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Published

Actions for Effectiveness of SafeWork NSW in exercising its compliance functions

Effectiveness of SafeWork NSW in exercising its compliance functions

Finance
Industry
Health
Compliance
Internal controls and governance
Management and administration
Procurement
Project management
Regulation
Risk

What this report is about 

This report assesses how effectively SafeWork NSW, a part of the Department of Customer Service (DCS), has performed its regulatory compliance functions for work health and safety in New South Wales. 

The report includes a case study examining SafeWork NSW's management of a project to develop a realtime monitoring device for airborne silica in workplaces. 

Findings 

There is limited transparency about SafeWork NSW's effectiveness as a regulator. The limited performance information that is available is either subsumed within DCS reporting (or other sources) and is focused on activity, not outcomes. 

As a work health and safety (WHS) regulator, SafeWork NSW lacks an effective strategic and data-driven approach to respond to emerging WHS risks. 

It was slow to respond to the risk of respirable crystalline silica in manufactured stone. 

SafeWork NSW is constrained by an information management system that is over 20 years old and has passed its effective useful life. 

While it has invested effort into ensuring consistent regulatory decisions, SafeWork NSW needs to maintain a focus on this objective, including by ensuring that there is a comprehensive approach to quality assurance. 

SafeWork NSW's engagement of a commercial partner to develop a real-time silica monitoring device did not comply with key procurement obligations. 

There was ineffective governance and process to address important concerns about the accuracy of the real-time silica monitoring device. 

As such, SafeWork NSW did not adequately manage potential WHS risks. 

Recommendations 

The report recommended that DCS should: 

  • ensure there is an independent investigation into the procurement of the research partner for the real-time silica detector 
  • embed a formal process to review and set its annual regulatory priorities 
  • publish a consolidated performance report 
  • set long-term priorities, including for workforce planning and technology uplift 
  • improve its use of data, and start work to replace its existing complaints handling system 
  • review its risk culture and its risk management framework 
  • review the quality assurance measures that support consistent regulatory decisions

 

Read the PDF report.

Parliamentary reference - Report number #390 - released 27 February 2024
 

Published

Actions for Health 2023

Health 2023

Health
Whole of Government
Asset valuation
Compliance
Financial reporting
Information technology
Internal controls and governance
Project management
Regulation
Risk
Shared services and collaboration
Workforce and capability

What this report is about

Results of the Health portfolio of agencies' financial statement audits for the year ended 30 June 2023.

The audit found

Unmodified audit opinions were issued for all Health portfolio agencies' financial statements. 

The number of monetary misstatements increased in 2022–23, driven by key accounting issues, including the first-time recognition of paid parental leave and plant and equipment fair value adjustments. 

The key audit issues were 

NSW Health identified errors regarding the recognition and calculation of long service leave entitlements for employees with ten or more years of service that had periods of part time service in the first ten years, resulting in prior period restatements. 

Comprehensive revaluation of buildings at the Graythwaite Charitable Trust found errors in the previous year's valuation, resulting in prior period restatements. 

New parental leave legislation increased employee liabilities for portfolio agencies. The Ministry of Health corrected the consolidated financial statements to record parental leave liabilities for all agencies within the Health portfolio.   

A repeat high-risk issue relates to processing time records by administrators that have not been reviewed prior to running the pay cycle.   

Thirty per cent of reported issues were repeat issues. 

The audit recommended 

Portfolio agencies should ensure any changes to employee entitlements are assessed for their potential financial statements impact under the relevant Australian Accounting Standards. 

Portfolio agencies should address deficiencies that resulted in qualified reports on:   

  • the design and operation of shared service controls
  • prudential non-compliance at residential aged care facilities.

 

This report provides Parliament and other users of the Health portfolio of agencies’ financial statements with the results of our audits, analysis, conclusions and recommendations in the following areas:

  • financial reporting
  • audit observations.

Financial reporting is an important element of good governance. Confidence and transparency in public sector decision-making are enhanced when financial reporting is accurate and timely.

This chapter outlines our audit observations related to the financial reporting of agencies in the Health portfolio of agencies (the portfolio) for 2023.

Section highlights

  • Unqualified audit opinions were issued for all portfolio agencies required to prepare general purpose financial statements.
  • The total number of errors (including corrected and uncorrected) in the financial statements increased compared to the prior year.
  • The Ministry of Health retrospectively corrected an $18.9 million adjustment in its financial statements relating to long service leave entitlements for certain employees.
  • Graythwaite Charitable Trust retrospectively corrected a $4.2 million adjustment in its financial statements related to prior period valuations. 

Appropriate financial controls help ensure the efficient and effective use of resources and administration of agency policies. They are essential for quality and timely decision-making.

This chapter outlines observations and insights from our financial statement audits of agencies in the Health portfolio.  

 Section highlights 

  • The 2022–23 audits identified one high-risk and 57 moderate risk issues across the portfolio.
  • The high-risk matter related to the forced-finalisation of time records.
  • The total number of findings increased from 67 to 111 in 2022–23.
  • Thirty per cent of the issues were repeat issues. Most repeat issues related to internal control deficiencies or non-compliance with key legislation and/or central agency policies.
  • Forced-finalisation of time records, accounting for the new paid parental leave provision and user access review deficiencies were the most commonly reported issues.
  • Qualified Assurance Practitioner's reports were issued on:
    • the design and operation of controls as documented by HealthShare NSW
    • the Ministry's Annual Prudential Compliance Statements in relation to residential aged care facilities.

Appendix one – Misstatements in financial statements submitted for audit

Appendix two – Early close procedures

Appendix three – Timeliness of financial reporting

Appendix four – Financial data

 

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

 

 

Published

Actions for Regional road safety

Regional road safety

Transport
Health
Community Services
Internal controls and governance
Management and administration
Project management
Risk

What this report is about

Around one-third of the state’s population lives in regional NSW, but deaths on regional roads make up around two-thirds of the state’s road toll.

Transport for NSW (TfNSW) is responsible for managing road safety outcomes across the NSW road network. This audit assessed the effectiveness of TfNSW’s delivery of road safety strategies, plans and policies in regional areas.

The NSW Road Safety Action Plan 2022–2026 has the stated goal of ‘no death or serious injury occurring on the road transport network’ by 2050.

What we found

There is a disproportionate amount of trauma on regional roads, but there are no specific road safety plans or trauma reduction targets for regional NSW.

TfNSW advises that the setting of state-wide road safety targets is consistent with other jurisdictions and international best practice. However, the proportion of road fatalities and serious injuries in regional NSW is almost the same as ten years ago.

There is no regional implementation plan to assist TfNSW to target the Road Safety Action Plan 2026 to regional areas.

TfNSW considers that local road safety outcomes should be managed by councils, but only 52% of regional councils participated in its Local Government Road Safety Program (LGRSP) in 2022–23. This program has not been updated since 2014, despite commitments to do so in 2021 and 2022.

TfNSW has not undertaken a systematic and integrated analysis of the combined impact of its road safety strategies and plans in regional NSW since 2012.

TfNSW reports against the Community Road Safety Fund (CRSF) annually but there is no consolidated, public reporting on total road safety funding allocated to regional NSW. The Fund underspend increased from 12% in 2019–20 to 20% in 2022–23.

What we recommended

We recommended TfNSW:

  • develop a regional implementation plan to support the NSW Road Safety Action Plan, including a framework to annually measure, analyse and publicly report on progress
  • develop a plan to measure and mitigate risks causing underspend in the CRSF
  • expedite the review of the LGRSP including recommendations to increase involvement of regional councils.

Disclosure of confidential information

Under the Government Sector Audit Act 1983 (the Act), the Auditor-General may disclose confidential information if, in the Auditor-General’s opinion, the disclosure is in the public interest, and that disclosure is necessary for the exercise of the Auditor-General’s functions.

Confidential information in the Act means Cabinet information or information subject to legal privilege. This performance audit report contained confidential information.

The NSW Premier has certified that in his opinion the disclosure of the confidential information was not in the public interest.

The confidential information has been redacted from this report.

Under section 36A(2) of the Government Sector Audit Act 1983, the Auditor-General may authorise the disclosure of confidential information if, in the Auditor-General’s opinion, the disclosure is in the public interest and necessary for the exercise of the Auditor-General’s functions. Confidential information under the Government Sector Audit Act 1983 means Cabinet information, or information that could be subject to a claim of privilege by the State or a public official in a court of law. This performance audit report contained confidential information which, in the opinion of the Auditor-General, is in the public interest to disclose and that disclosure is necessary for the exercise of the Auditor-General’s functions.

On 26 October 2023, pursuant to section 36A(2)(b) of the Government Sector Audit Act 1983, the Auditor-General notified the NSW Premier of the intention to include this information in the published report, having formed the opinion that its disclosure is in the public interest and is necessary for the exercise of the Auditor-General’s functions.

On 23 November 2023, pursuant to section 36A(2)(c) of the Government Sector Audit Act 1983, the NSW Premier certified that, in his opinion, the proposed disclosure of the confidential information contained in this report was not in the public interest. The Premier’s certificate follows. Section 36A(4) states that a certificate of the Premier that it is not in the public interest to disclose confidential information is conclusive evidence of that fact.

The issuance of the certificate by the NSW Premier prevents the publication of this information. The relevant sections of the report containing confidential information have been redacted.

One-third of the New South Wales population resides in regional areas, but two-thirds of the state’s road crash fatalities take place on regional roads.

Between 2017 and 2021, the average number of fatalities for every 100,000 of the population living in regional New South Wales was 8.33 — approximately four times higher than the equivalent measure for Greater Sydney. Similarly, the average number of serious injuries in regional New South Wales over the same period was 75.24 per 100,000 of the population, compared with 50.53 in Greater Sydney. Further, more than 70% of people who lose their lives in accidents on regional roads are residents of regional areas.

Residents of regional areas face particular transport challenges. They often need to travel longer distances for work, health care, or recreation purposes, yet their public transport options are more limited than metropolitan residents. Vehicle safety is also an issue. According to the NSW Road Safety Progress Report 2021, of the light vehicles registered in New South Wales that were manufactured in or after 2000, 48.4% of light vehicles in regional areas had a five-star Australasian New Car Assessment Program (ANCAP) rating, compared to 54.8% in metropolitan areas. Road conditions in regional areas can also be more challenging for drivers.

Regional New South Wales covers 98.5% of the total area of the state. The road network in New South Wales is vast — spanning approximately 200,000 kilometres.

The road network includes major highways, state roads and local roads. Speed limits range from 10 km/hr in high pedestrian shared zones, up to 110 km/hr on high volume and critical road corridors. Eighty per cent of the network has a 100 km/h speed limit, which is mostly applied as a default speed limit, regardless of the presence of safety features and treatments.

Speed is the primary causal factor in more crashes in New South Wales than any other factor, and car crashes in regional areas are more likely to be fatal because of the higher average speeds involved.

The responsibility for managing road safety outcomes across the entire New South Wales road network lies with Transport for NSW (TfNSW), pursuant to Schedule 1 of the Transport Administration Act 1988.

While its safety responsibilities are state-wide, TfNSW does not own or directly manage all of the road network in regional New South Wales, which spans approximately 200,000 kilometres. Approximately 80% of the roads are classified as Local Roads and are administered and managed by local councils. Local councils also maintain Regional Roads that run through their local government areas. TfNSW is responsible for managing State Roads (approximately 20% of roads), which are major arterial roads. It also provides funding for councils to manage over 18,000 km (approximately 10%) of state-significant Regional Roads.

According to TfNSW, between 2016 and 2020, there were 9,776 people killed or seriously injured on roads in regional New South Wales. Adding to the tragic loss of life, according to TfNSW, the estimated cost to the community between 2016 and 2020 resulting from regional road trauma and fatalities was around $13.7 billion.

TfNSW also noted that the ‘risk of road trauma is pervasive, and a combination of effective road safety measures is required to systematically reduce this risk’.

TfNSW released its first long-term road-safety strategy in December 2012, which introduced the goal of ‘Vision Zero’ — a long-term goal of zero deaths or serious injuries on NSW roads. The terminology was changed to ‘Towards Zero’ in the 2021 Road Safety Plan and has been retained in the NSW Road Safety Action Plan 2022–2026. Towards Zero has the stated goal of ‘no death or serious injury occurring on the road transport network’ by 2050.

The objective of this audit is to assess the effectiveness of TfNSW’s delivery of ‘Towards Zero’ in regional areas.

In making this assessment, the audit examined whether TfNSW:

  • is effectively reducing the number of fatalities and serious injuries on regional roads
  • has an effective framework, including governance arrangements, for designing and refreshing the NSW Road Safety Strategy 2012–2021 and the NSW Road Safety Action Plan 2022–2026
  • effectively makes use of whole-of-government and other relevant sources of data to support decision-making, and to evaluate progress and outcomes
  • effectively manages accountabilities, including roles and responsibilities, with respect to road safety outcomes and the use of data.

This audit focused on the policies and strategies used by TfNSW for managing road safety outcomes in regional areas. We did not evaluate individual road safety projects, programs and initiatives as part of this audit.

Whilst Regional Roads and Local Roads (as defined by the Road Network Classifications) are owned and maintained by local councils, we included these roads in this audit as TfNSW may advise and assist councils to promote and improve road safety, as well as manage grant programs that focus on improving road safety outcomes on these roads. Hereafter, unless otherwise stated, references to ‘regional roads’ refer to all classifications of roads in the state which are in regional New South Wales, irrespective of their ownership.

Local councils in regional areas are key stakeholders for the purposes of this audit, and we interviewed eight as part of the audit process (noting that this was not intended to be a representative sample). Road asset management by local councils is also out of scope for this audit as it is the focus of a subsequent performance audit by the Audit Office of New South Wales.b

The Audit Office of New South Wales has undertaken several performance audits relating to road safety since 2009 and these have been referenced while undertaking this audit. They include:

  • Condition of State Roads (August 2006)
  • Improving Road Safety: Heavy Vehicles (May 2009)
  • Improving Road Safety: School Zones (March 2010)
  • Improving Road Safety: Speed Cameras (July 2011)
  • Regional Assistance Programs (May 2018)
  • Mobile speed cameras (October 2018)
  • Rail freight and Greater Sydney (October 2021).

Conclusion

TfNSW has acknowledged that there is a disproportionate amount of road trauma on regional roads in the NSW Road Safety Strategy 2012–2021, the NSW Road Safety Plan 2021, and the NSW Road Safety Action Plan 2022–2026. However, TfNSW has not articulated or evaluated a strategy for implementing road safety policy in regional New South Wales to assist in guiding targeted activities to address regional road trauma. There is also no transparency about the total amount of funding invested in improving road safety outcomes for regional New South Wales.

People living in regional New South Wales make up one-third of the state’s population, but deaths on regional roads make up around two-thirds of the state’s total road toll. This statistic is almost the same in 2023 as it was ten years ago when TfNSW released its first long-term road safety strategy.

More than 70% of people who died on roads between 2012 and 2022 in regional New South Wales were residents of regional areas. Speed is the greatest contributing factor to road fatalities and serious injuries across the entire state. However, it is responsible for more fatalities on regional roads (43%) than in Greater Sydney (34%).

TfNSW’s road safety strategies and plans acknowledge that most road fatalities occur in regional New South Wales but none of its existing strategies or plans show evidence of tailoring measures to suit particular regional settings or ‘hot spots’. There are infrastructure initiatives (such as Saving Lives on Country Roads) and behavioural programs targeting regional areas (such as Driver Reviver). However, these activities are not aligned to a regional-specific strategy or plan that addresses issues specific to regional areas.

TfNSW has state-wide responsibility for managing road safety outcomes. TfNSW advised the audit that a regional plan and regional trauma reduction targets are not needed as the state-wide plan and targets apply equally for all areas of New South Wales, and local road safety factors are best managed by local councils. TfNSW partners with local councils. However, only 52% of councils in regional New South Wales participate in TfNSW’s Local Government Road Safety Program, compared to 84% of councils in metropolitan areas. TfNSW has not undertaken any evaluations to determine whether projects completed under the Local Government Road Safety Program have reduced road trauma at the local level.

Notwithstanding the above points, TfNSW works with local councils (who are road authorities for local roads in their respective areas under the Roads Act 1993) and other key stakeholders such as the NSW Police Force to achieve the NSW Government’s road safety policy objectives.

TfNSW advised that ‘the setting of state-wide road safety targets is consistent with other jurisdictions and international best practice. Importantly, delivery of road safety countermeasures is tailored and applied with a focus on road user groups across all geographic locations to maximise trauma reductions’. There may be legitimate reasons for the existing approach, as articulated by TfNSW. However, the proportion of road fatalities in regional New South Wales roads has not reduced since 2012 – despite a long-term reduction in the overall number of deaths on the state’s roads between 2012–2021. The audit report has recommended that a regionally focused implementation plan could address this issue. TfNSW has accepted this report’s recommendation that such a plan be developed.

Specific road safety initiatives targeted to regional areas have not been implemented or expanded

Text removed pursuant to section 36A of the Government Sector Audit Act 1983 (NSW), in compliance with the issuance of a Premier’s certificate preventing the publication of this information.

TfNSW increased the use of other forms of automated enforcement (such as tripling enforcement hours in mobile speed cameras).
However, the use of automated enforcement has a strong metropolitan focus with most red light and fixed speed cameras being in metropolitan areas. Average speed cameras are the only camera type overwhelmingly located in regional areas but these apply only to heavy vehicles and are positioned on major freight routes. 

There is no consolidated, public reporting of what proportion of total road safety funding is directed to regional New South Wales each year. The main source of funding for road safety in New South Wales, the Community Road Safety Fund, has been underspent since 2019.

Fines from camera-detected speeding, red-light and mobile phone use offences are required to be used solely for road safety purposes through the Community Road Safety Fund (CRSF), as set out in the Transport Administration Amendment (Community Road Safety Fund) Act 2012.

The CRSF has been underspent every year since 2019–20. The underspend has increased from 12% in 2019–20 to 20% in 2022–23 where the full year underspend was forecasted to be $104 million. Of this underspend, $13.5 million was dedicated for regional road infrastructure projects. TfNSW advised the audit that much of the underspend is the result of delays to infrastructure projects due to COVID-19, bushfires, and floods, as well as skills shortages. However, TfNSW has not provided any evidence that it had a plan to mitigate these risks – meaning the level of underspend could continue to grow. TfNSW also advised ‘there is no reason to expect budget management and controls will not return to pre-COVID circumstances’.

In total, TfNSW received $700 million in funding for road safety in 2021–22 (including federal contributions and the Community Road Safety Fund). Of this, $411 million (or ~59%) was directed to regional New South Wales. This is the most recent comprehensive financial data that was provided by TfNSW to the audit team. The 2022–23 NSW Budget allocated $880 million for road safety in 2022–23, with a forecasted total allocation for road safety of $1.6 billion in recurrent expenses and $0.8 billion in capital expenditure over the period 2022–23 to 2025–26.

Appendix one – Response from Transport for NSW

Appendix two – The Safe Systems framework and NSW road safety strategies and plans

Appendix three – About the audit

Appendix four – Performance auditing

 

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

 

Parliamentary reference - Report number #386 - released 30 November 2023

Published

Actions for Management of the Critical Communications Enhancement Program

Management of the Critical Communications Enhancement Program

Finance
Health
Justice
Whole of Government
Cyber security
Information technology
Infrastructure
Internal controls and governance
Project management
Risk
Service delivery
Shared services and collaboration

What the report is about

Effective radio communications are crucial to NSW's emergency services organisations.

The Critical Communications Enhancement Program (CCEP) aims to deliver an enhanced public safety radio network to serve the five emergency services organisations (ESOs), as well as a range of other users.

This report assesses whether the NSW Telco Authority is effectively managing the CCEP.

What we found

Where it has already been delivered (about 50% of the state), the enhanced network meets most of the requirements of ESOs.

The CCEP will provide additional infrastructure for public safety radio coverage in existing buildings agreed to with ESOs. However, radio coverage inside buildings constructed after the CCEP concludes will be at risk because building and fire regulations do not address the need for in-building public safety radio coverage.

Around 98% of radios connected to the network can be authenticated to protect against cloning, though only 42% are.

The NSW Telco Authority has not settled with ESOs on how call encryption will be used across the network. This creates the risk that radio interoperability between ESOs will not be maximised.

When completed, the public safety radio network will be the only mission critical radio network for ESOs. It is unclear whether governance for the ongoing running of the network will allow ESOs to participate in future network operational decisions.

The current estimated capital cost for the NSW Telco Authority to complete the CCEP is $1.293 billion. This is up from an estimated cost of $400 million in 2016. The estimated capital cost was not publicly disclosed until $1.325 billion was shown in the 2021–22 NSW Budget Papers.

We estimate that the full cost to government, including costs to the ESOs, of implementing the enhanced network is likely to exceed $2 billion.

We made recommendations about

  • The governance of the enhanced Public Safety Network (PSN) to support agency relationships.
  • The need to finalise a Traffic Mitigation Plan for when the network is congested.
  • The need to provide advice to the NSW Government about the regulatory gap for ensuring adequate network reach in future buildings.
  • The need to clarify how encryption and interoperability will work on the enhanced network.
  • The need for the NSW Telco Authority to comply with its policy on Infrastructure Capacity Reservation.
  • Expediting measures to protect against the risk of cloning by unauthenticated radios.

Public safety radio networks are critical for operational communications among Emergency Services Organisations (ESOs), which in New South Wales include:

  • NSW Ambulance
  • Fire and Rescue NSW
  • NSW Police Force
  • NSW Rural Fire Service
  • NSW State Emergency Service.1

Since 1993, these five ESOs have had access to a NSW Government owned and operated radio communications network, the Public Safety Network (PSN), to support their operational communications. Around 60 to 70 other entities also have access to this network, including other NSW government entities, Commonwealth government entities, local councils, community organisations, and utility companies.

Pursuant to the Government Telecommunications Act 2018 ('the Act'), the New South Wales Government Telecommunications Authority ('NSW Telco Authority') is responsible for the establishment, control, management, maintenance and operation of the PSN.2

Separate to the PSN, all ESOs and other government entities have historically maintained their own radio communication capabilities and networks. Accordingly, the PSN has been a supplementary source of operational radio communications for these entities.

These other radio networks maintained by ESOs and other entities are of varying size and capability, with many ageing and nearing their end-of-life. There was generally little or no interoperability between networks, infrastructure was often co-located and duplicative, and there were large gaps in geographic coverage.

In 2016, the NSW Telco Authority received dedicated NSW Government funding to commence the Critical Communications Enhancement Program (CCEP).

According to NSW Telco Authority's 2021–22 annual report, the CCEP is a transformation program for operational communications for NSW government agencies. The CCEP '…aims to deliver greater access to public safety standard radio communications for the State’s first responders and essential service agencies'. The objective of CCEP is to consolidate the large number of separate radio networks that are owned and operated by various NSW government entities and to enhance the state’s existing shared PSN. The program also aims to deliver increased PSN coverage throughout New South Wales.

The former NSW Government intended that as the enhanced PSN was progressively rolled-out across NSW, ESOs would migrate their radio communications to the enhanced network, before closing and decommissioning their own networks.

About this Audit

This audit assessed whether the CCEP is being effectively managed by the NSW Telco Authority to deliver an enhanced PSN that meets ESOs' requirements for operational communications.

We addressed the audit objective by answering the following two questions:

  1. Have agreed ESO user requirements for the enhanced PSN been met under day-to-day and emergency operational conditions?
  2. Has there been adequate transparency to the NSW Government and other stakeholders regarding whole-of-government costs related to the CCEP?

In answering the first question, we also considered how the agreed user requirements were determined. This included whether they were supported by evidence, whether they were sufficient to meet the intent of the CCEP (including in considering any role for new or alternative technologies), and whether they met any relevant technical standards and compliance obligations (including for cyber security resilience).

While other NSW government agencies and entities use the PSN, we focused on the experience of the five primary ESOs because these will be the largest users of the enhanced PSN.

Both the cost and time required to complete the CCEP roll-out have increased since 2016. While it was originally intended to be completed in 2020, this is now forecast to be 2027. Infrastructure NSW has previously assessed the reasons for the increases in time and cost. A summary of the findings made by Infrastructure NSW is presented in Chapter 1 of this report. Accordingly, as these matters had already been assessed, we did not re-examine them in this performance audit.

The auditee for this performance audit is the NSW Telco Authority, which is a statutory authority within the Department of Customer Service portfolio.

In addition to being responsible for the operation of the PSN, section 5 of the Act also prescribes that the NSW Telco Authority is:

  • to identify, develop and deliver upgrades and enhancements to the government telecommunications network to improve operational communications for government sector agencies
  • to develop policies, standards and guidelines for operational communications using telecommunications networks.

The NSW Telco Authority Advisory Board is established under section 10 of the Act. The role of the board is to advise the NSW Telco Authority and the minister on any matter relating to the telecommunications requirements of government sector agencies and on any other matter relating to the functions of the Authority. As of 2 June 2023, the responsible minister is the Minister for Customer Service and Digital Government.

The five identified ESOs are critical stakeholders of the CCEP and therefore they were consulted during this audit. However, the ESOs were not auditees for this performance audit.

Conclusion

In areas of New South Wales where the enhanced Public Safety Network has been implemented under the Critical Communications Enhancement Program, the NSW Telco Authority has delivered a radio network that meets most of the agreed requirements of Emergency Services Organisations for routine and emergency operations.
In April 2023, the enhanced Public Safety Network (PSN) was approximately 50% completed. In areas where it is used by Emergency Services Organisations (ESOs), the PSN generally meets agreed user requirements. This is demonstrated through extensive performance monitoring and reporting, which shows that agreed performance standards are generally achieved. Reviews by the NSW Government and the NSW Telco Authority found that the PSN performed effectively during major flood events in 2021 and 2022.

Where it is completed, PSN coverage is generally equal to or better than each ESO's individual pre-existing coverage. The NSW Telco Authority has a dedicated work program to address localised coverage gaps (or 'blackspots') in those areas where coverage has otherwise been substantively delivered. Available call capacity on the network far exceeds demand in everyday use. Any operational issues that may occur with the PSN are transparent to ESOs in real time.

The NSW Telco Authority consulted extensively with ESOs on requirements for the enhanced PSN, with relatively few ESO requirements not being included in the specifications for the enhanced PSN. Lessons from previous events, including the 2019–20 summer bushfires, have informed the design and implementation of the enhanced PSN (such as the need to ensure adequate backup power supply to inaccessible sites). The network is based on the Project 25 technical standards for mission-critical radio communications, which is widely-accepted in the public safety radio community throughout Australia and internationally.

There is no mechanism to ensure adequate radio coverage within new building infrastructure after the CCEP concludes, but the NSW Telco Authority and ESOs have agreed an approach to prioritise existing in-building sites for coverage for the duration of the CCEP.
The extent to which the PSN works within buildings and other built structures (such as railway tunnels) is of crucial importance to ESOs, especially the NSW Police Force, NSW Ambulance, and Fire and Rescue NSW. This is because a large proportion of their operational communications occurs within buildings.

There is no mechanism to ensure the adequacy of future in-building coverage for the PSN in new or refurbished buildings after the CCEP concludes. Planning, building, and fire regulations are silent on this issue. We note there are examples in the United States of how in-building coverage for public safety radio networks can be incorporated into building or fire safety codes.

In regard to existing buildings, it is not possible to know whether a building requires its own in-building PSN infrastructure until nearby outside radio sites, including towers and antennae, have been commissioned into the network. Only then can it be determined whether their radio transmissions are capable of penetrating inside nearby buildings. Accordingly, much of this work for in-building coverage cannot be done until outside radio sites are finished and operating.

In March 2023, the NSW Telco Authority and ESOs agreed on a list of 906 mandatory and 7,086

non-mandatory sites for in-building PSN coverage. Most of these sites will likely be able to receive radio coverage via external antennae and towers, however this cannot be confirmed until those nearby external PSN sites are completed. The parties also agreed on an approach to prioritising those sites where coverage is needed but not provided by antennae and towers. Available funding will likely only extend to ensuring coverage in sites deemed mandatory, which is nonetheless expected to meet the overall benchmark of achieving 'same or better' coverage than what ESOs had previously.

There is a risk that radio interoperability between ESOs will not be maximised because the NSW Telco Authority has not settled with ESOs how encryption will be used across the enhanced PSN.
End-to-end encryption of radio transmissions is a security feature that prevents radio transmissions being intercepted or listened to by people who are not meant to. The ability of the PSN to provide end-to-end encryption of operational communications is of critical importance to the two largest prospective users of the PSN: the NSW Police Force and NSW Ambulance. Given that encryption excludes other parties that do not have the requisite encryption keys, its use creates an obstacle to achieving a key intended benefit of the CCEP, that is a more interoperable PSN, where first responders are better able to communicate with other ESOs.

Further planning and collaboration between PSN participants are necessary to consider how these dual benefits can be achieved, including in what operational circumstances encrypted interoperability is necessary or appropriate.

The capital cost to the NSW Telco Authority of the CCEP, originally estimated at $400 million in 2016, was not made public until the 2021–22 NSW Budget disclosed an estimate of $1.325 billon.
The estimated capital cost to complete all stages of the CCEP increased over time. This increasing cost was progressively disclosed to the NSW Government through Cabinet processes between 2015–16 and 2021–22.

In 2016, the full capital cost to the NSW Telco Authority of completing the CCEP was estimated to be $400 million. This estimated cost was not publicly disclosed, nor were subsequent increases, until the cost of $1.325 billion was publicly disclosed in the 2021–22 NSW Budget (revised down in the 2022–23 NSW Budget to $1.293 billion).

There has been no transparency about the whole-of-government cost of implementing the enhanced PSN through the CCEP.
In addition to the capital costs incurred directly by the NSW Telco Authority for the CCEP, ESOs have incurred costs to maintain their own networks due to the delay in implementing the CCEP. The ESOs will continue to incur these costs until they are able to fully migrate to the enhanced PSN, which is expected to be in 2027. These costs have not been tracked or reported as part of transparently accounting for the whole-of-government cost of the enhanced PSN. This is despite Infrastructure NSW in 2019 recommending to the NSW Telco Authority that it conduct a stocktake of such costs so that a whole-of-government cost impact is available to the NSW Government.

1 The definition of 'emergency services organisation' is set out in the State Emergency and Rescue Management Act 1989 (NSW). In addition to the five ESOs discussed in this report, the definition also includes: Surf Life Saving New South Wales; New South Wales Volunteer Rescue Association Inc; Volunteer Marine Rescue NSW; an agency that manages or controls an accredited rescue unit; and a non-government agency that is prescribed by the regulations for the purposes of this definition.
2 Section 15(1) of the Government Telecommunications Act 2018 (NSW).

The NSW Telco Authority established and tracked its own costs for the CCEP

Over the course of the program from 2016, the NSW Telco Authority prepared a series of business cases and program reviews that estimated its cost of implementing the program in full, including those shown in Exhibit 6 below.

Exhibit 6: Estimated costs to fully implement the CCEP
Source Capital cost ($ million) Operating cost
($ million)
Completion date
March 2016 business case 400 37.3 2020
November 2017 internal review 476.7 41.7 2022
March 2020 business case 950–1,050 -- 2025
October 2020 business case 1,263.1 56.1 2026

Source: CCEP business cases as identified.

In response to the 2016 CCEP business case, the then NSW Government approved the NSW Telco Authority implementing the CCEP in full, with funding provided in stages. The NSW Telco Authority tracked its costs against approved funding, with monthly reports provided to the multi-agency Program Steering Committee

Throughout the program, the NSW Government was informed of increasing costs being incurred by the NSW Telco Authority for the CCEP

The various business cases, program updates, and program reviews prepared by the NSW Telco Authority were provided to the NSW Government through the required Cabinet process when seeking approval for the program proceeding and requests for both capital and operational funding. These provided clear indication of the changing overall cost of the CCEP to the NSW Telco Authority, as well as the delays that were being experienced.

There was no transparency to the Parliament and community about changes in the capital cost of the CCEP until the 2021–22 NSW Budget

As the business cases for the CCEP were not publicly available, the only sources of information about capital cost were NSW Budget papers and media releases. The information provided in the annual Budget papers prior to the 2021–22 NSW Budget provided no visibility of the estimated full capital cost to complete all stages of the CCEP. As shown in Exhibit 7 below, this information was fragmented and complex.

Media releases about the progress of the CCEP did not provide the estimated total cost to the NSW Telco Authority of $1.325 billion to complete all stages of the CCEP until June 2021. Prior to this date, media releases only provided funding for the initial stages of the program or for the stages subject to a funding announcement.

Even during the September 2019 and March 2020 Parliamentary Estimate Committee hearings where the costings and delays to the CCEP were raised, the estimated full cost of the CCEP was not revealed.

Exhibit 7: CCEP funding in NSW Budget papers from 2015–16 to 2022–23
Financial year Type of major work Description of expenditure Forecast estimate to complete ($ million) Estimated duration
2015–16 New work Infrastructure Rationalisation Program: Planning and Pilot 18.3 2015–16
2016–17 Work in progress CCEP Planning and Pilot 18.3 2015–17
New work CCEP 45 2016–17
2017–18 New work CCEP 190.75 2017–21
2018–19 Work in progress CCEP North Coast and State-wide Detailed Design 190.75 2017–21
New work CCEP Greater Metropolitan Area 236 2018–22
2019–20 Work in progress CCEP 426.9 2018–22
2020–21 Work in progress CCEP 664.8 2018–22
2021–22 Work in progress CCEP 1,325 2018–26
2022–23 Work in progress CCEP 1,292.8 2018–26

Source: NSW Treasury, Annual State Budget Papers.

The original business case for the CCEP included estimated ESO costs, though these costs were not tracked throughout the program

Estimates for ESO costs for operating and maintaining their own radio networks over the four years from 2016–17 were included in the original March 2016 business case. They included $75.2 million for capital expenditure and $95 million for one-off operating costs. These costs, as well as costs incurred by ESOs due to the delay in the program, were not subsequently tracked by the NSW Telco Authority.

In January 2017, Infrastructure NSW reviewed the CCEP business case of March 2016. In this review, Infrastructure NSW recommended that the NSW Telco Authority identify combined and apportioned costs and cashflow for all ESOs over the CCEP funding period reflecting all associated costs to deliver the CCEP. These to include additional incidental capital costs accruing to ESOs, transition and migration to the new network and the cost (capital and operational) of maintaining existing networks. This recommendation was implemented in the November 2017 program review, with ESO capital costs estimated as $183 million.

In 2019, Infrastructure NSW conducted a Deep Dive Review on the progress of the CCEP. In this review, Infrastructure NSW made what it described as a 'critical recommendation' that the NSW Telco Authority:

…coordinate a stocktake of the costs of operational bridging solutions implemented by PSAs [ESOs] as a result of the 18-month delay, so that a whole-of-government cost impact is available to the NSW Government.  

It should be noted that the delay to CCEP completion now is seven years and that further ‘operational bridging solutions’ have been needed by the ESOs.

'Stay Safe and Keep Operational' costs incurred by ESOs will be significantly higher than originally estimated

Stay Safe and Keep Operational (SSKO) funding was established to provide funding to ESOs to maintain their legacy networks while the CCEP was refreshing and enhancing the PSN. This recognised that much of the network infrastructure relied on by ESOs had reached – or was reaching – obsolescence and would either require extensive maintenance or replacement before the PSN was available for ESOs to migrate to it. ESOs may apply to NSW Treasury for SSKO funding, with their specific proposals being reviewed (and endorsed, where appropriate) by the NSW Telco Authority. Accordingly, SSKO expenditure does not fall within the CCEP budget allocation.

As shown in the table below, extracted from the March 2016 CCEP business case, the total expected cost for SSKO purposes over the course of the CCEP was originally $40 million, assuming the enhanced PSN would be fully available by 2020.

Exhibit 8: Stay Safe and Keep Operational forecast costs, 2017 to 2020
Year 2017 2018 2019 2020 Total
SSKO forecast ($ million) 12.5 15 10 2.5 40

Source: March 2016 CCEP business case.

In October 2022, the expected completion date for the CCEP was re-baselined to August 2027. Accordingly, ESOs will be required to continue to maintain their radio networks using legacy equipment for seven years longer than the original 2020 forecast. This will likely become progressively more expensive and require additional SSKO funding. For example, NSW Telco Authority endorsed SSKO bids for 2022–23 exceeded $35 million for that year alone.

Compared to the original forecast made in the March 2016 CCEP business case of $40 million, we found ESOs had estimated SSKO spending to 2027 will be $292.5 million.

A refresh of paging network used by ESOs and the decommissioning of redundant sites were both removed from the original 2016 scope of the CCEP

Paging

A paging network is considered an important user requirement by the Fire and Rescue NSW, NSW Rural Fire Service, and NSW State Emergency Service. The 2016 CCEP business case included a paging network refresh within the program scope of works. This was reiterated in the November 2017 internal review of the program. These documents did not estimate a cost for this refresh. The March 2020 and October 2020 business cases excluded paging from the program scope. The audit is unable to identify when, why or by whom the decision was made to remove paging from the program scope, something that was also not well communicated to the affected ESOs.

In 2021, after representations from the affected ESOs, the NSW Telco Authority prepared a separate business case for a refresh of the paging network at an estimated capital cost of $60.31 million. This program was subsequently approved by the NSW Government and included in the 2022–23 NSW Budget.

In determining an estimated full whole-of-government cost of delivering the enhanced PSN, we have included the budgeted cost of the paging network refresh on the basis that:

  • it was expressly included in the original approved March 2016 business case
  • the capability is deemed essential to the needs of three ESOs.

Decommissioning costs

The 2016 CCEP business case included cost estimates for decommissioning surplus sites (whether ‘old’ GRN sites or sites belonging to ESOs’ own networks). These estimates were provided for both the NSW Telco Authority ($38 million) and for the ESOs ($55 million). However, while these estimates were described, they were not included as part of the NSW Telco Authority's estimated capital cost ($400 million) or (more relevantly) operating cost ($37.3 million) for the CCEP. This is despite decommissioning being included as one of eight planned activities for the rollout of the program.

In the October 2020 business case, an estimate of $201 million was included for decommissioning agency networks based on a model whereby:

  • funding would be coordinated by the NSW Telco Authority
  • scheduling and reporting through an inter-agency working group and
  • where appropriate, agencies would be appointed as the most appropriate decommissioning party.

This estimated cost is not included in the CCEP budget.

In determining an estimated full whole-of-government cost of the enhanced PSN, we have included the estimated cost of decommissioning on the basis that:

  • decommissioning was included in the 2016 CCEP business case as one of eight 'planned activities for the rollout of the program'
  • effective decommissioning of surplus sites and equipment (including as described in the business case as incorporating asset decommissioning, asset re-use, and site make-good) is an inherent part of the program management for an enhanced PSN
  • costs incurred in decommissioning are entirely a consequence of the CCEP program.

The estimated minimum cost of building an enhanced PSN consistent with the original proposal is over $2 billion

We have derived two estimated minimum whole-of-government costs for delivering an enhanced PSN. These are:

  • $2.04 billion when calculated from NSW Telco Authority data – shown as estimate A in Exhibit 9 below.
  • $2.26 billion when calculated from ESO supplied data – shown as estimate B in Exhibit 9.

Both totals include:

  • budgeted amounts for both CCEP capital expenditure ($1,292.8 million) and operating expenditure ($139 million)
  • the NSW Telco Authority's 2020 estimated cost for decommissioning ($201 million)
  • the NSW Telco Authority's approved funding for paging refresh ($60.3 million).

The two estimated totals primarily vary around the capital expenditure of ESOs (particularly SSKO funding). To determine these costs, we used ESO provided actual SSKO costs to date, as well as their estimates for maintaining their legacy radio networks through to 2027.

The equivalent cost estimates from the NSW Telco Authority were sourced from the November 2017 internal review and the October 2020 business case for CCEP. It should be noted that the amounts for both estimates are not audited, or verified, but do provide an indication of how whole-of-government costs have grown over the course of the program.

The increase in and reasons for the increase in total CCEP costs (capital and one-off operating) incurred or forecast by the NSW Telco Authority (from $437.3 million in 2016 to $1,431.8 million in 2022) have been provided to the NSW Government through various business cases and reviews prepared by the NSW Telco Authority, as well as by reviews conducted by Infrastructure NSW as part of its project assurance responsibilities.

However, the growth in ESO costs and other consequential costs, such as paging and decommissioning, from around $263 million in the 2016 CCEP business case to between $600 million and $800 million, has to a large degree remained invisible and unexplained to the NSW Government and other stakeholders

Exhibit 9: Estimated whole-of-government costs of the enhanced PSN
  Estimated whole-of-government cost, over time
Cost type 20161 20172 20203 2023–Estimate A4 2023–Estimate B5
$ million $ million $ million $ million $ million
CCEP capital expenditure 400a 476.7b 1,263.1c 1,292.8d 1,292.8d
CCEP operating expenditure 37.3a 41.7b 41.5e 139d 139d
CCEP total 437.3 518.4 1,304.6 1,431.8 1,431.8
ESO capital expenditure 75.2a,f 183b,e 75.4e 258.4g 292.5
ESO one-off operating expenditure 93a n.a.l 86.5e 86.5h 273
ESO total 168.2 183 161.9 344.9 565.5
Paging n.a.i n.a.i n.a.j 60.3k 60.3k
Decommissioning 93 n.a.l 201.0 201h 201
Paging and decommissioning total 93 n.a. 201 261.3 261.3
Whole-of-government total 698.5 701.4 1,667.5 2,038 2,258.6

Notes:
  1. Financial year 2016 to Financial year 2020.
  2. Financial year 2016 to Financial year 2021.
  3. Financial year 2016 to Financial year 2025.
  4. Financial year 2016 to Financial year 2026.
  5. Financial year 2022 to Financial year 2025.
  6. Stay Safe and Keep Operational (SSKO) costs plus terminals costs.
  7. November 2017 internal review and October 2020 Business case.
  8. October 2020 Business case.
  9. Included in CCEP capital expenditure at that time.
  10. By 2020, a refresh of the paging network had been removed from the CCEP scope.
  11. A separate business case for a refresh of the paging network was approved by government in 2022.
  12. Figure not included in the source document.
Sources:
  1. March 2016 CCEP business case.
  2. November 2017 Internal Review conducted by the NSW Telco Authority.
  3. October 2020 CCEP business case.
  4. Derived from business cases, with ESO costs drawn from NSW Telco Authority data.
  5. Derived from business cases, with ESO costs based on data provided to the Audit Office of New South Wales by each of the five ESOs.

Appendix one – Response from agency

Appendix two – Trunked public safety radio networks

Appendix three – About the audit

Appendix four – Performance auditing

 

 

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

 

Parliamentary reference - Report number #383 - released 23 June 2023

 

Published

Actions for New South Wales COVID-19 vaccine rollout

New South Wales COVID-19 vaccine rollout

Health
Internal controls and governance
Management and administration
Project management
Risk
Service delivery

What the report is about

The Australian Government led and implemented the Australian COVID-19 vaccine rollout, with the support of state and territory governments. As part of the Australian Government's vaccine rollout, NSW Health launched its vaccination program on 22 February 2021, with responsibility for distributing and administering COVID-19 vaccine stock provided by the Australian Government.

This audit examined the period 1 January 2021 to 31 December 2021 and focused on NSW Health's contribution to the Australian Government led vaccine roll out in four Local Health Districts (LHDs), in particular the administration of two doses of vaccine to people aged 16 and over.

What we found

On 16 October 2021, NSW Health, in partnership with the Australian Government's vaccination program, achieved its first objective to fully vaccinate 80% of people in NSW aged 16 and over. Demand for the vaccine reduced in December 2021, and NSW Health did not reach its target of 95% fully vaccinated for people aged 16 and over until June 2022.

Despite challenges such as uncertain supply and changes to clinical advice affecting vaccine eligibility, NSW Health's overall delivery of vaccination services was effective and efficient.

During the audit period, NSW Health implemented effective strategies to allocate vaccines and reduce wastage to optimise the number of vaccines available.

NSW Health implemented its own booking system after it identified that the Australian Government's system would not manage bookings. There were problems with NSW Health's interim vaccine booking system, and NSW Health fully resolved these issues by September 2021.

As at 19 October 2022, vaccination rates for Aboriginal peoples and culturally and linguistically diverse people remained below the 95% target.

What we recommended

By June 2023, NSW Health should conduct a comprehensive review of the COVID-19 vaccine rollout and incorporate lessons learned into pandemic response plans.

The first three cases of COVID-19 in New South Wales were diagnosed in January 2020. By 30 June 2021, 128 people were being treated in hospital and one person was in intensive care. By the end of December 2021, 187,504 total cases and 663 deaths were reported in New South Wales. As at 27 October 2022, NSW Health reported more than three million total cases and 5,430 deaths.

The COVID-19 pandemic continues to have a significant impact on the people and the health sector of New South Wales. The Australian, state, territory, and local governments have directed significant resources towards health responses and economic recovery.

On 13 November 2020, National Cabinet (comprised of the Australian, state, and territory governments) endorsed the Australian COVID-19 Vaccination Policy. Australia's vaccination program was launched on 21 February 2021 with the goal of providing safe and effective vaccines to the people who most needed them as quickly as possible, to support the physical, mental and economic wellbeing of the nation.

The Australian Government led and implemented the Australian vaccine rollout, with the support of state and territory governments. As part of the Australian Government's vaccine rollout, NSW Health launched its vaccination program on 22 February 2021, with responsibility for distributing and administering COVID-19 vaccine stock provided by the Australian Government.

The overall objective of this audit was to assess the effectiveness and efficiency of NSW Health’s contribution to the Australian COVID-19 vaccine rollout. It is important to note that in New South Wales, primary care providers (GPs and pharmacies) and aged care providers administered the majority of vaccines. Primary care providers and aged care providers are the responsibility of the Australian Government.

The audit had a particular focus on whether NSW Health:

  • set clear vaccination targets underpinned and/or guided by evidence
  • managed the rollout of the vaccination program effectively and efficiently
  • managed demand of vaccines effectively and efficiently.

The audit examined the period 1 January 2021 to 31 December 2021 and focused on NSW Health's contribution to the Australian Government led vaccine rollout in four Local Health Districts (LHDs), in particular the administration of two doses of vaccine to people aged 16 and over. We did not audit the subsequent rollout for ages five to 15, or the booster rollout (third and fourth doses) as these activities mostly occurred outside the date of our review.

This audit also did not assess the Australian Government’s allocation of vaccine supplies to New South Wales because we do not audit the Australian Government's activities. On 17 August 2022, the Australian National Audit Office completed a performance audit which assessed the Australian Department of Health and Aged Care's effectiveness in the planning and implementation of Australia's COVID-19 vaccine rollout.

This audit is one of a series of audits that have been completed or are in progress regarding the New South Wales COVID-19 emergency response. This includes the planned performance audit ‘Coordination of the response to COVID-19 (June to November 2021)’, and financial audit assurance activities focusing on Local Health District processes and controls to manage the receipt, distribution and inventory management of vaccine stock. The Audit Office New South Wales '2022–25 Annual Work Program' details the ongoing focus our audits will have on providing assurance on the effectiveness of emergency responses.

Conclusion

By 12 December 2021, NSW Health had administered two doses of vaccines to one third of eligible people in New South Wales aged 16 and over – contributing significantly to the achievement of the NSW Government vaccination target of 80% fully vaccinated before 31 December 2021. Despite challenges such as uncertain supply and changes to clinical advice affecting vaccine eligibility, NSW Health's overall delivery of vaccination services was effective and efficient.

NSW Health implemented its own booking system after it identified that the Australian Government's system would not manage bookings. There were problems with NSW Health's interim vaccine booking system, and NSW Health fully resolved these issues by September 2021.

Vaccination levels in some vulnerable populations remain below the 95% double dose target currently in place. Access to quality data to regularly measure vaccination rates in some vulnerable populations remains an ongoing challenge for the NSW and Australian Governments. As a result, NSW Health is unable to fully ensure it has delivered on its shared responsibility with the Australian Government to vaccinate vulnerable people.

NSW Health managed challenges regarding the uncertain supply of vaccines from the Australian Government and filled gaps beyond its agreed responsibilities in the National Partnership on COVID-19 Response. During the Delta outbreak of the pandemic, NSW Health sought to achieve the best possible public health outcome from limited vaccine supply by opening up additional vaccination clinics in highly affected areas and redistributing vaccine supplies from areas with fewer cases to highly affected local government areas in south west Sydney.

During the audit period, NSW Health implemented effective strategies to allocate vaccines and reduce wastage to optimise the number of vaccines available. Our financial audit report, 'Health 2022', includes additional information on vaccine supply stock held by NSW Health.

NSW Health demonstrated agility by using a range of strategies to promote vaccination, including direct engagement with communities to develop culturally appropriate services such as pop-up clinics. NSW Heath recruited prominent community members, such as faith leaders, elders and sportspeople, to promote vaccination within their communities. However, at the date of this report, there are still vulnerable populations with vaccination rates lower than the current 95% double dose vaccination target. There is also a lack of regularly updated data for some cohorts which prevents NSW Health from accurately monitoring vaccination rates in some populations it has identified as vulnerable.

In March 2021, NSW Health identified that the booking system provided by the Australian Government was an online directory of vaccine clinics and would not manage bookings. To overcome this, NSW Health amended an internal-use system to be publicly facing. This solution was not user-friendly for staff or those seeking to make an appointment. Between June to September 2021, NSW Health progressively resolved booking system related issues, by developing and rolling out a new purpose-built booking solution for NSW Health vaccination clinics.

Appendix one – Response from agency

Appendix two – Australian audits on the vaccine rollouts

Appendix three – Committee members 

Appendix four – About the audit 

Appendix five – Performance auditing 

 

Copyright notice

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

 

Parliamentary reference - Report number #369 - released 7 December 2022

Published

Actions for Audit Insights 2018-2022

Audit Insights 2018-2022

Community Services
Education
Environment
Finance
Health
Industry
Justice
Local Government
Premier and Cabinet
Planning
Transport
Treasury
Universities
Whole of Government
Asset valuation
Cross-agency collaboration
Compliance
Cyber security
Financial reporting
Fraud
Information technology
Infrastructure
Internal controls and governance
Management and administration
Procurement
Project management
Regulation
Risk
Service delivery
Shared services and collaboration
Workforce and capability

What the report is about

In this report, we have analysed the key findings and recommendations from our audit reports over the past four years.

This analysis includes financial audits, performance audits, and compliance audits of state and local government entities that were tabled in NSW Parliament between July 2018 and February 2022.

The report is framed by recognition that the past four years have seen significant challenges and emergency events.

The scale of government responses to these events has been wide-ranging, involving emergency response coordination, service delivery, governance and policy.

The report is a resource to support public sector agencies and local government to improve future programs and activities.

What we found

Our analysis of findings and recommendations is structured around six key themes:

  • Integrity and transparency
  • Performance and monitoring
  • Governance and oversight
  • Cyber security and data
  • System planning for disruption
  • Resource management.

The report draws from this analysis to present recommendations for elements of good practice that government agencies should consider in relation to these themes. It also includes relevant examples from recent audit reports.

In this report we particularly call out threats to the integrity of government systems, processes and governance arrangements.

The report highlights the need for balanced advice to government on options and risks, for transparent documentation and reporting of directions and decisions, and for early and open sharing of information with integrity bodies and audit.

A number of the matters highlighted in this report are similar to those described in our previous Insights Report, (Performance Audit Insights: key findings from 2014–2018) specifically in relation to cyber and information security, to performance measurement, reporting and evaluation, and system and workforce planning and capability.

Fast facts

  • 72 audits included in the Audit Insights 2018–2022 analysis
  • 4 years of audits tabled by the Auditor-General for New South Wales
  • 6 key themes for Audit Insights 2018–2022.

picture of Margaret Crawford Auditor-General for New South Wales in black dress with city skyline as backgroundI am pleased to present the Audit Insights 2018–2022 report. This report describes key findings, trends and lessons learned from the last four years of audit. It seeks to inform the New South Wales Parliament of key risks identified and to provide insights and suggestions to the agencies we audit to improve performance across the public sector.

The report is framed by a very clear recognition that governments have been responding to significant events, in number, character and scale, over recent years. Further, it acknowledges that public servants at both state and council levels generally bring their best selves to work and diligently strive to deliver great outcomes for citizens and communities. The role of audit in this context is to provide necessary assurance over government spending, programs and services, and make suggestions for continuous improvement.

A number of the matters highlighted in this report are similar to those described in our previous Insights Report, (Performance Audit Insights: key findings from 2014–2018) specifically in relation to cyber and information security, to performance measurement, reporting and evaluation, and system and workforce planning and capability.

However, in this report we particularly call out threats to the integrity of government systems, processes and governance arrangements. We highlight the need for balanced advice to government on options and risks, for transparent documentation and reporting of directions and decisions, and for early and open sharing of information with integrity bodies and audit. Arguably, these considerations are never more important than in an increasingly complex environment and in the face of significant emergency events and they will be key areas of focus in our future audit program.

While we have acknowledged the challenges of the last few years have required rapid responses to address the short-term impacts of emergency events, there is much to be learned to improve future programs. I trust that the insights developed in this report provide a helpful resource to public sector agencies and local government across New South Wales. I would be pleased to receive any feedback you may wish to offer.

Margaret Crawford
Auditor-General for New South Wales

Integrity and transparency Performance and monitoring Governance and oversight Cyber security and data System planning Resource management
Insufficient documentation of decisions reduces the ability to identify, or rule out, misconduct or corruption. Failure to apply lessons learned risks mistakes being repeated and undermines future decisions on the use of public funds. The control environment should be risk-based and keep pace with changes in the quantum and diversity of agency work. Building effective cyber resilience requires leadership and committed executive management, along with dedicated resourcing to build improvements in cyber security and culture. Priorities to meet forecast demand should incorporate regular assessment of need and any emerging risks or trends. Absence of an overarching strategy to guide decision-making results in project-by-project decisions lacking coordination. Governments must weigh up the cost of reliance on consultants at the expense of internal capability, and actively manage contracts and conflicts of interest.
Government entities should report to the public at both system and project level for transparency and accountability. Government activities benefit from a clear statement of objectives and associated performance measures to support systematic monitoring and reporting on outcomes and impact. Management of risk should include mechanisms to escalate risks, and action plans to mitigate risks with effective controls. In implementing strategies to mitigate cyber risk, agencies must set target cyber maturity levels, and document their acceptance of cyber risks consistent with their risk appetite. Service planning should establish future service offerings and service levels relative to current capacity, address risks to avoid or mitigate disruption of business and service delivery, and coordinate across other relevant plans and stakeholders. Negotiations on outsourced services and major transactions must maintain focus on integrity and seeking value for public funds.
Entities must provide balanced advice to decision-makers on the benefits and risks of investments. Benefits realisation should identify responsibility for benefits management, set baselines and targets for benefits, review during delivery, and evaluate costs and benefits post-delivery. Active review of policies and procedures in line with current business activities supports more effective risk management. Governments hold repositories of valuable data and data capabilities that should be leveraged and shared across government and non-government entities to improve strategic planning and forecasting. Formal structures and systems to facilitate coordination between agencies is critical to more efficient allocation of resources and to facilitate a timely response to unexpected events. Transformation programs can be improved by resourcing a program management office.
Clear guidelines and transparency of decisions are critical in distributing grant funding. Quality assurance should underpin key inputs that support performance monitoring and accounting judgements. Governance arrangements can enable input into key decisions from both government and non-government partners, and those with direct experience of complex issues.     Workforce planning should consider service continuity and ensure that specialist and targeted roles can be resourced and allocated to meet community need.
Governments must ensure timely and complete provision of information to support governance, integrity and audit processes.          
Read more Read more Read more Read more Read more Read more

 

This report brings together a summary of key findings arising from NSW Audit Office reports tabled in the New South Wales Parliament between July 2018 and February 2022. This includes analysis of financial audits, performance audits, and compliance audits tabled over this period.

  • Financial audits provide an independent opinion on the financial statements of NSW Government entities, universities and councils and identify whether they comply with accounting standards, relevant laws, regulations, and government directions.
  • Performance audits determine whether government entities carry out their activities effectively, are doing so economically and efficiently, and in accordance with relevant laws. The activities examined by a performance audit may include a selected program or service, all or part of an entity, or more than one government entity. Performance audits can consider issues which affect the whole state and/or the local government sectors.
  • Compliance audits and other assurance reviews are audits that assess whether specific legislation, directions, and regulations have been adhered to.

This report follows our earlier edition titled 'Performance Audit Insights: key findings from 2014–2018'. That report sought to highlight issues and themes emerging from performance audit findings, and to share lessons common across government. In this report, we have analysed the key findings and recommendations from our reports over the past four years. The full list of reports is included in Appendix 1. The analysis included findings and recommendations from 58 performance audits, as well as selected financial and compliance reports tabled between July 2018 and February 2022. The number of recommendations and key findings made across different areas of activity and the top issues are summarised at Exhibit 1.

The past four years have seen unprecedented challenges and several emergency events, and the scale of government responses to these events has been wide-ranging involving emergency response coordination, service delivery, governance and policy. While these emergencies are having a significant impact today, they are also likely to continue to have an impact into the future. There is much to learn from the response to those events that will help the government sector to prepare for and respond to future disruption. The following chapters bring together our recommendations for core elements of good practice across a number of areas of government activity, along with relevant examples from recent audit reports.

This 'Audit Insights 2018–2022' report does not make comparative analysis of trends in public sector performance since our 2018 Insights report, but instead highlights areas where government continues to face challenges, as well as new issues that our audits have identified since our 2018 report. We will continue to use the findings of our Insights analysis to shape our future audit priorities, in line with our purpose to help Parliament hold government accountable for its use of public resources in New South Wales.

Appendix one – Included reports, 2018–2022

Appendix two – About this report

 

Copyright notice

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

Published

Actions for Health capital works

Health capital works

Health
Compliance
Infrastructure
Procurement
Project management

This report examines whether NSW Health effectively planned and delivered major capital works to meet the demand for health services in New South Wales.

The report found that NSW Health has substantially expanded health infrastructure across New South Wales since 2015. However, the program was driven by Local Health District priorities without assessment of the State’s broader and future‑focussed health requirements.

The report found that unclear decision making roles and responsibilities between Health Infrastructure and the Ministry of Health limited the ability of NSW Health to effectively test and analyse investment options.

Project delays and budget overruns on some major projects indicate that Health Infrastructure's project governance, risk assessment and management systems could be improved.

The Auditor‑General recommends that NSW Health ensure its capital projects offer the greatest value to New South Wales by establishing effective policy guidance and enhancing project governance and management systems.

Read full report (PDF)

Since 2011–12, NSW Health has aimed to improve its facilities and build 'future focused' infrastructure. The NSW Government’s 2015–16 election commitments established a four-year $5.0 billion capital program for NSW Health to build and upgrade more than 60 hospitals and health services. The 2019–20 State Budget committed a further $10.1 billion over four years for another 29 projects. This is the largest investment to date on health capital works in New South Wales.

Recent reviews of infrastructure have recognised that population and demographic growth will require a change in the delivery and composition of health infrastructure, including considering greater use of non-traditional, non-capital health service options and assets.

To ensure that expenditure on capital works represents the best value for money, NSW Health's business cases need to be robust and supported by evidence that demonstrates they are worthy investments. The NSW Process of Facility Planning has been the main framework guiding the detailed planning and development of NSW Health's capital works proposals. This framework was developed by the then NSW Department of Health in 2010. Its aim is to ensure investment proposals are supported by rigorous planning processes that address health service needs and provide value for money.

Infrastructure projects of the complexity and scale being delivered by NSW Health carry inherent risks. For example, unplanned cost escalations can potentially impact on the State’s finances. Unforeseen delays can also reduce the intended benefits. The growth in the State’s health capital spend and project profile, means its exposure to such risks has increased over time.

The objective of this audit was to assess the effectiveness of planning and delivery of major capital works to meet demand for health services in New South Wales. To address this objective, the audit examined whether:

  • the Ministry of Health has effective procedures for planning and prioritising investments in major health capital works
  • Health Infrastructure develops robust business cases for initiated major capital works that reliably inform government decision making
  • Health Infrastructure has effective project governance and management systems that support delivering projects on-time, within budget and achievement of intended benefits.

The audit focused on the Ministry of Health and Health Infrastructure – being the lead agencies within NSW Health responsible for prioritising, planning and delivering major health capital works across the State. The audit examined 13 business cases for eight discrete projects over a ten-year period.

Conclusion

NSW Health has substantially expanded health infrastructure across New South Wales since 2015. However, its planning and prioritisation processes were not assessed against a long-term statewide health infrastructure plan and lacked rigorous assessment against non-capital options creating a risk that they do not maximise value for New South Wales.

The scale of NSW Health's capital investment is significant and has grown substantially in recent years. The NSW Government’s election commitments in 2015–16 and 2019–20 collectively set out a $15.0 billion capital program to build and upgrade 89 hospitals and health services. NSW Health developed this infrastructure program in the absence of a statewide health infrastructure strategy and investment framework to focus its planning and decisions on the types of capital investments required to meet the long-term needs of the NSW health system.

Consequently, locally focused priorities of the State’s 17 Local Health Districts have been the primary drivers of NSW Health’s capital investments since 2015–16. Local Health District investment proposals for hospitals were developed without consideration of alternative health options such as community health service models, technology-driven eHealth care, or private sector options. Without rigorous assessment against a range of potential health service options, there is a risk that selected projects do not maximise value for New South Wales.

In recognition of the need for a statewide approach to infrastructure planning, the Ministry of Health recently developed a 20-year Health Infrastructure Strategy and prioritisation framework in 2019. The strategy was approved by the NSW Government in April 2020.

NSW Health's ability to effectively test and analyse its capital investment options has been compromised by unclear decision-making roles and responsibilities between its Health Infrastructure and the Ministry of Health agencies.

While both Health Infrastructure and the Ministry of Health have responsibilities for the assessment of business cases for proposed infrastructure projects, confusion about the roles of each agency at key steps compromised the efficacy of the process. Health Infrastructure and the Ministry of Health have differing views about which agency is responsible for testing business case inputs and conducting comprehensive options appraisals.

As a result of this confusion, Health Infrastructure and the Ministry of Health did not rigorously test Local Health District capital investment proposals against defined statewide health infrastructure investment priorities. The NSW Process of Facility Planning does not clarify the responsibilities of all parties in validating and prioritising Local Health District's Clinical Service Plans and progressing them to business cases.

NSW Health's infrastructure priorities are not sufficiently supported by transparent documentation of selection methodology and the rationale for decisions. Consequently, there is a risk that recommended options, whilst having some economic and health service merit, do not represent the greatest value.

Substantial delays and budget overruns on some major projects indicate that Health Infrastructure's project governance, risk assessment and management systems could be improved.

Health Infrastructure did not fully comply with NSW Government guidelines for developing business cases and making economic appraisals for proposed capital investments. These weaknesses, along with delays and budget overruns on some projects, demonstrate a need for Health Infrastructure to strengthen its project governance, management and quality control systems.

 

Over the period of review, NSW Government policies for business case development and submission have emphasised that effective governance arrangements are critical to a proposal's successful implementation.

NSW Health's Process of Facility Planning similarly highlights the importance of effective governance and project management for achieving good outcomes. It prescribes a general governance structure managed by Health Infrastructure that can be tailored to the planning and delivery of health infrastructure projects greater than $10.0 million.

Project challenges indicate opportunities for strengthening governance and project management

The three major hospital redevelopments examined in metropolitan, regional and rural areas had a combined Estimated Total Cost of more than $1.2 billion and comprised eight discrete projects and 13 separate business cases.

Almost all these projects experienced delivery challenges which impacted achievement of their original objectives and intended benefits. This is expected in complex and large-scale health infrastructure programs. However, in some projects the impacts were significant and resulted in substantial delays, unforeseen costs, and diversion of resources from other priority areas.

Our review of the selected case studies highlighted opportunities for enhancing governance and project management. Specifically, it indicates a need for improving transparency in the management of contingencies, risk management and assessments particularly relating to adverse site conditions and the selection of contractors. There is also a need to strengthen forward planning for options to address unfunded priorities within business cases that risk complicating the delivery of future project stages resulting in unforeseen costs and potentially avoidable budget overruns.

Need for increased transparency and accountability in the management of contingency funds

In February 2017, the Ministry's Capital Strategy Group approved the use of surplus funds of $13.76 million from Stage 1 of the Hornsby Ku-ring-gai Hospital Redevelopment for new works deemed needed to support Stage 2. Following this decision, Health Infrastructure finalised and submitted a business case addendum for Stage 1 to the Ministry in March 2017, addressing the new works comprising a two-storey building for medical imaging and paediatric floors. The business case addendum also addressed options to fit out and procure major medical imaging equipment. The Ministry approved the Stage 1 business case in July 2017, noting the Ministry's Capital Strategy Group had already approved the use of remaining Stage 1 funds to deliver the new works.

Stage 1 was completed in 2015, almost two years before the Stage 1 business case addendum was prepared in February 2017.

The Ministry's decision to approve the new works using $13.76 million of surplus Stage 1 funds did not comply with the NSW Treasury Circular TC 12/20. This policy establishes the Treasurer's approval must be sought and received before a new capital project with an Estimated Total Cost of $5.0 million or more can be approved by NSW Health. The Ministry therefore exceeded its delegated authority in making this decision, as it was not evident it had sought and received the Treasurer's approval prior to doing so.

Consequently, the surplus Stage 1 funds should not have been used by the Ministry to deliver new works in the circumstances. Instead, they should have been released from the Stage 1 project in accordance with established NSW Health procedures, and the Stage 1 Estimated Total Cost revised down accordingly. This did not occur, and NSW Health ultimately directed $11.0 million in surplus Stage 1 funds to the new works.

These circumstances indicate a need to strengthen transparency and accountability within NSW Health for the approval of new projects, and how contingency funds are used in the management of major health capital works. They also demonstrate the impact of weaknesses with options appraisal as the initial Stage 1 business case did not consider alternative options for addressing the initially unfunded works later covered by the Stage 1 business case addendum and ultimately funded from the Stage 1 contingency provision.

Weaknesses in service delivery planning resulted in unaccounted-for costs

In addition to proposing the above-noted new works, the 2017 Stage 1 Business Case Addendum for the Hornsby-Ku-ring-gai development sought to retrospectively address the estimated funding gap of around $14.0 million for the internal fit out, supply of major medical imaging equipment, and cost to operate the medical imaging service at Hornsby Ku-ring-gai Hospital also not addressed in the originally Stage 1 business case.

The Stage 1 business case addendum considered various procurement options to purchase and run the medical imaging services ranging from State operation purchase options to private operation purchase options.

It recommended outsourcing the operation and provision of equipment to the private sector based on estimated savings to the public sector initially of around $650,000 per annum reducing over time to $270,000. The Ministry endorsed this option in June 2017, but it did not ultimately proceed.

A July 2018 report to the Executive Steering Committee on the project shows NSW Health later decided to deliver operation of the medical imaging unit 'traditionally' with an updated estimate of the cost at approximately $16.4 million. The report also shows the Ministry supported the costs now being met by the Northern Sydney Local Health District.

This means the funding gap previously identified in the Stage 1 business case addendum for fitting out the medical imaging building and supply of major medical equipment would need to be met fully by the State, representing a $16.4 million cost overrun for the project.

Examined reports to the Executive Steering Committee show this was largely funded by the Northern Sydney Local Health District via the disposal of land realising approximately $15.0 million in proceeds.

This initially unforeseen cost, along with the additional $11.0 million for the new works approved under the Stage 1 business case addendum, were ultimately merged with the Stage 2 project initially approved in 2017–18 with an Estimated Total Cost of $200 million.

The extent of budget variation on the Hornsby Kur-ring-gai development has not been transparent

The 2019–20 State Budget provided an additional $65.0 million for a further Stage 2A to deliver additional built capacity to support outpatient services, enhanced allied health services, re-housed community health services and the delivery of prioritised clinical services unfunded as part of Stage 2. The funds were approved based on an Investment Decision Template (IDT) that examined two options in addition to the base case representing scoping alternatives to the preferred master planned capital solution.

However, we found the IDT showed around 23 per cent of the $65.0 million sought (i.e. $15.0 million) was to be allocated to fund the deficit in Stage 2, which had arisen as a result of project delays due to adverse site conditions. This was not discussed in the IDT.

The February 2020 report to the Executive Steering Committee shows a combined Stage 2 and 2A final forecast cost of $292.6 million against a potential budget of $290.7 million representing an overall deficit for the project of around 0.6 per cent.

However, this favourable final budget position does not transparently show the funding challenges experienced over the project's implementation to-date. The three major budget issues include:

  • inappropriate use of around $11.0 million in Stage 1 contingency for originally unfunded works contrary to Treasury policy
  • the additional $16.4 million cost unforeseen in the Stage 1 business case for delivering medical imaging services mostly funded through the sale of land
  • an additional $15.0 million from Stage 2A to cover the budget overrun in Stage 2 due to adverse site conditions.

The cumulative impact of these events is that Stages 1 and 2 of the Hornsby project cost approximately $42.4 million than it should have in the circumstances around 14 per cent more than what the revised combined Estimated Total Cost for both stages should have been after releasing the $11.0 million in surplus Stage 1 funds, with Stage 2 delayed by around 14 months.

Opportunity for strengthening risk management for adverse site conditions

Major construction projects often experience adverse site conditions which can be difficult to fully detect in advance. However, we found this was a common occurrence in the projects we examined sometimes with significant time and/or budget impacts indicating scope to enhance related risk and cost assessments. Specifically:

  • Hornsby Ku-ring-gai Hospital Redevelopment Stage 2: adverse site conditions during demolition works resulted in an 11-month delay for delivering the medical imaging unit and 14-month delay completing Stage 2 main works including need for additional $15.0 million in funds to cover the resultant budget deficit for the project.
  • Blacktown Mt Druitt Hospital Redevelopment Stage 2: adverse site conditions combined with project complexity delayed completion of the early works by approximately five months. This contributed to the delay in completing the main construction works which occurred around nine months later than planned in the business case.
  • Dubbo Health Service Redevelopment Stages 3 and 4: Health Infrastructure advised adverse site conditions including asbestos containing materials and ground conditions delayed works for the main building with completion forecast for March 2021, around 21 months later than planned in the final business case. This resulted in the need for additional $13.5 million to cover increased construction costs and risks, increasing the Stage 3 and 4 forecast final cost from $150 million to $163.5 million as at February 2020.

These examples indicate a risk the cumulative impact of adverse site conditions may be substantial when measured across both time and Health Infrastructure's full delivery program. They also point to potential for Health Infrastructure to achieve efficiencies and improved outcomes from strengthening its approach to assessing and mitigating the risks from adverse site conditions.

Limited due diligence with prospective contractors risks avoidable delays and costs

Main construction works on Stage 1 of the Dubbo Health Service Redevelopment were completed in October 2015, approximately 13 months later than planned in the final business case. Delays were mainly due to insolvency of the early works contractor resulting in their departure from the project. The ensuing 11-month delay in completing the early works significantly impacted the overall schedule and delivery of main construction works.

The insolvency event was significant as it affected nine separate Health Infrastructure projects – three of which had yet to reach practical completion. It also affected state-funded projects in other sectors. It resulted in the need for additional funding of $11.5 million that was provided in the 2014–15 State Budget increasing the total Stage 1 and 2 budget from $79.8 million to $91.3 million.

Health Infrastructure’s analysis of lessons learned shows it worked actively to mitigate the impacts of the insolvency event across all affected projects. However, it also indicates a risk the lessons were mainly focused on mitigating the impacts after an insolvency event occurred rather than on prevention.

Although Health Infrastructure initially commissioned a financial assessment of the now insolvent early works contractor before engagement, it did not detect any risks of the impending insolvency and instead concluded the contractor was in a strong financial position. However, the contractor became insolvent shortly after commencement approximately seven months later. This indicates a risk of weaknesses in the assessment performed that was not explicitly addressed by the lessons learned.

Delivery of the main construction works were further impacted by disputes with the main works contractor over the scope of works for the renal unit resulting in Health Infrastructure terminating the contract in November 2016 following lengthy negotiations over several months.

The scope of works relating to the renal unit were ultimately transferred to Stages 3 and 4 and were delivered in December 2019, around five years later than originally planned in the business case.

Health Infrastructure advised the delay was ultimately beneficial to the project because the refurbishment works for the renal unit, initially scheduled for Stages 1 and 2, would have been demolished to accommodate the new Western Cancer Centre proposed after Stages 1 and 2 and currently being delivered in parallel with Stages 3 and 4.

Health Infrastructure advised the actual cost of Stages 1 and 2 was $84.7 million against the budget of $91.3 million. The residual $6.6 million relates to the renal works not delivered during Stage 1 and 2 and transferred to Stage 3 and 4.

Health Infrastructure advised the contractual provisions for mitigating insolvency events 'in-flight' are limited highlighting the importance of proactive and effective due diligence prior to engaging contractors for significant construction projects.

Need for a quality framework linked to staff training and capability development

Health Infrastructure's 2017-20 Corporate Plan identifies the development of a quality framework to support delivery of future-focused outcomes as a key organisational priority. Related initiatives within the Corporate Plan describe a framework underpinned by a Quality Committee providing advice on:

  • records management, to meet the requirements of the State Records Act 1998
  • project assurance, to ensure future focused outcomes and enhance Health Infrastructure's Standards, Policies, Procedures and Guidelines, Templates and Design Guidance Notes
  • knowledge management and library services, to promote and leverage from project learnings.

Although Health Infrastructure has some elements of a quality framework it is not yet fully in place. Health Infrastructure advised it had yet to establish the quality framework and related committee described in its Corporate Plan due in part to its focus on responding to the growth of its capital program.

Health Infrastructure's Development and Innovation team has been active in supporting continuous improvement in knowledge and project management including development of business cases. Although useful, these initiatives have relied heavily on leveraging and disseminating insights from Gateway reviews and have not formed part of a systematic quality and continuous improvement framework.

The limited focus on the quality of business cases is reflected in internal performance monitoring and reporting which focuses mainly on tracking the delivery of projects against internal benchmarks, often revised from the baselines in the business case, and expenditure against cashflow targets. There is no evident internal monitoring and/or reporting to the Chief Executive and Board on defined quality metrics linked to business case development and staff capability.

Performance reporting on balanced scorecard metrics has similarly focused mainly on process rather than quality and has been inconsistent in recent years.

Appendix one – Response from agency

Appendix two – About the audit

Appendix three – Performance auditing

Appendix four – Ministry of Health planning tools and guidelines

Appendix five – Streamlined investment decision process for Health Capital Projects

Appendix six – Timeline of business cases and relevant policy guidelines

 

Copyright notice

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

Parliamentary reference - Report number #338 - released 12 August 2020

Published

Actions for Their Futures Matter

Their Futures Matter

Justice
Community Services
Education
Health
Whole of Government
Cross-agency collaboration
Internal controls and governance
Management and administration
Project management

The Auditor-General for New South Wales, Margaret Crawford, released a report today examining whether the Department of Communities and Justice had effective governance and partnership arrangements in place to deliver ‘Their Futures Matter’.

Their Futures Matter was intended to place vulnerable children and families at the heart of services, and direct investment to where funding and programs deliver the greatest social and economic benefits. It was a four-year whole-of-government reform in response to the 2015 Tune Review of out-of-home care.

The Auditor-General found that while important foundations were put in place, and new programs trialled, the key objective to establish an evidence-based whole-of-government early intervention approach for vulnerable children and families in NSW was not achieved.

Governance and cross-agency partnership arrangements to deliver Their Futures Matter were found to be ineffective. 'Their Futures Matter lacked mechanisms to secure cross portfolio buy‑in and did not have authority to drive reprioritisation of government investment', the Auditor-General said.

At the reform’s close, the majority of around $380 million in investment funding remains tied to existing agency programs, with limited evidence of their comparative effectiveness or alignment with Their Futures Matter policy objectives. The reform concluded on 30 June 2020 without a strategy or plan in place to achieve its intent.

The Auditor-General made four recommendations to the Department of Communities and Justice, aimed at improving implementation of outstanding objectives, revising governance arrangements, and utilising the new human services data set to address the intent of the reform. However, these recommendations respond only in part to the findings of the audit.

According to the Auditor-General, ‘Cross-portfolio leadership and action is required to ensure a whole-of-government response to delivering the objectives of Their Futures Matter to improve outcomes for vulnerable children, young people and their families in New South Wales.’

Read full report (PDF)

In 2016, the NSW Government launched 'Their Futures Matter' (TFM) - a whole-of-government reform aimed at delivering improved outcomes for vulnerable children, young people and their families. TFM was the government's key response to the 2015 Independent Review of Out of Home Care in New South Wales (known as 'the Tune Review').

The Tune Review found that, despite previous child protection reforms, the out of home care system was ineffective and unsustainable. It highlighted that the system was not client-centred and was failing to improve the long-term outcomes for vulnerable children and families. The review found that the greatest proportion of relevant expenditure was made in out of home care service delivery rather than in evidence-based early intervention strategies to support children and families when vulnerabilities first become evident to government services (such as missed school days or presentations to health services).

The then Department of Family and Community Services (FACS) designed the TFM reform initiatives, in consultation with central and human services agencies. A cross-agency board, senior officers group, and a new unit in the FACS cluster were established to drive the implementation of TFM. In the 2016–17 Budget, the government allocated $190 million over four years (2016–17 to 2019–20) to the reform. This resourced the design and commissioning of evidence-based pilots, data analytics work, staffing for the implementation unit and secretariat support for the board and cross-agency collaboration.

As part of the TFM reform, the Department of Premier and Cabinet, NSW Treasury and partnering agencies (NSW Health, Department of Education and Department of Justice) identified various existing programs that targeted vulnerable children and families (such as the preceding whole-of-government ‘Keep Them Safe’ reform coming to an end in June 2020). Funding for these programs, totalling $381 million in 2019–20, was combined to form a nominal ‘investment pool’. The government intended that the TFM Implementation Board would use this pool to direct and prioritise resource allocation to evidence-based interventions for vulnerable children and families in NSW.

This audit assessed whether TFM had effective governance and partnership arrangements in place to enable an evidence-based early intervention investment approach for vulnerable children and families in NSW. We addressed the audit objective with the following audit questions:

  • Was the TFM reform driven by effective governance arrangements?
  • Was the TFM reform supported by effective cross-agency collaboration?
  • Has the TFM reform generated an evidence base to inform a cross-agency investment approach in the future?

The audit did not seek to assess the outcomes for children, young people and families achieved by TFM programs and projects.

Conclusion

The governance and cross-agency partnership arrangements used to deliver the Their Futures Matter reform were ineffective. Important foundations were put in place, and new programs trialled over the reform's four years. However, an evidence-based whole-of-government early intervention approach for vulnerable children and families in NSW − the key objective of the reform − was not established. The reform concluded in June 2020 without a strategy or plan in place to achieve its intent.

The governance arrangements established for the Their Futures Matter (TFM) reform did not provide sufficient independence, authority and cross-agency clout to deliver on the reform’s intent. This hindered delivery of the reform's key elements, particularly the redirection of funding to evidence-based earlier intervention supports, and limited the impact that TFM could have on driving system change.

TFM increased focus on the contribution that other agencies outside of the former Family and Community Services portfolio could make in responding to the needs of vulnerable children and families, and in reducing the demand costs of related government service delivery. Despite being a whole-of-government reform, TFM lacked mechanisms to secure cross-portfolio buy-in and lacked the powers to drive reprioritisation of government investment in evidence-based and earlier intervention supports across agencies. At the reform’s close, the majority of the reform's investment pool funding remained tied to existing agency programs, with limited evidence of their comparative effectiveness or alignment with Their Futures Matter policy objectives.

TFM began building an evidence base about ‘what works’, including piloting programs and creating a new dataset to identify risk factors for vulnerability and future costs to government. However, this evidence base does not yet comprehensively map how existing services meet needs, identify system duplications or gaps, nor demonstrate which government funded supports and interventions are most effective to make a difference to life outcomes for vulnerable children and families in NSW.
Despite these issues, the need, intent and vision for Their Futures Matter remains relevant and urgent, as issues identified in the Tune Review remain pertinent.

Their Futures Matter (TFM) is a whole-of-government reform to deliver improved outcomes for vulnerable children, young people and their families.

Supported by a cross-agency TFM Board, and the TFM Unit in the then Department of Family and Community Services (FACS), the reform aimed to develop whole-of-government evidence-based early intervention investment approaches for vulnerable children and families in NSW.

Governance refers to the structures, systems and practices that an organisation has in place to:

  • assign decision-making authorities and establish the organisation's strategic direction
  • oversee the delivery of its services, the implementation of its policies, and the monitoring and mitigation of its key risks
  • report on its performance in achieving intended results, and drive ongoing improvements.

We examined whether the TFM reform was driven by effective governance arrangements and cross-agency collaboration.

The reform agenda and timeframe set down for Their Futures Matter (TFM) were ambitious. This chapter assesses whether the TFM Board and TFM Unit had the capability, capacity and clout within government to deliver the reform agenda.

Creating a robust evidence base was important for Their Futures Matter, in order to:

  • identify effective intervention strategies to improve supports and outcomes for vulnerable children and families
  • make efficient use of taxpayer money to assist the maximum number of vulnerable children and families
  • inform the investment-based approach for future funding allocation.

This chapter assesses whether the TFM reform has developed an evidence base to inform cross-agency investment decisions.

Appendix one – Response from agency

Appendix two – TFM governance entities

Appendix three – TFM Human Services Data Set

Appendix four – TFM pilot programs

Appendix five – About the audit

Appendix six – Performance auditing

 

Copyright notice

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

Parliamentary reference - Report number #337 - released 24 July 2020

Published

Actions for Health 2019

Health 2019

Health
Asset valuation
Compliance
Financial reporting
Fraud
Information technology
Internal controls and governance
Management and administration
Procurement
Project management

This report focuses on key observations and findings from the most recent financial audits of the Ministry of Health, local health districts, specialty health networks, health corporations and independent health agencies in New South Wales. The report also summarises self-reported performance measures across the network.

The number and value of adjustments to financial statements of entities in the Health Cluster decreased from the prior year. And unqualified audit opinions were issued for all heath entities’ financial statements.

Audit findings relating to internal controls deficiencies increased across health entities. Contributing to this increase were deficiencies in information system controls, which accounted for nearly a quarter of all control deficiencies. Repeat audit findings also accounted for more than a quarter of all control deficiencies.

The report notes health entities continued to experience challenges with managing employees’ excessive annual leave and time recording practices. The Ambulance Service of New South Wales continued to report high overtime payments to its employees. 

Download Health 2019 report (PDF).

This report analyses the results of our audits of financial statements of the agencies comprising the Health cluster for the year ended 30 June 2019. The table below summarises our key observations.

1. Machinery of Government changes

Cluster changes Machinery of Government (MoG) changes refer to how the government reorganises agency structures and functions and realigns ministerial responsibilities. The Health cluster was not impacted by the MoG changes.

2. Financial reporting

Financial reporting

The financial statements of NSW Health and its controlled entities received unqualified audit opinions before the legislative deadline.

The number of corrected and uncorrected misstatements decreased from the prior year.

Management implemented more robust processes for its oversight of complex asset revaluations in 2018–19. We found no significant errors in 2018–19.

Financial performance Overall, NSW Health recorded an operating surplus of $1.1 billion in 2018–19, an increase of $699 million from 2017–18. This was the result of additional funding received for capital expenditure on the construction of new facilities, upgrades and redevelopments.

Budgeted expense for the 15 local health districts and two speciality networks increased from $18.3 billion to $19.4 billion in 2018–19. The 15 health entities recorded unfavourable variances between actual and budgeted expenses.
Excess annual leave

Managing excess annual leave remains a challenge for NSW Health, 36.9 per cent of the workforce have excess annual leave balances.

Recommendation: Health entities should further review their approach to managing excess annual leave in 2019–20, and:

  • monitor current and projected leave balances to the end of the financial year on a monthly basis
  • agree formal leave plans with employees to reduce leave balances over an acceptable timeframe
  • encourage staff who perform key control functions to take at least two consecutive weeks’ leave a year to mitigate fraud risks.
Overtime payments NSW Health entities generally manage overtime well. The Ambulance Service of NSW’s overtime payments of $83.1 million (9.8 per cent of total salaries and wages), remain significantly higher than other health entities.

Recommendation: The Ambulance Service of NSW should further review the effectiveness of its rostering practices to identify strategies to reduce overtime payments.

3. Audit observations

Internal control deficiencies We identified more internal control deficiencies in 2018–19. The number of repeat issues from prior years also remains high with more than one quarter of issues having been previously reported. More than a quarter of deficiencies related to information system controls.
Infrastructure delivery NSW Health defines projects with a budgeted cost greater than $50.0 million as 'major projects'. There were significant revisions to planned financial completion dates and budgeted costs of these projects. The revised total budgets for the 30 ongoing major capital projects at 30 June 2019 is $10.2 billion, $2.2 billion more than the original budget.
Health Infrastructure completed three major capital projects during 2018–19.
Asset maintenance The total cost of maintaining the health entities’ $19.8 billion of assets was $635 million for 2018–19. Health entities' approaches to setting maintenance budgets vary. Most entities are addressing their backlog maintenance, although many were not able to quantify the full extent of their backlog maintenance. Although health entities continue to use fully depreciated assets, the replacement cost of these assets is decreasing.

 

 

This report provides parliament and other users of the financial statements of agencies within the Health cluster with the results of our audits, our observations, analysis, conclusions and recommendations in the following areas for the year ended 30 June 2019:

  • financial reporting
  • audit observations. 

 The Health cluster was not impacted by the Machinery of Government changes on 1 July 2019. 

Financial reporting is an important element of good governance. Confidence and transparency in public sector decision making are enhanced when financial reporting is accurate and timely.

This chapter outlines our audit observations related to the financial reporting of agencies in the health cluster for 2019.

Section highlights

  • We issued unqualified audit opinions for all health entities’ financial statements and identified fewer misstatement than last year. Health entities continue to meet statutory deadlines.
  • The Ministry of Health sets significant accounting policies centrally and provides a template for the preparation of health entities’ financial statements. These processes promote consistent quality in the financial reports of health entities and reduce the number of misstatements we identify.
  • NSW Health recorded an operating surplus of $1.1 billion, an increase of $699 million from 2017–18. This is because of additional capital grants for new facilities, upgrades and redevelopments. The capital replacement ratio (investment in new assets divided by depreciation) for NSW Health is 2.6.
  • NSW Health’s expenses increased by 7.0 per cent in 2018–19 (5.5 per cent in 2017–18). This is one percentage point higher than the projected long-term annual expense growth rate of six per cent. The primary causes for the growth in expenses are increased:
    • employee related expenses because provisions for employee benefits increased when the discount rate decreased
    • operating expenses associated with the opening of Northern Beaches Hospital.
  • Excess annual leave balances continue to increase for the NSW Health workforce, with excess annual leave balances impacting 37 per cent of employees (34 per cent in 2017–18).
  • Health entities should further review their approach to managing excess annual leave in 2019–20 by monitoring current and projected leave balances on a regular basis, agreeing formal leave plans with employees and encouraging staff that perform key control functions to take a minimum of two consecutive weeks’ leave a year as a fraud mitigation strategy.
  • The Ambulance Services continued to report overtime payments higher than other health entities. The Ambulance Service paid its employees $83.1 million in overtime payments in 2018–19 ($74.8 million in 2017–18).
  • We issued a qualified audit opinion for the Ministry of Health's Annual Prudential Compliance Statement for aged care facilities operated by NSW Health. We identified 40 instances of material non-compliance with the Fees and Payments Principles 2014 (No. 2) (the Principles) in 2018–19 (17 in 2017–18).

Audit opinions 

We issued unqualified audit opinions for all health entities and quality of financial reporting continues to improve

We identified fewer misstatements this year, and the errors were less significant. In 2018–19 no errors exceeded $5.0 million (eight errors recorded in 2017–18). Ten health entities conducted a full revaluation of their land, buildings and infrastructure systems in 2018–19, but more robust processes avoided the errors identified in the previous year.

Number of misstatements
Year ended 30 June 2019 2018 2017
  green circle with white tick red circle with white exclamation mark green circle with white tick red circle with white exclamation mark green circle with white tick red circle with white exclamation mark
Less than $50,000 -- -- -- 6 3 3
$50,000 to $249,999 -- 1 -- -- 2 3
$250,000 to $999,999 1 -- -- -- 1 3
$1 million to $4,999,999 -- 2 -- 2 1 5
$5 million and greater -- -- 6 2 1 2
Total number of misstatements 1 3 6 10 8 16

green circle white tick Corrected mistatements. red circle white exclamation mark Uncorrected statements.
Source: Statutory Audit Reports issued by the Audit Office.

We issued a qualified audit opinion for our compliance audit of the Ministry of Health's Annual Prudential Compliance Statement

The Ministry of Health operates eight aged care facilities in NSW and is required to comply with the Fees and Payments Principles 2014 (No. 2) (the Principles) when entering into agreements with and managing payments to and from care recipients. The Principles are set by the Commonwealth Assistant Minister for Social Services. We identified 40 instances of material non-compliance in 2018–19, including:

  • not agreeing maximum accommodation amounts payable with aged care recipients before they entered the residential care services
  • not entering into accommodation agreements with care recipients within the specified period
  • charging incorrect fees for activities or services to one care recipient
  • not refunding two bond balances within the statutory framework
  • not paying the correct amount of interest for 14 care recipients’ bonds refunded during the year.

Appropriate financial controls help ensure the efficient and effective use of resources and administration of agency policies. They are essential for quality and timely decision making.

This chapter outlines our observations and insights from our financial statement audits of agencies in the health cluster.

Section highlights

  • The number of internal control deficiencies has increased since 2017–18. More than a quarter of control deficiencies are repeat issues and almost a quarter relate to information system controls. Both employee time recording and leave management remain as repeat issues in 2018–19.
  • Control deficiencies that relate to managing employees' leave, employees’ time recording or information system limitations can be difficult for entities to resolve in a timely manner.
  • Agreements for the treatment of New South Wales residents while they are interstate, and interstate residents while they are in New South Wales, are unsigned for Queensland, Victoria and the Australian Capital Territory for 2016–17, 2017–18 and 2018–19.
  • NSW Health recorded $113.6 million in revenue from fees charged to Medicare ineligible patients during 2018–19 but has received payment for less than half of this.
  • NSW Health reported that they completed three major capital projects during 2018–19.
  • As at 30 June 2019 there were 30 ongoing major capital health projects in NSW. The revised capital budget for these projects in total was $2.2 billion more than the original budget of $8.0 billion.
  • Health entities spent $635 million maintaining assets with a fair value of $19.8 billion of assets. Almost all entities were working through backlog maintenance during 2018–19, although several were unable to quantify the backlog.
  • While entities are now regularly reassessing the useful lives of their assets, entities are still using a high volume of assets that are fully depreciated. Due to the age and nature of these assets the impact was not material.

Appendix one – List of 2019 recommendations

Appendix two – Status of 2018 recommendations

Appendix three – Financial data 

Appendix four – Analysis of financial indicators

Appendix five – Analysis of performance against budget

 

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.

Published

Actions for Internal Controls and Governance 2019

Internal Controls and Governance 2019

Education
Community Services
Finance
Health
Industry
Justice
Planning
Premier and Cabinet
Transport
Treasury
Whole of Government
Compliance
Cyber security
Fraud
Information technology
Internal controls and governance
Management and administration
Procurement
Project management

This report covers the findings and recommendations from the 2018–19 financial audits that relate to internal controls and governance at 40 of the largest agencies in the NSW public sector. The 40 agencies selected for this report constitute around 84 per cent of total expenditure for all NSW public sector agencies.

The report provides insights into the effectiveness of controls and governance processes across the NSW public sector. It evaluates how agencies identify, mitigate and manage risks related to:

  • financial controls
  • information technology controls
  • gifts and benefits
  • internal audit
  • contingent labour
  • sensitive data.

The Auditor-General recommended that agencies do more to prioritise and address vulnerabilities in their internal controls and governance. The Auditor-General also recommended agencies increase the transparency of their management of gifts and benefits by publishing their registers on their websites.

This report analyses the internal controls and governance of 40 of the largest agencies in the NSW public sector for the year ended 30 June 2019.

1. Internal control trends

New, repeat and high risk findings

There was an increase in internal control deficiencies of 12 per cent compared to last year. The increase is predominately due to a 100 per cent increase in repeat financial and IT control deficiencies.

Some agencies attributed the delay in actioning repeat findings to the diversion of staff from their regular activities to implement and operationalise the recent Machinery of Government changes. As a result, actions to address audit recommendations have been deferred or re prioritised, as the changes are implemented.

Agencies need to ensure they are actively managing the risks associated with having these vulnerabilities in internal control systems unaddressed for extended periods of time.

Common findings

A number of findings were common to multiple agencies. These findings often related to areas that are fundamental to good internal control environments and effective organisational governance, such as:

  • out of date policies or an absence of policies to guide appropriate decisions
  • poor record keeping and document retention
  • incomplete or inaccurate centralised registers or gaps in these registers
  • policies, procedures or controls no longer suited to the current organisational structure or business activities.

2. Information technology controls

IT general controls

We examined information security controls over key financial systems that support the preparation of agency financial statements. We found:

  • user access administration deficiencies at 58 per cent of agencies related to granting, review and removal of user access
  • an absence of privileged user activity reviews at 35 per cent of agencies
  • password controls that did not align to password policies at 20 per cent of agencies.

We also found 20 per cent of agencies had deficient IT program change controls, mainly related to segregation of duties in approval and authorisation processes, and user acceptance testing of program changes prior to deployment into production environments. User acceptance testing helps identify potential issues with software incompatibility, operational workflows, absent controls and software issues, as well as areas where training or user support may be required.

3. Gifts and benefits

Gifts and benefits registers

All agencies had a gifts and benefits policy and 90 per cent of agencies maintain a gifts and benefits register. However, 51 per cent of the gifts and benefits registers we examined contained incomplete declarations, such as missing details for the approving officer, value of the gift and/or benefit offered and reasons supporting the decision.

In some cases, gaps in recorded information meant the basis for decisions around gifts and benefits was not always clear, making it difficult to determine whether decisions in those instances were appropriate, compliant with policy and were not direct or indirect inducements to the recipients to favour suppliers or service providers.

Agencies should ensure their gifts and benefits register includes all key fields specified in the Public Service Commission's minimum standards for gifts and benefits. Agencies should also perform regular reviews of the register to ensure completeness and ensure any gift or benefit accepted by a staff member meets the public's expectations for ethical behaviour.

Managing gifts and benefits

We found opportunities to improve gifts and benefits processes and enhance transparency. For example, only three per cent of agencies publish their gifts and benefits registers on their websites.

Agencies can improve management of gifts and benefits by:

  • ensuring agency policies comprehensively cover the elements necessary to make it effective in an operational environment, such as identifying risks specific to the agency and actions that will be taken in the event of a policy breach
  • establishing and publishing a statement of business ethics on the agency's website to clearly communicate expected behaviours to clients, customers, suppliers and contractors
  • providing on-going training, awareness activities and support to employees, not just at induction
  • publishing their gifts and benefits registers on their websites to demonstrate a commitment to a transparently ethical environment.
Reporting and monitoring

Only 35 per cent of agencies reported trends in the number and nature of gifts and benefits recorded in their registers to the agency's senior executive management and/or a governance committee.

Agencies should regularly report to the agency executive or other governance committee on trends in the offer and acceptance of gifts and benefits.

4. Internal audit

Obtaining value from the internal audit function

Agencies have established and maintained internal audit functions to provide assurance on the effectiveness of agency controls and governance systems. However, we identified areas where agencies' internal audit functions could improve their processes to add greater value. For example, only 73 per cent of CAEs regularly attend meetings of the agency board or executive management committee.

Internal audit functions can add greater value by involving the CAE more extensively in executive forums as an observer.

Internal audit functions should also consider producing an annual report on internal audit. An annual report allows the internal audit function to report on their performance and add value by drawing to the attention of audit and risk committees and senior management strategic issues, thematic trends and emerging risks.

Role of the Chief Audit Executive

Forty-five per cent of agencies assigned responsibilities to the Chief Audit Executive (CAE) that were broader than internal audit, but 17 per cent of these had not documented safeguards to protect the independence of the CAE.

The reporting lines and status of the CAE at some agencies also needs review. At two agencies, the CAE reported to the CFO.

Agencies should ensure:

  • the reporting lines for the CAE comply with the NSW Treasury policy, and the CAE does not report functionally or administratively to the finance function or other significant recipients of internal audit services
  • the CAE's duties are compatible with preserving their independence and where threats to independence exist, safeguards are documented and approved.
Quality assurance and improvement program

Thirty-five per cent of agencies did not have a documented quality assurance and improvement program for its internal audit function.

The policy and the International Standards for the Professional Practice of Internal Auditing require agencies to have a documented quality assurance and improvement program. The results of this program should be reported annually.

Agencies should ensure there is a documented and operational Quality Assurance and Improvement Program for the internal audit function that covers both internal and external assessments.

5. Managing contingent labour

Obtaining value for money from contingent labour

According to NSW Procurement data, spend on contingent labour has increased by 75 per cent over the last five years, to $1.5 billion in 2018–19. Improvements in internal processes and a renewed focus on agency monitoring and oversight of contingent labour can help ensure agencies get the best value for money from their contingent workforces.

Agencies can improve their management of contingent labour by:

  • preparing workforce plans to inform their resourcing strategy and ensure that engaging contingent labour aligns with the strategy and best meets business needs
  • involving agency human resources units in decisions about engaging contingent labour
  • regularly reporting on contingent labour use and tenure to agency executive teams
  • strengthening on-boarding and off-boarding processes.

We also found 57 per cent of the 23 agencies we examined with contingent labour spend of more than $5 million in 2018–19 have implemented the government's vendor management system and service provider 'Contractor Central'.

6. Managing sensitive data

Identifying and assessing sensitive data

Sixty-eight per cent of agencies maintain an inventory of their sensitive data and where it resides. However, these inventories are not always complete and risks may be overlooked.

Agencies can improve processes to manage sensitive data by:

  • identifying and maintaining an inventory of sensitive data through a comprehensive and structured process
  • assessing the criticality and sensitivity of the data so that protection of high risk data can be prioritised.
Managing data breaches

Eighty-eight per cent of agencies have established policies to respond to potential data breaches when they are identified and 70 per cent of agencies maintain a register to record key information in relation to identified data breach incidents.

Agencies should maintain a data breach register to effectively manage the actions undertaken to contain, evaluate and remediate each data breach.

 

This report covers the findings and recommendations from our 2018–19 financial audits that relate to internal controls and governance at 40 of the largest agencies (refer to Appendix three) in the NSW public sector. The 40 agencies selected for this volume constitute around 84 per cent of total expenditure for all NSW public sector agencies.

Although the report includes several agencies that have changed as a result of the Machinery of Government changes that were effective from 1 July 2019, its focus on sector wide issues and insights means that its findings remain relevant to NSW public sector agencies, including newly formed agencies that have assumed the functions of abolished agencies.

This report offers insights into internal controls and governance in the NSW public sector

This is the third report dedicated to internal controls and governance at NSW State Government agencies. The report provides insights into the effectiveness of controls and governance processes in the NSW public sector by:

  • highlighting the potential risks posed by weaknesses in controls and governance processes
  • helping agencies benchmark the adequacy of their processes against their peers
  • focusing on new and emerging risks, and the internal controls and governance processes that might address those risks.

Without strong governance systems and internal controls, agencies increase the risks associated with effectively managing their finances and delivering services to citizens. For example, if they do not have strong information technology controls, sensitive information may be at risk of unauthorised access and misuse.

Areas of specific focus of the report have changed since last year

Last year's report topics included transparency and performance reporting, management of purchasing cards and taxi use, and fraud and corruption control. We are reporting on new topics this year and re-visiting agency management of gifts and benefits, which we first covered in our 2017 report. Re-visiting topics from prior years provides a baseline to show the NSW public sectors’ progress implementing appropriate internal controls and governance processes to mitigate existing, new and emerging risks in the public sector.

Our audits do not review all aspects of internal controls and governance every year. We select a range of measures and report on those that present heightened risks for agencies to mitigate. This year the report focusses on:

  • internal control trends
  • information technology controls, including access to agency systems
  • protecting sensitive information held within agencies
  • managing large and diverse workforces (controls around employing and managing contingent workers)
  • maintaining an ethical culture (management of gifts and benefits)
  • effectiveness of internal audit function and its oversight by Audit and Risk Committees.

The findings in this report should not be used to draw conclusions on the effectiveness of individual agency control environments and governance arrangements. Specific financial reporting, internal controls and audit observations are included in the individual 2019 cluster financial audit reports, which will be tabled in parliament from November to December 2019.

Internal controls are processes, policies and procedures that help agencies to:

  • operate effectively and efficiently
  • produce reliable financial reports
  • comply with laws and regulations
  • support ethical government.

This chapter outlines the overall trends for agency controls and governance issues, including the number of audit findings, the degree of risk those deficiencies pose to the agency, and a summary of the most common deficiencies we found across agencies. The rest of this report presents this year’s controls and governance findings in more detail.

Key conclusions and sector wide learnings

We identified four high risk findings, compared to six last year. None of the findings are common with those in the previous year. There was an overall increase of 12 per cent in the number of internal control deficiencies compared to last year. The increase is predominately due to a 100 per cent increase in the number of repeat financial and IT control deficiencies.
 
Some agencies attributed the delay in actioning repeat findings to the diversion of staff from their regular activities to implement and operationalise the recent Machinery of Government changes. As a result, actions to address audit recommendations have been deferred or re-prioritised, as the changes are implemented. Agencies need to ensure they are actively managing the risks associated with having these vulnerabilities in internal control systems unaddressed for extended periods of time.
 
We also identified a number of findings that were common to multiple agencies. These common findings often related to areas that are fundamental to good internal control environments and effective organisational governance. Examples include:
  • out of date policies or an absence of policies to guide appropriate decisions
  • poor record keeping and document retention
  • incomplete or inaccurate centralised registers or gaps in these registers.

Policies, procedures and internal controls should be properly designed, be appropriate for the current organisational structure and its business activities, and work effectively.

This chapter outlines our audit observations, conclusions and recommendations, arising from our review of agency controls to manage key financial systems.

Key conclusions and sector wide learnings
Government agencies’ financial reporting is heavily reliant on information technology (IT). We continue to see a high number of deficiencies related to IT general controls, particularly those related to user access administration. These controls are key in adequately protecting IT systems from inappropriate access and misuse.
IT is also important to the delivery of agency services. These systems often provide the data to help monitor the efficiency and effectiveness of agency processes and services they deliver. Our financial audits do not review all agency IT systems. For example, IT systems used to support agency service delivery are generally outside the scope of our financial audit. However, agencies should also consider the relevance of our findings to these systems.
Agencies need to continue to focus on assessing the risks of inappropriate access and misuse and the implementation of controls to adequately protect their systems, focussing on the processes in place to grant, remove and monitor user access, particularly privileged user access.

This chapter outlines our audit observations, conclusions and recommendations, arising from our review of agency controls to manage gifts and benefits. 

Key conclusions and sector wide learnings

We found most agencies have implemented the Public Service Commission's minimum standards for gifts and benefits. All agencies had a gifts and benefits policy and 90 per cent of agencies maintained a gifts and benefits register and provided some form of training to employees on the treatment of gifts and benefits.

Based on our analysis of agency registers, we found some areas where opportunities existed to make processes more effective. In some cases, gaps in recorded information meant the basis for decisions around gifts and benefits was not always clear, making it difficult to determine whether decisions in those instances were appropriate and compliant with policy. Fifty-one per cent of the gifts and benefits registers reviewed contained declarations where not all fields of information had been completed. Seventy-seven per cent of agencies that maintained a gifts and benefits register did not include all key fields suggested by the minimum standards.

Areas where agencies can improve their management of gifts and benefits include:

  • ensuring agency policies comprehensively cover the elements necessary to make it effective in an operational environment, such as identifying risks specific to the agency and actions that will be taken in the event of a policy breach
  • establishing and publishing a statement of business ethics on the agency's website to clearly communicate expected behaviours to clients, customers,suppliers and contractors
  • updating gifts and benefits registers to include all key fields suggested by the minimum standards, as well as performing regular reviews of the register to ensure completeness
  • providing on-going training, awareness activities and support to employees, not just at induction
  • regularly reporting gifts and benefits to executive management and/or a governance committee such as the audit and risk committee, focussing on trends in the number and types of gifts and benefits offered to and accepted by agency staff
  • publishing their gifts and benefits registers on their websites to demonstrate a commitment to a transparently ethical environment.

This chapter outlines our audit observations, conclusions and recommendations, arising from our review of agency internal audit functions.

Key conclusions and sector wide learnings 

We found agencies have established and maintained internal audit functions to provide assurance on the effectiveness of agency controls and governance systems as required by TPP15-03 'Internal Audit and Risk Management Policy for the NSW Public Sector'. However, we identified areas where agencies' internal audit functions could improve their processes to add greater value, including: 

  • documenting and implementing safeguards to address conflicting roles performed by the Chief Audit Executive (CAE)
  • ensuring the reporting lines for the CAE comply with the NSW Treasury policy, and the CAE reports neither functionally or administratively to the finance function or other significant recipients of internal audit services
  • involving the CAE more extensively in executive forums as an observer
  • documenting a Quality Assurance and Improvement Program for the internal audit function and performing both internal and external performance assessments to identify opportunities for continuous improvement
  • reporting against key performance indicators or a balanced scorecard and producing an annual report on internal audit to bring to the attention of the audit and risk committee and senior management strategic issues, thematic trends and emerging risks that may require further attention or resources.

This chapter outlines our audit observations, conclusions and recommendations, arising from our review of agency controls to on-board, manage and off-board contingent labour.

Key conclusions and sector wide learnings

Agencies have implemented controls to manage contingent labour and most agencies have some level of reporting and oversight of contingent labour at an executive level. However, the increasing trend in spend on contingent labour warrants a renewed focus on agency monitoring and oversight of their use of contingent labour. Over the last five years spend on contingent labour has increased by 75 per cent, to $1.5 billion in 2018–19.

There are also some key gaps that limit the ability of agencies to effectively manage contingent labour. Key areas where agencies can improve their management of contingent labour include: 

  • preparing workforce plans to inform their resourcing strategy, and confirm prior to engaging contingent labour, that this solution aligns with the strategy and best meets business needs
  • involving agency human resources units in decisions about engaging contingent labour
  • regularly reporting on contingent labour use to agency executive teams, particularly in terms of trends in agency spend, tenure and compliance with policies and procedures
  • strengthening on-boarding and off-boarding processes, including establishing checklists to on-board and off-board contingent labour, making provisions for knowledge transfer, and assessing, documenting and capturing performance information.

This chapter outlines our audit observations, conclusions and recommendations, arising from our review of governance and processes in relation to the management of sensitive data.

Key conclusions and sector wide learnings

Information technology risks are rapidly increasing. More interfaces between agencies and greater connectivity means the amounts of data agencies generate, access, store and share continue to increase. Some of this information is sensitive information, which is protected by the Privacy Act 1988.

It is important that agencies understand what sensitive data they hold, the risks associated with the inadvertent release of this information and how they are mitigating those risks. We found that agencies need to continue to identify and record their sensitive data, as well as expand the methods they use to identify sensitive data. This includes data held in unstructured repositories, such as network shared drives and by agency service providers.

Eighty-eight per cent of agencies have established policies to respond to potential data breaches when they are identified and 70 per cent of agencies maintain a register to record key information in relation to identified data breach incidents.

Key areas where agencies can improve their management of sensitive data include:

  • identifying sensitive data, based on a comprehensive and structured process and maintaining an inventory of the data
  • assessing the criticality and sensitivity of the data so that the protection of high risk data can be prioritised
  • developing comprehensive data breach management policies to ensure data breaches are appropriately managed
  • maintaining a data breach incident register to record key information in relation to identified data breaches incidents, including the estimated cost of the breach
  • providing on-going training and awareness activities to employees in relation to sensitive data and managing data breaches.

Appendix one – List of 2019 recommendations 

Appendix two – Status of 2018 recommendations

Appendix three – In-scope agencies

 

© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.