Local pay determination formed a key plank in the Conservative government's attempt to restructure industrial relations in the NHS, and to 'reassert managerial control' of the paybill at local (trust) level. This paper reports the findings of a national survey of Unison lead negotiators, complemented by case study interviews and documentary research, on the processes and outcomes of local pay determination, and its impact on industrial relations at both national and local levels. The paper strongly refutes recent suggestions that local pay leads to 'improved' industrial relations and greater pay equity. Moreover, and contrary to claims that Staff Side organizations are 'too weak' to challenge 'new managerial strategies: the study's findings show that the search for managerial control remains, as always, a contested terrain.