The article discusses the changes that have occurred in general practice in London, United Kingdom (UK) over the last twenty years. It examines and aims to enhance understanding of the challenges faced by urban general practitioners (GPs) in the UK, specifically those in London. Key aspects explored include: organizational changes in the National Health Service (NHS); delivery of healthcare and the changing professional role of GPs; the doctor-patient partnership; changing disease burden; the diversity of UK city populations and health seeking behaviour; alternative care; occupational stress and litigation culture; and technology. The metropolitan dimension presents challenges specific to a large, city environment and these are embedded alongside those facing the discipline as a whole. The evolving role of GPs reflects transient political, social, legal and medical organizational changes and such influences present general practice in the UK with the constant challenge of change. New approaches, expectations and ideas are continually addressed by modern metropolitan general practice, which in response is changing fast. There are both negative and positive outcomes of change that will be pivotal to future development of the discipline.