The NHS will be top heavy with highly paid consultants and other specialists by 2011, but short of thousands of nurses, a leaked Department of Health document warns. It predicts a "volatile" four years, with about 37,000 jobs going next year, though numbers are expected to pick up later. It says "sharp reductions" will cut the 1,366,000 NHS workforce by 2.7 per cent.

The strategy document, written by the Department of Health's workforce directorate, also suggests that those still employed by the NHS will have to work harder or be paid less.

It predicts bitter opposition from the British Medical Association as the numbers of consultants and specialists such as physiotherapists, healthcare scientists and technicians are "managed down".

The Conservatives seized on the predicted job cuts yesterday as proof that the Government's health policy is now driven by a financial crisis. Britain's biggest health union vowed to oppose any cuts in nurses' pay.

The document, leaked to the Health Service Journal, forecasts that by 2010-11, the NHS will have 3,200 too many full-time consultants "which we cannot afford to employ", and 16,200 too many allied health professionals, scientists and technicians. At the same time, there will be shortages of 14,000 nurses, 1,200 GPs, and 1,100 junior doctors. It suggests ways to cut the NHS's expanding wage bill, by doing away with national pay bargaining so that regional and local deals can bring down nurses' pay.

It suggests that unemployment will help to "create downward pressure on wages", and that the unions might agree to "cafeteria style" pay awards which trade hours for pay. This would mean that the unions would achieve their goal of a 35-hour week in theory, but "in practice most staff might be expected to cash in extra hours for more pay".

It also calls for a review of doctors' pay structure, and for specialist doctors to be encouraged to retrain as GPs, and urges NHS employers to use a "market model", buying in skills as and when they are needed. Trusts should "concentrate on buying in the skills they need to the standards they require without necessarily seeking to predict, commission or control the supply".

Mike Jackson, the deputy head of health for Britain's main public-sector union, said the union would oppose local pay deals, claiming they were "not necessary" because of the flexibility already in the system. He added: "Patient care would be damaged by any attempt to cut nurses pay.

"We've spent years working to get decent pay to make sure enough nurses want to stay in the job. Any cut would undo all that good work. As it is, we face huge demographic challenges - 20 per cent of our nurses are aged between 50 and 59 - and if we start cutting pay, it will make the job of attracting enough nurses even more difficult."

The shadow Health Secretary, Andrew Lansley, said: "This latest fiasco in workforce planning is the bleakest possible start to 2007 for the NHS."

He added: "The financial crisis in the NHS is now driving government policy. By cynically using the misery of unemployment to cut pay in the NHS, Labour ministers are making hard-working doctors and nurses pay for governmental incompetence. The effect on morale will be dire.

"NHS resources, and the responsibility for spending them, need to be given to frontline staff so they can build a more effective NHS which responds to the needs of its staff as well as to the needs of patients. We can never again allow such a tragic failure of central planning."