England’s biggest nursing union is to ballot its members on whether to join a “make or break” mega-strike that would lead to mass action by nurses in every hospital trust in the country, the Observer can reveal. The move by the Royal College of Nursing to “up the ante” by holding a single national vote – rather than conducting ballots in each individual trust as it did last October – would, if passed, mean twice as many trusts being hit by industrial action by nurses as have been so far. And junior doctors warned on Saturday they might coordinate action with the RCN if the nurses’ union won a fresh mandate for further strikes. “Coordinated action in the future is definitely something we would consider,” said Dr Vivek Trivedi, co-chair of the BMA’s junior doctors committee. Options could include action on the same dates as nurses or alternating dates. He said: “Like doctors, nurses have had cuts in pay in real terms. We are different professions, but we are basically fighting for the same thing. If it is able to be done in a way which maintains safety but increases the pressure on the government, it is something we would be willing to consider.” Sir Julian Hartley, chief executive of NHS Providers, said in an interview on Sky News on Saturday that coordinated strike action would be “completely unprecedented” and “uncharted territory”. The RCN has said it is not planning at present to coordinate action with doctors. The RCN’s high-stakes strike action decision follows its announcement on Friday that its members had rejected by 54% to 46% a government pay offer of a 5% pay rise this year and a cash payment for last year, despite the union’s leadership recommending its approval. With feeling running high among many nurses that their own union set the bar too low in talks with ministers, the RCN is now preparing a final concerted push to secure more for them. The union is warning ministers that if they do not reopen negotiations, they will face a potential nightmare summer, autumn and winter of action by nurses, junior doctors and potentially hospital consultants, who are also threatening to ballot for strikes – all in the run-up to a likely 2024 general election. Pat Cullen, the RCN’s general secretary, who had advised her members to back the deal, told the Observer that ministers now had no option but to reopen pay talks. “The government has to act fast again now that nursing staff have chosen to escalate the strike situation. All 280,000 of our NHS members in England will get a fresh vote this summer on whether to strike through to December. If the majority support it, we will be striking in double the number of places than we have to date. “The prime minister cannot run an NHS without nurses and doctors for the rest of the year. His last pay offer has failed the fairness test with nurses, and so they are expecting him to put another on the table. Our members do not feel valued and, until they do, they will remain a political problem for Rishi Sunak to address.” Because of the way the RCN conducted its previous ballots on a trust by trust basis, strikes involving tens of thousands of RCN members since November have only affected around half of the NHS trusts in England – those which voted for strike action. In the other half, RCN members rejected action and worked as normal. One of Rishi Sunak’s promises to the nation soon after entering Downing Street was that he would bring down waiting lists in 2023 – a pledge that will be seriously in danger if more and wider strike chaos breaks out. On Saturday senior NHS figures warned that the strikes by junior doctors had left staff-to-patient ratios at lower levels than during the pandemic, and would lead to far longer waiting lists that would take years to bring down. They also talked of a morale crisis and a potential exodus of key NHS staff as a result. Hartley said: “Trusts are extremely concerned about the effect on staff morale that repeated rounds of industrial action are having. Staffing ratios in some places have been much worse than what we had to deal with during Covid, and that takes its toll. “We have more than 120,000 vacancies across the NHS and staff have had to deal with unprecedented pressures this winter. There is a real worry that the impact on morale is going to have a lasting effect on staff retention. We need a workforce appropriately rewarded, supported and recognised for the great work that it does.” Dr Tom Dolphin, a consultant anaesthetist at a London hospital, said staff had worked hard during last week’s junior doctor strikes to protect patient safety, but inevitably a large number of operations were postponed. “There was a huge backlog that was developing even before the pandemic and strike action has added to it,” he said. “It’s going to take years to work through. It’s frustrating that doctors have been put in this position, but we can’t continue in this way because junior doctors have been leaving to go to Australia and other countries. “Some of my consultant colleagues are also looking elsewhere because we’ve had worse pay erosion than the junior doctors. It means the workforce is generally under strain at a time when we need as many doctors as we can, alongside nurses and others in the NHS.” A national strike by nurses would take the NHS crisis to a new level. The RCN will need 50% of its members to vote in the ballot, which will open next month, and at least 50% of these to vote yes to national action. Union sources say it will require 70,000 RCN NHS nurses to vote yes, 20,000 fewer than voted to reject the government pay offer. “It is achievable,” said a union source. The source added: “The reason that we are doing this is that the only way we are going to get the government to take action is to apply more pressure and the only way to apply more pressure is to have the mandate to strike in every part of the country.” The source said it was “all or nothing”. “You either get the 51% and you can take everyone out or you get 49% and you cannot take out anybody.” Immediately after the result of the RCN vote was announced, the union said it would hold an unprecedented 48-hour strike, including at night, from 30 April, before its mandate for action runs out at the start of next month. A four-day strike by junior doctors ended at 7am on Saturday. A government spokesman said that the vote by the RCN to reject the pay offer was “hugely disappointing” and that further strikes would be “hugely concerning for patients”. Also on Friday, Unison, the UK’s biggest union, announced that its NHS members – who include many nurses as well as other health service employees – had accepted the government pay offer by 74% to 26%. The British Medical Association (BMA) has urged the government to engage in talks over junior doctors’ demands for “pay restoration” to 2008 levels. Ministers have claimed that would amount to a 35% pay rise and called on junior doctors to cancel plans for any further strikes before any discussions could take place.