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.

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?

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.

The theoretical notion of risk is sweeping all before it. Politicians, government planners, scientists and doctors, including psychiatrists, are having to confront a more formalised concept of risk. This is not to say that our awareness, as human beings, of notions of risk has hitherto been largely negligible. However, there is an evident contemporary preoccupation with risk, its assessment and management, which signals society's unwillingness to tolerate or bear anything but the most minimal possibility of adverse outcomes. There are competing definitions and concepts of risk which complicate discussions between experts and the lay public. For example, Thompson (1990) distinguishes between ‘real’ risk, ‘observed’ risk, and ‘perceived’ risk. Real risk is thought to reflect how things stand in the real world. That is, it is a term which refers to actual risk, the actual negative consequences which exist, be they random or otherwise. Whereas observed risk is our evaluation of negative consequences based upon a theoretical model of the physical world. This is further distinguished from perceived risk which is conceived of as being the estimate of real risk in the absence of a theoretical model of the world. The distinction which is being drawn is a subtle one but it is an attempt to capture the idea that our perception of risk is judgmental in nature and does not necessarily correspond with objective reality. The underlying assumption, that our subjective evaluation of risk may not coincide with the true nature of things, is one that psychiatrists are familiar with. The lay perception of the risk that psychiatric patients pose to the public is, at the least, an exaggeration of the objective facts. However, the observed risk, that is the risk calculated by experts that psychiatric patients pose to the public may not be an accurate reflection of the actual risk posed by psychiatric patients.

Pereira et al's paper (1999, this issue) is to be welcomed in that it highlights an area of clinical decision that requires a careful balance of short- and long-term risks and benefits in the individual patient. In this (necessarily) brief commentary I will concentrate on this aspect, and leave aside any ethical and medico-legal considerations.

Desmond Kelly's decision to enter psychiatry was finally settled while dining with the late Dr William Sargant at his club. After National Service he returned to St Thomas' to do his MD and, after six months at the Maudsley Hospital spent a year at Johns Hopkins, Baltimore on a Nuffield Fellowship. His consultant career began with 10 years at St George's where, in addition to extensive teaching and committee duties, he published over 50 papers and his book Anxiety and Emotions. He then became Medical Director at Roehampton Priory Hospital.

He established links between the Priory and Charing Cross, University College London and St George's. These links with medical schools culminated in accreditation by the Royal College of Psychiatrists. In 1992 he became a Visiting Professor at University College London. Dr Kelly's involvement with issues in addition to his clinical and management responsibilities have included the College's ‘Defeat Depression’ campaign. He is currently Patron of ‘The National Depression Campaign’, its successor.

It is his involvement in independent practice, however, which sets him apart. His leadership grew from Medical Directorship of a single hospital to becoming Group Medical Director of a score of hospitals throughout the UK, with a seven-fold increase in bed provision and a steady development of specialist services. During this time he became a Board Member of the parent company and was also Chairman of the group for five years.

Desmond Kelly retired this year.

Sri Lanka is a developing country situated in the Indian ocean with a population of about 18.5 million. Its education and health care services are free in the state sector. Psychiatric services are mainly confined to the units in the general hospitals and two large mental hospitals situated in Angoda and Mulleriyawa (suburbs of Colombo) at the moment. However the institutional care is gradually changing and many professionals are aware of the importance of community care. There are a few reasonably organised community centres available at present.

British Medical Journalwww.bmj.com – this is an excellent site. It has the full text of all articles published in the British Medical Journal since the beginning of 1997.

The College is aware of the Cyberanalysis clinic website and has been in contact with Dr Razzaque and his psychiatric tutor. We have agreed that the reference within the website to Dr Razzaque as being an Inceptor within the Royal College of Psychiatrists should be removed.