A body representing more than 200 NHS trusts across England says new ways of negotiating pay need to be considered.
The chief executive of the Foundation Trust Network (FTN), Chris Hopson, has questioned whether national agreements can deliver the savings needed for the health service.
He said it was time to consider setting pay regionally or trust-by-trust.
Unison has warned against putting at risk current proposals, covering more than one million NHS workers.
A new national deal on pay, terms and conditions for most NHS staff in England appears tantalisingly close.
Trade unions are consulting on changes to the Agenda for Change scheme, covering more than one million workers. One of the main modifications is a clearer link between annual pay increments and performance.
Mr Hopson said NHS trusts completely supported the deal on the table.
However, he argued that when you look at the challenges trusts face over the next five years - a flat budget, rising costs, and the need to improve care at nights and weekends - it will not be enough.
End Quote Chris Hopson Foundation Trust NetworkLooking to the next five years, the NHS urgently needs a major debate on whether the current approach to pay, terms and conditions is fit for purpose and affordable."
Pay takes up 60-70% of an average trust's costs, and safety concerns mean it is impossible to cut staff numbers in the same way as other public services, Mr Hopson said.
While acknowledging that any improvements are welcome, he said he estimated the current deal on offer would secure an average hospital annual savings of about £250,000, out of the £11m needed, which some people might call "a drop in the ocean".
In particular, Mr Hopson questioned whether enough was being done to reform annual increments - awarded irrespective of pay deals as staff build up experience.
"Can the NHS, for example, continue to afford a system that gives 60% of staff a 2% pay increase every year, irrespective of performance, on top of any cost of living increase?"
The time had come to look at a different approach, he added.
"Trusts now have a pressing need for the NHS to start discussing the different ways we could set pay, terms and conditions including looking at whether we should set pay nationally, regionally or trust by trust - exactly the same debate as the education service is now having."
This is an idea that is already being pursued by a consortium of trusts in the south west of England.
Pay "cartels"Janet Davies from the Royal College of Nursing said abandoning national pay negotiations would not resolve the severe financial pressures in the NHS.
"Our experience shows that the cost of moving to individual negotiation can outweigh any potential benefit.
"Nor will the NHS be able to raise the standard of care by moving to a system of pay cartels. The present Agenda for Change system is a transparent and fair system that allows employers to plan ahead with certainty and to reward experience," Ms Davies said.
Christina McAnea, from Unison, warned against jeopardising the changes being considered by unions.
"If the FTN is saying the current proposals are not enough it puts the whole thing at risk."
She said most trusts were failing to pick up savings that were there for the taking under the existing arrangements, and she urged them to tell the government that the efficiencies demanded could not be achieved.
Health minister Dr Dan Poulter said changes to NHS employee contracts were long overdue.
"Patient care lies at the heart of this. This is why discussions have been about making a much stronger link between providing high quality patient care and annual pay progression - with a much stronger emphasis on behaviours referenced in the NHS Constitution around compassion, dignity and respect."
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