Dozens of women have suffered delayed diagnosis of breast cancer because a major district health board doesn't have enough facilities.
Counties Manukau DHB breast cancer service is turning down more referrals by toughening the threshold for seeing patients and has reduced the number of follow-up appointments.
However, wait times are still too long because of growing numbers of women needing help and more complex cases.
"Demand exceeds capacity," a new report by chief executive Margie Apa has warned.
"This has resulted in clinical risk, manifesting as delayed diagnosis of breast cancer in 35 women in 2019... currently, all waiting times to be seen at the breast clinic are longer than target due to existing capacity issues."
"Priority one" patients are those with a high suspicion of cancer and should be seen in less than 14 days. The current waiting time is between 12 and 16 days.
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Delays are worse for those deemed "priority two" because of a low suspicion of cancer.
They should be seen within six weeks at the most, but are currently seen between 12 and 23 weeks after referral.
Extra clinics have been scheduled, and another breast clinic will be built as part of a redevelopment of the Manukau Health Park (the Super Clinic and surgery centre).
In the report, Apa acknowledged the "gold standard" model of care provided by her DHB and good treatment outcomes when compared nationally. However, the breast cancer team "is affected by a number of resource and capacity limited challenges affecting service delivery and outcomes".
"These challenges are a consequence of lack of growth of clinics and are related to physical space constraints at Manukau Health Park... theatre access is constrained due to operating theatre space capacity and competing demands on the breast surgeons' time (all breast surgeons also have other speciality commitments)."
The report comes soon after an investigation by the Herald found more than half of the country's 20 DHBs identified infrastructure issues as a major risk to the treatment and safety of patients.
Counties Manukau DHB has more pressure than most, given a growing population that also suffers from high levels of deprivation and obesity. That has meant residents can get worse treatment than up the motorway in suburbs covered by Auckland and Waitematā DHBs.
The threshold to get cataract surgery is much tougher in South Auckland, for example, and Middlemore women's health services have struggled to cope with growing demand, including in maternity, where the death or stillbirth of babies in 2016 and 2017 were linked to problems such as a lack of staff and bed space.
Women with debilitating gynaecological conditions, including suspected endometriosis, are often turned down for treatment, primarily because of a lack of theatre capacity.
Apa compared her DHB's breast cancer clinic to that run by neighbouring Auckland DHB, which she said deals with half the workload but runs twice as many clinics every week, and employs the same number of specialist breast surgeons.
"The resource constraints are particularly stark compared to other DHBs in our region," she wrote.
The complexity of breast cancer care is increasing, with more advanced and intensive treatments. Counties' population is booming as new subdivisions go up, and it serves more Māori and Pacific women, who are more likely to present with advanced disease.
Health Minister David Clark has said that the Government is rebuilding old, inadequate hospital facilities, but a recent national stocktake underlined a "huge" problem.
"The Treasury's best estimate is that about $14 billion will be needed to be invested over the next decade, and that may well yet prove to be a conservative estimate."
The four DHBs that make up the northern region – Northland, Waitematā, Auckland and Counties Manukau – made a case for a new hospital, possibly two, in their recent northern region long-term investment plan.
Over the next 20 years nearly 60 per cent of New Zealand's population growth will be in Auckland and Northland, the report found, meaning another 2055 beds and 41 theatres will be required.