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Actions for Compliance with the NSW Cyber Security Policy

Compliance with the NSW Cyber Security Policy

Whole of Government
Compliance
Cyber security
Information technology

What the report is about

This audit assessed nine agencies’ compliance with the NSW Cyber Security Policy (CSP) including whether, during the year to 30 June 2020, the participating agencies:

  • met their reporting obligations under the CSP
  • reported accurate self-assessments of their level of maturity implementing the CSP’s requirements including the Australian Cyber Security Centre’s (ACSC) Essential 8.

What we found

Key elements to strengthen cyber security governance, controls and culture are not sufficiently robust and not consistently applied. The CSP is not achieving the objectives of improved cyber governance, controls and culture because:

  • the CSP does not specify a minimum level for agencies to achieve in implementing the 'mandatory requirements' or the Essential 8
  • the CSP does not require agencies to report their target levels, nor does it require risk acceptance decisions to be documented or formally endorsed
  • each participating agency had implemented one or more of the mandatory requirements in an ad hoc or inconsistent basis
  • none of the participating agencies had implemented all of the Essential 8 controls
  • agencies tended to over-assess their cyber security maturity - all nine participating agencies were unable to support all of their self-assessments with evidence
  • there is no monitoring of the adequacy or accuracy of agencies' self-assessments.

What we recommended

In this report, we repeat recommendations made in the 2019 and 2020 Central Agencies reports, that Cyber Security NSW and NSW Government agencies need to prioritise improvements to cyber security resilience as a matter of urgency.

Cyber Security NSW should:

  • monitor and report compliance with the CSP
  • require agencies to report the target and achieved levels of maturity
  • require agencies to justify why it is appropriate to target a low level of maturity
  • require the agency head to formally accept the residual risk
  • challenge agencies' target maturity levels.

Agencies should resolve discrepancies between their reported level of maturity and the level they are able to support with evidence.

Separately, the agencies we audited requested that we not disclose our audit findings. We reluctantly agreed to anonymise our findings, even though they are more than 12 months old. We are of the view that transparency and accountability to the Parliament of New South Wales are part of the solution, not the problem.

The poor levels of agency cyber security maturity are a significant concern. Improvement requires leadership and resourcing.

Fast facts

The NSW Cyber Security Policy requires agencies to report their level of maturity implementing the mandatory requirements, which includes the ACSC's Essential 8.

  • 100% of audited agencies failed to reach level one maturity for at least three of the Essential 8 controls.

  • 53% of mandatory requirements implemented in an ad hoc or inconsistent manner, or not at all.

  • 89 of the 104 reporting agencies across government met the reporting deadline of 31 August.

This report assesses whether state government agencies are complying with the NSW Cyber Security Policy. The audit was based on the level of compliance reported at 30 June 2020.

Our audit identified non-compliance and significant weaknesses against the government’s policy.

Audited agencies have requested that we not report the findings of this audit to the Parliament of New South Wales, even though the findings are more than 12 months old, believing that the audit report would expose their weaknesses to threat actors.

I have reluctantly agreed to modify my report to anonymise agencies and their specific failings because the vulnerabilities identified have not yet been remedied. Time, leadership and prioritised action should have been sufficient for agencies to improve their cyber safeguards. I am of the view that transparency and accountability to the Parliament is part of the solution, not the problem.

The poor levels of cyber security maturity are a significant concern. Improvement requires dedicated leadership and resourcing. To comply with some elements of the government’s policy agencies will have to invest in technical uplift and some measures may take time to implement. However, other elements of the policy do not require any investment in technology. They simply require leadership and management commitment to improve cyber literacy and culture. And they require accountability and transparency. Transparent reporting of performance is a key means to improve performance.

Cyber security is increasingly a focus of governments around Australia. The Australian Cyber Security Centre (ACSC) is the Australian Government’s lead agency for cyber security and is part of the Australian Signals Directorate, a statutory authority within the Australian Government’s Defence portfolio. The ACSC has advised that government agencies at all levels, as well as individuals and other organisations were increasingly targeted over the 2021 financial year1. The ACSC received over 67,500 cybercrime reports, a 13 per cent increase on the previous year. This equates to one reported cyber attack every eight minutes. They also noted that attacks by cyber criminals and state actors are becoming increasingly sophisticated and complex and that the attacks are increasingly likely to be categorised as ‘substantial’ in impact.

High profile attacks in Australia and overseas have included a sustained malware campaign targeted at the health sector2, a phishing campaign deploying emotet malware, spear phishing campaigns targeting people with administrator or other high-level access, and denial of service attacks. The continuing trend towards digital delivery of government services has increased the vulnerability of organisations to cyber threats.

The COVID-19 pandemic has increased these risks. It has increased Australian dependence on the internet – to work remotely, to access services and information, and to communicate and continue our daily lives. Traditional security policies within an organisation’s perimeter are harder to enforce in networks made up of home and other private networks, and assets the organisation does not manage. This has increased the cyber risks for NSW Government agencies.

In March 2020, Service NSW suffered two cyber security incidents in short succession. Technical analysis undertaken by the Department of Customer Service (DCS) concluded that these cyber breaches resulted from a phishing exercise through which external threat actors gained access to the email accounts of 47 staff members. These attacks resulted in the breach of a large amount of personal customer information contained in these email accounts. These attacks were the subject of the Auditor-General's report on Service NSW's handling of personal information tabled on 18 December 2020.

This audit also follows two significant performance audits. Managing cyber risks, tabled on 13 July 2021 found Transport for NSW and Sydney Trains were not effectively managing their cyber security risks. Integrity of data in the Births, Deaths and Marriages Register, tabled 7 April 2020 found that although there are controls in place to prevent and detect unauthorised access to, and activity in the register, there were significant gaps in these controls.

The NSW Cyber Security Policy (CSP) was issued by Cyber Security NSW, a business unit within the Department of Customer Service, and took effect from 1 February 2019. It applies to all NSW Government departments and public service agencies, including statutory authorities. Of the 104 agencies in the NSW public sector that self-assessed their maturity implementing the mandatory requirements, only five assessed their maturity at level three or above (on the five point maturity scale). This means that, according to their own self-assessments, 99 agencies practiced requirements within the framework in what the CSP’s maturity model describes as an ad hoc manner, or they did not practice the requirement at all. Cyber Security NSW and NSW Government agencies need to prioritise improvements to their cybersecurity and resilience as a matter of priority.

This audit looks specifically at the compliance of nine key agencies with the CSP. It looks at their achievement implementing the requirements of the policy, the accuracy of their self-assessments and the attestations they made as to their compliance with the CSP.

The CSP outlines the mandatory requirements to which all NSW Government departments and public service agencies must adhere. It seeks to ensure cyber security risks to agencies’ information and systems are appropriately managed. The key areas of responsibility for agencies are:

  • Lead - Agencies must implement cyber security planning and governance and report against the requirements outlined in the CSP and other cyber security measures.
  • Prepare - Agencies must build and support a cyber security culture across their agency and NSW Government more broadly.
  • Prevent - Agencies must manage cyber security risks to safeguard and secure their information and systems.
  • Detect/Respond/Recover - Agencies must improve their resilience including their ability to rapidly detect cyber incidents and respond appropriately.
  • Report - Agencies must report against the requirements outlined in the CSP and other cyber security measures.

DCS has only recommended, but not mandated the CSP for state owned corporations, local councils and universities.

NSW Government agencies must include an attestation on cyber security in their annual report and provide a copy to Cyber Security NSW by 31 August each year stating whether, for the preceding financial year, the agency has:

  • assessed its cyber security risks
  • appropriately addressed cyber security at agency governance forums
  • a cyber incident response plan that is integrated with the security components of business continuity arrangements, and the response plan has been tested during the previous 12 months (involving senior business executives)
  • certified the agency’s Information Security Management System (ISMS) or confirmed the agency’s Cyber Security Framework (CSF)
  • a plan to continuously improve the management of cyber security governance and resilience.

The purpose of the attestation is to focus the agency's attention on its cyber risks and the mitigation of those risks.

Agencies assess their level of compliance in accordance with a maturity model. The CSP does not mandate a minimum maturity threshold for any requirement, including implementation of the Australian Cyber Security Centre's (ACSC) Essential 8 Strategies to Mitigate Cyber Security Incidents (Essential 8).

Agencies are required to set a target maturity level based on their risk appetite for each requirement, seek continual improvement in their maturity, and annually assess their maturity on an ascending scale of one to five for all requirements (refer to Appendix two for the maturity model). Each control within the Essential 8 is assessed on an ascending scale of zero to three reflecting the agency's level of alignment with the strategy (refer to Appendix three for the maturity model).

Scope of this audit

We assessed whether agencies had provided accurate reporting on their level of maturity implementing the requirements of the CSP in a documented way and covering all their systems.

The scope of this audit covered nine agencies (the participating agencies). These agencies were selected because they are the lead agency in their cluster, or have a significant digital presence within their respective cluster. The list of participating agencies is in section 1.2. The audit aimed to determine whether, during the year to 30th June 2020, the participating agencies:

  • met their reporting obligations under the CSP
  • provided accurate reporting in self-assessments against the CSP’s mandatory requirements, including their implementation of the Australian Cyber Security Centre’s (ACSC) Essential 8
  • achieved implementation of mandatory requirements at maturity levels which meet or exceed the ‘level three - defined’ threshold (i.e. are documented and practiced on a regular and consistent basis).

While the audit does assess the accuracy of agency self-assessed ratings, the audit did not assess the appropriateness of the maturity ratings.

Conclusion

Key elements to strengthen cyber security governance, controls and culture are not sufficiently robust and not consistently applied. There has been insufficient progress to improve cyber security safeguards across NSW Government agencies.
The NSW CSP replaced the NSW Digital Information Security Policy from 1 February 2019. New requirements of the CSP were, inter alia, to strengthen cyber security governance, strengthen cyber security controls and improve cyber security culture.
The CSP is not achieving the objective of improved cyber governance, controls and culture because:
  • The CSP does not specify a minimum level for agencies to achieve in implementing the 'mandatory requirements' or the Essential 8 Strategies to Mitigate Cyber Security Incidents.
  • The CSP does not require agencies to report their target levels, nor does it require risk acceptance decisions to be documented or formally endorsed.
  • All of the participating agencies had implemented one or more of the mandatory requirements in an ad hoc or inconsistent basis.
  • None of the participating agencies had implemented all of the Essential 8 controls to at least level one.
  • Agencies tended to over-assess their cyber security maturity, with all nine participating agencies unable to support some of their self-assessments of compliance with one or more mandatory criteria. Optimistic assessment of the current state of cyber resilience undermines effective decision making and risk management in responding to cyber risks.
  • There is no systematised and formal monitoring, by either Cyber Security NSW or another agency, of the adequacy or accuracy of agencies' cyber self-assessment processes.

 

1. Key findings

The CSP allows agencies to determine their own level of maturity to implement the 'mandatory requirements', which can include not practicing a policy requirement or implementing a policy requirement on an ad hoc basis. These determinations do not need to be justified

Agencies can decide not to implement requirements of the CSP, or they can decide to implement them only in an informal or ad-hoc manner. The CSP allows agencies to determine their desired level of maturity in implementing the requirements on a scale of one to five - level one being 'initial – not practiced' and level five being 'optimised'. The desired level of maturity is determined by the agency based on their own assessment of the risk of the services they provide and the information they hold.

The reporting template for the 2019 version of the CSP stated that level three maturity - where a policy requirement is practiced on a regular and consistent basis and its processes are documented - was required for compliance with the CSP. This requirement was removed in the 2020 revision of the reporting template.

This CSP does not require the decisions on risk tolerance, or the timeframes agencies have set to implement requirements to be documented or formally endorsed by the agency head. There is no requirement to report these decisions to Cyber Security NSW.

Some comparable jurisdictions require formal risk acceptance decisions where requirements are not implemented. The NSW CSP does not have a similar formal requirement

Some jurisdictions, with a similar policy framework to NSW, require agencies to demonstrate reasons for not implementing requirements, and require agency heads to formally acknowledge the residual risk. The NSW CSP does not require these considerations to be documented, nor does it require an explicit acknowledgement and acceptance of the residual risk by the agency head or Cyber Security NSW. The NSW CSP does not require that the records of how agencies considered and decided which measures to adopt to be documented and auditable, limiting transparency and accountability of decisions made.

All of the participating agencies had implemented one or more of the mandatory requirements in an ad hoc or inconsistent basis

All of the participating agencies had implemented one or more of the mandatory requirements at level one or two. Maturity below level three typically means not all elements of the requirement have been implemented, or the requirements have been implemented on an ad-hoc or inconsistent basis.

None of the participating agencies has implemented all of the Essential 8 controls at level one – that is, only partly aligned with the intent of the mitigation strategy

Eight of the nine agencies we audited had not implemented any of the Essential 8 strategies to level three – that is, fully aligned with the intent of the mitigation strategy. At the time of this audit the ACSC advised that:

as a baseline organisations should aim to reach to reach Maturity Level Three for each mitigation strategy3.

The Australian Signals Directorate4 currently advises that, with respect to the Essential 8:

[even] level three maturity will not stop adversaries willing and able to invest enough time, money and effort to compromise a target. As such, organisations still need to consider the remainder of the mitigation strategies from the Strategies to Mitigate Cyber Security Incidents and the Australian Government Information Security Manual

All agencies failed to reach even level one maturity for at least three of the Essential 8.

Cyber Security NSW modified the ACSC model for implementation of the Essential 8

The NSW maturity model used for the Essential 8 does not fully align with the ACSC’s model. At the time of this audit the major difference was the inclusion of level zero in the NSW CSP maturity scale. Level zero broadly means that the relevant cyber mitigation strategy is not implemented or is not applied consistently. Level zero had been removed by the ACSC in February 2019 and was not part of the framework at the time of this audit. It was re-introduced in July 2021 when the ACSC revised the detailed criteria for each element of the essential 8 maturity model. The indicators to reach level one on the new ACSC model are more detailed, specific and rigorous than those currently prescribed for NSW Government agencies. Cyber Security NSW asserted the level zero on the CSP maturity scale:

is not identical to the level zero of the ACSC’s previous Essential 8 maturity model, but is a NSW-specific inclusion designed to prevent agencies incorrectly assessing as level one when they have not achieved that level.

Attestations did not accurately reflect whether agencies implemented the requirements

Of the nine participating agencies, seven did not modify the proforma wording in their attestation to reflect their actual situation. Despite known gaps in their implementation of mandatory requirements, these agencies stated that they had 'managed cyber security risks in a manner consistent with the Mandatory Requirements set out in the NSW Government Cyber Security Policy'. Only two agencies modified the wording of the attestation to reflect their actual situation.

Attestations should be accurate so that agencies’ and the government’s response to the risk of cyber attack is properly informed by an understanding of the gaps in agency implementation of the policy requirements and the Essential 8. Without accurate information about these gaps, subsequent decisions as to prioritisation of effort and deployment of resources are unlikely to effectively mitigate the risks faced by NSW Government agencies.

Participating agencies were not able to support all of their self-assessments with evidence and had overstated their maturity assessments, limiting the effectiveness of agency risk management approaches

Seven of the nine participating agencies reported levels of maturity against both the mandatory requirements and the Essential 8 that were not supported by evidence.

Each of the nine participating agencies for this audit had overstated their level of maturity against at least one of the 20 mandatory requirements. Seven agencies were not able to provide evidence to support their self-assessed ratings for the Essential 8 controls.

Where agency staff over-assess the current state of their cyber resilience, it can undermine the effectiveness of subsequent decision making by Agency Heads and those charged with governance. It means that actions taken in mitigating cyber risks are less likely to be appropriate and that gaps in implementing cyber security measures will remain, exposing them to cyber attack.

Agencies' self-assessments across government exposed poor levels of maturity in implementing the mandatory requirements and the Essential 8 controls

We reviewed the data 104 NSW agencies provided to Cyber Security NSW. The 104 agencies includes nine audited agencies referred to in more detail in this report. Our review of the 104 agency self-assessment returns submitted to Cyber Security NSW highlighted that, consistent with previous years, there remains reported poor levels of cyber security maturity. We reported the previous years’ self-assessments in the Central Agencies 2019 Report to Parliament and the Central Agencies 2020 Report to Parliament.

Only five out of the 104 agencies self-assessed that they had implemented all of the mandatory requirements at level three or above (against the five point scale). Fourteen agencies self-assessed that they had implemented each of the Essential 8 controls at level one maturity or higher (using Cyber NSW’s four point scale). The remainder reported at level zero for implementation of one or more of the Essential 8 controls, meaning that for the majority of agencies the cyber mitigation strategy has not been implemented, or is applied inconsistently.

Where agencies had reported in both 2019 and 2020, agencies’ self-assessments showed little improvement over the previous year’s self-assessments:

  • 14 agencies reported improvement across both the Essential 8 and the mandatory requirements
  • 8 agencies reported a net decline in both the Essential 8 and the mandatory requirements.

The poor levels of maturity in implementing the Essential 8 over the last couple of years is an area of significant concern that requires better leadership and resourcing to prioritise the required significant improvement in agency cyber security measures.

2. Recommendations

Cyber Security NSW should:

1. monitor and report compliance with the CSP by:

  • obtaining objective assurance over the accuracy of self-assessments
  • requiring agencies to resolve inaccurate or anomalous self-assessments where these are apparent

2. require agencies to report:

  • the target level of maturity for each mandatory requirement they have determined appropriate for their agency
  • the agency head's acceptance of the residual risk where the target levels are low

3. identify and challenge discrepancies between agencies' target maturity levels and the risks of the information they hold and services they provide

4. more closely align their policy with the most current version of the ACSC model.

Participating agencies should:

5. resolve the discrepancies between their reported level of maturity and the level they are able to demonstrate with evidence, and:

  • compile and retain in accessible form the artefacts that demonstrate the basis of their self-assessments
  • refer to the CSP guidance when determining their current level of maturity
  • ensure the attestations they make refer to departures from the CSP
  • have processes whereby the agency head and those charged with governance formally accept the residual cyber risks.

Repeat recommendation from the 2019 Central Agencies report and the 2020 Central Agencies report

6. Cyber Security NSW and NSW Government agencies need to prioritise improvements to their cyber security and resilience as a matter of urgency.


The objective of the CSP is to ensure cyber security risks are appropriately managed. However, meeting this objective depends on the requirements being implemented at all agencies to a level of maturity that addresses their specific cyber security risks. Agency systems and data are increasingly interconnected. If an agency does not implement the requirements, or implements them only in an ad-hoc or informal way, an agency is more susceptible to their systems and data being compromised, which may affect the confidentiality of citizens' data and the reliability of services, including critical infrastructure services.

Agencies determine their own target level of maturity, which may mean the requirement is not addressed, or is addressed in an ad hoc or inconsistent way

While the CSP is mandatory for all agencies, it does not set a minimum maturity threshold for agencies to meet.

The reporting template issued in 2019 stated that agencies were required to reach level three maturity in order to comply with the CSP. The 2020 revision6 of the CSP and guidance indicates that level three maturity may not be sufficient to mitigate risks. It advises the agency may determine the level to which it believes it is suitable to implement the requirements, and allows for an agency to aim for a target level of maturity less than level three. The agency can set its optimal maturity level with reference to its risk tolerance with the objective that that aim ‘to be as high as possible’. However, ‘as high as possible’ does not necessarily mean ‘fully implemented’. The CSP contemplates that a lower level of maturity is sufficient if it aligns with the agency's risk tolerance.

2019 reporting template 2020 reporting template
‘A Mandatory Requirement is considered met if a maturity level of three is achieved. The Agency may choose to pursue a higher maturity level if required.

There is no mandated level for the Essential 8 Maturity reporting’.

‘There is no mandated maturity level for either the Mandatory Requirement reporting or Essential 8 reporting. Agencies need to risk-assess their optimal maturity and aim to be 'as high as possible’.
Source: Maturity Reporting Template v4.0, February 2019.
Source: CSP Reporting Template 2020, May 2020.

The Department of Customer Service asserts that while the quotes above were part of their annual templates and policy documents, their documents were incorrect. They assert that the policy has never required a minimum level of maturity to be reached. They have responded to our enquiries that:

…a level three maturity was not a requirement of the Policy or Maturity Model’ and ‘it is misleading to suggest it was a requirement of the Policy.

This audit found that, based on the 2020 reporting template there is no established minimum baseline. Consequently, because the Department of Customer Service had not established a minimum baseline agencies are able to target lower levels (providing they were within the agency’s own risk appetite), which includes targeting to not practice a CSP policy requirement, or to practice a CSP policy requirement on an ad hoc basis.

Where requirements are not implemented, documentation of formal acceptance of the residual risks by the agency head is not required

The New Zealand Government has an approach that is not dissimilar to NSW, in that it also identifies 20 mandatory requirements and allows for a risk based approach to implementation. However, the New Zealand approach puts more rigor around risk acceptance decisions.

The New Zealand Government requires that agencies that do not implement the requirements must demonstrate that a measure is not relevant for them. It requires agencies to document the rationale for not implementing the measure, including explicit acknowledgement of the residual risk by the agency head. They require these records to be auditable.

A security measure with a ‘must’ or ‘must not’ compliance requirement is mandatory. You must implement or follow mandatory security measures unless you can demonstrate that a measure is not relevant in your context.

Not using a security measure without due consideration may increase residual risk for your organisation. This residual risk needs to be agreed and acknowledged by your organisation head.

A formal auditable record of how you considered and decided which measures to adopt is required as part of the governance and assurance processes within your organisation.

Source: Overview of Protective Security Requirements, New Zealand Government (PSR-Overview-booklet.pdf (protectivesecurity.govt.nz).

The NSW CSP does not require these considerations to be documented or auditable and does not require an explicit acknowledgement or acceptance of the residual risk by the agency head.

None of the participating agencies achieved level three implementation for all mandatory risk prevention and mitigation requirements

Maturity level three is the minimum level whereby an agency has implemented documented processes that are practiced on a regular basis across their environment. An agency has not reached level three if the requirement is implemented on an ad-hoc or inconsistent basis, or if not all elements of the requirement have been implemented.

None of the participating agencies achieved level three implementation for all mandatory requirements.

The requirements of the CSP are organised into five sections. Agency implementation of these requirements is discussed in the next five sections of this report.

  • Lead: Planning and governance requirements. Section 2.1
  • Prepare: Cyber security culture requirements. Section 2.2
  • Prevent: Managing cyber incident prevention requirements. Section 2.3
  • Detect/Respond/Recover: Resilience requirements. Section 2.4
  • Report: Reporting requirements. Section 2.5.

 


6The reporting template issued in 2019 required agencies to reach level three, but that guidance was removed in the 2020 revision.

Appendix one – Response from agencies

Appendix two – The maturity model for the mandatory requirements

Appendix three – Essential 8 maturity model

Appendix four – About the audit

 

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 Rail freight and Greater Sydney

Rail freight and Greater Sydney

Transport
Information technology
Infrastructure
Management and administration
Project management
Service delivery

What the report is about

The movement of freight contributes $66 billion annually to the NSW economy. Two thirds of all freight in NSW moves through Greater Sydney, and the volume of freight moving through Greater Sydney is expected to increase by 48 per cent by 2036.

This audit assessed the effectiveness of transport agencies in improving the use of rail freight capacity in Greater Sydney, and to meet current and future freight demand.

What we found

Transport agencies do not have strategies or targets in place to improve the efficiency or capacity of the metropolitan shared rail network for freight.

The transport agencies acknowledge that they do not have sufficient information to achieve the most efficient freight outcomes and they do not know how to use the shared rail network to maximise freight capacity without compromising passenger rail services.

The Freight and Ports Plan 2018-2023 contains one target for rail freight - to increase the use of rail at Port Botany to 28 per cent by 2021. However, Transport for NSW (TfNSW)'s data indicates this target will not be met.

Sydney Trains records data on train movements and collects some data on delays and incidents. TfNSW collects data for the construction of the Standard Working Timetable and third-party contracts.

However, a lack of clarity around what data is gathered and who has ownership of the data makes data sharing difficult and limits its analysis and reporting.

The Freight and Ports Plan 2018-2023 includes the goal of 'Reducing avoidable rail freight delays', but the transport agencies do not have any definition for an avoidable delay and, as a result, do not measure or report them.

TfNSW and Sydney Trains are appointed to manage and deliver the Transport Asset Holding Entity of New South Wales (TAHE)'s obligations to allow rail freight operators to use the shared rail network. There are no performance measures in rail freight operator contracts or inter-agency agreements. This limits transport agencies' ability to improve performance.

TfNSW’s Freight Branch is working on four freight-specific strategies; a review of the Plan, a freight rail strategy, a port efficiency strategy and a freight data strategy.

TfNSW has not yet determined the timeframes or intended outcomes of these strategies.

What we recommended

Transport agencies should:

  • commit, as part of the review of Future Transport 2056, to delivering the freight-specific strategies currently in development and develop whole-of-cluster accountability for this work including timeframes, specific targets and clear roles and responsibilities 
  • improve the collection and sharing of freight data
  • develop a plan to reduce avoidable freight delays
  • systematically collect data on the management of all delays involving and/or impacting rail-freight
  • develop and implement key performance indicators for the agreements between the transport agencies.

Fast facts    

  • 288 million tonnes of freight volume predicted to pass through Greater Sydney in 2036, up from 194 million in 2016 (an increase of 48%)

  • 54 trucks that can be replaced by one 600 m long port shuttle freight train    

  • 26,671 freight trains that passed through the metropolitan shared rail network between 1 July 2020 and 30 June 2021

The movement of freight contributes $66.0 billion annually to the New South Wales economy — or 13 per cent of the Gross State Product. Two thirds of all freight in New South Wales moves through Greater Sydney, and the volume of freight moving through Greater Sydney is expected to increase by 48 per cent by 2036. This increasing demand is driven by increasing population and economic growth.

The sequence of activities required to move goods from their point of origin to the eventual consumer (the supply chain) is what matters most to shippers and consumers. Road can provide a single-mode door-to-door service, whereas conveying goods by rail typically involves moving freight onto road at some point. In Greater Sydney, 80 per cent of all freight is moved on road. Freight often passes through intermodal terminals (IMTs) as it transitions from one mode of transport to the next.

In 2016, Transport for NSW (TfNSW) released Future Transport 2056 - the NSW Government's 40-year vision for transport in New South Wales, which is intended to guide investment over the longer term. In Future Transport 2056, TfNSW noted that New South Wales will struggle to meet increasing demand for freight movements unless rail plays a larger role in the movement of freight.

Sydney Trains manages the metropolitan shared rail network, which is made up of rail lines that are used by both passenger and freight trains. The Transport Administration Act 1988 requires that, for the purposes of network control and timetabling, NSW Government transport agencies give ‘reasonable priority’ to passenger trains on shared lines. As the Greater Sydney population and rail patronage continue to grow, so too will competition for access to the shared rail network. See Appendix two for details of the area encompassed by Greater Sydney.

Freight operators can also use dedicated rail freight lines operated by the Australian Rail Track Corporation (ARTC - an Australian Government statutory-owned corporation). As the metropolitan shared rail network connects with dedicated freight lines, freight operators often use both to complete a journey.

TfNSW, Sydney Trains and the Transport Asset Holding Entity (TAHE) work in conjunction with other rail infrastructure owners and private sector entities, including port operators, privately operated IMTs and freight-shipping companies. TfNSW and Sydney Trains are responsible for managing the movement of freight across the metropolitan shared rail network. TAHE is the owner of the rail infrastructure that makes up the metropolitan shared rail network. The NSW Government established TAHE, a NSW Government state-owned corporation, on 1 July 2020 to replace the former rail infrastructure owner - RailCorp. The Auditor-General for New South Wales has commenced a performance audit on TAHE which is expected to table in 2022.

On 1 July 2021, TAHE entered into new agreements with TfNSW and Sydney Trains to operate, manage and maintain the metropolitan shared rail network. Until 30 June 2021, and in accordance with TAHE's Implementation Deed, TAHE operated under the terms of RailCorp's existing arrangements and agreements.

This audit assessed the effectiveness of TfNSW, Sydney Trains and TAHE in improving the use of rail freight capacity in Greater Sydney, and to meet current and future freight demand.

The audit focused on:

  • the monitoring of access to shared rail lines
  • the management of avoidable delays of rail freight movements
  • steps to increase the use of rail freight capacity in Greater Sydney.

Conclusion

Transport agencies do not have clear strategies or targets in place to improve the freight efficiency or capacity of the metropolitan shared rail network. They also do not know how to make best use the rail network to achieve the efficient use of its rail freight capacity. These factors expose the risk that rail freight capacity will not meet anticipated increases in freight demand.

Future Transport 2056 notes that opportunities exist to shift more freight onto rail, and that making this change remains an important priority for the NSW Government. However, the transport agencies acknowledge that they do not have sufficient information to achieve the most efficient freight outcomes. In particular, transport agencies do not know how to use the shared rail network in a way that maximises freight capacity without compromising passenger rail services.

Neither Future Transport 2056 nor the Freight and Ports Plan 2018–2023 give any guidance on how transport agencies will improve the efficiency or capacity of the shared rail network. Other than a target for rail freight movements to and from Port Botany, which TfNSW's data indicates will not be met, there are no targets for improving rail freight capacity across the shared network. The lack of specific strategies, objectives and targets reduces accountability and makes it difficult for transport agencies to effectively improve the use of rail freight capacity in line with their commitment to do so.

Sydney Trains and Transport for NSW do not effectively use data to improve rail freight performance and capacity.

To drive performance improvement when planning for the future, transport agencies need good quality data on freight management and movements. Sydney Trains records data on train movements in real-time and collects some data on delays and incidents. TfNSW collects data for the construction of the Standard Working Timetable (SWTT) and third-party contracts. However, the different types of data gathered and the separation between the teams responsible mean that there is a lack of clarity around what data is gathered and who has ownership it. This lack of coordination prevents best use of the data to develop a single picture of how well the network is operating or how performance could be improved.

Sydney Trains' ability to evaluate the effectiveness of its incident and delay mitigation strategies is also limited by a lack of information on its management of rail-freight related delays or incidents. While Sydney Trains collects data on major incidents, it can only use this to conduct event-specific analysis on the causes of an incident, and to review the operational and management response. The use of complete and accurate incident data would assist to define, identify and reduce avoidable delays. Reducing avoidable delays is a goal of the Freight and Ports Plan 2018–2023. More complete data on all incidents would help TfNSW to have more effective performance discussions with rail freight operators to help improve performance.

TfNSW has started developing strategies to identify how it can use rail freight capacity to achieve efficient freight outcomes, but it has not committed to implementation timeframes for this work.

TfNSW’s Freight Branch has started work on four freight-specific strategies to improve freight efficiency: a review of the Plan, a freight rail strategy, a port efficiency strategy and a freight data strategy. However, none of these strategies will be fully developed before the end of 2022. TfNSW has not yet determined the implementation timeframes or intended outcomes of these strategies, although TfNSW reports that it is taking an iterative approach and some recommendations and initiatives will be developed during 2022. 

Appendix one - Response from agencies

Appendix two - The Greater Sydney region

Appendix three - TfNSW strategic projects 

Appendix four - Sydney Trains path priority principles 

Appendix five - Sydney Trains delay management

Appendix six - About the audit 

Appendix seven - 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 #357 - released (19 October 2021).

Published

Actions for Managing climate risks to assets and services

Managing climate risks to assets and services

Planning
Environment
Treasury
Industry
Infrastructure
Management and administration
Risk
Service delivery

What the report is about

This report assessed how effectively the Department of Planning, Industry and Environment (DPIE) and NSW Treasury have supported state agencies to manage climate risks to their assets and services.

Climate risks that can impact on state agencies' assets and services include flooding, bushfires, and extreme temperatures. Impacts can include damage to transport, communications and energy infrastructure, increases in hospital admissions, and making social housing or school buildings unsuitable.

NSW Treasury estimates these risks could have significant costs.

What we found

DPIE and NSW Treasury’s support to agencies to manage climate risks to their assets and services has been insufficient.

In 2021, key agencies with critical assets and services have not conducted climate risk assessments, and most lack adaptation plans.

DPIE has not delivered on the NSW Government commitment to develop a state-wide climate change adaptation action plan. This was to be complete in 2017.

There is also no adaptation strategy for the state. These have been released in all other Australian jurisdictions. The NSW Government’s draft strategic plan for its Climate Change Fund was also never finalised.

DPIE’s approach to developing climate projections is robust, but it hasn’t effectively educated agencies in how to use this information to assess climate risk.

NSW Treasury did not consistently apply dedicated resourcing to support agencies' climate risk management until late 2019.

In March 2021, DPIE and NSW Treasury released the Climate Risk Ready NSW Guide and Course. These are designed to improve support to agencies.

What we recommended

DPIE and NSW Treasury should, in partnership:

  • enhance the coordination of climate risk management across agencies
  • implement climate risk management across their clusters.

DPIE should:

  • update information and strengthen education to agencies, and monitor progress
  • review relevant land-use planning, development and building guidance
  • deliver a climate change adaptation action plan for the state.

NSW Treasury should:

  • strengthen climate risk-related guidance to agencies
  • coordinate guidance on resilience in infrastructure planning
  • review how climate risks have been assured in agencies’ asset management plans.

Fast facts

4 years

between commitments in the NSW Climate Change Policy Framework, and DPIE and NSW Treasury producing key supports to agencies for climate risk management.

$120bn

Value of physical assets held by nine NSW Government entities we examined that have not completed climate risk assessments.

Low capability to do climate risk assessment has been found across state agencies. The total value of NSW Government physical assets is $365 billion, as at 30 June 2020.

x3

NSW Treasury’s estimates of the annual fiscal and economic costs associated with natural disasters will triple by 2060–61.

According to the Intergovernmental Panel on Climate Change in 2021, each of the last four decades has been successively warmer and surface temperatures will continue to increase until at least the mid-century. The Commonwealth Scientific and Industrial Research Organisation (CSIRO) and the Bureau of Meteorology (BoM) have reported that extreme weather across Australia is more frequent and intense, and there have been longer-term changes to weather patterns. They also report sea levels are rising around Australia increasing the risk of inundation and damage to coastal infrastructure and communities.

According to the Department of Planning, Industry and Environment (the department), in New South Wales the impacts of a changing climate, and the risks associated with it, will be felt differently across regions, populations and economic sectors. The department's climate projections indicate the number of hot days will increase, rainfall will vary across the state, and the number of severe fire days will increase.

The NSW Government is a provider of essential services, such as health care, education and public transport. It also owns and manages around $365 billion in physical assets (as at June 2020). More than $180 billion of its assets are in major infrastructure such as roads and railway lines.

In NSW, climate risks that could directly impact on state agencies' assets and services include flooding, bushfires, and extreme temperatures. In recent years, natural hazards exacerbated by climate change have damaged and disrupted government transport, communications and energy infrastructure. As climate risks eventuate, they can also increase hospital admissions when people are affected by poorer air quality, and make social housing dwellings or schools unsafe and unusable during heatwaves. The physical impacts of a changing climate also have significant financial costs. Taking into account projected economic growth, NSW Treasury has estimated that the fiscal and economic costs associated with natural disasters due to climate change will more than triple per year by 2061.

The department and NSW Treasury advise that leading practice in climate risk management includes a process that explicitly identifies climate risks and integrates these into existing risk management, monitoring and reporting systems. This is in line with international risk management and climate adaptation standards. For agencies to manage the physical risks of climate change to their assets and services, leading practice identified by the department means that they need to:

  • use robust climate projection information to understand the potential climate impacts
  • undertake sound climate risk assessments, within an enterprise risk management framework
  • implement adaptation plans that reduce these risks, and harness opportunities.

Adaptation responses that could be planned for include: controlling development in flood-prone locations; ensuring demand for health services can be met during heatwaves; improving thermal comfort in schools to support student engagement; proactive asset maintenance to reduce disruption of essential services, and safeguarding infrastructure from more frequent and intense natural disasters.

According to NSW Treasury policy, agencies are individually responsible for risk management systems appropriate to their context. The department and NSW Treasury have key roles in ensuring that agencies are supported with robust information and timely, relevant guidance to help manage risks to assets and services effectively, especially for emerging risks that require coordinated responses, such as those posed by climate change.

This audit assessed whether the department and NSW Treasury are effectively supporting NSW Government agencies to manage climate risks to their assets and services. It focused on the management of physical risks to assets and services associated with climate change.

Conclusion

The Department of Planning, Industry and Environment (the department) has made climate projections available to agencies since 2014, but provided limited guidance to assist agencies to identify and manage climate risks. NSW Treasury first noted climate change as a contextual factor in its 2012 guidance on risk management. NSW Treasury only clarified requirements for agencies to integrate climate considerations into their risk management processes in December 2020.
The department has not delivered on a NSW Government commitment for a state-wide climate change adaptation action plan, which was meant to be completed in 2017. Currently many state agencies that own or manage assets and provide services do not have climate risk management in place.
Since 2019, the department and NSW Treasury have worked in partnership to develop a coordinated approach to supporting agencies to manage these risks. This includes guidance to agencies on climate risk assessment and adaptation planning published in 2021.
More work is needed to embed, sustain and lead effective climate risk management across the NSW public sector, especially for the state's critical infrastructure and essential services that may be exposed to climate change impacts.

The NSW Government set directions in the 2016 NSW Climate Change Policy Framework to 'manage the impact of climate change on its assets and services by embedding climate change considerations into asset and risk management’ and more broadly into 'government decision-making'.

The department released climate projections and has made information on projected climate change impacts available since 2014, but this has not been effectively communicated to agencies. The absence of a state-wide climate change adaptation action plan has limited the department's implementation of a coordinated, well-communicated program of support to agencies for their climate risk management.

NSW Treasury is responsible for managing the state's finances and providing stewardship to the public sector on financial and risk management, but it did not consistently apply dedicated resourcing to support agencies' climate risk management until late 2019. NSW Treasury estimates the financial costs of climate-related physical risks are significant and will continue to grow.

The partnership between the department and NSW Treasury has produced the 2021 Climate Risk Ready NSW Guide and Course, which aim to help agencies understand their exposure to climate risks and develop adaptation responses. The Guide maps out a process for climate risk assessment and adaptation planning and is referenced in NSW Treasury policy on internal audit and risk management. It is also referenced in NSW Treasury guidance to agencies on how to reflect the effects of climate-related matters in financial statements.

There is more work to be done by the department on maintaining robust, accessible climate information and educating agencies in its use. NSW Treasury will need to continue to update its policies, guidance and economic analyses with relevant climate considerations to support an informed, coordinated approach to managing physical climate risks to agencies' assets and services, and to the state's finances more broadly.

The effectiveness of the department and NSW Treasury's support involves the proactive and sustained take-up of climate risk management by state agencies. There is a key role for the department and NSW Treasury in monitoring this progress and its results.

Prior to 2021, support provided by the Department of Planning, Industry and Environment (the department) to agencies for managing physical climate risks to their assets and services has been limited. NSW Treasury has a stewardship role in public sector performance, including risk management, but has not had a defined role in working with the department on climate risk matters until mid-2019. The low capacity of agencies to undertake this work has been known to NSW Government through agency surveys by the department in 2015 and by the department and NSW Treasury in 2018.

The support delivered to agencies around climate risk management, including risk assessment and adaptation planning, has been slow to start and of limited impact. The department's capacity to implement a coordinated approach to supporting agencies has also been limited by the absence of a state-wide adaptation strategy and related action plan.

In 2021, products were released by the department and NSW Treasury with potential to improve support to agencies on climate risk assessment and adaption planning (that this, Climate Risk Ready NSW Guide and Course, which provides links to key NSW Treasury polices). The department and NSW Treasury are now leading work to develop a more coordinated approach to climate risk management for agencies' assets and services, and building the resilience of the state to climate risk more broadly.

Climate projections are a key means of understanding the potential impacts of climate change, which is an important step in the climate risk assessment process. The Department of Planning, Industry and Environment (the department) used a robust approach to develop its climate projections (NARCliM). The full version of NARCliM (v1.0) is based on 2007 models11 and while still relevant, this has limited its perceived usefulness and uptake. The process of updating these projections requires significant resourcing. The department has made recent updates to enhance the currency and usefulness of its climate projections. NARCliM (v2.0) should be available in 2022.

While climate projections have been available to agencies and the community more broadly since 2013–14, the department has not been effective in educating the relevant data users within agencies in how to use the information for climate risk assessments and adaptation planning.

The absence of a strategy focused on this is significant and has contributed to the current low levels of climate risk assessment uptake across agencies (see section 2). Agencies are required to use the climate projections developed by the department when developing long term plans and strategies as part of the NSW Government Common Planning Assumptions.


11 The department advises the 2007 global climate models were released to users by the Intergovernmental Panel on Climate Change in 2010.
It is too soon to determine the impact of the 2021 Climate Risk Ready NSW (CRR) Guide and Course, produced by the Department of Planning, Industry and Environment (the department) and NSW Treasury. But there are opportunities for these agencies to progress these developments in partnership: especially with the establishment of senior executive steering and oversight committees related to climate risk.

For the department, key opportunities to embed climate risk management include leveraging land use planning policies and guidance to drive adaptation, which has potential to better protect the state's assets and services. NSW Treasury has a role in continuing to update its policies, guidance and economic analyses with relevant climate change considerations to support an informed, coordinated approach to addressing physical climate risks to agencies' assets and services, and to the state's finances more broadly.

There is currently no plan on how the department and NSW Treasury intend to routinely monitor the progress of agencies with implementing the CRR Guide or developing climate risk 'maturity' more broadly. As agencies are responsible for implementing risk management systems that meet NSW Treasury standards, which now clearly includes consideration of climate risk (TPP20-08), establishing effective monitoring, reporting and accountability around this progress should be a priority for the department and NSW Treasury.

Appendix one – Response from agencies

Appendix two – Timeline of key activities 

Appendix three – About the audit 

Appendix four – 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 #355 - released (7 September 2021).

Published

Actions for Managing cyber risks

Managing cyber risks

Whole of Government
Transport
Cyber security
Information technology
Internal controls and governance
Procurement
Risk

What the report is about

This audit assessed how effectively Transport for NSW (TfNSW) and Sydney Trains identify and manage their cyber security risks.

The NSW Cyber Security Policy (CSP) sets out 25 mandatory requirements for agencies, including implementing the Australian Cyber Security Centre’s Essential 8 strategies to mitigate cyber security incidents, and identifying the agency’s most vital systems, their ‘crown jewels’. 

The audited agencies have requested that we do not disclose detail of the significant vulnerabilities detected during the audit, as these vulnerabilities are not yet remediated. We provided a detailed report to the agencies in December 2020 outlining significant issues identified in the audit. We have conceded to the agencies' request but it is disappointing that transparency to the Parliament and the public on issues that potentially directly affect them needs to be limited in this way.

What we found

TfNSW and Sydney Trains are not effectively managing their cyber security risks.

Both agencies have assessed their cyber security risks as unacceptably high and both agencies had not identified all of the risks we detected during this audit – some of which are significant.

Both agencies have cyber security plans in place that aim to address cyber security risks. TfNSW and Sydney Trains have combined this into the Transport Cyber Defence Rolling Program, part of the Cyber Defence Portfolio (CDP). 

However, neither agency has reached its target ratings for the CSP and the Essential 8 and maturity is low in relation to significant risks and vulnerabilities exposed.

Further, neither agency is fostering a culture where cyber security risk management is an important and valued aspect of decision-making.

TfNSW is not implementing cyber security training effectively across the cluster with only 7.2% of staff having completed basic cyber security training.

What we recommended

TfNSW and Sydney Trains should:

  • develop and implement a plan to uplift the Essential 8 controls to the agency's target state
  • as a matter of priority, address the vulnerabilities identified as part of this audit and previously described in a detailed Audit Office report provided to both agencies
  • ensure cyber security risk reporting to executives and the Audit and Risk Committee
  • collect supporting information for the CSP self assessments 
  • classify all information and systems according to importance and integrate this with the crown jewels identification process
  • require more rigorous analysis to re-prioritise CDP funding 
  • increase uptake of cyber security training.

TfNSW should assess the appropriateness of its target rating for each of the CSP mandatory requirements.

Department of Customer Service should:

  • clarify the requirement for the CSP reporting to apply to all systems
  • require agencies to report the target level of maturity for each mandatory requirement.

Fast facts

  • $42m Total value of the Transport Cyber Defence Rolling Program over three years.
  • 7.2% Percentage of staff across the Transport cluster who had completed introductory cyber security training

Response to requests by audited agencies to remove information from this report

In preparing this audit report, I have considered how best to balance the need to support public accountability and transparency with the need to avoid revealing information that could pose additional risk to agencies’ systems. This has involved an assessment of the appropriate level of detail to include in the report about the cyber security vulnerabilities identified in this audit.

In making this assessment, the audit team consulted with Transport for NSW (TfNSW), Sydney Trains, and Cyber Security NSW to identify content which could potentially pose a threat to the agencies’ cyber security.

In December 2020, my office also provided TfNSW and Sydney Trains with a detailed report of many of the significant vulnerabilities identified in this audit, to enable the agencies to address the cyber security risks identified. The detailed report was produced as a result of a 'red team' exercise, which was conducted with both agencies' knowledge and consent. The scope of this exercise reflected the significant input provided by both agencies. More information on this exercise is at page 12 of this report.

TfNSW and Sydney Trains have advised that in the six months from December 2020 and at the time of tabling this audit report, they have not yet remediated all the vulnerabilities identified. As a result, they, along with Cyber Security NSW, have requested that we not disclose all information contained in this audit report to reduce the likelihood of an attack on their systems and resulting harm to the community. I have conceded to this request because the vulnerabilities identified have not yet been remediated and leave the agencies exposed to significant risk.

It should be stressed that the risks identified in the detailed report exist due to the continued presence of these previously identified vulnerabilities, rather than due to their potential publication. The audited agencies, alone, are accountable for remediating these vulnerabilities and addressing the risks they pose.

It is disappointing that transparency to the Parliament and the public on issues that potentially directly affect them needs to be limited in this way.

That said, the conclusions drawn in this report are significant in terms of risk and remain valid, and the recommendations should be acted upon with urgency.

Cyber security risk is an increasing area of concern for governments in Australia and around the world. In recent years, there have been a number of high-profile cyber security attacks on government entities in Australia, including in New South Wales. Malicious cyber activity in Australia is increasing in frequency, scale, and sophistication. The Audit Office of New South Wales is responding to these risks with a program of audits in this area, which aim to identify the effectiveness of particular agencies in managing cyber risks, as well as their compliance with relevant policy.

Cyber Security NSW, part of the Department of Customer Service (DCS) releases and manages the NSW Cyber Security Policy (CSP). The CSP sets out 25 mandatory requirements for agencies, including making it mandatory for agencies to implement the Australian Cyber Security Centre Essential 8 Strategies to Mitigate Cyber Security Incidents (the Essential 8). The Essential 8 are key controls which serve as a baseline set of protections which agencies can put in place to make it more difficult for adversaries to compromise a system. Agencies are required to self-assess their maturity against the CSP and the Essential 8, and report that assessment to Cyber Security NSW annually.

The CSP makes agencies responsible for identifying and managing their cyber security risks. The CSP sets out responsibilities and governance regarding risk identification, including making agencies responsible for identifying their 'crown jewels', the agency's most valuable and operationally vital systems. Once these risks are identified, agencies are responsible for developing a cyber security plan to mitigate those risks.

This audit focussed on two agencies: Transport for NSW (TfNSW) and Sydney Trains. TfNSW is the lead agency for the Transport cluster and provides a number of IT services to the entire cluster, including Sydney Trains. This audit focussed on the activities of TfNSW's Transport IT function, which is responsible for providing cyber security across the cluster, as well as directly overseeing four of TfNSW's crown jewels. Sydney Trains is one of the agencies in the Transport cluster. While it receives some services from TfNSW, it is also responsible for implementing its own IT controls, as well as controls to protect its Operational Technology (OT) environment. This OT environment includes systems which are necessary for the operation and safety of the train network.

To test the mitigations in place and the effectiveness of controls, this audit involved a 'red team' simulated exercise. A red team involves authorised attackers seeking to achieve certain objectives within the target's environment. The red team simulated a determined external cyber threat actor seeking to gain access to TfNSW's systems. The red team also sought to test the physical security of some Sydney Trains' sites relevant to the agency's cyber security. The red team exercise was conducted with the knowledge of TfNSW and Sydney Trains.

This audit included the Department of Customer Service as an auditee, as they have ownership of the CSP through Cyber Security NSW. This audit did not examine the management of cyber risk in the Department of Customer Service.

This audit assessed how effectively selected agencies identify and manage their cyber security risks. The audit assessed this with the following criteria:

  • Are agencies effectively identifying and planning for their cyber security risks?
  • Are agencies effectively managing their cyber security risks?

Following this in-depth portfolio assessment, the Auditor-General for NSW will also table a report on NSW agencies' compliance with the CSP in the first quarter of 2021–22.

Conclusion

Transport for NSW and Sydney Trains are not effectively managing their cyber security risks. Significant weaknesses exist in their cyber security controls, and both agencies have assessed that their cyber risks are unacceptably high. Neither agency has reached its Essential 8 or Cyber Security Policy target levels. This low Essential 8 maturity exposes both agencies to significant risk. Both agencies are implementing cyber security plans to address identified cyber security risks.
This audit identified other weaknesses, such as low numbers of staff receiving basic cyber security awareness training. Cyber security training is important for building and supporting a cyber security culture. Not all of the weaknesses identified in this audit had previously been identified by the agencies, indicating that their cyber security risk identification is only partially effective.
Agency executives do not receive regular detailed information about cyber risks and how they are being managed, such as information on mitigations in place and the effectiveness of controls for cyber risk. As a result, neither agency is fostering a culture where cyber security risk management is an important and valued aspect of executive decision-making.
TfNSW and Sydney Trains are partially effective at identifying their cyber security risks and both agencies have cyber security plans in place

Both agencies regularly carry out risk assessments and have identified key cyber security risks, including risks that impact on the agencies' crown jewels. These risks have been incorporated into the overall enterprise risk process. However, neither agency regularly reports detailed cyber risk information to agency executives to adequately inform them about cyber risk. The Cyber Security Policy (CSP) requires agencies to foster a culture where cyber security risk management is an important and valued aspect of decision-making. By not informing agency executives in this way, TfNSW and Sydney Trains are not fulfilling this requirement.

Agencies' cyber security risk assessment processes are not sufficiently comprehensive to identify all potential risks. Not all of the weaknesses identified in this audit had previously been identified by the agencies.

To address identified cyber security risks, both agencies have received funding approval to implement cyber security plans. TfNSW first received approval for its cyber security plan in 2017. Sydney Trains received approval for its cyber security plan in February 2020. In 2020–21 TfNSW and Sydney Trains combined their plans into the Transport Cyber Defence Rolling Program business case valued at $42.0 million over three years. This is governed as part of a broader Cyber Defence Portfolio (CDP). The CDP largely takes a risk-based approach to annual funding. The Cyber Defence Portfolio Steering Committee and Board can re-allocate funds from an approved project to a different project. This re-allocation process could be improved by making it more risk-based.

TfNSW and Sydney Trains are not effectively managing their cyber security risks

Neither agency has fully mitigated its cyber security risks. These risks are significant. Neither TfNSW nor Sydney Trains have reduced their cyber risk to levels acceptable to the agencies. Both agencies have set a risk tolerance for cyber security risks, and the identified enterprise-level cyber security risks remain above this rating. Both agencies' self-attested maturity against the Essential 8 remains low in comparison to the agencies' target levels, and in relation to the significant risks and vulnerabilities that are exposed. Little progress was made against the Essential 8 in 2020.

Neither agency has reached its target levels of maturity for the CSP mandatory requirements. Not reaching the target rating of the CSP mandatory requirements risks information and systems being managed inconsistently or not in alignment with good governance principles. The Transport Cyber Defence Rolling Program has a KPI to achieve a target rating of three for all CSP requirements where business appropriate. TfNSW considers this target rating to be its target for all the CSP requirements. However TfNSW has not undertaken analysis to determine whether this target is appropriate to its business.

The CSP makes agencies accountable for the cyber risks of their ICT service providers. While both agencies usually included their cyber security expectations in contracts with third-party suppliers, neither agency was routinely conducting audits to ensure that these expectations were being met.

The CSP requires agencies to make staff aware of cyber security risks and deliver cyber security training. TfNSW is responsible for delivering cyber security training across the Transport cluster, including in Sydney Trains. TfNSW was not effectively delivering cyber security training across the cluster because training was not mandatory for all staff at the time of the audit and completion rates among those staff assigned the training was low. As such, only 7.2 per cent of staff across the Transport cluster had completed introductory cyber security training as at January 2021.

Agencies have assessed their cyber risks as being above acceptable levels

An agency's risk tolerance is the amount of risk which the agency will accept or tolerate without developing further strategies to modify the level of risk. Risks that are within an agency's risk tolerance may not require further mitigation and may be deemed acceptable, while risks which are above the agency's risk tolerance likely require further mitigation before they become acceptable to the agency.

Both agencies have defined their risk tolerance and have identified risks which are above this level, indicating that they are unacceptable to the agency. TfNSW has defined 'very high' risks as generally intolerable and 'high' risks as undesirable. Its risk tolerance is 'medium'. Sydney Trains has four classifications of risk: A, B, C and D. A and B risks are deemed 'unacceptable' and 'undesirable' respectively, while C risks are considered 'tolerable'. This aligns with the TfNSW definition of a medium risk tolerance.

Transport IT reported five enterprise-level cyber security risks through its enterprise risk reporting tool in September 2020, all of which relate to cyber security or have causes relating to cyber security. These risks are in aggregate form, rather than relating to specific vulnerabilities. At the time of the audit, one of these risks was rated as very high and the other four rated as high. At this time, Transport IT had identified a further seven divisional-level risks which were above the agency’s risk tolerance.

Similarly, Sydney Trains has identified one main cyber security risk in its IT enterprise-level risk register and another with a potential cyber cause. Both of these IT risks are deemed to have a residual risk of ‘unacceptable’.

Similarly, two cyber-related OT risks have been determined to be above the agency's risk tolerance. One risk is rated as 'unacceptable'. Another risk, while not entirely cyber rated, is rated 'undesirable' and is deemed to have some causes which may stem from a cyber-attack.

Agencies have assessed their current cyber risk mitigations as requiring improvement

In addition to the risk ratings stated above, at the time of the audit neither agency believed that its controls were operating effectively. Transport IT had rated the control environments for its cyber security enterprise risks as 'requires improvement'. Mitigations were listed in the risk register for these risks but, in some cases, they were unlikely to reduce the risk to the target state or by the target date. For example, one risk had actions listed as 'under review' and no further treatment actions listed, but a due date of July 2021, while another risk was being treated by the CDP with a due date of July 2021. The CDP identified in May 2020 that while the average risk identified as part of that program will be reduced to a medium level by this date, ten high risks will still remain. Given the delays in the program, this number may be higher. As such, it seems unlikely that the enterprise risk will be reduced to below a 'high' level by July 2021.

Sydney Trains’ IT and OT risk registers cross-reference controls and mitigations against the causes and consequences. The IT cyber security risk identified in the register had causes with no mitigations designed for them. Further, some of these causes did not have future mitigations designed for them. This risk also had controls in place which are identified as partially effective. For the unacceptable OT risk noted above, while there was a control designed for each of the potential causes, Sydney Trains had identified all of the controls in place as either partially effective or ineffective. This indicates that Sydney Trains was not effectively mitigating the causes of its cyber risks and, even where it had designed controls or mitigations, these were not always implemented to fully mitigate the cause of the risk.

Additional information on gaps in cyber mitigations which were exposed in the course of this audit has been detailed to both agencies. The Foreword of this report provides information about why this detail is not included here.

Essential 8 maturity is low across TfNSW and Sydney Trains and little progress was made in 2020

CSP mandatory requirement 3.2 states that agencies must implement the ACSC Essential 8. Agencies must also rate themselves against each of the Essential 8 on a maturity scale from zero to three and report this to Cyber Security NSW. A full list of the Essential 8 can be found in Exhibit 1. Both agencies have a low level of maturity against the Essential 8 not just in comparison to the targets they have set, but also in relation to the risks and vulnerabilities exposed. Both agencies have set target maturity ratings for the Essential 8 but none of the Essential 8 ratings across either agency are currently implemented to this level. Having a low level of Essential 8 maturity exposes both agencies to significant risks and vulnerabilities. Little progress was made between the 2019 and 2020 attestation periods.

Transport IT has set a target rating of three across all of the Essential 8. Sydney Trains has set a target rating of three for its IT systems. Sydney Trains had an interim target of two for its OT systems in 2020 and advised that this has since increased to three. It should be noted that not all the Essential 8 are applicable to OT systems.

None of the Essential 8 ratings across either agency are currently implemented to the target levels. Given that the Essential 8 provide the controls which are most commonly able to deter cyber-attacks, having maturity at a low level potentially exposes agencies to a cyber security attack.

Some work is underway across both TfNSW and Sydney Trains to improve the Essential 8 control ratings. The CDP provided some resources to the Essential 8 over 2019–20, with uplift focusing on specific systems. The CDP work in 2019 and 2020 relevant to the Essential 8 largely focussed on determining the current state of the Essential 8 and creating a target state roadmap. As a result, there was little improvement between the 2019 and 2020 attestation periods. The CDP has a workstream for the Essential 8 in its FY 2020–21 funding allocation, however as noted above in Exhibit 6 this was delayed as resources were redeployed to Project La Brea. Regardless, work on some specific aspects of the Essential 8 remain part of the 2020–21 CDP allocation, with workstreams allocated to improving three of the Essential 8. In addition, some work from Project La Brea should lead to an improvement in the Essential 8.

Sydney Trains' Cyber Uplift Program included a workstream which had in scope the uplift in the Essential 8 in IT. There were also other workstreams which aimed to improve some of the Essential 8 for OT systems. Work is also ongoing as part of the CDP to uplift these scores in Sydney Trains.

TfNSW and Sydney Trains have not reached their target maturity across the CSP mandatory requirements and TfNSW has not evaluated its cluster-wide target to ensure it is appropriate

Cyber Security NSW allows each agency to determine its target level of maturity for the first 20 CSP mandatory requirements. Agencies can tailor their target levels to their risk profile. Not reaching the target rating of the CSP mandatory requirements risks information and systems being managed inconsistently or not in alignment with good governance principles.

Sydney Trains has set its target level of maturity for IT and OT. All of Sydney Trains' target maturity levels are at least a three (defined), with a target of four (quantitatively managed) for many of the mandatory requirements. While Cyber Security NSW does not currently mandate a minimum level of maturity, in 2019 there was a requirement for each agency to target a minimum level of three.

Sydney Trains has not met its target ratings across the mandatory requirements.

The Transport Cyber Defence Rolling Program has a program KPI to ensure that the entire cluster reaches a minimum maturity level of three against all the CSP requirements by 2023. TfNSW has not reviewed its CSP mandatory requirement targets to determine if a three is desirable for all requirements or if a higher target level may be more appropriate. It is important for senior management to set cyber security objectives as a demonstration of leadership and a commitment to cyber security.

TfNSW has not met its target ratings across the mandatory requirements for its Group IT ISMS, which was the focus of this audit.

Both agencies claimed progress in their implementation of the mandatory requirements between 2019 and 2020. The audit did not seek to verify the self-assessed results from either agency.

Both agencies operate ISMS in line with the CSP

CSP mandatory requirement 3.1 requires agencies to implement an Information Security Management System (ISMS) or Cyber Security Framework (CSF), with scope at least covering systems identified as the agency's ‘crown jewels’. The ISMS or CSF should be compliant with, or modelled on, one or more recognised IT or OT standard. As noted in the introduction, an ISMS ‘consists of the policies, procedures, guidelines, and associated resources and activities, collectively managed by an organisation, in the pursuit of protecting its information assets.’ Both agencies operate an ISMS compliant with the CSP requirement.

As noted in the introduction, TfNSW operates four ISMS. The Transport IT ISMS is certified against ISO27001, the most common standard for ISMS certification. Three of TfNSW’s six crown jewels are managed within this ISMS. The other ISMS are not certified to relevant standards, though TfNSW claims that they align with relevant controls. This is sufficient for the purposes of the CSP.

Sydney Trains operates two ISMS, one for IT and another for OT. Neither of these are certified to relevant ISMS Standards, however there have been conformance reviews of both IT and OT with relevant standards. These ISMS cover all crown jewels in the agency.

There are currently 11 ISMS in operation across the Transport cluster. TfNSW has proposed moving towards a holistic approach to these ISMS, with the CDP Board responsible for governing the available security controls and directing agency IT and OT teams to implement these.

Agencies are not routinely conducting audits of third-party suppliers to ensure compliance with contractual obligations

CSP mandatory requirement 1.5 makes agencies accountable for the cyber risks of their ICT service providers and ensuring that providers comply with the CSP and any other relevant agency security policies. The ACSC has provided advice on what organisations should do when managing third party suppliers of ICT. The ACSC advises that organisations should use contracts to define cyber security expectations and seek assurance to ensure that these contract expectations are being met. While both agencies usually include specific cyber security expectations in contracts, neither is routinely seeking assurance that these expectations are being met.

The NSW Government has mandated the use of the 'Core& One' contract template for low-value IT procurements and the Procure IT contract template for high-value IT procurements. Both of these contracts contain space for the procuring agency to include cyber security controls for the contractor to implement. The Procure IT contract template also includes a right-to-audit clause which allows agencies to receive assurance around the implementation of these controls. TfNSW and Sydney Trains used the mandated contracts for relevant contracts examined as part of this audit.

TfNSW included security controls in all the contracts examined as part of this audit. Compliance with ISO27001 was the most commonly stated security expectation. Of the contracts examined as part of this audit, only one contract did not have a right-to-audit clause. This contract was signed in October 2016. While these clauses are in place, TfNSW rarely conducted these audits on its third-party providers. Of the eight TfNSW contracts examined in detail, only two of these had been audited to confirm compliance with the stated security controls.

Sydney Trains included security controls in all but one of the contracts examined as part of this audit. Sydney Trains did not require contractors to be compliant with ISO27001, but only required compliance with whole-of-government policies. Sydney Trains does not routinely conduct audits of its third-party suppliers, however it did conduct deep-dive risk analyses of its top ten highest risk IT suppliers. This involved a detailed review of both the suppliers' security posture and also the contract underpinning the relationship with the supplier.

The CDP funding for 2020–21 includes a workstream for strategic third-party contract remediation. This funding is to conduct some foundational work which will allow the CDP to make further improvements in future years. While this funding will not address gaps in contract requirements or management across all contracts, this workstream aims to reduce the risks posed by strategic suppliers covering critical assets. Similarly, work is currently underway as part of the CDP to conduct OT risk assessments for key suppliers to Sydney Trains in a similar way to the work undertaken for IT suppliers.

Sydney Trains has risk assessed its third-party suppliers but TfNSW has not done so

It is important to conduct a risk assessment of suppliers to identify high-risk contractors. This allows agencies to identify those contractors who may require additional controls stated in the contract, those who require additional oversight, and also where auditing resources are best targeted.

Sydney Trains has risk assessed all its IT suppliers and, as noted above, has conducted a deep-dive risk analysis of its top ten highest risk suppliers. TfNSW has not undertaken similar analysis of its key suppliers, however it has identified risks attached to each of its strategic suppliers and has documented these. As a result of not risk assessing its suppliers, TfNSW cannot take a targeted approach to its contract management.

TfNSW demonstrated poor records handling relating to the contracts examined as part of this audit

TfNSW was not able to locate one of the contracts requested as part of the audit's sample. Other documentation, such as contract management plans, could not be located for many of the other contracts requested as part of this audit. These poor document handling practices limits TfNSW's ability to effectively oversee service providers and ensure that they are implementing agreed controls. It also limits public transparency on the effectiveness of these controls.

The Transport cluster is not effectively implementing cyber security awareness training

Agencies are responsible for implementing regular cyber security education for all employees and contractors under mandatory requirement 2.1 in the CSP. TfNSW is responsible for delivering this training to the whole Transport cluster, including Sydney Trains. The Transport cluster has basic cyber awareness training available for all staff. TfNSW also offers additional training provided by Cyber Security NSW targeted at executives and executive assistants. While TfNSW has training available to staff, it is not delivering this effectively. TfNSW does not make training mandatory for most staff nor does it require staff to repeat training regularly. Even among those staff who have been assigned the training, completion rates are low, meaning that delivery is not effectively monitored. Cyber security training is important for building and supporting a cyber security culture.

TfNSW is responsible for creating and rolling out all forms of training to agencies within the Transport cluster. Both TfNSW and Sydney Trains have the same mandatory cyber awareness training that is automatically assigned to new starters. At the time of the audit, this training was not mandatory for ongoing staff. TfNSW does make additional cyber security training available to staff who can choose to undertake the training themselves, or can be assigned the training by their manager. All TfNSW cyber security training is delivered via online modules and it is the responsibility of managers to ensure that it is completed.

Cyber security training completion rates for both TfNSW and Sydney Trains are low. Only 13.5 per cent of staff across the Transport cluster had been assigned the Cyber Safety for New Starters training as of January 2021. Although this course is mandatory for new starters, only 53 per cent of staff assigned the Cyber Safety for New Starters training module had completed the course by January 2021. As a result, only 7.2 per cent of staff across the entire Transport cluster had completed this training at that time. In Sydney Trains, less than one per cent of staff had completed this training as at January 2021 and a further 7.6 per cent of staff have completed the 'Cyber Security: Beyond the Basics' training. These low completion rates indicate that TfNSW is not effectively rolling out cyber security training across the cluster.

In October 2020, the Department of Customer Service released 'DCS-2020-05 Cyber Security NSW Directive - Practice Requirement for NSW Government', which made annual cyber security training mandatory for all staff from 2021. In line with this requirement, TfNSW has advised that it will be gradually implementing mandatory annual training from July 2021 for all staff.

The Transport cluster undertakes activities to build a cyber-aware culture in accordance with the CSP, but awareness remains low

Increasing staff awareness of cyber security risks and maintaining a cyber secure culture are both mandatory requirements of the CSP. While TfNSW does undertake some activities to build a cyber aware culture, awareness of cyber security risks remains low. This can be demonstrated by the low training rates outlined above, and the 'Spot the Scammer' exercise, described in Exhibit 7. TfNSW is responsible for delivering these awareness raising activities across the cluster.

TfNSW frequently communicates with staff across the Transport cluster about various cyber security risks through multiple avenues. Both agencies use the intranet, emails and other awareness raising activities to highlight the importance for staff to be aware of the seriousness of cyber risks. Advice given on the intranet includes tips for spotting scammers on mobile phones, promoting the cluster-wide training courses, as well as various advice that staff could use when dealing with cyber risks in the workplace.

In addition to these awareness raising activities, TfNSW has also undertaken a cluster-wide phishing email exercise called 'Spot the Scammer'. This is outlined in Exhibit 7. This exercise was carried out in 2019 and 2020 and allowed the Transport cluster to measure the degree to which staff were able to identify phishing emails. As can be seen in Exhibit 7, the results of this exercise indicate that staff awareness of phishing emails remains low.

Exhibit 7 - Spot the Scammer exercise
In both 2019 and 2020, TfNSW performed a ‘Spot the Scammer’ exercise in which they sent out over 25,000 emails to staff based on a real phishing attack in order to measure awareness and response. The exercise tested staff 'click through rate', the percentage of staff who clicked on the fake phishing link. In 2019, these results were then compared to industry benchmarks, with over a 20 per cent click through rate being considered 'very high'. Both TfNSW and Sydney Trains were considered to have a ‘very high’ click through rate in comparison to these benchmarks in both 2019 and 2020. This indicates that staff awareness of phishing emails was low. The click through rate for TfNSW was 24 per cent in 2020, an increase from 22 per cent in 2019. For Sydney Trains, the click through rate in 2020 was 32 per cent, which was a decrease from 40 per cent in 2019.
Source: Audit Office analysis of TfNSW documents.

Appendix one – Response from agencies

Appendix two – Cyber Security Policy mandatory requirements

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 #353 - released (13 July 2021).

Published

Actions for WestConnex: changes since 2014

WestConnex: changes since 2014

Transport
Compliance
Infrastructure
Internal controls and governance
Management and administration
Project management
Risk

What the report is about

The report examined whether Transport for NSW (TfNSW) and Infrastructure NSW (INSW) effectively assessed and justified major scope changes to the WestConnex project since 2014.

What we found

NSW Government decisions to fund WestConnex-related projects outside WestConnex's $16.812 billion budget have reduced transparency and understate the full cost of WestConnex.

The NSW Government's decision to separate Sydney Gateway from WestConnex has reduced transparency over the cost of the road component of Sydney Gateway. $1.76 billion of the cost to complete Sydney Gateway is funded outside the WestConnex budget.

Network integration costs, currently estimated at $2.3 billion, are also funded outside the WestConnex budget. Many of these costs are directly attributable to WestConnex and ought to be included in the reported budget.

The Parramatta Road Urban Amenity Improvement Program, costing $198 million, should also be included as part of the WestConnex reported budget.

Decisions to exclude or remove these elements from WestConnex without justification have seen $4.26 billion of projects funded outside the $16.8 billion budget.

Positively, robust analysis was used to develop and incorporate design improvements into the 2015 WestConnex Updated Strategic Business Case.

The separate components of WestConnex underwent all required assurance reviews. However, the NSW Government's assurance framework does not require ongoing ‘whole-of-program’ assurance for large and complex projects like WestConnex. The absence of a holistic review of WestConnex allows for some costs and benefits to avoid scrutiny.

What we recommended

TfNSW should:

  • review the impact of scope changes on project objectives, costs and benefits for complex infrastructure projects
  • ensure that estimated costs and benefits of works which are reasonably required to meet consent conditions are included in business cases for complex large infrastructure projects
  • establish centralised and project specific record keeping for major infrastructure projects.

Infrastructure NSW should provide transparent whole of program assurance on total costs and benefits when complex projects are split into sub-projects.

Government should consider enhancing public transparency of existing infrastructure assurance processes by requiring that large complex infrastructure programs undergo periodic review at a whole-of-program level.

Fast facts

  • $16.812b 2015 WestConnex business case budget
  • $2.3b current estimated cost of network integration works to enable WestConnex, funded outside the WestConnex budget
  • $1.76b cost to complete Sydney Gateway to enable WestConnex and also funded outside the WestConnex budget
  • $198m Parramatta Road Urban Amenity Improvement Program, originally part of WestConnex but now funded outside the WestConnex budget

WestConnex

WestConnex is a 33 km motorway network that will link the western and south‑western suburbs with the Sydney CBD and the Airport and Port Botany precinct. It will also connect with proposed future motorway links to the north shore, northern beaches, and southern Sydney. The project is being delivered in three stages, with completion scheduled for 2023.

When first conceived by Infrastructure NSW (INSW) in 2012, WestConnex was described as a single integrated concept. In August 2013, government approved a business case for an integrated concept of WestConnex, with an estimated cost of $14.881 billion (in nominal outturn costs). Transport for NSW (TfNSW) is the government agency (sponsor agency) accountable for the delivery of WestConnex in accordance with the business case. In August 2014, the NSW Government established the Sydney Motorway Corporation to fund, deliver and operate WestConnex.

In November 2015, the NSW Government publicly released an updated WestConnex business case with greater detail and design enhancements, which increased the estimated cost to $16.812 billion.

Subsequent to this update, further changes were made to the design, including realignment of the M4 to M5 Link connection to the Western Harbour Tunnel project, an expanded interchange at Rozelle, the deletion of the Camperdown Intersection, and the addition of the Iron Cove Link. The reported budget for WestConnex was not changed as a result of these design updates.

To fund WestConnex, Sydney Motorway Corporation consolidated a concessional loan of $2 billion from the Australian Government, private sector debt and equity funding from the State. The Australian Government also provided a $1.5 billion contribution to the State to partially fund construction of WestConnex.

In August 2018, the NSW Government sold 51 per cent of its stake in Sydney Motorway Corporation for $9.26 billion. At the time of writing, the NSW Government is in the process of selling its remaining 49 per cent stake of Sydney Motorway Corporation.

About this audit

In the course of delivering a complex major infrastructure project, it is reasonable to expect changes to the original design and scope. Changes may occur as the design moves from a high‑level concept to a detailed design for project delivery, as new risks or issues are identified, as demands change, or as other interdependent projects are approved. Changes can also occur in response to potential cost or delivery overruns which arise as a result of planning deficiencies. Where design and scope changes significantly change the project costs and/or expected benefits, the justification for these changes should be robust and transparent.

Following our 2014 performance audit, 'WestConnex: Assurance to the government', the NSW Government established the Infrastructure Investor Assurance Framework (IIAF) to improve accountability and transparency over major projects that are developed, procured, or delivered by government agencies. Under the framework, TfNSW, as project sponsor, is responsible for ensuring the WestConnex project meets all IIAF requirements. These include ensuring the project remains strategically aligned and viable, and benefits are on track. INSW is responsible for coordinating the assurance review process and reporting directly to NSW Cabinet on project delivery against time, budget and risks to project delivery.

The objective of this performance audit is to assess whether TfNSW and INSW effectively assessed and justified major scope changes to the WestConnex project since 2014.

 

Conclusion

Government decisions to separate WestConnex related projects and deliver them outside WestConnex's 2015 business case budget of $16.812 billion has understated the total cost of WestConnex achieving its objectives. The rationale for separating these elements from the WestConnex project scope has not been transparent. Together, these projects represent costs of $4.26 billion funded outside the $16.812 billion WestConnex budget.

Since 2015, the NSW Government has removed several projects from the scope described in the 2015 WestConnex business case, and funded them separately:
  • In mid‑2017, the Sydney Gateway became a separate project outside WestConnex. This project, estimated in 2015 to cost $800 million, now has an estimated cost of $2.56 billion. The project remains partly funded by an $800 million contribution from the $16.812 billion WestConnex budget, with $1.76 billion funded outside the WestConnex budget.
  • In late 2018, the Parramatta Road Urban Amenity Improvement Program became a separate project outside the 2015 WestConnex budget. This project was part of the 2015 WestConnex Business Case and is intended to create urban renewal opportunities around Paramatta Road. It is estimated to cost $198 million.

Work required to integrate WestConnex with existing roads ('network integration') was funded outside the $16.812 billion budget for the November 2015 WestConnex business case. TfNSW is obliged to deliver network integration works to meet the conditions of planning approval for WestConnex. As such, these costs should be included in the WestConnex budget. The current estimated cost of these network integration works is $2.3 billion.

The rationale to exclude or remove each of these elements from the WestConnex project scope has not been transparent, nor supported by robust analysis and justification. These elements are required for WestConnex to achieve its objectives. The additional project costs will also deliver additional benefits not included in the 2015 WestConnex business case. Removing them understates the total cost of achieving the objectives set out in the 2013 and 2015 WestConnex business cases.

WestConnex's complex financing arrangements further reduce transparency on costs.

Transparency over the total cost of WestConnex – including elements funded from other project budgets – is further limited by the project's complex financing arrangements.

Prior to 2018, the Audit Office provided assurance on costs borne and levied by Sydney Motorway Corporation and its controlled entities. Since the NSW Government sold its majority stake in WestConnex in August 2018, the Auditor‑General no longer has the mandate to provide this assurance. Considering this, and the lack of transparency on the cost of projects removed from the WestConnex project scope, there is no transparent or comprehensive view of the total cost to deliver WestConnex – nor of how these cost would be offset by the sale of the government's remaining stake.

There is no 'whole‑of‑program' assurance over the WestConnex program of works. This limits transparency and confidence that WestConnex will meet intended objectives within its budget.

After INSW conducted a gateway review of a draft of the 2015 WestConnex Business Case under the IIAF, the project was broken up into separate components to support staged delivery. Each of these projects, including the Sydney Gateway, as well as the Network Integration Program, underwent the required assurance reviews under the IIAF. INSW also provided monthly progress updates to government. These individual projects are, in themselves, significant in scale and complexity. Addressing them as discrete components for the purposes of the assurance review process is justified and there is no requirement under the IIAF to holistically review projects which together deliver final benefits of the WestConnex program. However, whole‑of‑program review would improve transparency over total costs and benefits.

In 2016, TfNSW revised the design of the M4‑M5 Link and Rozelle to address traffic and integration issues.

TfNSW identified that the concept designs used for the M4‑M5 Link and Rozelle Interchange in the 2015 WestConnex Business Case would not integrate well with surface roads, including the proposed Bays Precinct, and would result in increased traffic on Victoria Road and the ANZAC Bridge. Following a comprehensive review conducted in mid‑2016, TfNSW refined the design of the M4‑M5 Link and Rozelle Interchange to address these limitations without increasing the cost of delivery. TfNSW documented the rationale for the design changes, including how the changes improved on the original design to increase capacity, improve traffic conditions and create more open space.

1. Key findings

Government decisions to fund WestConnex related projects outside of WestConnex's $16.812 billion reported budget have reduced transparency over costs and understate the full cost of WestConnex

In 2015, the work required to integrate WestConnex with existing roads ('network integration') was funded as a separate project with an estimated cost of $1.534 billion outside the 2015 WestConnex budget of $16.812 billion. TfNSW then created the Network Integration Program to respond to the conditions of planning approval for WestConnex. The current estimated cost to deliver all network integration works is $2.3 billion.

Since the 2015 WestConnex Business Case, the NSW Government has removed several elements from the scope of WestConnex and funded them as separate projects, while keeping the published WestConnex budget at an estimated $16.812 billion. Projects removed include:

  • Sydney Gateway, currently costed at $2.56 billion (with an $800 million contribution from WestConnex)
  • Parramatta Road Urban Amenity Improvement Program, costed at $198 million in late 2018 and funded though new funding to the Greater Sydney Commission.

Together, these projects represent costs of $4.26 billion that are not included in the WestConnex budget, but are required for WestConnex to achieve the objectives of the 2013 and 2015 WestConnex Business Cases. The costs of these elements in supporting the objectives of WestConnex is not tracked centrally, and there is no single point of oversight over them. Exhibit 1 compares total WestConnex forecast costs (including related projects) between November 2015 and April 2021.

 

November 2015
($ million)

April 2021
($ million)
WestConnex
Stage 1
Stage 1A (M4 Widening) 497 517
Stage 1B (M4 East) 3,802 3,782
Total 4,299 4,299
Stage 2
King Georges Road Interchange 131 131
New M5 4,335 4,335
Sydney Gateway Contribution 800 800
Total 5,266 5,266
Stage 3
M4‑M5 Link and Rozelle Interchange 7,049 7,049
Urban renewal (Parramatta Road) 198 ‑‑
Urban renewal (Rozelle) ‑‑ 198
Total 7,247 7,247
Total reportable WestConnex 16,812 16,812

Exhibit 1: WestConnex and related projects forecast costs
  November 2015
($ million)
April 2021
($ million)
Related projects
Network integration 1,534 2,300
Urban renewal (Parramatta Road) ‑‑ 198
Sydney Gateway Road Component ‑‑ 1,760
Total 1,534 4,258

Source: AO research.

Many network integration costs are directly attributable to WestConnex and ought to be included in the reported budget for WestConnex

Prior to 2015, the scope of WestConnex included enabling works needed before or during construction, as well as funding for future works to address any adverse traffic outcomes created by WestConnex which become apparent after its opening. These works are also known as network integration works.

When government approved the 2015 WestConnex Business Case, it noted that the project would require $1.534 billion for network integration works to address the impacts of WestConnex on the road network. However, the WestConnex project budget of $16.812 billion did not include funding for network integration works. Instead, Roads and Maritime Services (RMS, now TfNSW) was to fund network integration through its normal budget allocation.

It is important to recognise these costs as part of the total WestConnex project cost because:

  • TfNSW created the Network Integration Program to respond to network traffic and transport elements of the planning conditions of approval for WestConnex granted by the then NSW Department of Planning and Environment under the Environment, Planning and Assessment Act 1979.
  • NSW Treasury guidelines for business cases note that accurate cost estimates include assessment of the financial impact of meeting the conditions of planning approval.
  • Travel time and vehicle operating cost benefits attributed to the WestConnex project in the 2015 WestConnex Business Case assume that some network integration works, then costed at $373 million, were in place.

Refer to Appendix two for more detail on network integration works.

Some of the projects in the WestConnex Network Integration Program provide community and place benefits, such as parklands and cycleways. These benefits have not been attributed to WestConnex. Additionally, some network integration works are likely to deliver additional traffic related benefits to WestConnex. As the Network Integration Program’s primary purpose is to meet the conditions of planning approval for WestConnex, TfNSW should attribute all the costs and benefits of the program to WestConnex.

To September 2021, the total funded cost of the Network Integration Program is approximately $2.077 billion. TfNSW estimates that it will need a further $222 million to complete all expected network integration works.

The NSW Government's decision to separate Sydney Gateway from WestConnex has reduced transparency and accountability for TfNSW's underestimation of the cost of the road component of Sydney Gateway

Sydney Gateway is a high‑capacity connection between the new St Peters Interchange and the Sydney Airport and Port Botany precinct. It includes a road and rail components. The road component was included in the scope of WestConnex in the 2015 WestConnex Business Case. The November 2015 design, which TfNSW costed at $800 million, involved separate roadways from the St Peters Interchange to the International terminal, and to the domestic terminals and Mascot airport precinct.

By October 2016, TfNSW was aware that the $800 million budget for Sydney Gateway was insufficient and revised the forecast cost for the road component to $1.8 billion. The original cost estimate did not sufficiently consider the cost of:

  • constructing a complex design adjacent to the airport precinct
  • obtaining access to land required for the project
  • managing environmental contamination.

On 9 August 2017, the then Minister for WestConnex announced that the Sydney Gateway project was not part of WestConnex.

The 2015 WestConnex Business Case notes that material changes to the WestConnex budget, funding, scope, or timeframe are subject to Cabinet approval processes. It states that, when seeking approval for material changes, the portfolio Minister will make a submission to the relevant Cabinet Committee. Changes in project scope required the approval of the then Cabinet Committee on Infrastructure and should have been endorsed by the WestConnex Interdepartmental Steering Committee.

TfNSW and the NSW Department of Premier and Cabinet (DPC) assert that there is no documentation to support the government’s decision to separate Sydney Gateway from the WestConnex Program, or the WestConnex Interdepartmental Steering Committee's endorsement of a submission to Cabinet seeking approval for the separation.

The established governance processes for major scope changes were not followed in this instance. The lack of transparency regarding government's decision to separate Sydney Gateway from WestConnex also reduces visibility of TfNSW's underestimation of the cost of delivering the road component of Sydney Gateway.

The November 2018 Final Business Case for Sydney Gateway, which was approved by the government, included an estimate of $2.45 billion (nominal outturn cost) for the road component. This estimate included an $800 million contribution from WestConnex. A more recent estimate (late 2020) for this project is $2.56 billion (nominal outturn cost).

The Parramatta Road Urban Amenity Improvement Program should be included as part of the WestConnex budget

A specific objective of the 2015 WestConnex Business Case was the creation of opportunities for urban renewal along and around Parramatta Road. The business case included an allocation of $198 million in the $16.812 billion WestConnex budget for the Parramatta Road Urban Amenity Improvement program, designed to implement aspects of the objective. In November 2018, the NSW Government removed the Parramatta Road Urban Amenity Improvement Program from the WestConnex program of works and reallocated the $198 million (inside the $16.812 billion WestConnex budget) for urban renewal works around the Rozelle Interchange. As part of this decision, government approved new funding of $198 million to the Greater Sydney Commission for the urban amenity program, outside the $16.812 billion WestConnex budget. This understates the cost of WestConnex meeting its objectives by $198 million.

There is no requirement for ongoing ‘whole‑of‑program’ assurance of the WestConnex program of works, including related projects

In August 2015, INSW conducted its first Gateway Review of WestConnex as a program consisting of composite projects. Following that review, TfNSW registered each of the components of WestConnex with INSW as individual projects, rather than keeping WestConnex registered as a program or mega‑project. This is not inconsistent with the IIAF and all WestConnex related projects, including Sydney Gateway and the Network Integration Program, have undergone independent assurance reviews as individual projects under the IIAF.

Once a program like WestConnex is broken down into its composite parts, there is no requirement for the sponsor agency (TfNSW) or INSW to provide independent assurance on the program as a whole until it is completed. This is then done as part of the Gateway review for benefits realisation, which examines whether project benefits are being measured and meet expectations. These individual projects are, in themselves, significant in scale and complexity. While addressing them as discrete components for the purposes of the assurance review process can be justified, the absence of strategic, holistic reviews of WestConnex allows for total costs and benefits to become opaque and avoid scrutiny. Programs of this scale require greater ongoing transparency on total costs and benefits in order to ensure confidence they will meet intended objectives within budget.

There is a lack of public transparency on the total costs and benefits of the WestConnex project

Prior to 2018, the Audit Office provided assurance on costs borne and levied by Sydney Motorway Corporation and its controlled entities. Since the NSW Government sold 51 per cent of its stake in WestConnex in August 2018, the Auditor‑General no longer has the mandate to provide this assurance. The Audit Office is also unable to provide any assurance regarding the performance of tolling concessions.

This means that the total costs of WestConnex, including those levied on road users through tolling, are not reported alongside the full cost of delivering the project. This information, and independent assurance over that information, would provide transparency and context to the outcome of government's sale of its interest in WestConnex.

To enhance the transparency of existing infrastructure assurance processes, government could consider requiring large and complex infrastructure programs to undergo periodic review at a whole‑of‑program level. This could take the form of annual reports to Parliament on the total costs and benefits of selected large and complex projects by the responsible agency. The reports could include an assessment of the cost to government and cost to the community of funding and financing. Independent assurance of the agency report would provide Parliament with greater confidence that infrastructure is delivered economically and providing value for money for the people of NSW.

The Australian National Audit Office provides similar assurance on selected Department of Defence acquisition projects as part of its annual Major Projects Report.

Design enhancements included in the 2015 WestConnex Updated Strategic Business Case were supported by robust analysis

The 2015 WestConnex Business Case contained more detail than the 2013 WestConnex business case. Design enhancements were made as a result of modelling analysis conducted over the two years since the 2013 business case. Enhancements included a full underground link between Kingsgrove and St Peters as part of the New M5 and re‑alignment of the M4‑M5 link tunnel (Stage 3) to include the Rozelle Interchange. The Rozelle Interchange will provide a direct connection to the Anzac Bridge and Victoria Road, and will enable a connection to the proposed Western Harbour Tunnel and Beaches Link. A map and description of these elements can be found at Exhibits 2 and 3 of this report.

In 2016, TfNSW revised the design of the M4‑M5 Link and Rozelle to address traffic and integration issues

As part of preparing the 2015 WestConnex Business Case, TfNSW prepared a Project Definition and Delivery Report (PDDR) for the M4‑M5 Link. This report describes the scope of the project, including a high‑level concept design. TfNSW identified limitations with the proposed design of the M4‑M5 in the PDDR, which it would need to address as the project moved to a detailed design stage. In particular, these limitations included:

  • poor integration with the Bays Precinct masterplan
  • traffic capacity constraints on Victoria Road and Anzac Bridge
  • construction complexity.

Following a comprehensive review in mid‑2016, TfNSW changed the design of the M4‑M5 Link and Rozelle Interchange to address these limitations. These changes included:

  • deletion of the Camperdown intersection to improve traffic conditions on Parramatta Road
  • a fully underground and larger Rozelle Interchange with 10‑hectare dedicated parklands
  • a toll‑free tunnel link from Iron Cove Bridge to Anzac Bridge
  • increasing the lanes in the dual tunnels from three to four each way.

TfNSW documented, but did not publish, the rationale for the design changes, including how the changes addressed the limitations of the previous design while providing increased community benefit through the creation of open space. TfNSW undertook cost comparison studies which estimated that these changes would have a neutral impact on the estimated project cost while achieving the same or improved benefits.

TfNSW's record‑keeping systems for large infrastructure investments negatively impact accountability and transparency

In response to our formal requests for relevant information, made during the conduct of this audit, TfNSW advised that complete and valid records of key decision‑making processes, analysis and advice were unavailable. Additionally, TfNSW often provided information that was incomplete or unverifiable (for instance, unsigned briefing notes). This is not consistent with accepted governance practices and does not comply with the requirements of the State Records Act 1998.

We also requested that TfNSW provide a list of relevant documents held by the Sydney Motorway Corporation (SMC). While TfNSW acknowledged that SMC may hold material relevant to the audit, TfNSW did not have a list or description of these documents. As SMC is now a majority privately held entity, both the Audit Office and TfNSW have limited power to require SMC to provide documentation.

The delivery timeframe for large and complex infrastructure projects such as WestConnex frequently exceeds five years, and some projects can take over a decade to deliver. These projects represent a significant investment of public resources and government agencies should expect independent review and assurance activities such as performance audits. The establishment of dedicated record keeping facilities for major infrastructure projects, such as data rooms, would improve transparency and accountability. This would ensure that the use of public resources is fully auditable in line with public expectations and the requirements of the Government Sector Finance Act 2018, the State Records Act 1998 and the Public Finance and Audit Act 1983.

2. Recommendations

By December 2021, TfNSW should:

1. review the impact of scope changes on project objectives, costs and benefits for complex infrastructure projects

2. when preparing business cases for complex large infrastructure projects, ensure that the estimated costs and benefits of works which are reasonably expected to meet consent conditions are included in the overall project cost and its benefits (as per Treasury guidelines)

3. establish and maintain centralised and project‑specific record keeping, including through dedicated project data rooms, to ensure major infrastructure projects can readily be subject to external oversight and assurance.

By June 2022, INSW should:

4. provide transparent whole‑of‑program assurance on total costs and benefits throughout the project life‑cycle when complex projects are split into sub‑projects.

By June 2022, NSW Government should:

5. consider enhancing the public transparency of existing infrastructure assurance processes by requiring that large complex infrastructure programs undergo periodic review at a whole‑of‑program level. This could take the form of reports to Parliament on the total costs and benefits on selected large and complex projects by the responsible agency, including cost to government and cost to community of funding and financing, as well as an accompanying independent assessment of the agency report.

Following our 2014 performance audit report 'WestConnex: Assurance to the government', the NSW Government established the Infrastructure Investor Assurance Framework (IIAF). INSW is responsible for the development, implementation and administration of the IIAF. The assurance framework involves gateway reviews, health checks, deep dive reviews, and project monitoring and reporting at various stages in the lifecycle of a project. The main aims of the IIAF are to help ensure major infrastructure projects are delivered on time and on budget, and to ensure that reports are regularly monitored by the Cabinet of the NSW Government. The IIAF gateway review process is compulsory for all significant investments and expenditure under the NSW Treasury Gateway Policy.

In accordance with the IIAF, INSW is responsible for the following:

  • providing a dedicated Assurance Team including Gateway Review Managers to coordinate Reviews
  • determining appropriate expert reviewers, and manages scheduling, commissioning and administration of Assurance Review reports. Infrastructure NSW is independent of the Expert Review Team
  • monitoring Tier 1 – High Profile/High Risk projects, Tier 2 and Tier 3 (if required) project performance through independent Assurance Reviews
  • providing independent analysis and advice on key risks and any corrective actions recommended for Tier 1 – High Profile/High Risk, Tier 2 and Tier 3 projects
  • escalating projects to Infrastructure Investor Assurance Committee (IIAC) and Cabinet where projects present ‘red flag issues’ and where corrective action is needed
  • working with delivery agencies to register all capital projects with an estimated cost greater than $10.0 million and ensures they are risk profiled and assigned a risk‑based project tier with an endorsed IIAF Project Registration report
  • preparing forward looking annual Cluster Assurance Plans
  • maintaining and continuously improves the IIAF process
  • reporting to the IIAC, Cabinet and Infrastructure NSW Board
  • regularly report to NSW Treasury on the performance of the IIAF.

In relation to WestConnex, TfNSW is the sponsor agency responsible for meeting relevant IIAF requirements, including:

  • registering and risk profiling projects
  • IIAF gateway, health check, and deep dive assurance reviews
  • regular reporting.

Under the IIAF, it is mandatory for all capital projects valued over $10.0 million to be registered with INSW. Capital projects can be registered either as a program (comprising of a group of related projects or activities) or as a project (which may or may not be part of a program).

According to the IIAF, programs tend to have a lifespan of several years and aim to deliver outcomes and benefits related to an organisation's strategic objectives. Projects tend to have a shorter lifespan, and deal with outputs. Projects can, however, be grouped under a single program if they are similar in nature or if they are aimed at collectively achieving a strategic objective. Complex projects can be delivered in multiple stages, under different contracts, and across different time periods.

The last assurance review of the entire WestConnex program of works as a whole was in 2015

INSW conducted the first IIAF gateway review of WestConnex in August 2015. TfNSW developed a draft WestConnex Updated Strategic Business Case to consolidate the latest analysis on WestConnex, and to confirm that the project remained fit for purpose, economically viable, and financially deliverable. The review followed a recommendation in our 2014 performance audit report that business cases be thoroughly revisited.

During September 2015, INSW conducted additional informal reviews to identify strategic risks associated with public release of the WestConnex business case. Subsequently, INSW gave the Premier of NSW its views on the draft business case, including the following points:

  • The $398 million budget for Sydney Gateway was insufficient to meet the benefits claimed in the business case for a ‘functional’ connection to Sydney Airport and Port Botany. INSW studies indicate a future‑proof solution would require a minimum spend of $755 million.
  • Enabling works for WestConnex estimated at $1.534 billion were excluded from the cost of WestConnex. Significant work remained for RMS to identify mitigation measures to address planning approvals and network performance issues.
  • Enabling works (a Southern Connector), an access ramp and surface road improvements within St Peters were excluded from the draft 2015 business case despite their inclusion in the WestConnex scope in the 2014–15 State Budget.
  • The overall cost of works not funded within the WestConnex budget ranged from $2.011 billion to $2.196 billion. This included the enabling works, access ramp and surface road improvements and the shortfall for Sydney Gateway.

All WestConnex related projects, including Sydney Gateway have undergone independent assurance reviews under the IIAF

Since INSW submitted the first WestConnex progress update report to Cabinet in June 2015, INSW has been reporting monthly on the different stages of the WestConnex Program, including Sydney Gateway, as the projects were registered with INSW as High‑Profile, High‑Risk projects. Separate reporting enabled INSW to report and review each stage with more detailed scrutiny, compared to the reporting and reviewing at a program level.

WestConnex Stage 2 (New M5) underwent both mandatory and non‑mandatory reviews at key points in the project lifecycle. Three mandatory gateway reviews – at Gate 2 (Final business case), Gate 3 (Readiness for market), and Gate 4 (Tender evaluation) – were conducted by TfNSW before the introduction of IIAF. Four non‑mandatory health check reviews and one non‑mandatory deep dive review were conducted after the introduction of the IIAF managed by INSW.

Similarly, WestConnex Stage 3 projects – M4‑M5 link, M4‑M5 Tunnels, and Rozelle Interchange – also underwent mandatory and non‑mandatory reviews at key points in their lifecycle under IIAF.

The M4‑M5 Link had two mandatory gateway reviews and one non‑mandatory health check review under IIAF. These reviews were conducted before Stage 3 was split into two stages, due to major design changes to the Rozelle Interchange and the M4‑M5 tunnels.

The M4‑M5 tunnels had two mandatory gateway reviews (at Gates 3 and 4), one non‑mandatory health check review, and one non‑mandatory deep dive review under IIAF.

Rozelle Interchange also underwent three mandatory gateway reviews at Gate 3 (part 1), Gate 3 (part 2), and Gate 4, two non‑mandatory health check reviews, and one non‑mandatory deep dive review under IIAF.

Since mid‑2017, the Sydney Gateway project has undergone required independent assurance reviews, as well as a number of optional assurance reviews

In November 2016, INSW conducted a mandatory Gate 1 gateway review on a strategic business case for the Sydney Gateway Project. TfNSW did not proceed with this business case. Following the separation of Sydney Gateway from WestConnex in mid‑2017, TfNSW developed a new business case for Sydney Gateway. It has undergone the required Gate 1, Gate 2, and Gate 3 gateway reviews, as well as two non‑mandatory health check reviews, and three non‑mandatory deep dive reviews under IIAF.

Network integration works have undergone all IIAF required assurance reviews

TfNSW completed a strategic business case for the Network Integration Program in August 2020, and INSW completed a gateway review in November 2020. This is despite network integration projects starting as early as 2015, with $645 million having been spent by June 2020. The strategic business case included a prioritisation process for completing remaining works in the program. Prior to November 2020, TfNSW registered individual network integration projects with INSW, and these projects have undergone gateway reviews where required.

The Network Integration Program strategic business case does not include Rozelle interchange network integration works ($353 million) and additional network integration works to settle a contractor claim adjacent to St Peters Interchange ($190 million). These were excluded from the business case on the basis they had already been approved by government, and as such were not subject to the prioritisation elements of the business case. TfNSW has not developed separate business cases for these works, although the scope of the St Peters Interchange works was developed through a negotiated process.

TfNSW did not prepare business cases for some network integration works which have commenced, including the $323 million Campbell Road/Euston Road works

Prior to its development of the August 2020 strategic business case, TfNSW did not prepare business cases for many network integration works that have commenced, and in some instances were completed, before 2019. Significantly, TfNSW did not prepare a business case for the Campbell Road/Euston Road works, which cost $323 million and have been completed.

In 2016, TfNSW’s Business Case Policy requires the creation of business cases for capital projects costing over $1.0 million. At the time of writing this report, TfNSW’s draft policy requires full business cases for capital projects costing $10.0 million or more.

There is no requirement for ongoing ‘whole‑of‑program’ assurance of the WestConnex program of works, including related projects

INSW conducted its first gateway review of WestConnex (as a program, which consisted of composite projects) in August 2015. Following that review, TfNSW registered each of the components of WestConnex with INSW as individual projects, rather than keeping WestConnex registered as a program or complex project. The IIAF allows this to occur.

Separate registration enabled INSW to report and review each stage with more scrutiny compared to whole‑of‑program level review.

Such an approach has merit, considering the individual stages (and components of these stages) are multi‑million dollar works in their own right. Each project has its own timing for gateway reviews at stages such as 'Readiness for Market' and 'Tender Evaluation'.

Once a program such as WestConnex is broken down into its composite parts, there is no requirement for the sponsor agency (TfNSW) or INSW to conduct independent assurance on the program of works as a whole until the whole program is completed as part of the Benefits Realisation (Gate 6) gateway review. The absence of strategic, holistic reviews of projects of the scale and complexity such as WestConnex during their delivery allows for total costs and benefits to become opaque and avoid scrutiny. Projects of this scale require greater ongoing transparency on total costs and benefits in order to ensure confidence they will meet intended objectives within budget.

INSW has advised us that it has prepared a proposal to expand its assurance function to include whole‑of‑program review of inter‑related infrastructure projects.

Appendix one – Responses from agencies

Appendix two – Network integration works

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 #351 - released (17 June 2021).

Published

Actions for Acquisition of 4–6 Grand Avenue, Camellia

Acquisition of 4–6 Grand Avenue, Camellia

Transport
Asset valuation
Compliance
Fraud
Infrastructure
Internal controls and governance
Management and administration
Procurement
Risk

The Auditor-General for New South Wales, Margaret Crawford, has today released a report on Transport for NSW’s (TfNSW) acquisition of 4–6 Grand Avenue in Camellia.

This audit, which was requested on 17 November 2020 by the Hon. Andrew Constance MP, the Minister for Transport and Roads, examined:

  • whether TfNSW conducted an effective process to purchase 4–6 Grand Avenue, Camellia
  • whether TfNSW has effective processes and procedures to identify and acquire property required to deliver the NSW Government’s major infrastructure projects.

The audit found that TfNSW conducted an ineffective process when it purchased 4–6 Grand Avenue, Camellia. The audit also found that TfNSW’s internal policies and procedures to guide the transaction were, and continue to be, insufficient.

The Auditor-General has made seven recommendations to address the issues identified in the report.

On 17 November 2020, the Hon. Andrew Constance MP, the Minister for Transport and Roads, requested this audit under section 27B(3)(c) of the Public Finance and Audit Act 1983.

On 15 June 2016, Transport for New South Wales (TfNSW) acquired 6.3 hectares of land at 4–6 Grand Avenue, Camellia, by agreement from Grand 4 Investments Pty Ltd. Grand 4 Investments was a business entity established by the owners of Billbergia Pty Ltd, a property development and investment company.

TfNSW paid Grand 4 Investments $53.5 million and assumed liability for addressing environmental issues and contamination associated with the site. This took place seven months after the vendor acquired the land as part of a competitive Expression of Interest process, in which TfNSW also participated, for $38.15 million.

TfNSW is the NSW Government agency responsible for most major transport infrastructure projects in New South Wales. TfNSW acquired the Camellia site for use as a stabling and maintenance depot to support the Parramatta Light Rail (PLR) project.

Consistent with the minister’s request, this audit assessed:

  • whether TfNSW conducted an effective process to purchase 4–6 Grand Avenue, Camellia
  • whether TfNSW has effective processes and procedures to identify and acquire property required to deliver the NSW Government’s major infrastructure projects.

In considering the effectiveness of the processes for this purchase, the audit considered:

  • the requirements of the Land Acquisition (Just Terms Compensation) Act 1991 (the Act)
  • the application of sound processes to manage risk to the NSW Government and to achieve value for money
  • the application of disciplines associated with complex procurement, such as probity, in a NSW Government context.
The acquisition of the 4–6 Grand Avenue site in Camellia was consistent with a 2014 feasibility study for the PLR, but occurred before the completion of detailed project planning or an acquisition strategy.

TfNSW made two attempts to acquire the 4–6 Grand Avenue site in Camellia, and was successful on the second attempt. TfNSW recognised the risks associated with early acquisition and had high-level strategies in place should the site not be required.

The specific site had been identified in a feasibility study for the PLR commissioned by TfNSW in 2014 as one of several options in Camellia for a stabling and maintenance depot. However, TfNSW had not done any substantive analysis of the various options to identify a preferred location before the two opportunities to acquire 4–6 Grand Avenue were brought to TfNSW’s attention by the landowners (or their agents). On both occasions, TfNSW chose to actively pursue acquisition in advance of any such analysis.

The acquisition was also not informed by a Property Acquisition Strategy, which TfNSW policy recommends in order to guide the process and manage acquisition specific risks.

In 2015, TfNSW identified that it would require a stabling and maintenance depot in the Camellia area for the Parramatta Light Rail

In 2014, TfNSW commissioned an external engineering consultancy to undertake a feasibility design study for the Parramatta Light Rail - the Parramatta Transport Corridor Strategy Feasibility Design study (herein referred to as ‘the feasibility study’). In early 2015, TfNSW received the feasibility study, which was one of several key sources that informed the development of business cases for the PLR.

The feasibility study recommended that TfNSW should consolidate the maintenance and cleaning operations with overnight stabling facilities on one site. The study noted that the optimal location for any such site would be in close proximity to the proposed network, and noted that the site must have access to road connections to accommodate access for cars and trucks.

The study found that a centrally located stabling and maintenance facility would be required for all routes serving the Parramatta CBD, and that the Camellia industrial area was a preferred location for such a facility. The study noted that the Camellia area was contaminated.

The feasibility study notes that its conclusions were based on assumptions about the light rail system adopted and decisions made by the future operator of the system, who had not yet been selected or appointed.

TfNSW's decision to progress a potential acquisition in 2015 considered the risk that the site may not be required

TfNSW's FIC was responsible for making decisions on funding allocations at a whole of program level within TfNSW. FIC was also responsible for approving ‘high-risk/high-value’ variations to program budgets. Members of the FIC included:

  • Secretary of Transport for NSW
  • Deputy Secretary, Infrastructure and Services
  • Deputy Secretary, Freight, Strategy and Planning
  • Deputy Secretary, Customer Services
  • Deputy Secretary Finance and Investment
  • Deputy Secretary People and Corporate Services.

An April 2015 submission, from the then Deputy Director-General to the agency’s FIC, sought authorisation and funding approval to participate in an Expression of Interest sale process. It noted the risk that the project may not go ahead. The submission advised that:

By acquiring a strategic site now, it reduces the risk of having to pay an improved value or a value that may be subject to rapidly improving land values due to changes in land use and rezoning.

The property can be acquired for the project, held strategically and income generated by leasing the site as hardstand 1 space until the project requires the land for the Parramatta Light Rail project.

If the project does not proceed in the medium to longer term, the property can be sold at a premium to what has been paid today as property fundamentals improve.

This submission acknowledged the risks associated with environmental contamination and proposed that these risks would be managed by negotiating a contract where the remediation and associated expenses would be at the landowner’s cost. 

TfNSW assessed the 4–6 Grand Avenue site as one of several sites in Camellia that was a feasible location for a stabling and maintenance facility

The Departmental feasibility study assessed six potential sites for a stabling and maintenance facility, including 4–6 Grand Avenue, noting strengths and weaknesses of each site. A different site on Grand Avenue was assessed as the ‘base case’ option (1 Grand Avenue). The study’s comments on the 4–6 Grand Avenue site included the following:

With an area of approximately 63,000m2, this site has sufficient space for a depot with the required stabling yard and maintenance facilities. The location allows for good road access and LRT [light rail transit] access would be from Grand Avenue, which may require a road crossing or signalised intersection. The site has been used for general industrial uses; however the land has been cleared and is currently undergoing remediation 2. The site is not affected by flooding based on one in 100-year flood data.

In early 2015, once the opportunity to acquire 4–6 Grand Avenue emerged, TfNSW commissioned a specific feasibility study of the 4–6 Grand Avenue site. The feasibility studies clearly documented the existence of environmental contamination. In April 2015, the report concluded:

Given the limitations of this report and within the parameters that have been set it is concluded that from a spatial and geographic perspective the site at 6 Grand Avenue would be suitable as a stabling and maintenance depot for the Parramatta light rail project. There are few engineering and environmental constraints that would affect the feasibility level analysis of this site and all issues identified, within this desk study, are considered to be resolvable. However this being said there is a significant amount of work necessary to reach the final layout and definition of the stabling and maintenance depot. There are numerous items which require further consideration and conformation; planning approvals could impose restrictions on building heights, noise mitigation measures, light and visual impact requirements all of which can have significant impacts on the spatial requirements of any stabling and maintenance depot. 

The acquisition of 4–6 Grand Avenue was not informed by a Property Acquisition Strategy

For major projects, TfNSW typically requires the project team to complete a Property Acquisition Strategy, which is intended to guide both process as well as specific acquisition issues expected to be faced during the project. The Property Acquisition Strategy is not a mandated document but is a recommended tool to support property acquisition as part of major projects.

TfNSW did not have a Property Acquisition Strategy in place to guide the 2015 Expression of Interest process. On 6 November 2015, the then Project Director for the PLR project emailed the property team, noting a need to develop a Property Acquisition Strategy to close off the scoping design and preliminary business case.

In January 2016, TfNSW developed a draft Property Acquisition Strategy for the Parramatta Light Rail Project, although it was silent on the potential sites for the stabling and maintenance facility.

TfNSW focussed on 4–6 Grand Avenue because it was available and aligned to TfNSW's strategic interests

In early 2015, officials commenced monitoring the market for industrial real estate in the Camellia area and surrounds for possible sites for a stabling and maintenance facility.

In March 2015, then owner of the site, Akzo Nobel Pty Limited released the 4–6 Grand Avenue site through an Expression of Interest process managed by CBRE.

TfNSW’s then Deputy Director-General, Planning, sought approval from FIC to lodge an Expression of Interest up to $30.0 million. Approval was sought on the basis that it would ‘provide certainty for the Parramatta Light Rail project by allowing for a depot site in a suitable location and potentially avoid higher costs or longer timeframes associated with compulsory acquisition following completion of the project’s business case’. FIC approved the request at its meeting on 9 April 2015.

At this time, TfNSW had not conducted any analysis of financial or operational benefits and costs of the potential sites identified in earlier feasibility studies. TfNSW staff advised us that the decision to participate in the Expression of Interest process for 4–6 Grand Avenue was because it was available. There is no documentation substantiating this statement, which TfNSW staff provided verbally as part of this audit.

In November 2015, TfNSW was advised that it was unsuccessful in the Expression of Interest process and that Grand 4 Investments (a related entity of Billbergia) had purchased 4–6 Grand Avenue. TfNSW did not conduct any further analysis of alternative potential sites in Camellia between this date and commencing discussions with Grand 4 Investments in April 2016. In that time there had been some movement on other properties that were included in the feasibility study, including 37–39a Grand Avenue being under offer in September 2015.

In March 2016, TfNSW approached CBRE to organise a meeting with Grand 4 Investments. On 1 April 2016, TfNSW met with Grand 4 Investments.

TfNSW advises that a perceived benefit of the 4–6 Grand Avenue site was that it was not subject to other uses or leaseholds that would increase the cost of compulsory acquisition. Officers involved in the acquisition advised that other nominated sites in the feasibility study were subject to other uses or leaseholds. 


1  A hardstand space is a large, paved area to store cars, heavy vehicles and machinery.
2  Officers familiar with the acquisition could not confirm the nature of remediation being undertaken, but noted that the previous landowner had cleared buildings from the site, which may have been considered part of remediation.
TfNSW's independent valuation, which it commissioned and received after the acquisition, specifically excluded consideration of environmental contamination risk. As a result, TfNSW is exposed to the risk that the acquisition was not fully compliant with the Land Acquisition (Just Terms Compensation) Act 1991 (the Act) because it did not use an accurate estimate of market value during negotiations. That said, the acquisition of 4–6 Grand Avenue by agreement was consistent with preferred processes described in the Act.

TfNSW acquired the site from the landowner by agreement, and this is consistent with provisions in the Act. Obtaining approval for compulsory acquisition should negotiations for agreement break down is also consistent with the Act. That said, TfNSW did not at any time assess whether a compulsory acquisition could have resulted in acquisition at a lower cost than what was negotiated by agreement.

Despite the high risks associated with the acquisition, TfNSW did not commission a formal valuation in time to inform the negotiation and purchase. Instead, TfNSW relied on internal advice to estimate market value, but did not obtain a formal valuation from those advisors. For high-risk transactions, the greater expertise and arm's-length independence of an external specialist valuer should be preferred over an agency's own staff.

On 15 June 2016, the settlement date for the acquisition, TfNSW commissioned a formal independent valuation of the site. On 23 November 2016, TfNSW received the final formal valuation report. By not obtaining a formal independent valuation of the property in advance of acquisition to inform the acquisition value, TfNSW exposed itself to non-compliance with the Act by not establishing the market value as the basis for the acquisition price. TfNSW also breached its own internal policies.

TfNSW instructed the valuer to conduct its valuation within the following parameters:

  • Market valuation on an ‘as is’ basis – market value based on the methodology described in the Act. This approach valued the site at $25.0 million.
  • Market valuation on a speculative development basis – market value based on the financial value of the vendor's intended use of the site which, in this case, involved leasing the site for industrial use. This approach valued the site at $52.0 million, and TfNSW advised us this valuation supported the purchase price.
  • Disregard the impact of environmental contamination – TfNSW specifically instructed the independent valuer to disregard any known (or unknown) site contamination. As TfNSW knew of the significant environmental contamination affecting the site, this parameter resulted in a valuation that overstated the value of the site as it did not consider the cost of environmental remediation. The valuer applied this assumption for both market valuation approaches.

Additionally, as the independent valuer completed the valuation after the purchase was finalised, there is a risk that the valuation may have been influenced by the known purchase price.

TfNSW's failure to acquire a formal valuation and an assessment of the financial impact of environmental remediation before it purchased 4–6 Grand Avenue represents ineffective administration and governance.
TfNSW acquired the site at a time when there was demand and increasing prices for industrial property in the area. However, TfNSW did not effectively assess and manage the risks associated with the acquisition, and gaps in process led to increased risk. Briefings to decision-makers did not contain important information, and we found no evidence that gaps in advice were queried or explored by decision-makers.

TfNSW did not have plans or advice in place to assist in managing risk, such as:

  • a property acquisition plan
  • a comprehensive and up-to-date risk management plan
  • a negotiation strategy, or any authorisation limit or minimal acceptable position
  • an independent professional evaluation
  • external expert advice (with the exception of legal advice relating to the contract of sale).

TfNSW was aware of contamination issues affecting the land and had access to considerable information about the environmental conditions, such as site environmental audit reports and information on the NSW Environment Protection Authority's contaminated land register. However, TfNSW had not analysed specific technical information about the contamination and therefore was not aware of the risk implications and cost for remediation. Despite this, TfNSW changed its position from not accepting the risks and costs of contamination, to acquiring the site unconditionally. The basis for this decision is unclear and undocumented.

Briefing to senior leaders on the acquisition was silent on a number of important matters that would have been important for approvers to consider, including:

  • an explanation of the 40 per cent increase in purchase price between November 2015 and May 2016, and a 165 per cent increase from TfNSW’s offer in April 2015
  • the contamination risks associated with the site and an evidence-based estimate of potential costs to remediate the site
  • advice that an independent valuation had not been obtained, inconsistent with TfNSW policy.

Consideration of the acquisition by FIC was based on a summary business paper and was managed out-of-session, thereby removing the ability for comprehensive consideration of the acquisition proposal and its risks.

The probity management controls and assurances in place for the acquisition of the 4–6 Grand Avenue site were insufficient. These insufficiencies were exacerbated by the probity risk profile of the transaction.

The 4–6 Grand Avenue acquisition was a high-risk/high-value transaction, undertaken in a volatile property market in a short timeframe under pressure from Grand 4 Investments. TfNSW was engaging in a direct negotiation in advance of detailed planning for the acquisition, or the PLR as a whole. These circumstances contribute to heightened probity risk.

TfNSW did not establish a probity plan and sought no probity support throughout the acquisition. Also, with one exception, the staff involved in the acquisition did not complete conflict of interest declarations.

TfNSW was aware of the potential for probity or integrity issues with the transaction when it commissioned an internal audit in connection with the transaction in 2019. Internal discussions considered whether a misconduct investigation may be more appropriate, however no such investigation was undertaken.

TfNSW's insufficient probity practices, in addition to its failure to keep complete or comprehensive records of negotiations or decisions, reduce transparency of the process and its outcome and expose TfNSW to a greater risk of misconduct, corruption and maladministration.

At the time of the transaction, the TfNSW policy framework was not sufficiently risk-focussed and did not provide clarity on when officers ought to apply specific guidance or procedures. TfNSW's policies and procedures are more focussed on acquiring land to meet project needs and timeframes, and less on assuring value for money and managing risks.

At the time of its acquisition of 4–6 Grand Avenue, TfNSW had property acquisitions policies and procedures in place. Each of these were broadly sound in their content and intent. However, they lacked specificity on how or when to apply guidance, and when risk levels should elevate the importance of recommended guidance.

TfNSW's key guidance was principles based and relied on agency staff using their experience and expertise to apply guidance according to the circumstances of an individual transaction. This guidance was not duly applied in the acquisition of 4–6 Grand Avenue, Camellia. In addition, TfNSW does not have quality or control assurance to identify when TfNSW officers did not apply important policies or processes.

The primary focus of the TfNSW’s property acquisition guidance is to achieve vacant possession of land in a timeframe that meets the need of the relevant transport project. There is less specific focus on the need to meet the requirements of the NSW Government financial management framework.

Appendix one – Response from agency 

Appendix two – About the audit 

Appendix three – 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 #349 - released (18 May 2021).

Published

Actions for Internal Controls and Governance 2017

Internal Controls and Governance 2017

Finance
Education
Community Services
Health
Justice
Whole of Government
Asset valuation
Compliance
Cyber security
Information technology
Internal controls and governance
Project management
Risk

Agencies need to do more to address risks posed by information technology (IT).

Effective internal controls and governance systems help agencies to operate efficiently and effectively and comply with relevant laws, standards and policies. We assessed how well agencies are implementing these systems, and highlighted opportunities for improvement.
 

1. Overall trends

New and repeat findings

The number of reported financial and IT control deficiencies has fallen, but many previously reported findings remain unresolved.

High risk findings

Poor systems implementations contributed to the seven high risk internal control deficiencies that could affect agencies.

Common findings

Poor IT controls are the most commonly reported deficiency across agencies, followed by governance issues relating to cyber security, capital projects, continuous disclosure, shared services, ethics and risk management maturity.

2. Information Technology

IT security

Only two-thirds of agencies are complying with their own policies on IT security. Agencies need to tighten user access and password controls.

Cyber security

Agencies do not have a common view on what constitutes a cyber attack, which limits understanding the extent of the cyber security threat.

Other IT systems

Agencies can improve their disaster recovery plans and the change control processes they use when updating IT systems.

3. Asset Management

Capital investment

Agencies report delays delivering against the significant increase in their budgets for capital projects.

Capital projects

Agencies are underspending their capital budgets and some can improve capital project governance.

Asset disposals

Eleven per cent of agencies were required to sell their real property through Property NSW but didn’t. And eight per cent of agencies can improve their asset disposal processes.

4. Governance

Governance arrangements

Sixty-four per cent of agencies’ disclosure policies support communication of key performance information and prompt public reporting of significant issues.

Shared services

Fifty-nine per cent of agencies use shared services, yet 14 per cent do not have service level agreements in place and 20 per cent can strengthen the performance standards they set.

5. Ethics and Conduct

Ethical framework

Agencies can reinforce their ethical frameworks by updating code‑of‑conduct policies and publishing a Statement of Business Ethics.

Conflicts of interest

All agencies we reviewed have a code of conduct, but they can still improve the way they update and manage their codes to reduce the risk of fraud and unethical behaviour.

6. Risk Management 

Risk management maturity

All agencies have implemented risk management frameworks, but with varying levels of maturity.

Risk management elements

Many agencies can improve risk registers and strengthen their risk culture, particularly in the way that they report risks to their lead agency.

This report covers the findings and recommendations from our 2016–17 financial audits related to the internal controls and governance of the 39 largest agencies (refer to Appendix three) in the NSW public sector. These agencies represent about 95 per cent of total expenditure for all NSW agencies and were considered to be a large enough group to identify common issues and insights.

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, controls and service delivery comments are included in the individual 2017 cluster financial audit reports tabled in Parliament from October to December 2017.

This new report offers strategic insight on the public sector as a whole

In previous years, we have commented on internal control and governance issues in the volumes we published on each ‘cluster’ or agency sector, generally between October and December. To add further value, we then commented more broadly about the issues identified for the public sector as a whole at the start of the following year.

This year, we have created this report dedicated to internal controls and governance. This will help Parliament to understand broad issues affecting the public sector, and help agencies to compare their own performance against that of their peers.

Without strong control measures and governance systems, agencies face increased risks in their financial management and service delivery. If they do not, for example, properly authorise payments or manage conflicts of interest, they are at greater risk of fraud. If they do not have strong information technology (IT) systems, sensitive and trusted information may be at risk of unauthorised access and misuse.

These problems can in turn reduce the efficiency of agency operations, increase their costs and reduce the quality of the services they deliver.

Our audits do not review every control or governance measure every year. We select a range of measures, and report on those that present the most significant risks that agencies should mitigate. This report divides these into the following six areas:

  1. Overall trends
  2. Information technology
  3. Asset management
  4. Governance
  5. Ethics and conduct
  6. Risk management.

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

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

This chapter outlines the overall trends for agency controls and governance issues, including the number of findings, level of risk and the most common deficiencies we found across agencies. The rest of this volume then illustrates this year’s controls and governance findings in more detail.

Issues

Recommendations

1.1 New and repeat findings

The number of internal control deficiencies reduced over the past three years, but new higher-risk information technology (IT) control deficiencies were reported in 2016–17.

Deficiencies repeated from previous years still make up a sizeable proportion of all internal control deficiencies.

Recommendation

Agencies should focus on emerging IT risks, but also manage new IT risks, reduce existing IT control deficiencies, and address repeat internal control deficiencies on a more timely basis.

1.2 High risk findings

We found seven high risk internal control deficiencies, which might significantly affect agencies.

Recommendation

Agencies should rectify high risk internal control deficiencies as a priority

1.3 Common findings

The most common internal control deficiencies related to poor or absent IT controls.

We found some common governance deficiencies across multiple agencies.

Recommendation

Agencies should coordinate actions and resources to help rectify common IT control and governance deficiencies.

Information technology (IT) has become increasingly important for government agencies’ financial reporting and to deliver their services efficiently and effectively. Our audits reviewed whether agencies have effective controls in place over their IT systems. We found that IT security remains the source of many control weakness in agencies.

Issues Recommendations

2.1 IT security

User access administration

While 95 per cent of agencies have policies about user access, about two-thirds were compliant with these policies. Agencies can improve how they grant, change and end user access to their systems.

Recommendation

Agencies should strengthen user access administration to prevent inappropriate access to sensitive systems. Agencies should:

  • establish and enforce clear policies and procedures
  • review user access regularly
  • remove user access for terminated staff promptly
  • change user access for transferred staff promptly.

Privileged access

Sixty-eight per cent of agencies do not adequately manage who can access their information systems, and many do not sufficiently monitor or restrict privileged access.

Recommendation

Agencies should tighten privileged user access to protect their information systems and reduce the risks of data misuse and fraud. Agencies should ensure they:

  • only grant privileged access in line with the responsibilities of a position
  • review the level of access regularly
  • limit privileged access to necessary functions and data
  • monitor privileged user account activity on a regular basis.

Password controls

Forty-one per cent of agencies did not meet either their own standards or minimum standards for password controls.

Recommendation

Agencies should review and enforce password controls to strengthen security over sensitive systems. As a minimum, password parameters should include:

  • minimum password lengths and complexity requirements
  • limits on the number of failed log-in attempts
  • password history (such as the number of passwords remembered)
  • maximum and minimum password ages.

2.2 Cyber Security

Cyber security framework

Agencies do not have a common view on what constitutes a cyber attack, which limits understanding the extent of the cyber security threat.

Recommendation

The Department of Finance, Services and Innovation should revisit its existing framework to develop a shared cyber security terminology and strengthen the current reporting requirements for cyber incidents.

Cyber security strategies

While 82 per cent of agencies have dedicated resources to address cyber security, they can strengthen their strategies, expertise and staff awareness.

Recommendations

The Department of Finance, Services and Innovation should:

  • mandate minimum standards and require agencies to regularly assess and report on how well they mitigate cyber security risks against these standards
  • develop a framework that provides for cyber security training.

Agencies should ensure they adequately resource staff dedicated to cyber security.

2.3 Other IT systems

Change control processes

Some agencies need to improve change control processes to avoid unauthorised or inaccurate system changes.

Recommendation

Agencies should consistently perform user acceptance testing before system upgrades and changes. They should also properly approve and document changes to IT systems.

Disaster recovery planning

Agencies can do more to adequately assess critical business systems to enforce effective disaster recovery plans. This includes reviewing and testing their plans on a timely basis.

Recommendation

Agencies should complete business impact analyses to strengthen disaster recovery plans, then regularly test and update their plans.

Agency service delivery relies on developing and renewing infrastructure assets such as schools, hospitals, roads, or public housing. Agencies are currently investing significantly in new assets. Agencies need to manage the scale and volume of current capital projects in order to deliver new infrastructure on time, on budget and realise the intended benefits. We found agencies can improve how they:

  • manage their major capital projects
  • dispose of existing assets.
Issues Recommendations or conclusions

3.1 Capital investment

Capital asset investment ratios

Most agencies report high capital investment ratios, but one-third of agencies’ capital investment ratios are less than one.

Recommendation

Agencies with high capital asset investment ratios should ensure their project management and delivery functions have the capacity to deliver their current and forward work programs.

Volume of capital spending

Most agencies have significant forward spending commitments for capital projects. However, agencies’ actual capital expenditure has been below budget for the last three years.

Conclusion

The significant increase in capital budget underspends warrant investigation, particularly where this has resulted from slower than expected delivery of projects from previous years.

3.2 Capital projects

Major capital projects

Agencies’ major capital projects were underspent by 13 percent against their budgets.

Conclusion

The causes of agency budget underspends warrant investigation to ensure the NSW Government’s infrastructure commitment is delivered on time.

Capital project governance

Agencies do not consistently prepare business cases or use project steering committees to oversee major capital projects.

Conclusion

Agencies that have project management processes that include robust business cases and regular updates to their steering committees (or equivalent) are better able to provide those projects with strategic direction and oversight.

3.3. Asset disposals

Asset disposal procedures

Agencies need to strengthen their asset disposal procedures.

Recommendations

Agencies should have formal processes for disposing of surplus properties.

Agencies should use Property NSW to manage real property sales unless, as in the case for State owned corporations, they have been granted an exemption.

Governance refers to the high-level frameworks, processes and behaviours that help an organisation to achieve its objectives, comply with legal and other requirements, and meet a high standard of probity, accountability and transparency.

This chapter sets out the governance lighthouse model the Audit Office developed to help agencies reach best practice. It then focuses on two key areas: continuous disclosure and shared services arrangements. The following two chapters look at findings related to ethics and risk management.

Issues Recommendations or conclusions

4.1 Governance arrangements

Continuous disclosure

Continuous disclosure promotes improved performance and public trust and aides better decision-making. Continuous disclosure is only mandatory for NSW Government Businesses such as State owned corporations.

Conclusion

Some agencies promote transparency and accountability by publishing on their websites a continuous disclosure policy that provides for, and encourages:

  • regular public disclosure of key performance information
  • disclosure of both positive and negative information
  • prompt reporting of significant issues.

4.2 Shared services

Service level agreements

Some agencies do not have service level agreements for their shared service arrangements.

Many of the agreements that do exist do not adequately specify controls, performance or reporting requirements. This reduces the effectiveness of shared services arrangements.

Conclusion

Agencies are better able to manage the quality and timeliness of shared service arrangements where they have a service level agreement in place. Ideally, the terms of service should be agreed before services are transferred to the service provider and:

  • specify the controls a provider must maintain
  • specify key performance targets
  • include penalties for non-compliance.

Shared service performance

Some agencies do not set performance standards for their shared service providers or regularly review performance results.

Conclusion

Agencies can achieve better results from shared service arrangements when they regularly monitor the performance of shared service providers using key measures for the benefits realised, costs saved and quality of services received.

Before agencies extend or renegotiate a contract, they should comprehensively assess the services received and test the market to maximise value for money.

All government sector employees must demonstrate the highest levels of ethical conduct, in line with standards set by The Code of Ethics and Conduct for NSW government sector employees.

This chapter looks at how well agencies are managing these requirements, and where they can improve their policies and processes.

We found that agencies mostly have the appropriate codes, frameworks and policies in place. But we have highlighted opportunities to improve the way they manage those systems to reduce the risks of unethical conduct.

Issues Recommendations or conclusions

5.1 Ethical framework

Code of conduct

All agencies we reviewed have a code of conduct, but they can still improve the way they update and manage their codes to reduce the risk of fraud and unethical behaviour.

Recommendation

Agencies should regularly review their code-of-conduct policies and ensure they keep their codes of conduct up-to-date.

Statement of business ethics

Most agencies maintain an ethical framework, but some can enhance their related processes, particularly when dealing with external clients, customers, suppliers and contractors.

Conclusion

Agencies can enhance their ethical frameworks by publishing a Statement of Business Ethics, which communicates their values and culture.

5.2 Potential conflicts of interest

Conflicts of interest

All agencies have a conflicts-of-interest policy, but most can improve how they identify, manage and avoid conflicts of interest.

Recommendation

Agencies should improve the way they manage conflicts of interest, particularly by:

  • requiring senior executives to make a conflict-of-interest declaration at least annually
  • implementing processes to identify and address outstanding declarations
  • providing annual training to staff
  • maintaining current registers of conflicts of interest.

Gifts and benefits

While all agencies already have a formal gifts-and-benefits policy, we found gaps in the management of gifts and benefits by some that increase the risk of unethical conduct.

Recommendation

Agencies should improve the way they manage gifts and benefits by promptly updating registers and providing annual training to staff.

Risk management is an integral part of effective corporate governance. It helps agencies to identify, assess and prioritise the risks they face and in turn minimise, monitor and control the impact of unforeseen events. It also means agencies can respond to opportunities that may emerge and improve their services and activities.

This year we looked at the overall maturity of the risk management frameworks that agencies use, along with two important risk management elements: risk culture and risk registers.

Issues Recommendations or conclusions

6.1 Risk management maturity

All agencies have implemented risk management frameworks, but with varying levels of maturity in their application.

Agencies’ averaged a score of 3.1 out of five across five critical assessment criteria for risk management. While strategy and governance fared best, the areas that most need to improve are risk culture, and systems and intelligence.

Conclusion

Agencies have introduced risk management frameworks and practices as required by the Treasury’s:

  • 'Risk Management Toolkit for the NSW Public Sector'
  • 'Internal Audit and Risk Management Policy for the NSW Public Sector'.

However, more can be done to progress risk management maturity and embed risk management in agency culture.

6.2 Risk management elements

Risk culture

Most agencies have started to embed risk management into the culture of their organisation. But only some have successfully done so, and most agencies can improve their risk culture.

 

 

Conclusion

Agencies can improve their risk culture by:

  • setting an appropriate tone from the top
  • training all staff in effective risk management
  • ensuring desired risk behaviours and culture are supported, monitored, and reinforced through business plans, or the equivalent and employees' performance assessments.

Risk registers and reporting

Some agencies do not report their significant risks to their lead agency, which may impair the way resources are allocated in their cluster. Some agencies do not integrate risk registers at a divisional and whole-of-enterprise level.

Conclusion

Agencies not reporting significant risks at the cluster level increases the likelihood that significant risks are not being mitigated appropriately.

Effective risk management can improve agency decision-making, protect reputations and lead to significant efficiencies and cost savings. By embedding risk management directly into their operations, agencies can also derive extra value for their activities and services.

Published

Actions for Transport 2017

Transport 2017

Transport
Asset valuation
Information technology
Internal controls and governance
Project management

The following report focuses on key observations and findings from the most recent financial statement audits of agencies in the Transport cluster.

Unqualified audit opinions were issued for all agencies' financial statements. However, the report notes the agencies can improve their asset revaluation processes.

1. Financial reporting and controls

Audit opinions

Unqualified audit opinions were issued for all agencies' financial statements.

Early close

Early close procedures continue to facilitate timely preparation of financial statements and completion of audits, but agencies can improve their asset revaluation processes. The revaluations were not completed by the early close deadline.
Key audit matters The cluster corrected the value of rail tunnels and earthworks by recording an additional $8.5 billion in infrastructure assets.
Passenger revenue and patronage Revenue increased by seven per cent at a similar rate to patronage. Opal fare structure changes came into effect on 5 September 2016. Continued rises in patronage can increase pressure on public transport punctuality.
Negative balances on Opal Cards

There was $2.6 million in revenue not collected during 2016–17 financial year through negative balance Opal Cards. This represents 0.2 per cent of total annual passenger revenue. Transport advise the cumulative balance of negative balance Opal Cards is $4.2 million as at 30 June 2017.

Recommendation: Transport for NSW (TfNSW) should implement measures to prevent loss of revenue from passengers tapping off with negative balance Opal Cards.

Investment in infrastructure Agencies spent $8.5 billion on assets in 2016–17 and have contractual capital commitments of $11.3 billion over the next five years.
Internal controls IT systems user access administration remains an area of weakness.


2. Service Delivery

Punctuality According to Transport data, average punctuality is above target for Sydney Trains, Ferries and Light Rail, but below target for NSW Trains services. State Transit Authority of NSW (STA) is not meeting punctuality targets. STA continued working with TfNSW on delivering improved punctuality.
Public transport capacity Passenger crowding is above benchmark for many morning peak suburban rail services, as indicated by Transport data. Eleven of the 14 bus contract regions had full buses.

Bus crowding

There are no target measures on crowding for bus operators in any contract region.

Recommendation: TfNSW should develop target measures on crowding for bus operators in all contract regions and publish the results.

Customer satisfaction

Surveys conducted by Transport indicate customer satisfaction exceeded target for all modes of public transport.

This report provides Parliament and other users of Transport cluster agencies' financial statements with audit results, observations, conclusions and recommendations in the following areas:

  • Financial reporting and controls
  • Service delivery.

Confidence in public sector decision-making and transparency is enhanced when financial reporting is accurate and timely. Appropriate financial controls help ensure the efficient and effective use of resources and administration of agency policies.

This chapter outlines our audit observations, conclusions or recommendations related to financial reporting and controls of Transport cluster agencies for 2016–17.

Observation Conclusion or recommendation
Quality of financial reporting
Unqualified opinions were issued for all agencies’ financial statements. Unqualified audit opinions were issued on the 2016–17 financial statements of all agencies in the Transport cluster. Agencies complied with the new disclosure requirements required under accounting standard AASB 124 'Related Party Disclosures'.
Old tunnels and earthworks valued. The cluster corrected the value of rail tunnels and earthworks by recording an additional $8.5 billion in infrastructure assets.
Timeliness of financial reporting  
Most agencies complied with the statutory timeframes for completion of early close procedures and preparation and audit of financial statements. Early close procedures continue to facilitate timely preparation of financial statements and completion of audits, but agencies can make further improvement in the revaluation process.
TfNSW and RailCorp completed asset revaluations after the early close deadline. While all revaluation matters were resolved and corrected, completing the revaluation process earlier would enable more timely review, identification and resolution of matters.
Passenger revenue, patronage and cost recovery
Revenue increased by 7 per cent at a similar rate to patronage. Public transport passenger revenue increased by $93 million (seven per cent) in 2016–17, and patronage increased by 49 million (seven per cent) across all modes of transport. There were some changes in the method of calculating reported patronage between 2015–16 and 2016–17. If the methods had been consistent, the patronage increase would be 6.5 per cent. Opal fare structure changes came into effect on 5 September 2016.
Value of negative balance Opal Cards doubled since last year.

There was $2.6 million in revenue not collected during 2016–17 financial year through negative balance Opal Cards. This represents 0.2 per cent of total annual passenger revenue. Transport advise the cumulative balance of negative balance Opal Cards is $4.2 million as at 30 June 2017.

Recommendation: TfNSW should implement measures to prevent the loss of revenue from passengers tapping off with negative balance Opal cards.

The overall cost recovery from users of public transport increased slightly to 21.3 per cent. Cost of service per passenger journey for buses and ferries decreased. Revenue per passenger journey for all modes remained fairly stable.
Investment in infrastructure
There was a significant investment in transport assets in 2016–17. Agencies spent $8.5 billion on assets in 2016–17, including $3.8 billion on rail systems and $3.8 billion on road and maritime infrastructure systems.
Transport cluster have capital commitment of $11.3 billion over the next five years.
 
The transport cluster has significant contractual commitments over the next five years on rail and road infrastructure projects.
 

Internal controls

User access administration over systems remains an area of weakness. We identified six moderate and eight low risk issues related to user systems access administration across four agencies. This included review of highly privileged/super user account transactions not performed effectively and user access reviews not performed. These weaknesses increase the risk of users having excessive or unauthorised access to critical financial systems and information.

Achievement of government outcomes can be improved through effective delivery of the right mix of services, whether from the public, private or not‑for‑profit sectors. Service delivery reform will be most successful if there is clear accountability for service delivery outcomes, decisions are aligned to strategic direction and performance is monitored and evaluated.

This chapter outlines our audit observations, conclusions or recommendations related to service delivery in the Transport cluster agencies for 2016–17.

Observations Conclusion or recommendation

Punctuality

Average punctuality is above target for Sydney Trains, but below target for NSW Trains services. Punctuality targets are not met by all bus operators. Meeting punctuality targets is a continuing challenge for NSW Trains’ and STA bus services.
The 2017 performance audit 'Passenger Rail Punctuality' reported that based on forecast patronage increases, rail agencies will find it hard to maintain punctuality after 2019 unless the capacity of the network to carry trains and people is increased significantly. The 2017 performance audit found that given the likely lead times involved with major infrastructure projects, there remains a significant risk of poor punctuality after 2019. Transport advised it is currently either delivering or planning rail network upgrades to address current growth and longer-term future demand. This includes investments such as procurement of suburban and intercity trains, Sydney Metro services and further timetable planning into the 2020s.
 
After reaching its punctuality target in 2015–16 for the first time in 13 years, NSW Trains regional services was below the target in 2016–17. NSW Trains regional services achieved an average of 75 per cent punctuality in 2016–17, four per cent less than 2015–16.
The bus contracts do not have an option to impose financial penalties on STA for poor punctuality performance. In 2015–16, we recommended TfNSW should consider including financial penalties for not meeting each punctuality KPI in future contracts with bus operators. An opportunity to implement the recommendation requires a contract renewal process to be finalised with STA, which did not occur during 2016–17.

Public transport capacity

There are no target measures on crowding for bus operators in any contract region. Recommendation: TfNSW should develop target measures on crowding for bus operators in all contract regions and publish the results.

Customer Satisfaction

Customers on ferries continued to be most satisfied, followed by those on light rail. Sydney Trains and NSW Trains had fewer complaints in 2016–17. Customer satisfaction exceeded target for all modes of transport.

Project management

Transport cluster manages many of the State high profile/high risk projects. Major Transport projects include WestConnex, Sydney Metro Northwest, Sydney Metro City and Southwest, Woolgoolga to Ballina - Pacific Highway upgrade, NorthConnex, CBD and South East Light Rail and Newcastle Light Rail.
Safety performance
Road fatalities decreased by eight per cent between July 2016 and June 2017, from 390 to 359 deaths. Road fatalities mainly involved speed, fatigue and vehicle occupants not wearing available restraints.
 

Maintenance

RMS’ maintenance backlog of $3.7 billion is higher than the $3.4 billion reported in 2016. Transport cluster agencies manage $134 billion in property, plant and equipment. The total backlog maintenance of $4.1 billion at 30 June 2017 represents 3.1 per cent of those assets.

Published

Actions for Managing demand for ambulance services 2017

Managing demand for ambulance services 2017

Health
Information technology
Management and administration
Risk
Service delivery
Shared services and collaboration
Workforce and capability

NSW Ambulance has introduced several initiatives over the past decade to better manage the number of unnecessary ambulance responses and transports to hospital emergency departments. However, there is no overall strategy to guide the development of these initiatives nor do NSW Ambulance's data systems properly monitor their impact. As a result, the Audit Office was unable to assess whether NSW Ambulance's approach to managing demand is improving the efficiency of ambulance services.

Demand for ambulance services is increasing. Demographic factors including population growth and ageing have contributed to this and ongoing growth in demand is likely. It is important that NSW Ambulance finds ways to respond to this demand more efficiently, while maintaining patient safety standards and meeting community expectations.

Most triple zero calls to NSW Ambulance do not involve medical issues that require an emergency response. NSW Ambulance has introduced a range of initiatives to change the way it manages these less urgent requests for assistance. Its major demand management initiatives include using a telephone advice line, referring some patients to services other than hospital emergency departments and using specialist paramedics to respond to less urgent cases.

The role of NSW Ambulance has changed in recent years. It is aiming to become a ‘mobile health service’ that identifies the needs of patients and provides or refers them to the most appropriate type of care. This change involves a significant expansion of the clinical decision-making role of paramedics. Considerable strategic and organisational efforts are required to make this work. The successful implementation of demand management initiatives is important to NSW Ambulance's ability to continue to meet demand for its services.

This audit assessed NSW Ambulance's major demand management initiatives that aim to reduce unnecessary demand for ambulance responses and unnecessary transport to hospital emergency departments. It aimed to assess the extent to which these initiatives have improved the efficiency of its services.

Conclusion

NSW Ambulance has introduced several initiatives that aim to manage demand for its services from less urgent cases more efficiently. There is no overall strategy for these initiatives and NSW Ambulance’s data systems do not measure their outputs or outcomes. As a result, we are unable to assess the impact of NSW Ambulance's demand management initiatives on the efficiency of ambulance services. More focus is needed to ensure these initiatives achieve the efficiency improvements necessary to help NSW Ambulance meet future increases in demand.

Increasing demand for ambulance services is a key issue for NSW Ambulance. Demand has increased at a faster rate than population growth in recent years and continued growth is expected. NSW Ambulance has introduced several initiatives that aim to manage demand for its services from people with less urgent medical issues more efficiently and align its approach with the rest of the health system in New South Wales.

These individual initiatives lack a broader strategy to guide their development. NSW Ambulance’s demand management initiatives also lack clear goals and performance targets, with insufficient organisational resources allocated to support their implementation. NSW Ambulance does not have a data system that allows it to conduct accurate routine monitoring of the activity and performance of these initiatives.

More effort is required to make demand management initiatives a core part of NSW Ambulance's work. Key relationships with other health services to support demand management initiatives have only recently been established. NSW Ambulance has not communicated proactively with the public about its demand management initiatives. To ensure paramedics are as well prepared as possible for their expanded roles, they need better professional development and up to date technology.

Demand for ambulance services in New South Wales is increasing steadily. Forecast future increases in demand due to population growth and ageing mean that NSW Ambulance must improve its efficiency to maintain its performance.

Demand for ambulance services is growing at a rate higher than population growth. The increase in demand is likely to continue as the population continues to grow and age. NSW Ambulance has made several recent changes to remove large parts of demand for its services, including moving non-emergency patient transport to a separate government agency and changing the way triple zero calls are categorised.

These changes were expected to improve emergency response time performance, but the anticipated improvements have not been achieved. If demand continues to increase as forecast, NSW Ambulance will need to find more efficient ways to manage demand to maintain its performance.

NSW Ambulance has introduced initiatives to change the way it manages demand from patients who have less urgent medical issues. These have the potential to achieve positive results, but we were unable to fully assess their impact because of weaknesses in data systems and monitoring. More needs to be done to demonstrate progress toward the efficiency improvements required.

NSW Ambulance uses a telephone referral system to manage triple zero calls from people with medical issues that do not require an ambulance. This has the potential to achieve efficiency improvements but there are weaknesses in NSW Ambulance's use and monitoring of this system. Paramedics are now able to make decisions about whether patients need transport to a hospital emergency department. NSW Ambulance does not routinely measure or monitor the decisions paramedics make, so it does not know whether these decisions are improving efficiency. Extended Care Paramedics who have additional skills in diagnosing and treating patients with less urgent medical issues were introduced in 2007. NSW Ambulance analysis indicates that these paramedics have the potential to improve efficiency, but have not been used as effectively as possible.

Our 2013 audit of NSW Ambulance found that accurate monitoring of activity and performance was not being conducted. More than four years later, this remains the case. 

NSW Ambulance has recognised the need to change the way it manages demand and has developed initiatives that have the potential to improve efficiency. However, there are significant weaknesses in the strategy for and implementation of its demand management initiatives.

NSW Ambulance has identified the goal of moving from an emergency transport provider to a mobile health service and developed several initiatives to support this. Its demand management initiatives have the potential to contribute to the broader policy directions for the health system in New South Wales. However, there is no clear overall strategy guiding these initiatives and their implementation has been poor.

NSW Ambulance's reasons for changing its approach to demand management have not been communicated proactively to the community. Demand management initiatives that have been operating for over a decade still do not have clear performance measures or targets. Project management of new initiatives has been inadequate, with insufficient organisational resources to oversee them and inadequate engagement with other healthcare providers.

NSW Ambulance uses an in-house Vocational Education and Training course to recruit some paramedics, as well as recruiting paramedics who have completed a university degree. No other Australian ambulance services continue to provide their own Vocational Education and Training qualifications. Paramedics will need more support in several key areas to be able to fulfil their expanded roles in providing a mobile health service. Performance and development systems for paramedics are not used effectively. Up to date technology would help paramedics make better decisions and improve NSW Ambulance's ability to monitor demand management activity.

There are gaps in NSW Ambulance's oversight of the risks of some of the initiatives it has introduced, particularly its lack of information on the outcomes for patients who are not transported to hospital. Weaknesses in the way NSW Ambulance uses its data limit its ability to properly assess the risks of the demand management initiatives it has introduced.

Appendix one - Response from agency

Appendix two - About the audit

Appendix three - Performance auditing

 

Parliamentary reference - Report number #295 - released 13 December 2017

Published

Actions for Health 2017

Health 2017

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

The following report highlights results of the financial audits of entities in the NSW health cluster. The report focuses on key observations and findings from the most recent audits of these entities.

The report also includes a range of findings on service delivery. Overall, NSW Health is achieving most of their targets. Some local health districts are continuing to experience increased demand for their services and are finding it more difficult to meet their targets. For example, three local health districts had not achieved some emergency department response time targets for three consecutive years.

1. Financial reporting and controls

Financial Reporting

All health cluster entities received unqualified audit opinions and the quality of financial reporting remains high across the cluster.

Early close procedures were largely completed and all financial statements were submitted by the deadlines.

Financial performance

Overall, NSW Health recorded an operating surplus of $407 million in 2016–17. Eleven local health districts/specialty networks recorded operating deficits in 2016–17, four more than 2015–16.

Expenses across NSW Health increased by 4.4 per cent in 2016–17 (6.0 per cent in 2015–16), lower than the expected long term annual expense growth rate.

Excess annual leave Managing excess annual leave is a continual challenge for NSW Health, with thirty–five per cent of the workforce having excess balances.
Overtime payments NSW Health entities are generally managing overtime well; however NSW Ambulance’s overtime payments, $74.6 million in 2016–17, remain significantly higher than other health entities.
Time and leave recording practices Unapproved employee timesheets continue to be a problem for health entities. Weak timesheet approval controls increase the risk of staff claiming and being paid for hours they have not worked. There is also an increased risk of high volumes of roster adjustments, manual pays, salary overpayments and leave not being recorded accurately.

2. Service Delivery

Service Agreements Most of the service agreements between the Secretary of NSW Health and health entities were signed earlier than prior years.
Performance monitoring Five NSW Health entities are not meeting the Ministry of Health’s performance expectations at 30 June 2017.
Emergency department performance Data provided by the Ministry indicates NSW Health, on average, met emergency department triage response time targets across all triage categories for the fourth consecutive year.
Ambulance response times Data provided by the Ministry shows NSW Ambulance response times for imminently life‑threatening incidents of 7.5 minutes in 2016–17 was within the Ministry’s target of 10.0 minutes.

Data provided by the Ministry indicates NSW Ambulance response times for potentially life‑threatening incidents did not improve in 2016–17. The median response time of 11.1 minutes in 2016–17 was similar to 2015–16 (11.0 minutes). This is despite the number of Priority 1 responses reducing by 4.3 per cent.
Unplanned hospital re-admissions Data provided by the Ministry shows eight local health districts achieved the Ministry of Health’s unplanned hospital re‑admissions target in 2016–17. The target is for local health districts to reduce re‑admission rates from the previous financial year.

This report sets out the results of the 30 June 2017 financial statement audits of Health cluster entities.

The report has been structured into two chapters focusing on:

  • Financial reporting and controls
  • Service delivery.

This chapter outlines audit observations, conclusions and recommendations related to financial reporting and internal controls of entities for 2016-17.

Observation Conclusion or recommendation

2.1 Quality of financial reporting

All cluster entities received unqualified audit opinions and misstatements identified in financial statements fell. The quality of financial reporting remains high across the cluster.

2.2 Timeliness of financial reporting

Early close procedures were largely completed and all financial statements were submitted by the deadlines. Health entities controlled by the Ministry of Health continued submitting their financial statements well ahead of the statutory deadlines.

2.4 Financial and sustainability analysis

NSW Health recorded an operating surplus of $407 million in 2016–17.



Eleven local health districts/specialty networks recorded operating deficits in 2016–17, four more than 2015–16.


Expenses across NSW Health increased by 4.4 per cent in 2016–17 (6.0 per cent in
2015–16).

The capital replacement ratio of local health districts/specialty networks ranged from 0.5 to 5.7 in 2016–17. Seven local health districts had capital replacement ratio higher than one.

The statewide operating surplus was $84 million higher than 2015–16. Net surpluses contribute to NSW Health’s ability to invest in new facilities, upgrades and redevelopments.

The 2016–17 financial results were once again impacted by the NSW Government initiative to improve cash management across the sector.

The expense growth rate for NSW Health is 1.6 percentage points lower than the expected long term annual expense growth rate.

Substantial ongoing investment in hospitals and other assets across NSW Health is evidenced by high capital replacement ratios for some health entities in 2016–17.

2.5 Performance against budget
Ten local health districts/specialty networks’ expense budget variance was outside performance expectations agreed with the Ministry at the beginning of 2016–17. The Ministry continues to manage performance across NSW Health to improve the accuracy of budgeting practices.
2.7 Human Resources    

Thirty-five per cent of NSW Health’s workforce have excess annual leave balances.

 

 

 

 

 

 

NSW Ambulance had the highest average sick leave rate in NSW Health of 85.2 hours per FTE in 2016–17 (78.7 hours in 2015–16). This was higher than the statewide average of 62.1 hours (62.0 hours in 2015–16).

NSW Ambulance’s overtime payments in 2016–17 totalled $74.6 million; $2.8 million more than 2015–16 and significantly higher than other health entities

Other NSW Health entities are generally managing overtime well.

 

Unapproved employee timesheets continue to be a problem for health entities. Weak timesheet approval controls increase the risk of staff claiming and being paid for hours they have not worked.

 

Managing excess annual leave is a continual challenge for health entities.

Recommendation: Health entities should further review the approach to managing excess annual leave in 2017–18. They should:

  • 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.


NSW Ambulance continues to face significant challenges in managing sick leave.

Recommendation: NSW Ambulance should further implement and monitor targeted human resource strategies to address the high rates of sick leave taken

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

Recommendation: Health entities should conduct a risk‑based review of time and leave recording practices to ensure control weaknesses are identified and fixed.

This chapter outlines our audit observations, conclusions and recommendations relating to service delivery for 2016–17.

Observation Conclusion or recommendation
3.1 Service agreements in NSW Health

Most of the service agreements between the Secretary of NSW Health and health entities were signed earlier than prior years.

Thirteen local health districts/specialty networks signed their service agreements by the 31 July 2017 due date. This is a significant improvement with only seven local health districts/specialty networks meeting the date in 2015–16.

Having service agreements signed as close as possible to the start of each year provides the Ministry and NSW Health entities with clarity around roles, responsibilities, performance measures, budgets, and service volumes and levels.
3.2 Performance of NSW Health entities
Five NSW Health entities were not meeting the Ministry’s performance expectations at 30 June 2017. The Ministry is managing the five entities in accordance with its performance review process.
3.4 Emergency department response times

Data provided by the Ministry indicates NSW Health again, on average, met emergency department triage response time targets across all triage categories for the fourth consecutive year.

The Ministry manages performance across NSW Health to ensure patients presenting at emergency departments receive care in a clinically appropriate timeframe.

Based on the Ministry’s data, local health districts/specialty networks are, on average, meeting triage targets despite increasing emergency department attendances.

The data shows eleven local health districts met all triage targets in 2016–17, compared to eight in
2015–16. 

3.5 Emergency treatment performance

The Ministry manages public patient access to emergency services in public hospitals.

It has an emergency treatment performance target of 81 per cent of patients leaving emergency departments within four hours.

Data provided by the Ministry indicates NSW Health maintained its overall emergency treatment performance in 2016–17, but did not achieve its target. The State average emergency treatment performance was 74.2 per cent (74.2 per cent in 2015–16).

Based on the Ministry’s data, only four local health districts achieved the target in 2016–17, five in
2015–16.

3.6 Ambulance response times
NSW Ambulance has a response time target of 10.0 minutes for imminently life‑threatening incidents in New South Wales. Data provided by the Ministry indicates NSW Ambulance response times for imminently life-threatening incidents of 7.5 minutes in 2016–17 was within the Ministry’s target.
 
3.7 Transfer of care
The Ministry has a target of 90 per cent for the number of ambulance arrivals within a 30 minute ‘transfer of care’ timeframe. Data provided by the Ministry indicates the rate of ambulance arrivals within a 30 minute 'transfer of care' timeframe improved from 87.6 per cent in
2015–16 to 91.7 per cent in 2016–17, exceeding the Ministry’s target.
3.8 Average length of stay in hospital
Based on the Ministry’s 2016–17 data, the average length of stay for acute episodes was 3.0 days. The average length of stay in New South Wales hospitals is lower than the national average of 3.2 days (in 2015–16). The Ministry’s data shows the average length of stay by patients for acute episodes has remained stable in New South Wales hospitals for four years. 
3.9 Elective surgery access performance
Data provided by the Ministry indicates NSW Health continues to manage waiting times for elective surgery in public hospitals. The Ministry’s data shows NSW Health improved on‑time admission of patients for elective surgery in 2016–17 despite a 1.8 per cent increase in admissions. While the result improved, only one of the three targets for elective surgery waiting times was met in 2016–17.
3.10 Unplanned hospital re-admissions

Data provided by the Ministry indicates NSW Health, on average, did not reduce the rate of unplanned hospital re‑admissions in 2016–17. The Ministry has a target of reducing unplanned hospital re‑admissions compared to the previous financial year.

Low re‑admission rates may indicate good patient management practices and post-discharge care.

The Ministry’s data shows eight local health district met the target to reduce the rate of re‑admissions compared to the previous financial year. The statewide average rate increased from 6.3 per cent to 6.4 per cent.
3.11 Post discharge care for acute mental health patients
NSW Health has a goal to increase community-based care to acute mental health patients after they are discharged. Continuity of care in the community can lead to reduced symptom severity, lower re‑admission rates, and improved quality of life. The Ministry’s 2016–17 data shows the statewide average for post discharge follow-up of acute mental health patients within seven days was 70.0 per cent (66.0 per cent in 2015–16). The statewide average improved and met the NSW Health target of 70 per cent. Nine local health districts exceeded the NSW Health target.
3.12 Mental health acute re-admissions
NSW Health has a goal to reduce acute public sector mental health re-admissions. High re‑admission rates may indicate deficiencies in inpatient treatment and follow up care. The Ministry’s data shows twelve local health districts did not achieve the NSW Health target of 13 per cent mental health acute re‑admissions in 2016–17.
3.13 Unplanned and emergency re‑presentations

NSW Health aims to reduce the number of unplanned and emergency re‑presentations to emergency departments.

The Ministry’s 2016–17 data shows the State average of emergency department re‑presentations decreased marginally from 5.0 per cent in 2015–16 to 4.9 per cent.

Patients attending rural emergency departments are more likely to re‑present within 48 hours of being discharged than those in regional or metropolitan emergency departments.
3.14 Healthcare associated infection
The national target for the rate of Staphylococcus aureus (golden staph) bloodstream infection is two cases per 10,000 bed days. Data provided by the Ministry indicates the rate of golden staph bloodstream infection in New South Wales hospitals continues to be well below the target and national benchmark at 0.72 cases per 10,000 bed days in 2016–17 (0.75 in 2015–16).
3.15 Patient experience and satisfaction

The Bureau of Health Information analyses and reports on the results of patient surveys.

The Bureau’s survey shows 65 per cent of adult admitted patients rated the care they received in hospital as ‘very good’ and 29 per cent rated it as ‘good’.

NSW Health recognises that patient surveys are an important feedback mechanism on the health care system that can only come from personal experiences.