Part of the justification for the Lancashire and South Cumbria New Hospitals Programme (NHP) is that a modern estate is necessary to attract high quality medical students as an international centre of excellence. Workforce proposals produced by Healthier Lancashire and South Cumbria (LSC) aligns this with plans for improved recruitment and retention of doctors. These also relate to efforts at reducing reliance on locums and improving patient access to modern specialist services. This interrelationship between the demands of medical education, workforce inequalities, and the organisation of services has a long history which precedes the current NHP proposals. Indeed, it has been a structural feature of the region’s National Health Service (NHS) since 1948. Using the attempt by the newly founded University of Lancaster to obtain a Medical School from 1964 to 1968, this paper demonstrates the compounding relationship between medical education, workforce inequalities and hierarchical regionalism as a process of ‘sedimented governance’ which shapes the limits of future horizons for current health services leaders and the NHP.