In 1997 there were 57 000 notifiable crimes of serious or sexual violence recorded by police in England and Wales (Home Office, 1998) – more than 1000 per week or approximately one every 10 minutes. On 15 February 1999 the Home Secretary, Jack Straw, announced new measures “better to protect the public from dangerous people in our society” (House of Commons, 1999). He said the measures were to target “those who are capable of committing acts of a serious sexual or violent nature”. Of the 57 000 potential targets, Mr Straw believes 1800 men are already detained in prisons and special hospitals; he intends to identify a further 500 or so men currently at liberty and lock them away indefinitely, in advance of their offending. His intention in respect of the other 54 700 violent or sexual offenders, responsible for 99% of serious violence, is not stated. Mr Straw believes that the 500 men in the community (and the 1800 in custody) share a common psychiatric condition and that this is what makes them dangerous. His policy for identifying the men, and what he intends to do with them and similar people, is contained in the recently published consultation paper on dangerous people with severe personality disorder (Home Office & Department of Health, 1999).

Working in general psychiatry requires us to live with tensions. We have to live with the tension between the paternalism of compulsory admissions and advocating the autonomy and rights of people with a mental illness. A further tension is exacerbated by two movements of recent years, evidence-based medicine and user involvement. These are broadly to be welcomed, but will ultimately bring psychiatry further into the conflict between the ‘modern’ and ‘post-modern’ views of the world.

Compulsory treatment in the community is high on the agenda in the current review of mental health legislation and the government has already announced its intention to introduce a ‘community treatment order’ (CTO; Department of Health, 1998). Concern about the implications of community care has been gathering momentum over the last decade, spurred on by tragedies such as those involving Ben Silcock and Christopher Clunis in the early 1990s. The notion that community care has failed has taken deep root with the media and the government (Department of Health, 1998). This is despite the lack of any evidence to suggest that mental illness is less effectively treated (Johnstone et al, 1991; Anderson et al, 1993) or that violence attributable to the mentally ill is rising (Taylor & Gunn, 1999). It also indicates a tendency to ignore the fact that patients prefer to live in the community (Tyrer, 1998). Psychiatrists, who are increasingly implicated in this purported failure of care, feel besieged. In such a climate, the promise of more power is understandably attractive. However, we feel that psychiatrists should resist pressure for this sort of ‘quick fix’ and reflect upon some of the dilemmas involved.

Psychiatrists have been complaining about mental health legislation for over a century (Smith, 1891), usually in terms of the delays engendered, paperwork and bureaucracy, and the impositions on clinical practice. As a result they have gained more powers, and perhaps much-needed status within the medical profession, to the concern of some commentators (e.g. Fennell, 1996). Thus, the ‘triumph of legalism’ (Jones, 1993) of the Lunacy Act 1890 was modified by the Mental Treatment Act 1930, whereby outpatients and voluntary patients were encouraged and ‘asylums' became ‘mental hospitals'. Then came the radical change of the Mental Health Act (MHA) 1959, making compulsory detention an essentially medical decision and removing the routine of the courts, but retaining a theme of requiring ‘treatment in hospital’. The Mental Health Act 1983, however, was a touch anti-medical, since it strengthened the role of the approved social worker (ASW) and enhanced the importance of a patient's consent to treatment. “The primacy of the medical model and the paramountcy of the psychiatrist are certainly subject to greater limitations and external review”, was the opinion of William Bingley, then Mind's Legal Director, now Chief Executive of the Mental Health Act Commission – reviewing the Act in its early days (Bingley, 1985).