Confed chief's challenge is to get network choir singing in harmony

He sets the bar as high as it can go, saying he intends the confederation to become the dominant voice shaping health policy. This requires clarity of message, which brings to the fore the question of the confederation's structure.

Mr Barnett makes clear that the confed's networks - for mental health, primary care trusts, foundation trusts and the independent sector - are not the tail wagging the dog. They are now, largely, the dog.

He candidly describes using the networks as the confed's gateway to its own membership, while the "mother ship", as he puts, it will focus on cross-cutting issues and big policy ideas.

The core networks - for mental health, PCTs and foundation trusts - have certainly had successes. Their respective client groups strongly identify with them, they have a clear voice, are a focus for expertise and policy development, and reflect the realities of the way the modern NHS is structured.

Critically, the network concept has succeeded in its simplest aim: keeping the foundation trusts inside the tent.

But aligning this with confed members' expressed desire for blue sky thinking will be tough. The networks are there first and foremost to represent the interests of their members, not to divine the perfect health policy.

Mr Barnett is upfront about the difficulties of leading the confed "family". But his new brood has the added complexity of an adopted child. Sooner or later the Partners Network, representing the independent sector, will be battling it out with one of the other networks in front of the recently launched Co-operation and Competition Panel, which adjudicates on disputes about access to the health market. This may test to destruction whether the federal structure is able to express a clear view, or whether it will be reduced to putting out statements primarily designed to avoid offending any of its members.

With a change of government just months away there is no more important time for the confed to speak with a strong voice. As a start it needs to extract a commitment from shadow health secretary Andrew Lansley to end cheap, populist, front bench rhetoric which denigrates managers.

Marshalling the impressive but disparate forces of the networks to achieve this influence will be a tough challenge.