Workers at South East Coast Ambulance Service have begun voting on strike action.
Over 15,000 workers at a total of 11 trusts throughout England and Wales are taking part in the vote, which closes on 29 November.
Ballots involving other NHS staff are also expected to take place in the near future.
Rachel Harrison, Acting National Secretary at GMB Union said, "Ambulance workers don't do this lightly - and this would be the biggest ambulance strike for 30 years.
"But more than ten years of pay cuts, plus the cost-of-living crisis, means workers can't make ends meet. They are desperate.
"But this is much more about patient safety at least as much about pay. Delays up to 26 hours and 135,000 vacancies across the NHS mean a third of GMB ambulance workers think a delay they've been involved with has led to a death.
"Ambulance workers have been telling the Government for years things are unsafe. No one is listening. What else can they do?"
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