Objective: We analysed community participation in organising rural general medical practice in order to suggest ways to extend and sustain it. Design: A multisite, embedded case-study design collecting data through semistructured interviews, non-participation observation and a document analysis. Setting: One remote and two rural communities in Australia. Participants: Community members, GPs, health professionals, government officers and rural medical workforce consultants. Results: High levels of community participation in recruiting and retaining GPs, organising the business model, and contributing to practice infrastructure were evident. Community participation in designing health care was uncommon. Participation was primarily to ensure viable general practice services necessary to strengthen the social and economic fabric of the community. There were factors about the decision-making and partnership processes in each of the communities that threatened the viability of community participation. Conclusions: We recommend that a concept of community development and explicit facilitation of the processes involved is necessary to strengthen participation, create effective partnerships and ensure inclusive decision-making.