When a Consultant Surgeon leaves, the trust activates a recruitment process. When an Authorised Person (AP) for Water leaves, the same urgency rarely follows — even though the HTM obligations associated with that role are non-negotiable and the consequences of non-compliance can be more immediate and severe. This article explains the legal framework around AP appointments, what a vacancy actually means in compliance terms, and what interim arrangements are available.
Under HTM 04-01, HTM 06-02, HTM 03-01, and HTM 02-01, Authorised Person appointments are mandatory. These are not aspirational best practice roles — they are defined statutory appointments with specific competence requirements. There is no HTM-compliant route to operating without them.
What Is an Authorised Person?
The NHS Health Technical Memoranda establish a formal hierarchy of appointments for managing safety-critical building services in healthcare premises. At the operational level, this hierarchy has two key roles: the Authorised Person (AP) and the Authorised Engineer (AE).
An Authorised Person is a competent individual, appointed in writing by the employer, who has documented technical knowledge of a specific discipline and is responsible for overseeing safe systems of work within that discipline on the trust's estate. The appointment is personal to an individual — it cannot be shared, delegated informally, or left to a contractor to assume without a formal written appointment letter.
An Authorised Engineer is typically an independent specialist who provides oversight, audit, and guidance — they are not a substitute for the AP and cannot assume AP duties.
The Four Statutory AP Disciplines
AP (Water)
Responsible for Legionella risk management. Oversees written scheme, schematic verification, monthly monitoring programme, and disinfection procedures. Cannot be vacant — L8 ACoP requires a responsible person at all times.
AP (Electrical)
Responsible for high voltage and low voltage systems safety. Issues permits to work. Required for any HV switching operations. Vacancy creates immediate inability to issue safe systems of work for electrical maintenance.
AP (Ventilation)
Responsible for ventilation systems including operating theatres and isolation rooms. Mandatory where Class 1 (ultra-clean) or Class 2 (conventional clean air) theatres are present. Cannot be vacant in an acute trust with surgical theatres.
AP (Medical Gas)
Responsible for medical gas pipeline systems (MGPS). Required for any work on piped oxygen, nitrous oxide, medical air, or vacuum systems. Vacancy creates inability to authorise any MGPS maintenance or modification.
What a Vacancy Actually Means
The moment an AP leaves — through resignation, retirement, long-term sickness, or dismissal — the trust is in a position that the relevant HTM does not formally accommodate. This is not a grey area. The consequences are immediate and cascade through three areas.
Operational Consequences
An AP is required to issue permits to work for safety-critical maintenance activities. Without a named AP, planned maintenance cannot be formally authorised under the trust's safe systems of work framework. This does not mean maintenance stops — but it does mean the authorisation chain is broken, creating liability exposure for anyone who carries out work without a valid permit.
For water systems, this means the monthly Legionella monitoring programme lacks a formally responsible person. For electrical systems, it means any HV switching operations must be either deferred or conducted under emergency arrangements. For theatres, it means the ventilation validation programme that underpins clinical safety in operating environments has no AP oversight.
Regulatory and Reporting Consequences
The NHS Premises Assurance Model (PAM) Domain 4 specifically covers statutory and mandatory training and appointments. Vacancy in an AP role is a direct PAM non-compliance finding. Under PAM 2026-27, the shift from assurance to evidence-based compliance means this finding will require documentary evidence of both the gap and the interim risk management strategy — not just an acknowledgement that recruitment is underway.
The Health and Safety Executive has enforcement powers under the Health and Safety at Work Act 1974 and the Electricity at Work Regulations 1989. An undocumented AP vacancy, particularly one where work has continued without formal authorisation, creates the conditions for an improvement notice or, in the event of an incident, a prosecution.
Insurance and Indemnity Consequences
Many NHS trust insurance and indemnity frameworks require compliance with statutory maintenance obligations as a condition of cover. An AP vacancy, particularly one that has persisted for a significant period, can become relevant in any insurance claim arising from an incident in the relevant discipline.
Interim Arrangements — What Is and Is Not Acceptable
The HTMs do not leave trusts without any options when an AP vacancy arises. But the options are narrower than many Estates Directors assume.
| Approach | HTM Acceptable? | Conditions |
|---|---|---|
| Named individual appointed interim AP in writing | Yes | Must meet HTM competence requirements for the discipline; appointment must be documented; Authorised Engineer must be notified and agree |
| Contracted specialist assumes AP duties | Yes (conditional) | Contractor must be formally appointed in writing by the trust's responsible person; HTM competence requirements must be verified; indemnity position must be clarified |
| Authorised Engineer covers AP duties | No | AE and AP roles are distinct. The AE provides oversight and audit; they cannot assume operational AP responsibilities |
| Informal arrangement where experienced staff 'cover' | No | The appointment must be documented in writing. Informal arrangements provide no legal protection and may increase liability exposure |
| Vacancy left unfilled while recruitment proceeds | No | There is no HTM-compliant position in which a mandatory AP role is simply vacant. Risk acceptance must be formally documented |
The Risk Acceptance Framework
In practice, AP vacancies do arise and are sometimes unavoidable. The appropriate response is a documented risk acceptance process — not a silence in the compliance record. This process has three elements.
1. Formal Risk Assessment
A written assessment of the specific risks arising from the vacancy in this discipline on this estate. For an AP (Water) vacancy, this means an immediate review of the Legionella risk assessment and a determination of whether the monitoring programme can continue under temporary arrangements. For AP (Electrical), it means identifying which HV switching operations are planned and whether they can be deferred.
2. Interim Mitigation Plan
A documented plan covering: who has assumed responsibility for each specific AP duty (named individual, not job title); what authority they hold and how it was granted; what activities have been suspended or deferred; and the timeline for restoring full AP coverage.
3. Director-Level Sign-Off
The risk acceptance must be signed off at Director of Estates or equivalent level. This is not a delegable decision. The Estates Director is the responsible person under most trust governance frameworks for HTM statutory compliance, and the risk acceptance must be visible at that level.
Under PAM 2026-27, a trust with an AP vacancy that cannot produce a documented risk acceptance framework, interim mitigation plan, and Director sign-off is materially non-compliant. The absence of documentation is treated more seriously than the existence of a documented temporary gap with appropriate mitigation.
The Workforce Planning Dimension
AP vacancies are rarely sudden surprises. The most common cause is retirement — and with NHS estates workforces ageing significantly since the pandemic, this is a growing structural risk. An Estates Director who does not know the age profile and retirement horizon of their AP cohort is operating without a critical piece of succession intelligence.
The second most common cause is that AP roles are often held by individuals who carry multiple responsibilities. When a senior estates manager with AP (Water) and AP (Electrical) appointments leaves, two simultaneous vacancies can arise. The trust's AP register should clearly identify these compound risks.
At Sustain International, our AP Role Gap Analysis service begins with a review of the AP register against the HTM requirements for the estate — identifying not just current vacancies but near-term succession risks. This is the output that turns an HR problem into an operational risk management plan.
Is your AP register compliant?
Our AP Role Gap Analysis reviews your statutory appointments against HTM 04-01, 06-02, 03-01, and 02-01 requirements, identifies succession risks, and produces a compliance gap report with interim risk framework. Typically delivered in 2–4 weeks at a fixed fee.
Request a Scope Discussion →Sources: DHSC, Health Technical Memorandum 04-01: Safe Water Systems (2016); DHSC, Health Technical Memorandum 06-02: Electrical safety guidance for high voltage systems (2022); DHSC, Health Technical Memorandum 03-01: Ventilation in healthcare premises (2021); DHSC, Health Technical Memorandum 02-01: Medical Gas Pipeline Systems Parts A & B; Health and Safety Executive, ACOP L8: Legionnaires Disease — The Control of Legionella Bacteria in Water Systems (2013); NHS England, Premises Assurance Model 2026-27.