OBJECTIVE: To develop an effective but practical screening questionnaire for use by accident and emergency (A&E) staff to detect alcohol misuse early on in its natural history, without unreasonably prolonging patient waiting times; and to integrate an alcohol health worker (AHW) into A&E to provide counselling for referred patients. METHODS: Two pilot studies for adult patients were undertaken to develop the 1 min Paddington alcohol test (PAT), which has only three compulsory questions for detecting alcohol misuse: two cover peak consumption and frequency of possible binge drinking, and the third asks whether in the patients' view their attendance at A&E was alcohol related. The use of the PAT was validated in "appropriate" adult patients over a one year period. Patients found to be positive were invited to attend the A&E review clinic for counselling by the AHW. RESULTS: The development of the PAT resulted in a referral rate of one patient per 158 A&E adult attenders, facilitating a counselling rate of one patient per 263 A&E adult attenders by the AHW. This counselling rate is a 10-fold increase on the rate of one patient per 2610 adult attenders found in a study undertaken during 1988-90. CONCLUSIONS: The use of the PAT is one practical method for A&E staff to detect the alcohol misusing patient for referral to a departmental alcohol health worker.