• Alternatively, the department’s major health-related line functions, including key agency heads (such as NIH, FDA, CDC, CMS) and the surgeon general, could report directly to the secretary, while other agency heads and staff functions could report to a single subordinate, such as the deputy secretary.

Having a smaller number of senior subcabinet-level officials reporting directly to the secretary would enable better management and coordination of agency directors, aid in the development of cross-cutting policies, facilitate collaboration, and ensure consistency (alignment) across agencies, while allowing individual agency directors to focus on their agency responsibilities and pay less attention to political pressures. While day-to-day operations could be managed by a new senior official (or officials), agency heads should, of course, always have direct access to the secretary for major policy decisions, budget planning, and in times of crisis. The committee also recognized a number of disadvantages to this approach, strongest among them that it could dissuade some talented individuals from accepting appointment to high-profile and influential posts—such as the directorships of FDA, NIH, and CDC—if it moved them a level down the chain of command and limited direct access to the secretary. The scope of responsibilities of the agency heads would remain the same with this streamlined approach, but the coherence of agency activities to the department’s mission would be enhanced. Talented and experienced individuals will be attracted to top HHS positions because of their confidence in the leadership and direction of the department.

The committee recognizes—and recent experience indicates—that individual secretaries will have different management styles and that some will want to centralize management in their office, while others will rely more heavily on subcabinet officials, such as an ASH, to manage the department. There are instances in which both styles have worked well. In either case, secretaries generally should encourage initiative and creativity at the program level. Often the best ideas come from the agency heads who are most deeply involved in the specifics of their unit’s work.

Whatever internal configuration is chosen for the secretary’s office, the objective should be to encourage feedback loops across departmental units, so that they communicate with and learn more readily from each other, can align policies and programs more effectively, and work toward common goals. Whether that coordination rests with one or two people in

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