As the NHS reaches its 75th birthday, general practice represents something of a policy paradox: it is both highly visible, dominating headlines with perceived shortcomings and failings (Mroz, Papoutsi and Greenhalgh, 2022), and yet strangely invisible, with the most recent NHS reorganisation in England barely touching on its role. For example, in the latest Health and Care Act (Department of Health and Social Care, 2021) mention of general practice is confined to a few references to how it might be commissioned, with nothing at all about its form or function. Most strikingly, the most visible aspect of current primary care policy – an additional contract which provides funding for groups of GP practices to work together in networks – is not mentioned at all in the Act.

In part this dichotomy arises from the historical position of general practice in the NHS. In 1948, general practice was established not as an integral function of the hierarchical new NHS, but as a separate service, provided to the NHS by independent contractors (Peckham and Exworthy, 2003). This independent status has been both a strength and a weakness of general practice ever since (Lewis, 1998). Lauded for the fact that it may support innovation, and usefully allowing the central NHS to avoid providing premises, it has also been identified as problematic, generating unwarranted variation and difficulties in integrating primary care with other sectors (Chapman and Groom, 1999; Jones et al, 2015).

In terms of the themes set up in Chapter 1, general practice is perhaps an outlier, insulated by its independent status from the more significant NHS policy switches around competition or managerialism. Nevertheless, general practice policy since 1948 has seen a shift towards a more atomised approach (Norman, Russell and Merli, 2016), with the professional ideal of providing person-centred relationship-based care in ongoing tension with an approach which seeks to identify and manage biomedical problems in the most efficient way possible (Checkland et al, 2008).

In this chapter we consider general practice in the context of its history, and offer some thoughts about the future which take account of the unique status of primary care as both the entry-point to other services and as a semi-detached quasi-independent service.