Drainage reconnaissance sampling was initiated in northern Pakistan in 1992 as part of an Australian aid project and later extended by Pakistani agencies, achieving a coverage of some 100,000 square kilometres by 1997. Panned concentrate and <200 μm fraction (minus 80 mesh) samples were taken at varying sampling densities from some 4260 sites in the Northwest Frontier Province and Northern Areas, and analysed for Au, Bi, Co, Cu, Ni, Pb and Zn by atomic absorption spectrophotometry. In 1997, Minorco Services BV re-analysed the accumulated samples for a more comprehensive element suite, using methods with enhanced sensitivity for the previously analysed elements. This paper presents an interpretation of the new results in relation to regional geology and mineralisation. The survey encompasses the collision zone between the Eurasian and the Indian plates, and an intervening Cretaceous–Tertiary island arc system (the Kohistan and Ladakh arcs). These three main tectonic crustal units are separated by two major thrust faults, the Northern Suture Zone (NSZ) and the Main Mantle Thrust (MMT), which are zones of shearing up to 4 km wide that incorporate oceanic ophiolitic volcanics and alpine serpentinite intrusions. The area is characterised by extreme topographic relief, with peak elevations over 8000 m. Despite the semiarid climate, much of the higher ground has permanent snow cover and active glaciers, the meltwaters from which are the source of the extensive Indus River drainage system. Compression associated with the northward movement of the Indian Plate has resulted in 20 to 40 km of uplift since the Eocene (55 Ma), and erosion levels are deep. The remnants of former erosional episodes are retained in the form of various types of terrace deposits within river valleys. Aspects of the regional geology are well reflected in the multi-element geochemistry. The Eurasian and Indian plates are both characterised by high background values for Ba, Pb, Sn, Tl and the ratios K/Na and Rb/Sr. The Kohistan–Ladakh arcs are highlighted by elevated values for Co, Cu, Fe, Mn and V. A series of elongate patterns of enrichment for Cr, Ni and the ratio Mg/Ca delineate the NSZ and MMT. These relationships are well summarised by the results of principal component analysis, the first two factors derived clearly relating to the three regional geological units and the structures which separate them, respectively. Other factors can be interpreted to represent different styles of mineralisation, although no significant occurrences have been located to date. The results for some elements are influenced by variations in catchment area. Median concentrations for Ba, Co, Cu, Mo, Ni and Zn decrease with increasing catchment size, which is the normal pattern for downstream dilution. Arsenic, Au, Cr, Nb, Pd, Pt, Sb, Sn, V and W show the reverse tendency, i.e. enrichment in larger catchments. This behaviour is typical for elements which are dispersed in heavy mineral phases and is magnified by the sampling of trap sites, which are the loci for hydraulic concentration of heavy minerals. In the case of Au in panned concentrates, the extreme concentrations encountered (up to 480 ppm) are considered to represent patterns of concentration, rather than dispersion, of Au, some of which may be derived from bedrock sources which have been completely eroded. A brief orientation study suggests that more meaningful dispersion patterns could be delineated by sampling and analysis of the <75 μm fraction of low-energy sediments, rather than trap sites.