The final report of the Scoping Study Committee (Richardson Committee) reviewing the Mental Health Act 1983 is eagerly awaited. All psychiatrists, either individually or through the College, had an opportunity to express their views on what changes in legislation are needed and to comment on the draft proposals (Scoping Study Committee, 1999). Many psychiatrists did neither. Yet to use modem terminology, psychiatrists are one of the major ‘stakeholders' of mental health legislation. A valuable way of ascertaining colleagues' views in a structured way is by surveys of the type conducted by Buchanan & Gunn (1999, this issue). Given that the Richardson Committee has yet to publish proposals for ‘Part III’ the survey is timely. The response rate is, of course, very important and one is left wondering why a third of the general and community psychiatrists did not respond. Work load, burn-out or lack of familiarity with Part III of the Act are possible explanations.

Much of my professional career has been dedicated to showing that psychiatric coercions and excuses are incompatible with respect for individual liberty and responsibility (Szasz, 1961, 1997). Thus, I was both pleased and displeased to read the criticisms of mental health legislation by Zigmond (1998) and Szmukler & Holloway (1998). It is gratifying to see such views appear in the pages of so respected a publication as the Psychiatric Bulletin, the more so as no American psychiatric journal exhibits similar open-mindedness toward debating a subject that most psychiatrists consider taboo. At the same time, it is frustrating to see psychiatrists grappling with problems intrinsic to psychiatry's legal and social mandate, yet refusing to acknowledge the nature and implications of that mandate.

Moncrieff & Smyth (1999, this issue) are certainly right that community treatment orders (CTOs) are high on the agenda and that psychiatrists need to think long and hard about them – about the political and ethical implications, not just their practical and therapeutic applications. Their concerns are important and reflect a wide constituency – identical views were expressed and considered during the consultation that preceded the College's document proposing a Community Supervision Order in 1993 (Royal College of Psychiatrists, 1993). Moncrieff & Smyth make no mention of that document, nor the limited, but recent, survey of psychiatrists' opinions that accompanied it (Burns et al, 1993). Do all College documents achieve obscurity quite so quickly?

While carrying out research in a special hospital, I encountered a small group of middle-aged patients who spent most of their time engaged in sporting activities. They had considerable freedom within the high security perimeter, and were regarded as presenting no risks, as long as they had no access to children. All were detained under the legal category of psychopathic disorder, and none of them were receiving psychiatric treatment, unless the term milieu therapy were to be stretched to include a patient's mere presence within a hospital. Their past offences were such as to lead to a shared understanding that they were unlikely ever to be released, and a compromise had been reached. The patients were aware that they enjoyed a quality of life that was as good as they could expect in the circumstances. The hospital accepted that it would have the patients for as long as their restriction orders lasted, and saw itself as providing a valuable public service by keeping them locked up.

Thomas Szasz is justifiably famous for his critique of psychiatry. He was instrumental in focusing an important debate on the status of ‘mental illness' and its social implications for which we are all deeply indebted. However times have moved on. Holloway and I seek to cast different “skeletons from the closet” to those of Szasz. We seek to destigmatise mental illness, so it no longer constitutes a secret source of shame or pain to a family or person. We ask that mental illness be treated neither better nor worse than physical illness. Only if a person suffers from mental incapacity, whatever the cause – brain injury, exsanguination, schizophrenia, learning disability, stroke, toxic infection – and it is in that person's ‘best interests', carefully defined, should they be treated against their will. Szasz seems oblivious that every day, many more patients with a physical illness (associated with incapacity) are treated non-consensually than those with mental illness. It is just that we don't draw attention to it, and society accepts it is right. A little bit of homework on his part would have told him that in this country, exactly opposite to his assertion, the law does justify the “medical treatment of incompetent persons, say one who has a stroke or is unconscious as a result of an accident” (if it is in the patient's ‘best interests’). Again, exactly opposite to his claims, in this country no other person can consent on behalf of an incompetent patient. We argue that all patients in this position should have similar safeguards. Mental illness does not automatically confer incapacity, nor does it raise special issues requiring specific mental health legislation. But of course Szasz does not believe mental illness exists.

Recruitment into psychiatry varies across medical schools. There is evidence that positive attitudes towards psychiatry at the end of undergraduate education influence career choice and that a major determinant of positive attitudes is exposure to well organised and well taught psychiatry programmes. The General Medical Council's (GMC) guidance on undergraduate medical education provides many opportunities for psychiatrists to increase the exposure of medical students to psychiatry. These opportunities should be seized if we wish to increase recruitment into psychiatry.

Risk, and how to manage risk, have become dominant themes of this decade. Risk is essentially any feature of an organisation which is likely to prevent that organisation from achieving its primary aims (Rosen, 1995). In general, the lower the risk in an organisation, the higher the performance of that organisation is likely to be. In turn this can lead to more efficient use of resources. In the area of mental health, the consequences of risk can be serious, this being amply demonstrated by the public inquiries into homicides by mentally disordered people. Such inquiries consistently reveal inadequacies in local services providing mental health care (Appleby, 1997). The identification and management of risk within local mental health services has therefore become a priority. Clinicians as managers have a key role in such a development, particularly with the introduction of clinical governance (Oyebode et al, 1999). This paper outlines a simple approach to risk management in a local mental health service.

Health care professionals in Ireland are concerned about the effect of L v. Bournewood Community and Mental Health Trust ex parte L (1998). Despite Ireland's distinct legal system and different service provision, this case has highlighted existing concerns about the treatment of patients with a dual diagnosis of learning disability and mental illness.

This is one of three articles describing how one National Health Service (NHS) trust is tackling clinical governance. The first is by the trust chief executive, the ‘accountable officer’ in the White Paper The New NHS (Department of Health, 1997). The second is by the trust's director of research and development whose responsibilities include assisting clinical directorates to carry out an annual programme of improvements in clinical effectiveness. The third paper is by the mental health lead clinician’ for clinical governance.