If their decision is confirmed by the 450,000 NHS workers in Unison next week, the government may be forced to abandon its attempt to reach a long-term settlement.

In those circumstances Johnson has warned that he would be obliged by the Treasury to cut the pay increase that staff are banking on getting this year. Such a move would be likely to provoke a wave of hostility across the NHS, including overtime bans that could derail ministers’ plans to cut waiting times for patients.

GMB members, representing 25,000 NHS staff in England and Wales, rejected the deal by more than 96% in a ballot with high turnout. The offer was worth 8% over three years, with 2. 75% paid immediately this year - the best terms available in the public sector in the current pay round though still way below inflation, amounting to a cut in real wages. Ambulance workers, porters and cleaners in Unite had already voted to reject the deal by a majority of six to one. This week the Royal College of Midwives said a consultation of members found 99. 7% were opposed.

The GMB, which represents ambulance crews, porters, catering staff, ancillary workers, blood collection, nursing assistants and practitioners, cleaners, laboratory workers, drivers and maintenance staff, said it would seek a meeting with Johnson. Dame Karlene Davis, general secretary of the Royal College of Midwives, said this week: “Given the outlook for the economy in future years, acceptance of the three-year deal would represent a vote for a real terms pay cut.”

Unison and the Royal College of Nursing negotiated the deal on behalf of the smaller NHS unions and were expected to recommend it. But the Unison leadership failed to win a majority on its health executive. The RCN is poised to accept the three-year deal.

This represents the stirring of health workers as part of the wider movement of unrest amongst public sector workers with the threat of strike action also coming from civil servants, refuse collectors, teachers, academic staff, local government and others.