Health Technical Memorandum 05-03 Part K: Fire Risk Assessments in Complex Healthcare Premises
Health Technical Memorandum 05-03 Part K (HTM 05-03 Part K) is the official technical guidance issued by NHS England regarding the methodology and operational provisions for fire risk assessments (FRA) within complex healthcare environments. This edition supersedes all previous versions of Part K and sits within the wider HTM 05 series on fire safety. It provides a standardized framework for complying with the Regulatory Reform (Fire Safety) Order 2005 (FSO) and incorporates requirements from the Building Safety Act 2022 and the Fire Safety Act 2021.
The guidance is specifically designed for complex healthcare premises, defined as hospitals or facilities that place a high dependence on staff for patient evacuation, typically utilizing progressive horizontal evacuation. It introduces a distinct dual-level assessment structure: the Primary FRA, which governs shared building management and overarching fire precautions, and the Secondary FRA, which focuses on ward-level or department-specific management. The document details a nine-step assessment process aligned with PAS 79 and provides technical guidance on emerging hazards such as battery energy storage systems (BESS) and electric vehicle charging.
Professional users will find detailed criteria for evaluating physical protection measures, including compartmentation, fire-resisting doors, and external wall construction under PAS 9980. The memorandum establishes protocols for the Authorised Person (Fire Safety Maintenance) and provides structured templates in Appendix E and Appendix F to ensure consistency in reporting and significant findings.
Dual-Level FRA Framework
HTM 05-03 Part K requires that two levels of fire risk assessment are carried out to manage the interdependencies of complex hospital structures:
- Primary FRA: Relates to shared or overarching general fire precautions, building-wide facilities, and overall management arrangements. It focuses on communal escape routes, external walls, and systems maintained via planned preventive maintenance (PPM).
- Secondary FRA: Relates to locally managed areas such as individual wards or departments. It reviews local staffing levels, unobstructed escape routes, and daily/weekly checks on fire safety provisions.
- Interdependency: The FRA process is not considered complete until both levels are performed, as the secondary area relies on the building-wide features established in the primary assessment.
The Nine-Step Assessment Process
The guidance adopts the nine-step approach detailed in PAS 79 to evaluate fire risk to life safety. This process emphasizes the ALARP (as low as reasonably practicable) principle rather than auditing against modern design codes like HTM 05-02.
- Step 1: Obtain information on occupants, including independent, dependent, and very high dependency patients.
- Step 2: Identify fire hazards and existing control measures.
- Step 3: Assess the likelihood of fire, categorized from rare to almost certain.
- Step 4: Determine physical fire protection measures.
- Step 5: Evaluate fire safety management and staff training.
- Step 6: Assess consequences to occupants based on ASET/RSET (available safe egress time versus required safe egress time) principles.
- Step 7: Determine the risk level using an enhanced 5 x 5 risk matrix.
- Step 8: Formulate an action plan to address shortcomings.
- Step 9: Establish a review period, typically not exceeding 12 months.
Fire Safety Design and Physical Protection
The document provides specific benchmarks for the maintenance and assessment of physical fire barriers and escape facilities within existing buildings.
- Compartmentation: Sub-compartments should not exceed 750 m², while main compartments are limited to 2000 m² (3000 m² for single-storey buildings).
- Fire-resisting doors: Existing doors may be classified as notional FD30 if they satisfied standards at the time of manufacture. Upgrading involves fitting intumescent strips and smoke seals.
- Travel distances: The maximum distance in a single direction before a choice of escape routes is available should ideally be no more than 15 m. Overall travel distance within a sub-compartment should not exceed 30 m.
- External Walls: Fire risk appraisals of external walls (FRAEW) must follow PAS 9980 methodologies, particularly for buildings over 18 m in height.
- Structural Fire Resistance: Single-storey premises require 30 minutes, while buildings between one and four storeys above ground require 60 minutes.
Hazard Identification and Prevention
HTM 05-03 Part K provides practical advice on controlling specific healthcare-related fire hazards to reduce the likelihood of ignition.
- Medical Gases: Management of an oxygen-enriched atmosphere is critical, as materials not normally considered flammable may ignite and burn vigorously.
- Hazard Rooms: Specific areas like laboratories, pharmacies, and laundries must be fire-separated and evaluated using the Hazard room risk assessment matrix in Appendix B.
- Electrical Safety: Fixed electrical equipment must be covered in the Primary FRA, while portable appliance testing (PAT) protocols should be defined locally.
- Kitchen Extraction: Systems must be cleaned and maintained according to BESA TR19 to prevent oil and grease accumulation.
Frequently Asked Questions
What is the definition of a complex healthcare premise according to HTM 05-03 Part K?
It is a hospital or other healthcare facility that places a dependence on staff for the evacuation of patients.
How often should a fire risk assessment be reviewed in an NHS facility?
While there is no fixed maximum period, it is recommended that the review period should not exceed 12 months, or sooner if circumstances change.
What are the three options for fire-resisting doors that do not meet current benchmark standards?
The doors can be accepted as they are if they are 'notional FD30' doors, upgraded with intumescent strips and smoke seals, or replaced with a certified FD30s doorset.
What is the maximum travel distance allowed within a sub-compartment?
The maximum overall horizontal travel distance within a sub-compartment should not exceed 30 m.
What is the difference between a Primary and Secondary FRA?
A Primary FRA deals with building-wide management and shared fire precautions, while a Secondary FRA focuses on locally managed areas like wards and departments.
When is a Fire Risk Appraisal of the External Wall (FRAEW) required?
An FRAEW following PAS 9980 is required for relevant buildings, typically those over 18 m in height or where the risk of external fire spread is significant.
Are personal emergency evacuation plans (PEEPs) required for hospital visitors?
It is not possible to provide individual PEEPs for visitors; instead, a general PEEP must be developed for areas where visitors are present to facilitate their escape.
