This article analyses why some NHS trusts have departed from national arrangements and adopted a local pay regime, while others have not. It finds that the primary determinant is the attitude of management, particularly the chief executive. This is value driven and not a pragmatic response to the labour market. Although a healthy financial position is a necessary condition for a trust pay regime, it is not an adequate causative explanation. Moreover, while management sets the agenda, the pace, manner and extent of change, are tempered by the cohesiveness and vigour of the staff‐side and the power of the medical profession. It also suggests that in some trusts more immediately pressing priorities have taken precedence over the government initiative on local pay bargaining, so it will be some time before fully fledged pay systems are adopted.