Patients with conditions such as rheumatoid arthritis should be treated by plastic or orthopaedic surgeons who have appropriate hand surgery training and expertise. Where plastic surgeons are involved, it is in the interest of patients for their treatment to be undertaken in local acute hospitals and this is possible in many cases. Where however, more complex reconstruction is necessary, this may best be carried out in a plastic surgery unit. For these patients it is essential that specialist hand therapists are involved as part of the team at the outset.