Our review of literature reveals there has not been extensive, systematic research into intermediate tiers of the health service in England over the last seven decades. During this time, regions have continuously been a target for reform. There is no consensus among policy makers or commentators over where functions and responsibilities should be located. Differing views appear to have been shaped by different political strategies and policy trends. Organisational change has accelerated in recent years. Broadly speaking, operating within intractable tensions facing the health service, regions have progressively declined in their influence. Once responsible for the allocation of resources, their reduced role coincides with new forms of performance and financial management. Nevertheless, our review shows that longer-term strategic planning has usually occurred at an intermediate level. Through situating current changes in their historical and geographical context, a series of key themes and their implications for policy can be identified.