Health Technical Memorandum 05-01: Managing healthcare fire safety – NHS Fire Management Framework
Health Technical Memorandum 05-01: Managing healthcare fire safety (HTM 05-01) is the primary technical guidance issued by NHS England for the design, installation, and operation of fire safety management systems within healthcare environments. This document sits within the Firecode suite and provides a structured framework for healthcare organisations to comply with statutory duties under the Building Regulations 2010, the Regulatory Reform (Fire Safety) Order 2005 (FSO), and the Building Safety Act 2022. It replaces previous editions and introduces significant updates to management roles, documentation standards, and auditing requirements across the NHS estate.
The scope of HTM 05-01 extends to all healthcare premises, including complex healthcare organisations such as acute and mental health trusts, and non-complex facilities like GP practices and ambulance trusts. The guidance details regulatory requirements for physical fire precautions and the non-physical elements of fire safety, such as staff training and emergency response. It defines critical terminology including Compartmentation, Progressive horizontal evacuation, and patient Dependency levels (categorised as Independent, Dependent, and Very high dependency). The document is structured into chapters covering statutory duties, management systems, appropriate management levels, roles and responsibilities, and documentation including the Site/building fire information manuals and Departmental fire safety files.
Professional users of this document include Fire Safety Managers, Authorised Persons, Estate Directors, and Independent Expert Advisers. This edition formalises the transition to a risk-based approach where management structures are tailored to the complexity and risk profile of the specific service. It emphasizes the maintenance of the golden thread of safety information throughout the building lifecycle, ensuring compliance with Regulation 38 of the Building Regulations.
Statutory Fire Safety Duties and Enforcement
Healthcare organisations must navigate three principal legislative instruments governing fire safety. The Building Regulations 2010 set functional requirements for new works or material alterations, specifically focusing on five aspects in Part B of Schedule 1:
- B1: Means of warning and escape.
- B2: Internal fire spread (linings).
- B3: Internal fire spread (structure).
- B4: External fire spread.
- B5: Access and facilities for the fire service.
The FSO 2005 governs ongoing fire safety provisions to protect Relevant persons, while the Building Safety Act 2022 imposes duties on those managing higher-risk buildings. Enforcement is conducted by the fire and rescue authority, the Health and Safety Executive (HSE), and the Care Quality Commission (CQC).
Fire Safety Management Structure and Roles
A robust management structure is required to ensure accountability. This edition separates the previous Authorising Engineer (Fire) responsibilities into two distinct roles to match specific competencies:
- Independent Expert Adviser (Authorising Engineer): Focuses on auditing fire safety management systems and recommending individuals for appointment as Authorised Persons.
- Specialist Fire Engineer: Provides technical advice on complex fire engineering solutions, such as smoke control in atria or fire strategy work.
- Fire Safety Manager (Senior Operational Manager): Responsible for developing the fire safety management system and operating the Fire Safety Group (FSG).
- Fire Safety Adviser (Authorised Person (Fire)): Provides competent fire safety advice and assists the Responsible person in undertaking preventive measures.
Appropriate Management Levels
The document defines management levels based on patient and occupant characteristics to ensure proportionate resource allocation:
- Level 1 Management: Applied to acute hospitals, mental health hospitals, and diagnostic centres. It requires proactive identification of risk profile changes and dedicated staffing for evacuation assistance.
- Level 2 Management: Applied to minor injuries units and primary care centres. It is suitable where patients are predominantly independent and assisted evacuation is seldom required.
Documentation and the Golden Thread
To maintain the golden thread of information, the single fire safety manual is replaced by two specific documents:
- Site/building fire information manuals: Containing technical fire safety information required for compliance with Regulation 38, including as-installed drawings of passive and active precautions.
- Departmental fire safety files: Local files held at the ward or department level containing the local emergency action plan, secondary fire risk assessments, and records of fire drills.
Fire Safety Protocols
Organisations must develop comprehensive protocols for specific activities impacting fire risk. Key protocols listed in the guidance include:
- Hot works: Use of a robust permit-to-work system for operations involving open flames or heat.
- Medical gases: Procedures for the isolation of medical gas pipeline systems (MGPS) and storage of cylinders.
- New Technologies: Risk assessments for Photovoltaics (PV), Battery energy storage systems (BESS), and Electric vehicle (EV) charging facilities.
- Arson and Security: Management of waste and CCTV to deter arson-related incidents.
Frequently Asked Questions
What are the three main pieces of legislation for healthcare fire safety?
The principal legislative instruments are the Building Regulations 2010, the Regulatory Reform (Fire Safety) Order 2005, and the Building Safety Act 2022.
What is the difference between an Independent Expert Adviser and a Fire Engineer?
The Independent Expert Adviser acts as an auditor for fire safety management systems, while a Fire Engineer provides specialist technical advice for complex designs and fire strategy work.
What must be included in a Departmental fire safety file?
It should include the local emergency action plan, the secondary fire risk assessment, records of fire drills, locations of firefighting equipment, and the name of the local Fire Warden.
How are patient dependency categories defined in HTM 05-01?
Patients are categorised as Independent (can leave without assistance), Dependent (all others), and Very high dependency (evacuation would be potentially life-threatening).
Who is the 'Responsible person' in an NHS hospital trust?
In most healthcare organisations, the Responsible person under the FSO is the employer, which typically means the trust Board.
What is Regulation 38 of the Building Regulations?
It requires those carrying out building work to provide the Responsible person with information on the building's design and fire safety provisions to enable safe operation and maintenance.
What is the role of the Fire Safety Group (FSG)?
The FSG is responsible for reviewing all fire safety matters, approving fire safety protocols, and ensuring that fire incidents and audit outcomes are reported to the Board.
What is progressive horizontal evacuation?
It is the process of moving patients away from a fire into an adjacent fire-free compartment or subcompartment on the same level to reach a place of relative safety.
