Part of the process of recent public sector reform has involved replacing traditional cash-based accounts with accrual-based financial statements, similar to those found in the private sector. This article examines the use of accrual-based accounting in the public sector and provides examples from the UK National Health Service of situations where the accruals system may be deemed inappropriate. It shows that one possible response is to withdraw from the accruals mode and revert to cash measures, deeming the accruals adjustments to be ‘merely technical’. An alternative response is to change the mode of operating so that the cash impact of a transaction matches its accruals reporting impact. The conclusion is that there are modifications to public sector accounting practices away from those of the private sector that undermine the metaphor of running the public sector ‘like a business’.