Nearly 320 jobs are to go at a debt-ridden NHS trust in Lincolnshire.
Earlier cuts to save money provoked an angry reaction
United Lincolnshire Hospitals NHS Trust said 100 of the job cuts would come from agency staff as it tries to tackle a £15m overspend.
The cuts were announced at a public meeting on Tuesday but unions claim 300 jobs have already been lost in recent months through natural wastage.
A trust spokesman said the cuts would have "a fairly small impact" on clinical services.
Dr Keith Sands, medical director at the trust, said "efficiency measures" and a reduction in administrative and management staff were the main thrust of the changes.
Helen Scott-South, trust interim chief executive, said: "In this first part of the turnaround plan there will be a reduction in the size of the workforce of approximately 220 whole time
She said some of the reductions will be covered by normal staff turnover and transfers.
Campaigners said the cuts now meant more than 17,000 NHS job losses had been announced since February.
Health officials also said they were considering stopping maternity services and all surgery - apart from orthopaedic procedures - at Grantham Hospital.
The running of accident and emergency units at Skegness and Spalding could also be taken over by primary care trusts as part of the plans.
But managers insisted that no final decisions had been made.
Peter Savage from the union Unison said the cuts would affect patients.
He said: "The big problem with Lincolnshire is that it's a big place and people need to travel a long way.
"It's not the same as rationalising services in a city like Nottingham, which will have its problems but people will only have to travel around an extra mile. It is a long way from Grantham to Lincoln."
He said staff reactions to the cuts had been a mixture of anger, disappointment and confusion.
"We are going to start a campaign to defend the health service. We are meeting with staff and local politicians and want to organise rallies and demonstrations.
"Industrial action has not been ruled out, it is not our first step but we won't rule it out."
Amicus regional officer Steve Syson said: "Another 300 job cuts on top of the 300 already lost in Lincolnshire NHS over the last year really is catastrophic.
"Frontline services will be affected and the trust are talking about the need for more strategic changes for which we can read more job cuts."
The trust will consult stakeholders about the proposals for the next three months and hold another three-month public consultation.
Dr Sands said the trust's overspend has been reduced to £1.3m a month - which he described as "great progress".
Arthur Sandford, chairman of Trent Strategic Health Authority, said the trust had been overspending at the rate of £1.6m per month at the start of the financial year and had debts of nearly £25m.
The trust has already announced 29 senior hospital management posts will be scrapped as part of the plans.
A spokesperson said the management restructure would save about £1.6m each year.