Members of the GMB union have become the first to reject a new pay deal offered by the Scottish Government for NHS staff.
Sixty-six per cent of respondents to the GMB ballot voted against the offer, which means the threat of strike action by more than 8,000 members of the union working in the NHS, including 1,700 in the ambulance service, continues to loom.
The union has a mandate for strike action in a number of health boards and the ambulance service.
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Following negotiations with Scottish Health Secretary Humza Yousaf and the intervention of First Minister Nicola Sturgeon, the deal offered pay rises ranging from £2,205 to £2,751 - which ministers said meant NHS workers in Scotland would remain the best paid in the UK.
The lowest paid staff would get a rise of 11.3%, with an average increase of 7.5%.
GMB Scotland senior organiser Keir Greenaway said the rejection "reflects our members' views and the realities of this offer", calling on Mr Yousaf to meet with members before Christmas.
"It is still below inflation for the vast majority of staff, who worked through the depths of the pandemic and are struggling in the grip of this cost-of-living crisis, and it doesn't go far enough in itself to confront the understaffing crisis affecting frontline services either," he added.
"The Scottish Government has contrasted its approach on trade union engagement with that of the UK Government, so we are now asking the Cabinet Secretary to practice what he preaches by meeting our members this side of Christmas to continue discussions over their value and the sustainability of their services.
"It is important the Cabinet Secretary takes on board the views of all NHS staff and not just some, because we are talking about frontline workers who understand first-hand the crisis across service delivery and patient care, and they have clear and credible views on how these services can be recovered in the months and years ahead.
"The fact remains that GMB members in major services and health board areas have strong legal mandates for strikes and an imposition of this offer without further discussion would be seriously detrimental to the industrial relations the Scottish Government have been quick to promote.
"If the Cabinet Secretary wants to preserve those relations, he must meet our members urgently."
The union is the first to reject the deal, after Unite and Unison this week chose to accept what was described by Mr Yousaf as the "best and final" offer.
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