507 FOCUS | PROFESSIONAL REPRINTED FROM AJGP VOL. 47, NO. 8, AUGUST 2018 | © The Royal Australian College of General Practitioners 2018 GENERAL PRACTICE, the government asserts, 1 is at the centre of the health system. Most general practitioners (GPs) agree they have a key role in maintaining the health of the community and viability of the health system at large. However, many also feel that, despite emerging policy initiatives, much of their work is regarded as occurring at the margin, because ‘real medicine’, meaning ‘proper management of diseases’, occurs in the super/specialised hospital domain. Recent Productivity Commission reports emphasised how such sentiments have an impact on maintaining the GP workforce. 1,2 These reports highlighted two concerns (Supplementary Tables 1, 2, available online only): • the profession’s resilience to cope with the uncertainties inherent in early disease presentations and complexities typical of patients affected by multiple morbidities • the profession’s ability to meet various stakeholders’ desired health and/or administrative outcomes. In this paper, we explore the nature of the work of general practice and how that work affects people and their health outcomes and experiences. We highlight the systemic nature and contextual interdependencies between needs of patients and our ability to meet those needs in different practice contexts. On the basis of these insights, we elaborate that modelling the systemic nature of general practice work can enhance the profession’s input into practice and system redesign in collaboration with local meso- level organisations that support its implementation. Systemic thinking provides the blueprint to achieving a more effective, efficient and equitable health system. Key features of complex adaptive systems A complex adaptive system (CAS) consists of many interconnected agents and drivers that influence each other in various ways in different contexts. Changing agents and/or drivers results in feedback that may or may not improve intended system behaviour and outcomes. For example, consultation length is not merely a reflection of disease burden but also of local GP workforce size and nursing and allied health availability. A CAS often shows hierarchical layers that influence each other; for example, GPs interact at the same layer with other primary care services, but their work is also dependent on other system levels, such as local hospital/specialist performance and/or government policies. General practice in the hierarchy of a complex adaptive health system Issues affecting GP work and workforce are complex and dynamic, as they are linked and distributed across different organisational levels and varied environmental contexts. They occur in hierarchical systems where higher levels (eg federal health policy and funding) provide contextual constraints that limit the emergence of possible desired and/ or undesired outcomes arising from Joachim P Sturmberg, Di M O’Halloran, Geoff McDonnell, Carmel M Martin Background General practice is regarded as central to the Australian health system. However, issues affecting the general practitioner (GP) workforce have been focused mainly on remuneration, numbers and distribution. The focus is shifting to how best to enable GPs to deliver effective, efficient and equitable care. Objectives The aim of this paper is to identify important elements, dynamics and interdependencies that influence GPs’ work and their ability to continually improve outcomes for individuals and communities. Discussion Most important problems are multifaceted and cannot be reduced to a simple, single solution. Influence diagrams capture the interdependent domains that affect general practice, such as the variations in patients’ needs in the community and the impact of disadvantage and care expectations on outcomes. Identifying interrelationships between key domains should capture the dynamics that ‘feed the problem’. Finding ‘best possible solutions’ to improve interdependent system problems and avoid the inherent risk of unintended failures requires an ongoing mix of qualitative and quantitative modelling. General practice work and workforce Interdependencies between demand, supply and quality