The first result of a ballot among health workers on a three-year pay deal has shown massive rejection.
Members of the GMB union voted against the proposed agreement, worth an average of 6.5%, by almost 9-1.
The GMB, which represents tens of thousands of NHS staff, including ambulance workers, was the only one of 14 health unions to recommend rejection of the deal.
The GMB said a rise of 6.5% for staff in England amounted to three more years of real-terms pay cuts for over half of NHS employees, with RPI inflation set to increase by 9.6% over the same period.
A pay cap has been in place since 2010, which the GMB said had cost paramedics an average of over £14,000, midwives £18,000 and staff nurses £14,500.
The union will convene a meeting of representatives on June 15 to consider the next steps.
GMB general secretary Tim Roache (pictured) said: "GMB members across the NHS and ambulance service have overwhelmingly voted to reject this pay offer.
"After nearly a decade of pay pinching, the prospect of a further three years of cuts to wages is unacceptable.
"GMB members have sent a clear message to Jeremy Hunt - it's a no from us."
National officer Kevin Brandstatter added: "Jeremy Hunt's promise of jam tomorrow is simply not good enough for NHS workers.
"During the past eight years, our members in the health service have faced the biggest pay pinch in living memory.
"The offer won't allow them to claw any of the lost cash back - in fact, for the longer serving, most loyal NHS workers the 6.5% increase over three years actually means a real-terms pay cut.
"It does nothing to address the recruitment and retention crisis and it leaves the door open to new employees in the NHS being employed on worse terms and conditions than existing health service workers."
Ballot results from other health unions will be announced in the next few days.
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