The government is reportedly gearing up to impose the proposed contract for junior doctors after it was rejected by British Medical Association members.
The trade union had reached agreement with the government on conditions in the contract and had urged junior doctors to accept its terms, but 58 percent of the 68 percent turnout voted against it.
The decision came despite a campaign by the BMA which saw more than 130 roadshows take place across England, at which doctors and medical students were provided with details of the new contract.
After a saga dating back to 2012, which included a series of junior doctors strikes, the ultimate deal on the table agreed on by the government and the BMA included more attractive terms relating to unsociable hours with a new weekend working allowance and more rigorous oversight of the new guardian role to ensure safe working. But evidently doctors remain unconvinced.
The outcome of the vote has triggered Dr Johann Malawana resigned as BMA junior doctor committee chair, but he stressed that there should be no transition to a new contract until further talks take place.
"Having spoken to many junior doctors across the country in recent weeks it was clear that, while some felt the new contract represented an improved offer, others had reservations about what it would mean for their working lives, their patients and the future delivery of care in the NHS. There was also considerable anger and mistrust towards the government's handling of this dispute," he noted.
"There is much to do to in order to rebuild the trust that has been eroded over the last year. The government must now do the right thing, accept the outcome of this vote and work constructively with the BMA to address junior doctors' concerns with the new contract."
Forcing a deal
However, BBC News said it had spoken to government sources who claimed they were now "minded" to impose a deal and considering the legal position for doing so, and that an equality impact assessment had already been completed.
Health secretary Jeremy Hunt said in a statement that is it "extremely disappointing that junior doctors have voted against this contract, which was agreed with and endorsed by the leader of the BMA Junior Doctors' Committee and supported by senior NHS leaders".
"Only 40% of those eligible actually voted against this contract, and a third of BMA members didn't vote at all. We will now consider the outcome".
Diane Abbott MP, Labour's Shadow Secretary of State for Health, said the referendum result is "yet another sorry episode in the saga of the Government's mishandled negotiations with junior doctors. It is disappointing that several months on, we still do not have a contract in place that junior doctors feel able to support".