This study reviews hand surgical activity and the resources available for provision of hand surgery in England in 2001. Operation rates for three common procedures, viz. carpal tunnel release, Dupuytren's surgery and ganglion surgery, were considered. The local population and the number of hand surgeons in each NHS Hospital Trust were compared. We identified 275 consultant surgeons with an interest in hand surgery working in the NHS in England. Approximately two-thirds were orthopaedic surgeons, almost one-third were plastic surgeons and a small number were accident and emergency surgeons. Half of all hand surgeons worked in large units, with three or more hand surgeons, but almost 20% of hand surgery was delivered in hospitals in which there was no surgeon with a declared interest in hand surgery. Surgery rates for Dupuytren's contracture varied from 0.04 to 0.36 cases per 1,000 population per annum and for carpal tunnel syndrome varied from 0.25 to 1.31 cases per 1,000 per annum. We found a correlation between rates of surgery and the number of hand surgeons, locally. A recent audit (Burke, Dias, Heras-Pelou, Bradley, & Wildin, 2004. Providing care for hand disorders, a reappraisal of need. Journal of Hand Surgery, 29B: 575-579.) has suggested that one hand surgeon is required to meet the needs of a population of 125,000, with a national requirement for 393 hand surgeons. We conclude that there are insufficient hand surgeons in England and believe that the wide local variations in hand surgery rates are indicative of a significant unmet demand for hand surgery in the English population.