Nurses are to launch fresh strike action across England later this month after rejecting the government’s pay offer, sparking fears stoppages could go on until Christmas. In a major blow to ministers, union leaders and health service bosses, members of the Royal College of Nursing (RCN) voted narrowly, by 54% to 46%, on a turnout of 61%, to reject the government’s offer of a 5% pay rise this year and a cash payment for last year. The RCN announced a new round-the-clock strike lasting 48 hours, from 8pm on 30 April until 8pm on 2 May. Sources also told the Guardian that without any further movement by the government, stoppages could continue until the end of the year, with coordinated action by nurses and junior doctors possible. Pat Cullen, the RCN general secretary, said the proposed settlement was “simply not enough” and called for the health secretary, Steve Barclay, to “increase what has already been offered”. “Until there is a significantly improved offer, we are forced back to the picket line,” she said. “Meetings alone are not sufficient to prevent strike action and I will require an improved offer as soon as possible. In February, you opened negotiations directly with me and I urge you to do the same now.” Barclay said he was “pleased” the members of Unison voted to accept the NHS pay offer but described the RCN members’ vote to reject it as “hugely disappointing”. “Their decision to escalate strike action with no exemptions, based on a vote from a minority of members, is also hugely concerning,” he said. The ballot of RCN members, which was open for nearly three weeks, asked whether they should accept or reject a one-off 2% salary uplift and 4% Covid recovery bonus for 2022-23, and then a permanent 5% pay rise from April. When the RCN recommended that its members accept the pay offer made in mid-March, Cullen insisted the talks had reached a point “where you know the other side won’t give any more”. The RCN will now conduct a new England-wide statutory ballot to extend the scope and duration of the current mandate for industrial action, which runs out in May. If members vote for strike action, the new mandate is effective for six months. One hospital trust chief executive said the prospect of more strikes would be “catastrophic” for the NHS. “If nurses go back on strike, and they decide to coordinate their industrial action with junior doctors, there will be no one to run the health service – to provide the care,” they told the Guardian. “Junior doctors are already striking. If you have these two staff groups still in dispute, that will be catastrophic because doctors and nurses pretty much are the NHS workforce. If they aren’t available, you have no health service. How can you run a health service without nurses and junior doctors?” While RCN members rejected the government’s pay offer, Unison – which is the biggest union for healthcare workers overall – revealed 74% of those who voted did so to accept the offer, compared with 26% who wanted to reject it. Results of the ballots of GMB and Unite members will be announced on 28 April. Sara Gorton, the union’s head of health, said: “Clearly health workers would have wanted more, but this was the best that could be achieved through negotiation. Over the past few weeks, health workers have weighed up what’s on offer. They’ve opted for the certainty of getting the extra cash in their pockets soon.” There is concern among some of the remaining unions that the closeness of the RCN ballot means the decision to resume strikes could backfire and end up dividing nurses. One official said: “The fact that 54% said no and 46% said yes means things could become very difficult for the RCN. Given how narrow the margin was, you aren’t going to get picket lines like the ones we saw when they staged their walkouts in December, January and February. “And the legal mandate they had for those strikes runs out soon, because it only lasts for six months. Given that 46% have voted to accept the government’s improved deal, if the RCN reballots, are they really going to meet the legal threshold of a 50% turnout and at least 50% voting for further industrial action? “I just don’t think that the RCN will get a renewed strike mandate – and the government knows that. And therefore they have very little negotiating power.” Ministers were urged to go back to the negotiating table by the Tory MP Dan Poulter, who also practices as an NHS hospital doctor. He told the Guardian: “It is clear that for many NHS staff, a pay increase which is below the cost of living and below pay increases made to workers in the private sector was not enough. I hope the government now listens to the voice of nursing, leaves the current offer on the table and improves upon it.” Stephen Dorrell, a former Tory health secretary, urged both sides not to “retreat into the trenches”, adding: “Ministers have to accept a major share of the responsibility for the situation that we’re in. Their initial stance was to play it cool and avoid engaging positively. “That hasn’t worked, so I think the government needs to change its stance completely and make it clear sorting out these issues is a priority. Otherwise the risk is that months will pass and the issue won’t be resolved and the pressures in the NHS will get worse.” He stressed that a winter crisis in the NHS would only be compounded by further nurses strikes. “We nearly got there. The challenge now is not to go back to the beginning, it’s to find a way to build on the 46% who were willing to go along with it, albeit probably without much enthusiasm,” he said. Matthew Taylor, chief executive of the NHS Confederation, said the “mixed outcome [with different results from the RCN and Unison] leaves the NHS in limbo at a time when it desperately needs certainty” and that hospital bosses will be “anxious about the impact it will have on patient care and their efforts to bring down waiting lists”. A government spokesperson gave no signal that talks would resume. They called the RCN result “hugely disappointing” and that the offer made last month was “fair and generous”. The spokesperson added: “The fact that the Royal College of Nursing has announced an escalation in strike action with no derogations, based on a vote from the minority of the nursing workforce, will be hugely concerning for patients. “Hundreds of thousands of Agenda for Change staff continue to vote in ballots for other unions over the next two weeks and we hope this generous offer secures their support.”