Speaking to journalists last Monday, he was asked what responsibility he took — as someone who has been at the heart of the SNP government for almost 20 years — for the struggles facing the NHS and other public services.
He replied: “I’m going to fix it.”
Whether he succeeds or not may depend on how you define fix.
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Last week, a paper from researchers at the University of Edinburgh’s Usher Institute analysing data from NHS Scotland over an 11-year period made grim reading for the First Minister and Neil Gray, his Health Secretary.
The study found that healthcare in Scotland was already struggling before the pandemic, with a 35.3% increase in the elective care backlog between 2013 and 2019.
Covid made everything much worse.
The backlog increased by 73.1% in the four years during the pandemic, rising from 385,859 to 667,749 by 2023.
The researchers estimate that approximately 10% of the entire population in Scotland was on a waiting list for elective care by the end of 2023.
Without any increase in capacity, they calculate the waiting list will rise to nearly one million people by December 2026.
To clear the backlog, the NHS needs to treat an additional 32,300 cases per year over the next three years.
Demand is fast outpacing the NHS’s capacity to provide care.
People are already waiting an age.
The University of Edinburgh study found that between December 2019 and December 2023, the number of patients waiting over a year for treatment increased by more than 2400%.
And of course, the longer someone waits, the more likely their health deteriorates.
(Image: DerekMcArthur/Newsquest)
For some Scots, when they do get into hospital, they might struggle to get out.
Statistics released by Public Health Scotland last month revealed that in the financial year ending 31 March 2024, there were 666,190 days spent in hospital by people whose discharge was delayed.
That meant 1,820 daily hospital beds were occupied by people who shouldn’t have been there. This lack of beds adds to the lengthy waits in other parts of the NHS.
Over Christmas, 3,860 people waited more than eight hours in accident and emergency departments, while 1,642 waited for more than 12 hours.
Winter pressures exacerbated the issue, with 1,596 hospital admissions due to flu at the end of December pushing the total number of hospital admissions to its highest level in 15 years.
What also adds to the lengthy waits are staff shortages.
A shortage of GPs makes it difficult for many Scots to even get an initial appointment, prompting many to head to A&E instead.
Staffing levels have been hit by Brexit, making it far more difficult to recruit staff from the European Union.
This has led to increased use of agency and bank staff, which doesn’t come cheap. Agency spending on medical staff has risen by 8% over the last five years, jumping from £119.4 million in 2018-19 to £129.6 million in 2023-24.
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Those who work in the health service are under significant pressure, with high workloads, long hours, and increasing levels of burnout.
A recent survey by the BMA of over 980 doctors found 96% did not believe the NHS was adequately staffed.
They told the trade union they feel they are working in a system in constant crisis, leading to mental and physical exhaustion.
An astonishing 99% said they were extremely or very concerned about the impact of pressures on the NHS.
(Image: Damian Shields/Herald&Times)
Many in the profession believe the future of the health service is increasingly bleak.
In his New Year’s message, Dr Iain Kennedy, chair of BMA Scotland, warned that “the NHS as we know it will struggle to see out another year” without transformative measures. He stressed that reform must go beyond simply throwing money at the problem.
Polling expert Mark Diffley believes the state of the health service will play a significant role in the 2026 Scottish Parliament election, though it’s not certain that voter dissatisfaction will necessarily translate into votes against the SNP.
The NHS consistently ranks as the top concern for voters, he points out. A November survey showed 47% of Scottish voters listing it among their top three issues. Unsurprisingly, the older someone gets, the more important the health service becomes.
“It is the service that everyone consumes,” Mr Diffley says. “Everyone goes to a doctor or dentist or gets a prescription. Everyone has an interaction with the NHS regularly, or their families do. It’s universal.”
Given how important the health service is to voters, and given “how pissed off people are with it” due to waiting times and the like, it should be a “vote winner” for Anas Sarwar, says the pollster.
But it’s not clear if the public is convinced Labour would do a better job, especially given their plummeting poll ratings, with the party in Scotland “paying a pretty heavy price” for the decisions taken by Sir Keir Starmer south of the border.
It is also worth noting, says Mr Diffley, that while voters say the NHS is important when it comes to actually voting, the picture is more complicated.
“YouGov did a big UK-wide poll asking people why they voted the way they did at the 2024 election, and fixing the NHS was fairly low down.
“About 3% of people said they voted Labour specifically to fix the NHS.
“More votes were motivated by things like getting rid of the Tories.
“We shouldn’t isolate the NHS just because it’s the issue that comes up as the most important when you list a series of issues. That doesn’t mean there aren’t other really big things going on, like how long a government has been in power, how a government might be performing, and more generally, what your perception of the leader might be, or different leaders might be.”
That said, if Mr Swinney doesn’t fix the health service, the chances of the SNP getting back into government are reduced.
“Whether the absence of him fixing it absolutely means they’re going to lose, it’s not quite as straightforward as that. It will depend on what Labour’s offer is. It’ll depend on what other parties are offering.”
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The problem is that, as every party accepts and as medics have demanded, there needs to be long-term reform to the NHS.
The dilemma here is that voters tend not to see reform as a fix.
To win over wavering Scots, John Swinney will want to stand in front of voters next year and say that waiting lists are down, bed blocking isn’t as bad as it could be, and waits at A&E aren’t what they were.
But achieving this means spending substantial amounts of money, which, given limited budgets, is money that is not going into reform—into what politicians and clinicians might define as fixing the NHS.
“Typically, politicians are caught like rabbits in the headlights about how to do this,” Mr Diffley says.
“They need to be re-elected, and they need to be able to stand up during a campaign and say, ‘Look, we have cut waiting lists, or we are making progress on this stuff.’ But the real gain here is making kind of long-term change that improves the NHS for years and decades to come.
“The population is ageing. We’re living longer. We need more health services, but at the same time, there’s less money around, and there is a reticence.
“There’s potentially a really high political price to pay for anyone that proposes really significant reform to the NHS because although people are dissatisfied with the day-to-day running of it, they don’t want to see a significantly different model of how health is delivered.
“All of these things mitigate against each other. It becomes really, really, really, really difficult.
“I think it’s one of the hardest bits of polling data to read if you’re a politician. What can we do? What reforms would work? What reforms would not massively alienate the public?”
“They know they need short-term evidence of progress. They know there’s a bigger picture about the longer term, but they’re just very unsure about what the public wants and what the public will accept as a model for public health going forward.”
Can John Swinney fix the NHS in 16 months? Can he get to a point where he tells voters next year that it’s not quite as bad as it was? Possibly.
Long-term fixing for the years ahead? That seems unlikely.