports designed to reshape how specialist medical training is planned, accredited and delivered across regional, rural and remote Australia.

FATES 1 Barriers to Rural Accreditation Project (FATES 1) and FATES 2 Rural Training Models Project (FATES 2) bring together years of research, consultation and collaboration. Together, they move the rural workforce conversation from identifying the problem to setting out practical, scalable solutions.

Approximately seven million Australians live in rural areas, yet specialist services and training opportunities remain heavily concentrated in metropolitan centres. The reports reinforce a powerful finding: rural training is not simply metropolitan training in a different postcode. It develops contextual competence, broader generalist skills, community connection and an understanding of how care is delivered across distance, limited resources and dispersed teams.

Removing barriers without lowering standards
FATES 1 examined why rural hospitals can struggle to secure accreditation for specialist training posts. It found that accreditation must remain firm on standards while becoming more flexible in how those standards are met, with the focus kept squarely on outcomes for Trainees and patients.

The report recommends more streamlined accreditation processes, stronger administrative support for rural hospitals, greater use of flexible and digitally enabled supervision, and closer alignment between training posts, workforce data and community need. It also warns against applying inflexible caseload and case-mix requirements designed around metropolitan subspecialist units when rural services can offer broad, high-value operative and clinical experience.

Importantly, several recommendations have already informed RACS' own accreditation work and align closely with the new Australian Medical Council standards and procedures, which were developed over the same period. 

Dr Richard Bradbury, chair of the Rural Health Equity Steering Committee, CSET, and a Clinical Lead for the FATES 4 Project, says, “The goal is not rural training as an add-on. It is a training system designed around the people and places it ultimately serves.”

Three models for the future
FATES 2 builds on this foundation with 47 recommendations covering rural training networks, supervision, mentoring, orientation, culturally safe outreach and support for Trainees and their families.

At its core are three complementary training models: 
•    an improved urban hub-rural spoke model 
•    rural training networks that support longer, connected pathways in one region 
•    a Rural-Focused Urban Surgeon (RUFUS) model. RUFUS training recognises that urban surgeons also need the skills to care for rural patients through outreach, virtual healthcare and collaboration across geographically dispersed teams.

The report calls for longer placements, fewer relocations and earlier notice of rural rotations. It also highlights the practical barriers that can make rural training unnecessarily difficult, including accommodation, relocation costs and the loss of employment entitlements when Trainees move between jurisdictions.

A strong focus is placed on culturally safe training and outreach, including enabling Aboriginal and Torres Strait Islander and Māori Trainees to train closer to Country, community and whānau, and ensuring supervisors and training sites are equipped to provide culturally safe learning environments.

Evidence into action 
With FATES 1 and FATES 2 now released, the focus turns to implementation, and with it, a genuine opportunity to turn years of evidence into real, lasting change. Colleges now have a clear and practical roadmap from the recommendations most relevant to their own speciality and readiness, and there’s real momentum for jurisdictions, hospitals and training sites to build on together. This is a pivotal moment for rural specialist training in Australia and Aotearoa New Zealand. One that promises a brighter, more equitable future for rural communicates and the specialists who care for them. 

Looking ahead: the next chapter of FATES 
In a natural next step, RACS and its consortium partners are turning their attention to a related challenge: how does the profession develop, maintain and rebuild the generalist skills that rural, remote and other resource-limited settings demand? To address this, RACS is introducing the FATES 4 Generalism, Global, Regional, Rural, Remote and Deployable – Humanitarian and Military (GRiD) Project, an initiative designed to establish a sustainable home for generalism within the College, giving surgeons from all nine surgical specialties a structured way to develop, maintain and regain generalist capabilities.

“FATES 1 identified the barriers. FATES 2 designed the training models. GRiD takes that further, making sure the generalist skills our workforce develops are supported for the long term," Dr Bradbury says.

Acknowledgment 
These projects have been undertaken as part of the Australian Government Department of Health, Disability and Ageing Flexible Approach to Training in Expanded Settings (FATES) Scheme. FATES 1 was conducted by RACS, alongside the Royal Australasian College of Medical Administrators (RACMA). FATES expanded the consortium to include the Australian and New Zealand College of Anaesthetists (ANZCA), the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and the Royal Australasian College of Physicians (RACP). The FATES 4 GRiD Project further expands this consortium to include the Australian College of Rural and Remote Medicine (ACRRM).

The FATES initiatives at RACS are being delivered in support of the RACS Rural Health Equity Strategic Action Plan. The full reports, executive summaries and Strategic Action Plan are all available through the RACS rural activities page