Through an examination of national policies, case study and survey material, this article looks at the question of the possibility of union renewal through an examination of the various and varying responses of two unions, MSF and Unison, to the changing work and employment practices in the NHS.Many of the private sector companies and industries in which British trade unions were strongly entrenched in the 1970s suffered severely from the recessions of the 1980s and the almost continuous programme of restructuring which has followed (Gallie et al., 1996;Kelly, 1987). One consequence of these processes has been that the balance of British trade unionism has shifted away from the private and towards the public sector (Carter and Fairbrother, 1999) Part of the explanation for this movement is that managerial attitudes towards unions in the public sector have long been less hostile and indeed, for much of the postwar period, government policies favouring collective bargaining as the best method of conflict resolution found particular expression in the Whitley system, which dominated public sector relations.Despite this consensus-based tradition, there is clear evidence that the developing government antagonism towards the labour movement in the 1980s was also reflected in a changed policy towards public sector unions (Foster and Scott, 1998). Paradoxically, inside the core areas of public sector employment, such as the civil service, education and health, the hostility to unions saw no dramatic decline in union membership density. This paradox arose in part because government hostility to its own employees was mediated by both continued institutional arrangements and a great deal of residual support for traditional relations by managers, many of themselves in unions. Nevertheless, research suggests that changes enacted during the same period, such as decentralisation, market testing and Compulsory Competitive Tendering, are working long-term to threaten stable relations.Decentralisation and concomitant local bargaining have given rise to a debate