Centre-periphery relations have constituted a paradox for the English National Health Service (NHS) since its creation in 1948. Is it a top-down national service organised locally, or a bottom-up arrangement of local health systems managed nationally? North West England provides a regional case study which traces the changing organisational, relational and spatial dimensions of the intermediate tier. These reposition centre-periphery tensions. In foregrounding, situating and conceptualising region in these terms, I offer new insight into existing narratives and centre-periphery relations in the NHS.