Killaspy et al (Reference Killaspy, Banerjee and King2000) is one of several studies that demonstrate that non-attendance at psychiatric services is an index of increased pathology and greater need (Reference Swofford, Kasckow and Scheller GilkeySwofford et al, 1996; Reference Crawford and WesselyCrawford & Wessely, 1998) and serves as a corrective to earlier suggestions that non-attenders are not usually worthy of being seen (Reference RobinRobin, 1976). Although the authors suggest that the first episode of non-attendance “may be an important time to intervene to attempt to prevent loss to follow-up of those with serious mental illnesses” the trends in psychiatric services are increasingly moving in the opposite direction. The growth in geographical sectors covered by community teams has many advantages (Reference Johnson and ThornicroftJohnson & Thornicroft, 1993), but has naturally led to the dangers of preferentially looking after easier patients who belong within the area rather than difficult ones who might (with luck) go away if they are not seen. Although this behaviour might be considered ostrich-like in view of the fact that Killaspy et al found that patients who did not attend were more likely to be readmitted, they also noted that 27 (7%) of their patients were untraceable. I suspect that most of these were extremely ill, highly geographically mobile patients who would have absorbed a significant proportion of psychiatric resources if they had been contacted proactively and who would have been seen as imposing an additional burden on services that should be primarily involved in caring for the ‘real’ residents in the catchment area.

We have considerable evidence of this in the inner-city area of Paddington, where there are high rates of continuous psychiatric morbidity and more than 1 in 50 of the population is referred annually (Reference Shipley, Hilborn and HansellShipley et al, 2000). This is largely because so many of the population are geographically mobile and would normally stay only briefly in the area. Even when there is intervention by the psychiatric services in the form of admission there is a five-times greater chance that such patients will be admitted to a hospital outside their area (Reference Lamont, Ukoumunne and TyrerLamont et al, 2000) and not taken on by mainstream services. The general consequence of this is that those services that are specifically focused on the most geographically mobile population (e.g. homeless people with mental illnesses and street outreach projects) often find it difficult to arrange transfer of their patients when they eventually settle to a more permanent base because the services in the area concerned do not regard them as proper residents. I have found that patients who have transiently lived in the Paddington area are often returned there by other services on the grounds that their care belongs in the area and the patients wish to return.

In practice it is unlikely that the sound recommendation of Killaspy et al that services be more active in seeing non-attenders would be followed because it is likely to lead to the growth of imported psychopathology of severe mental illness and increased psychiatric morbidity in the areas concerned. We have recommended elsewhere (Reference Lamont, Ukoumunne and TyrerLamont et al, 2000) that the best way forward in tackling this problem is to create regional teams not preoccupied with catchment area boundaries, who could provide consistent and appropriate care for this forgotten non-attending population.