Distributional cost effectiveness analysis is a new method that can help to redesign prevention programmes by explicitly modelling the distribution of health opportunity costs as well as the distribution of health benefits. Previously we modelled cardiovascular disease (CVD) screening audit data from Liverpool, UK to see if the city could redesign its cardiovascular screening programme to enhance its cost effectiveness and equity. Building on this previous analysis, we explicitly examined the distribution of health opportunity costs and we looked at new redesign options co-designed with stakeholders. We simulated four plausible scenarios: a) no CVD screening, b) ‘current’ basic universal CVD screening as currently implemented, c) enhanced universal CVD screening with ‘increased’ population-wide delivery, and d) ‘universal plus targeted’ with top-up delivery to the most deprived fifth. We also compared assumptions around whether displaced health spend would come from programmes that might benefit the poor more and how much health these programmes would generate. The main outcomes were net health benefit and change in the slope index of inequality (SII) in QALYs per 100,000 person years. ‘Universal plus targeted’ dominated ‘increased’ and ‘current’ and also reduced health inequality by −0.65 QALYs per 100,000 person years. Results are highly sensitive to assumptions about opportunity costs and, in particular, whether funding comes from health care or local government budgets. By analysing who loses as well as who gains from expenditure decisions, distributional cost effectiveness analysis can help decision makers to redesign prevention programmes in ways that improve health and reduce health inequality.