Fly-on-the-wall documentaries typically only benefit the fly. This is a truth probably now held to be self evident at Rotherham foundation trust. But, if one of the things to take away from the BBC programme Can Gerry Robinson Fix the NHS? was that ideally there would be more local initiative across the NHS, what might that look like?

Apropos of nothing, here are five unrelated ideas on topical issues. They go with the grain of the current reforms but could help supercharge them. There are lots more where these came from: because if localism means anything it has to mean an energy and appetite for trying ideas like this, in one or more innovative health economies, without having to wait for instruction from Whitehall. So here goes.

First, at a time when there is lots of fuss about closing maternity units, why not let women themselves decide? Turn the tariff payment into a voucher and then let the choices that pregnant women make determine whether smaller units, midwife-led home births, or larger general hospital-based obstetric units prosper.

As a health authority commissioning director a decade ago, I still remember how our plan to close an underused community maternity unit provoked large numbers of local mothers into delivering their babies there. Hey presto - it was no longer unviable or uneconomic!

My point is this. The current debate on maternity services illustrates the missing connection between the reform programme on the one hand and how change is actually being managed in the NHS on the other. The maternity reconfiguration agenda seems almost entirely insulated from the (non-existent?) programme to implement the government's manifesto commitment that 'by 2009, all women will have choice over where and how they have their baby and what pain relief to use'.

Second, at a time when there is concern about the viability of smaller district general hospitals, rather than merging them with their neighbours - and in so doing creating even larger and less responsive monopolies - why not encourage the formation of (competing) chains of such hospitals spread across different localities?

This has been tried in several other countries and can work quite well, as the new meta-organisation forms distinctive competencies in reducing fixed costs and managing to tight margins across its constituent hospitals.

Over time, the right to run district general hospitals teetering on the edge of viability could then be tendered out to these competing networks - a situation likely to encourage greater transparency and innovation than the behind-the-bikesheds sweetheart deal recently negotiated between Heart of England and Good Hope Hospital trusts in the West Midlands.

Third, at a time when there are worries that commissioners may not yet be sufficiently strong to counteract the demand-inducing activities of hospitals, why not grant GPs and primary care trusts the right - but not the duty - to step in and run (or tender out the running) of any hospital's accident and emergency department where admissions are increasing by more than a certain amount a year? Of course PCTs should be seeking to prevent patients getting into hospital in the first place. But let's not deny the ability that hospitals themselves have to alter admissions thresholds in ways that are hard for their commissioners to tackle prospectively.

Furthermore, at a time when there are concerns that the out-of-hours system is working less than optimally, why not start sharing risk with out-of-hours providers and ambulance trusts for the A&E and emergency admissions used by their patients? (After all, 'out of hours' is around 118 out of 168 hours each week - so should really be renamed 'majority hours'). In this way they too would be incentivised to look for better ways of supporting patients in non-hospital settings. And while we're on the subject, the same approach could be tried with nursing homes too - an approach which has been well tested in
the US.

Fourth, at a time when there is lots of fuss over inflationary pay deals, and the unions are submitting evidence to the review bodies, why not require that any pay offer from NHS Employers has to be ratified by a secret ballot of NHS chief executives whose organisations are affected by it? Why should it only be the unions that can use the threat of non-ratification of a deal by their members as a sword of Damocles hanging over pay negotiations?

And fifth, at a time when there is lots of talk about a more muscular approach to public health, what about experimenting with new ways of incentivising and supporting lifestyle change? How about PCTs working with local authorities to offer council tax discounts for taxpayers in lower bands in return for being a non-smoker, or participating in a smoking cessation programmes, or attending parent/child health clinics?

If we tried this creative way of engaging people, we would be learning from experiments such as the one in West Virginia, which has some of the highest rates of diabetes, heart disease, obesity and smoking in the US. There 160,000 people - many of whom are parents of children enrolled in the Medicaid programme - can sign a 'personal responsibility contract', in return for which they get credits that can be used to purchase extra benefits.

Now maybe that's a daft idea - maybe they all are. But that's not my point. The point is it's surely time to start thinking outside the box on these and all the other issues we're currently grappling with. Only when the NHS does that - and is seen to be doing that - will the debate on local initiative versus Whitehall control be decisively answered in the NHS's favour.

Simon Stevens is chair of UnitedHealth Europe and visiting professor at the LSE.
Simon_L_Stevens@uhc.com